BILL NUMBER: SB 32 AMENDED
BILL TEXT
AMENDED IN SENATE MARCH 28, 2007
INTRODUCED BY Senator Steinberg
( Principal coauthor: Assembly Member
Laird )
( Coauthor: Assembly Member
Wolk )
DECEMBER 4, 2006
An act to amend Sections 12693.43, 12693.70, and 12693.73 of,
to amend and repeal Section 12693.981 of, to add Sections 12693.55,
12693.56, 12693.57, 12693.701, 12693.981a, and 12693.983 to, and to
add Chapter 16.2 (commencing with Section 12694.1) to Part 6.2 of
Division 2 of, the Insurance Code, and to amend Section 14005.23 of,
and to add Sections 14005.26, 14011.01, and 14011.61 to, the Welfare
and Institutions Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 32, as amended, Steinberg. Health care coverage: children.
(1) Existing law establishes various public programs to provide
health care coverage to eligible children, including the Medi-Cal
program administered by the State Department of Health Care Services
and county welfare agencies, and the Healthy Families Program
administered by the Managed Risk Medical Insurance Board. Children
through 18 years of age are eligible for health care coverage under
these programs if they meet certain household income and other
criteria including specified citizenship and immigration status
requirements. Under existing law, the applicant's signed statement as
to the value or amount of income is accepted for eligibility
purposes under the Healthy Families Program if documentation cannot
otherwise be provided.
This bill would expand eligibility for the Medi-Cal program and
would expand eligibility for the Healthy Families Program by allowing
children with family incomes at or below 300% of the federal poverty
level to qualify for the program and would delete the specified
citizenship and immigration status requirements. The bill would
accept the applicant's signature on the application for the Healthy
Families Program as verification of the value or amount of income for
purposes of establishing eligibility for the program. The bill would
create the Healthy Families Buy-In Program that would be
administered by the Managed Risk Medical Insurance Board and would
make the coverage provided under the Healthy Families Program
available to children whose household income exceeds 300% of the
federal poverty level and who meet other specified criteria. The bill
would specify the family contribution required for children enrolled
in the buy-in program. The bill would also make various related
modifications to the Medi-Cal program and the Healthy Families
Program. Because the expansion of and modifications to the Medi-Cal
program would impose certain duties on counties relative to
administration of that program, the bill would impose a
state-mandated local program. The bill would require the Managed Risk
Medical Insurance Board and the State Department of Health Care
Services to take specified actions to improve and coordinate the
application and enrollment processes for the Medi-Cal program and the
Healthy Families Program and to develop a process to transition the
enrollment of children from local children's health initiatives into
those programs.
(2) Existing law establishes the Healthy Families-to-Medi-Cal
Bridge Benefits Program to provide any person enrolled for coverage
under the Healthy Families Program who meets certain criteria, as
specified, with two calendar months of health care benefits in order
to provide the person with the opportunity to apply for the Medi-Cal
program.
This bill would establish the Healthy Families to Medi-Cal
Presumptive Eligibility Program to provide a child who meets certain
criteria, as specified, with presumptive eligibility benefits
identical to the full scope of benefits with no share of cost
provided under the Medi-Cal program until a Medi-Cal eligibility
determination is made, at which point either the child would be
enrolled in the Medi-Cal program with no interruption in coverage or
the presumptive eligibility benefits would terminate in accordance
with due process requirements. The bill would require the Managed
Risk Medical Insurance Board to execute a declaration upon
implementation of this program and would make the Healthy
Families-to-Medi-Cal Bridge Benefits Program inoperative as of the
date of that declaration.
(3) Existing law requires the state to administer, to the extent
allowed under federal law, and only if federal financial
participation is available, a program to provide a child who meets
specified eligibility requirements, including the income requirements
of the Healthy Families Program, with benefits identical to full
scope benefits under the Medi-Cal program with no share of cost for
the period during which the child has an application pending for
coverage under the Healthy Families Program.
This bill would establish, to the extent allowed by federal law
and to the extent federal financial participation is available, the
Medi-Cal Presumptive Eligibility Program that would provide a child
who meets specified eligibility requirements with presumptive
eligibility benefits identical to full scope benefits under the
Medi-Cal program with no share of cost until the child is found
eligible for the Medi-Cal program or for the Healthy Families Program
or is found ineligible for either of those programs.
(4) Existing law creates the Healthy Families Fund, and provides
that money in the fund is continuously appropriated for purposes of
the Healthy Families Program.
This bill would provide that the Managed Risk Medical Insurance
Board may implement the provisions of the bill expanding the Healthy
Family Program only to the extent that funds are appropriated for
those purposes in the annual Budget Act or in another statute.
(5) The California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Existing law creates the Healthy Families Program that is
administered by the Managed Risk Medical Insurance Board and also
establishes the Medi-Cal program that is administered by the State
Department of Health Care Services and county welfare agencies. Under
existing law, the Healthy Families Program arranges health care
coverage for children whose household income is at or below 200% of
the federal poverty level (FPL) and who meet other criteria. Existing
law also creates the County Health Initiative Matching Fund where
specified funds are deposited and administered by the Managed Risk
Medical Insurance Board. Under existing law, an applicant, including
a local initiative, may submit a proposal to the board for funding to
provide health care coverage to persons who meet certain income and
citizenship and immigration status requirements.
This bill would express the Legislature's findings concerning the
importance of providing health care coverage to all children in the
state. The bill would also declare the Legislature's intent to allow
all children living in California whose family income is under 300%
of the federal poverty level access to affordable, comprehensive
health coverage, to improve and modernize the process of enrolling
children in coverage and maintaining their enrollment, to provide
sustainable financing for children's health care coverage, and to
ensure interim coverage for children currently receiving health care
coverage through local Children's Health Initiatives.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no
yes .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. It is the intent of the Legislature to
accomplish the following:
(a) Allow all children, from birth to 19 years of age, living in
California to have access to affordable, comprehensive health care
coverage.
(b) Build upon the successful aspects of California's publicly
funded state health care coverage programs, the Healthy Families
Program and the Medi-Cal program, and improve their operations,
including modernizing and simplifying the processes of enrolling all
eligible children in coverage and maintaining their enrollment in the
programs.
(c) Build upon the lessons and successes of local children's
health initiatives.
(d) Support coverage for children currently enrolled in local
children's health initiatives until the expansion of the statewide
program is fully implemented and provide for a smooth transition for
these children into the Healthy Families Program and the Medi-Cal
program.
(e) Ensure sustainable financing that supports the statewide
programs over the long term, including maximizing federal funding for
those programs.
SEC. 2. Section 12693.43 of the
Insurance Code is amended to read:
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost Family
Value Package family value package in a given
geographic area.
(b) In each geographic area, the board shall designate one or more
Family Value Packages family value packages
for which the required total family contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with annual household incomes up to and including 150
percent of the federal poverty level.
(2) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with annual household income
to which subparagraph (B) of paragraph (6) of subdivision (a) of
Section 12693.70 is applicable. Notwithstanding any other provision
of law, if an application with an effective date prior to July 1,
2005, was based on annual household income to which subparagraph (B)
of paragraph (6) of subdivision (a) of Section 12693.70 is
applicable, then this subparagraph shall be applicable to the
applicant on July 1, 2005, unless subparagraph (B) of paragraph (6)
of subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income. The program shall provide prior notice to
any applicant for currently enrolled subscribers whose premium will
increase on July 1, 2005, pursuant to this subparagraph and, prior to
the date the premium increase takes effect, shall provide that
applicant with an opportunity to demonstrate that subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is no longer
applicable to the relevant family income greater than
200 percent and up to and including 250 percent of the federal
poverty level .
(4) Twenty-two dollars and fifty cents ($22.50) per child with a
maximum required contribution of sixty-seven dollars and fifty cents
($67.50) per month per family for applicants with an annual household
income greater than 250 percent and up to and including 300 percent
of the federal poverty level.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost Family Value
Package family value package may be offered to
and selected by applicants. However, the cost to the program of those
combinations that exceeds the price to the program of the highest
cost Family Value Package family value
package shall be paid by the applicant as part of the family
contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with annual household incomes up to and
including 150 percent of the federal poverty level.
(2) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, twelve dollars ($12) per child with
a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with annual household income
to which subparagraph (B) of paragraph (6) of subdivision (a) of
Section 12693.70 is applicable. Notwithstanding any other provision
of law, if an application with an effective date prior to July 1,
2005, was based on annual household income to which subparagraph (B)
of paragraph (6) of subdivision (a) of Section 12693.70 is
applicable, then this subparagraph shall be applicable to the
applicant on July 1, 2005, unless subparagraph (B) of paragraph (6)
of subdivision (a) of Section 12693.70 is no longer applicable to the
relevant family income. The program shall provide prior notice to
any applicant for currently enrolled subscribers whose premium will
increase on July 1, 2005, pursuant to this subparagraph and, prior to
the date the premium increase takes effect, shall provide that
applicant with an opportunity to demonstrate that subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is no longer
applicable to the relevant family income greater than
200 percent and up to and including 250 percent of the federal
poverty level .
(4) Twelve dollars ($12) per child with a maximum required
contribution of thirty-six dollars ($36) per month per family for
applicants with an annual household income greater than 250 percent
and up to and including 300 percent of the federal poverty level.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purpose
purposes of subdivision (e) of Section 11346.1
of the Government code Code , the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative law Law , is
hereby extended to 180 days.
SEC. 3. Section 12693.55 is added to the
Insurance Code , to read:
12693.55. The board shall maximize federal matching funds
available under the program and implement strategies that coordinate
and integrate other programs that provide health care coverage for
children to maximize federal and state matching funds.
SEC. 4. Section 12693.56 is added to the
Insurance Code , to read:
12693.56. The confidentiality and privacy protections of Sections
10500 and 14100.2 of the Welfare and Institutions Code shall apply
to all children seeking, applying for, or enrolled in, the program.
SEC. 5. Section 12693.57 is added to the
Insurance Code , to read:
12693.57. Upon implementation of Section 14005.26 of the Welfare
and Institutions Code and Section 12693.701, the board, in
consultation with the State Department of Health Care Services, shall
develop a process for the transition of eligible children from local
children's health initiatives to the Medi-Cal program and to the
Healthy Families Program. The process shall include, but not be
limited to, the following provisions:
(a) A child enrolled in comprehensive health care coverage
provided by a children's health initiative shall, upon his or her
annual renewal date, be automatically enrolled in the Medi-Cal
program or the Healthy Families Program, if an application is made
and the child is eligible for either program. The child shall be
enrolled in the same health plan that provided coverage to the child
under the local children's health initiative, if the health plan is a
participating plan in the Medi-Cal program or the Healthy Families
Program.
(b) For good cause, or upon the child's next annual renewal in the
Medi-Cal program or the Healthy Families Program, the child shall
change health plans or remain in the same health plan.
SEC. 6. Section 12693.70 of the
Insurance Code is amended to read:
12693.70. To be eligible to participate in the program, an
applicant shall meet all of the following requirements:
(a) Be an applicant applying on behalf of an eligible child, which
means a child who is all of the following:
(1) Less than 19 years of age. An application may be made on
behalf of a child not yet born up to three months prior to the
expected date of delivery. Coverage shall begin as soon as
administratively feasible, as determined by the board, after the
board receives notification of the birth. However, no child less than
12 months of age shall be eligible for coverage until 90 days after
the enactment of the Budget Act of 1999.
(2) Not eligible for no-cost full-scope Medi-Cal or Medicare
coverage at the time of application.
(3) In compliance with Sections 12693.71 and 12693.72.
(4) A child who meets citizenship and immigration status
requirements that are applicable to persons participating in the
program established by Title XXI of the Social Security Act, except
as specified in Section Sections 12693.701
and 12693.76.
(5) A resident of the State of California pursuant to Section 244
of the Government Code; or, if not a resident pursuant to Section 244
of the Government Code, is physically present in California and
entered the state with a job commitment or to seek employment,
whether or not employed at the time of application to or after
acceptance in, the program.
(6) (A) In either of the following:
(i) In a family with an annual or monthly household income equal
to or less than 200 percent of the federal poverty level.
(ii) When implemented by the board, subject to subdivision (b) of
Section 12693.765 and pursuant to this section, a child under the age
of two years who was delivered by a mother enrolled in the Access
for Infants and Mothers Program as described in Part 6.3 (commencing
with Section 12695). Commencing July 1, 2007, eligibility under this
subparagraph shall not include infants during any time they are
enrolled in employer-sponsored health insurance or are subject to an
exclusion pursuant to Section 12693.71 or 12693.72, or are enrolled
in the full scope of benefits under the Medi-Cal program at no share
of cost. For purposes of this clause, any infant born to a woman
whose enrollment in the Access for Infants and Mothers Program begins
after June 30, 2004, shall be automatically enrolled in the Healthy
Families Program, except during any time on or after July 1, 2007,
that the infant is enrolled in employer-sponsored health insurance or
is subject to an exclusion pursuant to Section 12693.71 or 12693.72,
or is enrolled in the full scope of benefits under the Medi-Cal
program at no share of cost. Except as otherwise specified in this
section, this enrollment shall cover the first 12 months of the
infant's life. At the end of the 12 months, as a condition of
continued eligibility, the applicant shall provide income
information. The infant shall be disenrolled if the gross annual
household income exceeds the income eligibility standard that was in
effect in the Access for Infants and Mothers Program at the time the
infant's mother became eligible, or following the two-month period
established in Section 12693.981 or the period established in
Section 12693.981a if the infant is eligible for Medi-Cal with
no share of cost. At the end of the second year, infants shall again
be screened for program eligibility pursuant to this section, with
income eligibility evaluated pursuant to clause (i), subparagraphs
(B) and (C), and paragraph (2) of subdivision (a).
(B) All income over 200 percent of the federal poverty level but
less than or equal to 250 300 percent
of the federal poverty level shall be disregarded in calculating
annual or monthly household income.
(C) In a family with an annual or monthly household income greater
than 250 300 percent of the federal
poverty level, any income deduction that is applicable to a child
under Medi-Cal shall be applied in determining the annual or monthly
household income. If the income deductions reduce the annual or
monthly household income to 250 300
percent or less of the federal poverty level, subparagraph (B) shall
be applied.
(b) The applicant shall agree to remain in the program for six
months, unless other coverage is obtained and proof of the coverage
is provided to the program.
(c) An applicant shall enroll all of the applicant's eligible
children in the program.
(d) In filing documentation providing
information to meet program eligibility requirements,
if the applicant's income documentation cannot be
provided, as defined in regulations promulgated by the board, the
applicant's signed statement as to the value or amount of income
signature on the application shall be deemed to
constitute verification of the applicant's value or amount of
income .
(e) An applicant shall pay in full any family contributions owed
in arrears for any health, dental, or vision coverage provided by the
program within the prior 12 months.
(f) By January 2008, the board, in consultation with stakeholders,
shall implement processes by which applicants for subscribers may
certify income at the time of annual eligibility review, including
rules concerning which applicants shall be permitted to certify
income and the circumstances in which supplemental information or
documentation may be required. The board may terminate using these
processes not sooner than 90 days after providing notification to the
Chair of the Joint Legislative Budget Committee. This notification
shall articulate the specific reasons for the termination and shall
include all relevant data elements that are applicable to document
the reasons for the termination. Upon the request of the Chair of the
Joint Legislative Budget Committee, the board shall promptly provide
any additional clarifying information regarding implementation of
the processes required by this subdivision.
SEC. 7. Section 12693.701 is added to the
Insurance Code , to read:
12693.701. (a) Notwithstanding any other provision of law, a
child under 19 years of age who meets the state residency
requirements of the Medi-Cal program or the Healthy Families Program
shall be eligible for either the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code) if he or she meets the income and
resource requirements of Section 14005.7 or 14005.30 of the Welfare
and Institutions Code or the Healthy Families Program if he or she
lives in a family with a household income at or below 300 percent of
the federal poverty level, including for both programs those children
for whom federal financial participation is not available under
Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.), or under Title XXI of the federal Social Security Act (42
U.S.C. Sec. 1397aa et seq.).
(b) A child described in subdivision (a) who is ineligible for the
full scope of benefits under the Medi-Cal program at no share of
cost because of his or her family's household income shall be
eligible for the Healthy Families Program if he or she is ineligible
for Medicare coverage and complies with Sections 12693.71 and
12693.72. A child's eligibility for the Healthy Families Program
pursuant to this section shall not affect that child's eligibility
for the Medi-Cal program with a share of cost in accordance with
Section 14005.7 of the Welfare and Institutions Code.
(c) Nothing in this section shall be construed to authorize the
denial of medical assistance under the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code) to a child who, without the
application of this section, would qualify for that assistance or to
excuse the Medi-Cal program or the Healthy Families Program of the
obligation to determine eligibility on all other available grounds.
(d) The board shall implement this section, and children made
eligible for the program by this section shall be able to enroll in
the program, no later than January 1, 2008.
SEC. 8. Section 12693.73 of the
Insurance Code is amended to read:
12693.73. Notwithstanding any other provision of law, children
excluded from coverage under Title XXI of the Social Security Act are
not eligible for coverage under the program, except as specified in
clause (ii) of subparagraph (A) of paragraph (6) of subdivision (a)
of Section 12693.70 and Section in Sections
12693.701 and 12693.76.
SEC. 9. Section 12693.981 of the
Insurance Code is amended to read:
12693.981. (a) (1) The Healthy Families-to-Medi-Cal Bridge
Benefits Program is hereby established to provide any person enrolled
for coverage under this part who meets the criteria set forth in
subdivision (b) with a two calendar-month period of health care
benefits in order to provide the person with an opportunity to apply
for Medi-Cal.
(2) The Healthy Families-to-Medi-Cal Bridge Benefits Program shall
be administered by the board.
(b) (1) Any person who meets all of the following requirements
shall be eligible for two additional calendar months of Healthy
Families benefits:
(A) He or she has been receiving, but is no longer eligible for,
benefits under the program.
(B) He or she appears to be income eligible for full-scope
Medi-Cal benefits without a share of cost.
(2) The two additional calendar months of benefits under this
chapter shall begin on the first day of the month following the last
day of the person's eligibility for benefits under the program.
(c) The two-calendar-month period of Healthy Families benefits
provided under this chapter shall be identical to the scope of
benefits that the person was receiving under the program.
(d) Nothing in this section shall be construed to provide Healthy
Families benefits for more than a two calendar-month period under any
circumstances, including the failure to apply for benefits under the
Medi-Cal program or the failure to be made aware of the availability
of the Medi-Cal program unless the circumstances described in
subdivision (b) reoccur.
(e) This section shall become inoperative if an unappealable court
decision or judgment determines that any of the following apply:
(1) The provisions of this section are unconstitutional under the
United States Constitution or the California Constitution.
(2) The provisions of this section do not comply with the State
Children's Health Insurance Program, as set forth in Title XXI of the
federal Social Security Act.
(3) The provisions of this section require that the health care
benefits provided pursuant to this section are required to be
furnished for more than two calendar months.
(f) This section shall become inoperative on the date that the
board executes a declaration stating that the implementation of the
Healthy Families to Medi-Cal Presumptive Eligibility Program
established pursuant to Section 12693.981a has commenced. As of the
next occurring January 1, this section is repealed, unless a later
enacted statute, enacted before that January 1 date, deletes or
extends the dates on which this section becomes inoperative and is
repealed.
SEC. 10. Section 12693.981a is added to the
Insurance Code , to read:
12693.981a. (a) The Healthy Families to Medi-Cal Presumptive
Eligibility Program is hereby established to provide a child who
meets the criteria set forth in subdivision (c) with presumptive
eligibility benefits until the child's eligibility for full scope
Medi-Cal benefits with no share of cost has been determined.
(b) The Healthy Families to Medi-Cal Presumptive Eligibility
Program shall be administered by the board.
(c) A child who meets both of the following requirements shall be
eligible for presumptive eligibility benefits under the Healthy
Families to Medi-Cal Presumptive Eligibility Program:
(1) He or she has been receiving, but is no longer eligible for,
benefits under the Healthy Families Program.
(2) He or she otherwise appears to be income-eligible for
full-scope Medi-Cal benefits with no share of cost.
(d) The presumptive eligibility benefits under this section shall
begin on the first day of the month following the last day of the
child's receipt of benefits under the Healthy Families Program.
Presumptive eligibility benefits under this section shall terminate
either at the end of the month during which a child's effective date
for benefits in the Medi-Cal program begins and the Medi-Cal Benefits
Identification Card has been issued and activated or at the end of
the month during which the county determines that the child is not
eligible for the Medi-Cal program. If the county determines that the
child is eligible for the Medi-Cal program, the county shall enroll
the child in the Medi-Cal program without an interruption in
coverage. If the county determines that the child is ineligible for
the Medi-Cal program, the county shall terminate the child's benefits
under the Healthy Families to Medi-Cal Presumptive Eligibility
Program in accordance with due process requirements.
(e) The income methodology for determining a child's family income
for the purposes of the Healthy Families to Medi-Cal Presumptive
Eligibility Program, as required by subdivision (c), shall be the
same methodology used in determining a child's eligibility for the
full scope of Medi-Cal benefits.
(f) The scope of presumptive eligibility benefits provided under
the Healthy Families to Medi-Cal Presumptive Eligibility Program
shall be identical to the full scope of benefits under the Medi-Cal
program with no share of cost.
(g) No family contribution is required for a child receiving
presumptive eligibility benefits under the Healthy Families to
Medi-Cal Presumptive Eligibility Program.
(h) To the extent necessary and to the extent allowed by federal
law, the State Department of Health Care Services and the board may
exchange a child's case file solely for the purpose of determining
the child's eligibility for the Medi-Cal program or the Healthy
Families Program, without requiring the family's consent. Any
information, including the child's case file, shall be kept
confidential by the department and the board pursuant to state and
federal law, and it shall be used only for the determination
of, or continuation of
eligibility for, the Medi-Cal program or the Healthy Families
Program.
(i) The board shall develop, in consultation with consumer
advocates and other stakeholders, a system for tracking cases where
children receive benefits under the Healthy Families to Medi-Cal
Presumptive Eligibility Program for more than two months and for
follow-up of those cases. The follow-up system shall include the
following activities to ensure that children in the Healthy Families
to Medi-Cal Presumptive Eligibility Program are enrolled in a timely
manner into the ongoing health care benefits program for which they
are eligible:
(1) The board shall identify those cases where children are
enrolled in the Healthy Families to Medi-Cal Presumptive Eligibility
Program for more than two months and determine the status of each
case, taking the necessary actions to complete the eligibility
determination process for each child to obtain the ongoing health
care benefits for which the child is eligible.
(2) If children in the Healthy Families to Medi-Cal Presumptive
Eligibility Program are not enrolled in full scope Medi-Cal with no
share of cost within two months of their enrollment date in the
Healthy Families to Medi-Cal Presumptive Eligibility Program, the
board shall contact the State Department of Health Care Services or
the county where the child resides in order to determine the status
of the child's application for, and enrollment in, the Medi-Cal
program. The board shall assist the department or county and the
family in enrolling the child in the program for which he or she is
eligible, which may include, but is not limited to, making telephone
calls and sending correspondence and providing assistance to obtain
necessary documentation.
(j) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the board
shall implement this section by means of all-county letters or
similar instructions without taking any further regulatory action.
Thereafter, the board may adopt regulations, as necessary, to
implement this section in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code.
(k) Upon implementation of the Healthy Families to Medi-Cal
Presumptive Eligibility Program pursuant to this section, the board
shall execute a declaration, which it shall retain, stating that
implementation of the section has commenced.
SEC. 11. Section 12693.983 is added to the
Insurance Code , to read:
12693.983. (a) The board and the State Department of Health Care
Services shall monitor the Healthy Families Presumptive Eligibility
Program in Section 12693.98a and the Healthy Families to Medi-Cal
Presumptive Eligibility Program in Section 12693.981a in order to
ensure that all children are enrolled in a timely manner in the
presumptive eligibility benefits for which they are eligible.
(b) The monitoring responsibilities required by this section shall
consist of the following activities:
(1) The board and the department shall collect the following data
on a monthly and annual basis:
(A) The number of children enrolled in the Healthy Families
Presumptive Eligibility Program and the number of children enrolled
in the Healthy Families to Medi-Cal Presumptive Eligibility Program.
(B) The length of time these children were enrolled in each
program.
(C) The status of the children enrolled in each program, including
a status report for each child enrolled more than one month in the
Healthy Families Presumptive Eligibility Program and more than two
months in the Healthy Families to Medi-Cal Presumptive Eligibility
Program.
(2) The board and the department shall record all attempts to
assist the child to enroll in ongoing health benefits programs and
shall record the final disposition of the child's application for
continuing health coverage.
(c) The board and the department shall report to the Legislature
the data collected pursuant to subdivision (b) on a monthly and
annual basis.
SEC. 12. Chapter 16.2 (commencing with Section
12694.1) is added to Part 6.2 of Division 2 of the
Insurance Code , to read:
CHAPTER 16.2. HEALTHY FAMILIES BUY-IN PROGRAM
12694.1. On or after ____, the board shall implement the Healthy
Families Buy-In Program that shall be referred to as the buy-in
program for purposes of this chapter.
12694.2. A child under 19 years of age is eligible for the buy-in
program if he or she meets all of the following criteria:
(a) Lives in a family whose monthly or annual income exceeds 300
percent of the federal poverty level.
(b) Is not eligible for full scope Medi-Cal benefits or the
Healthy Families Program.
(c) Has been without health care coverage for, at minimum, a
period of six consecutive months immediately preceding the date of
application for the buy-in program.
12694.3. (a) The board shall place a child who meets the
eligibility criteria of Section 12694.2 in a risk pool separate from
all other children enrolled in the Healthy Families Program if the
child is subject to any of the following coverage risks:
(1) The amount of the premium for health care coverage for the
child obtained outside of a public program would exceed 6 percent of
the family's gross annual income or would exceed 125 percent of the
average capitation rate paid to a participating health plan.
(2) The child was denied health care coverage in the private
market within the 12-month period immediately preceding the date of
application to the buy-in program.
(b) The board shall place a child who meets the eligibility
criteria of Section 12694.2 but is not subject to any coverage risk
described in subdivision (a) in the same risk pool as all other
children enrolled in the Healthy Families Program.
12694.4. The coverage for children in the buy-in program shall be
identical to the coverage for children enrolled in the Healthy
Families Program and shall be provided solely by a participating
health plan.
12694.5. (a) The family of a child described in subdivision (a)
of Section 12694.3 enrolled in the buy-in program shall pay the board
a monthly contribution that equals the lesser of the following
amounts:
(1) The average capitation rate paid to participating health plans
in the buy-in program in the service area where the child resides.
(2) One hundred twenty-five percent of the average full monthly
participating health plan capitation amount in the Healthy Families
Program.
(b) The family of a child other than as described in subdivision
(a) of Section 12694.3 enrolled in the buy-in program shall pay the
board a monthly contribution in an amount that equals the average
full monthly participating health plan capitation amount in the
Healthy Families Program.
(c) The family of a child enrolled in the buy-in program shall
receive the same discounts from their contributions under this
section as provided to applicants pursuant to paragraph (4) of
subdivision (d) of, and subdivisions (e) and (f) of, Section 12693.43
and shall be subject to the payment procedures set forth in Section
2699.6813 of Title 10 of the California Code of Regulations.
12694.6. (a) A county who finds a child ineligible for the
Medi-Cal program or the Healthy Families Program shall offer the
option of enrollment in the buy-in program.
(b) The board shall offer the option of enrollment in the buy-in
program for a child it finds ineligible for the Medi-Cal program or
the Healthy Families Program.
SEC. 13. Section 14005.23 of the
Welfare and Institutions Code is amended to read:
14005.23. (a) To the extent federal
financial participation is available, the department shall, when
determining eligibility for children under Section 1396a()(1)(D) of
Title 42 of the United States Code, designate a birth date by which
all children who have not attained the age of 19 years will meet the
age requirement of Section 1396a()(1)(D) of Title 42 of the United
States Code.
(b) On and after January 1, 2008, the department shall apply the
less restrictive income deduction described in Section 1396a(r) of
Title 42 of the United States Code when determining eligibility for
the children identified in subdivision (a). The amount of this
deduction shall be the difference between 133 percent and 100 percent
of the federal poverty level applicable to the size of the family.
SEC. 14. Section 14005. 26 is added to
the Welfare and Institutions Code , to read:
14005.26. (a) Notwithstanding any other provision of law, a child
under 19 years of age who meets the state residency requirements of
the Medi-Cal program or the Healthy Families Program (Part 6.2
(commencing with Section 12693) of Division 2 of the Insurance Code)
shall be eligible for either the Medi-Cal program if he or she meets
the income and resource requirements of Section 14005.7 or 14005.30,
or the Healthy Families Program if he or she lives in a family with
household income at or below 300 percent of the federal poverty
level, including for both programs those children for whom federal
financial participation is not available under Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.), or under
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa
et seq.).
(b) A child described in subdivision (a) who is ineligible for the
full scope of benefits under the Medi-Cal program at no share of
cost because of his or her family's household income, shall be
eligible for the Healthy Families Program pursuant to Section
12693.701 of the Insurance Code if he or she is ineligible for
Medicare coverage and complies with Sections 12693.71 and 12693.72 of
the Insurance Code. A child's eligibility for the Healthy Families
Program pursuant to this section shall not affect the child's
eligibility for the Medi-Cal program with a share of cost in
accordance with Section 14005.7.
(c) Nothing in this section shall be construed to authorize the
denial of medical assistance under the Medi-Cal program to a child
who, without the application of this section, would qualify for that
assistance or to excuse the Medi-Cal program or the Healthy Families
Program of the obligation to determine eligibility on all other
available grounds.
(d) The department shall maximize federal matching funds available
for eligible children's health insurance under the Medi-Cal program,
and the department shall implement strategies to coordinate and
integrate existing children's health insurance programs to maximize
available state and federal matching funds, such as matching funds
available for emergency or pregnancy-related Medi-Cal benefits, for
all eligible children.
(e) The department shall implement this section, and children made
eligible for the Medi-Cal program by this section shall be able to
enroll in the Medi-Cal program, no later than January 1, 2008.
SEC. 15. Section 14011.01 is added to the
Welfare and Institutions Code , to read:
14011.01. (a) The department, in coordination with the Managed
Risk Medical Insurance Board, stakeholders, and consumer advocates,
shall make technological improvements to the existing eligibility
determination and enrollment systems for the Medi-Cal program, such
as the Medi-Cal Eligibility Data System (MEDS), and the Healthy
Families Program based on the guidelines set forth in subdivisions
(b), (c), and (d) in order to better integrate the enrollment
processes for those programs.
(b) The improvements shall allow families, with their consent, to
be screened for, and apply to, multiple health care coverage programs
from more than one location.
(c) The improvements shall accomplish all of the following
objectives:
(1) Promote accessible enrollment opportunities through public
service programs that are widely used by families, including schools,
and other public access points.
(2) Minimize families being required to provide duplicative
application data and maximize the use of application data, with the
family's consent, to screen for eligibility for multiple programs.
(3) Support electronic and digital signature approaches to reduce
the burden of the applicant appearing in person, wherever possible.
(4) Reduce documentation requirements and, with the family's
consent, verify necessary information through other available
databases.
(5) Promote data integrity by expanding access to and improving
MEDS search and file clearance functionality.
(6) Include the ability to obtain birth and other state maintained
verification documents electronically.
(7) Support electronic exchange of information with the Statewide
Automated Welfare System.
(8) Guarantee privacy protections and secure information exchange.
(d) To improve the integration and efficiency of technological
systems used by the state to operate the Medi-Cal program and the
Healthy Families Program, the department shall take the following
actions:
(1) Establish reusable service-based interfaces to allow multiple
existing enrollment systems to exchange data electronically.
(2) Support the electronic submission of verification documents
that are also available for exchange and reuse by multiple existing
enrollment systems.
(3) Develop a plan and timeline for the implementation of
technology that provides an infrastructure to allow legacy systems,
new enrollment systems, and other systems to access common system
functions, features, and rules through a central repository of shared
services.
SEC. 16. Section 14011.61 is added to the
Welfare and Institutions Code , to read:
14011.61. (a) To the extent allowed under Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and Title
XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et
seq.), and only if federal financial participation is available under
Title XXI of the federal Social Security Act, the department shall
administer the Medi-Cal Presumptive Eligibility Program to provide a
child who meets the criteria set forth in subdivision (c) with
presumptive eligibility benefits for the period described in
subdivision (f).
(b) A county shall perform an initial screen of every application
for the Medi-Cal program or the Healthy Families Program that is
filed in that county. The initial screen shall be completed within 48
hours from the time of submission of the application for the
Medi-Cal program or the Healthy Families Program.
(c) On the basis of the initial screen performed by the county, a
child who meets all of the following requirements shall be eligible
for presumptive eligibility benefits under this section:
(1) The child, or his or her parent or guardian, submits an
application for the Medi-Cal program or the Healthy Families Program
directly to the county.
(2) The child's income, as screened by the county on the basis of
the application described in paragraph (1), appears to be within the
income levels necessary to establish eligibility for the Medi-Cal
program with no share of cost.
(3) The child is under 19 years of age at the time of the
application.
(4) The child is not receiving no-cost Medi-Cal benefits or
benefits under the Healthy Families Program at the time that the
application is submitted.
(d) When the county performs the initial screen and determines
that the child meets the criteria described in subdivision (c), the
county shall immediately establish presumptive eligibility for the
Medi-Cal program for that child. The presumptive eligibility benefits
provided under this section shall be identical to the benefits
provided to children who receive full-scope Medi-Cal benefits with no
share of cost and shall only be made available through a Medi-Cal
program provider.
(e) Once presumptive eligibility has been established, the county
shall continue to determine a child's eligibility for the Medi-Cal
program on the basis of the application submitted to it.
(f) The period of presumptive eligibility provided for under this
section begins on the first day of the month that the county finds
that the child meets all of the criteria described in subdivision (c)
and terminates on the last day of the month during which an
eligibility determination is completed and the child is either
enrolled in no-cost Medi-Cal or share-of-cost Medi-Cal or in the
Healthy Families Program or is determined ineligible for any of those
programs.
(g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions, without taking any further
regulatory action. Thereafter, the department may adopt regulations,
as necessary, to implement this section in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.
(h) The department, in consultation with representatives of the
local agencies that administer the Medi-Cal program, consumer
advocates, and other stakeholders, shall develop and distribute the
policies and procedures, including any all-county letters, necessary
to implement this section.
(i) Nothing in this section shall be construed to authorize the
denial of medical assistance under the Medi-Cal program to a child
who, without the application of this section, would qualify for that
assistance or to excuse the Medi-Cal program or the Healthy Families
Program of the obligation to determine eligibility on all other
available grounds.
(j) The department shall begin to implement this section on
January 1, 2008.
SEC. 17. Notwithstanding any other provision of
law, the Managed Risk Medical Insurance Board may implement the
provisions of this act expanding the Healthy Families Program only to
the extent that funds are appropriated for those purposes in the
annual Budget Act or in another statute.
SEC. 18. If the Commission on State Mandates
determines that this act contains costs mandated by the state,
reimbursement to local agencies and school districts for those costs
shall be made pursuant to Part 7 (commencing with Section 17500) of
Division 4 of Title 2 of the Government Code.
SECTION 1. (a) The Legislature finds and
declares the following:
(1) Investing in comprehensive health care coverage for children
is cost effective because children with coverage are healthier, are
at less risk of suffering from preventable illnesses, and are better
able to access needed health care services.
(2) Health care coverage helps children reach their potential in
school. Children with this coverage experience a 25 percent
improvement in health and a 63 percent improvement in "paying
attention in class" and "keeping up with school activities."
(3) Although approximately nine of every 10 children in California
have health care coverage, according to data in 2005 from the Center
for Health Policy Research at the University of California at Los
Angeles, approximately 763,000 children in the state are currently
without coverage. Of these, almost 60 percent are eligible for either
the healthy Families Program or the Medi-Cal program.
(4) The goal of providing all children with health care coverage
through California's two statewide programs is achievable now. With
less than 10 percent of all children being without coverage, the
state is almost there. Employer-based health care coverage, which now
covers 50 percent of children in California, and public programs,
which now cover 30 percent of children in this state, serve as strong
building blocks on which to provide coverage for all children in the
state.
(5) Local Children's Health Initiatives (CHIs) have provided
health care coverage to more than 86,000 children who are without
coverage and who are not eligible for state health care coverage
programs. A statewide system is required to provide sustainable
funding to ensure that all children in California have access to
health care coverage. Local CHIs provide successful models for a
statewide system to cover all children, but they do not have
long-term financial sustainability. Furthermore, there are nearly
12,000 children on waiting lists for these local CHIs. If California
does not act quickly to provide a statewide solution for children's
health care coverage, children will lose that benefit.
(b) It is the intent of the Legislature to take the following
actions:
(1) Allow all children, from birth to 18 years of age living in
California in families with a gross annual income up to 300 percent
of the federal poverty level, access to affordable, comprehensive
health care coverage.
(2) Build upon the successful aspects of California's publicly
funded state health care coverage programs, the Healthy Families
Program and the Medi-Cal program, and improve their operations to
enroll all eligible children in those programs, including modernizing
and simplifying the processes of enrolling children in coverage and
maintaining their enrollment.
(3) Create a statewide health care coverage system that builds
upon the lessons and successes of local CHIs.
(4) Promote voluntary opportunities to strengthen employer
participation in providing health care coverage for an employee's
dependents.
(5) Provide temporary, interim assistance to support coverage for
children currently enrolled in local CHIs while the statewide
programs are fully implemented.
(6) Ensure sustainable financing that supports the statewide
programs over the long term, including maximizing federal funding for
those programs.
(7) Promote opportunities for children to access services under
their health care coverage.
(8) Ensure a strong safety net as a vital component of access to
care.
(9) Do no harm as these reforms are implemented.