BILL ANALYSIS SENATE HEALTH COMMITTEE ANALYSIS Senator Elaine K. Alquist, Chair BILL NO: SB 438 S AUTHOR: Yee B AMENDED: April 23, 2009 HEARING DATE: April 29, 2009 4 CONSULTANT: 3 Dunstan/cjt 8 SUBJECT Medi-Cal: accelerated enrollment SUMMARY Requires the Department of Health Care Services (DHCS), to seek federal approval for an option to accelerate Medi-Cal enrollment for children and pregnant women who apply for Medi-Cal at a county welfare office. Transfers Healthy Families program eligibility determination to county welfare offices. CHANGES TO EXISTING LAW Existing federal law: Establishes the Medicaid program which provides comprehensive health coverage to low-income eligible individuals and families, including children; the aged, blind, and disabled; and pregnant women, through a program that reimburses states for the Medicaid programs in the individual states. Existing federal law establishes the Children's Health Insurance Program (CHIP) which provides matching funds for state health insurance programs. Provides specific guidance for determining eligibility for Medicaid and CHIP while preserving flexibility for states to administer according to the needs of the state. Continued--- STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 2 Existing state law: Establishes the state's Medicaid program known as Medi-Cal, administered by DHCS, which provides comprehensive health benefits to low-income children; their parents or caretaker relatives; pregnant women; elderly, blind or disabled persons; nursing home residents; and refugees who meet specified eligibility criteria. Authorizes DHCS to establish an accelerated enrollment for children making enrollment changes between Healthy Families and Medi-Cal, for children enrolling in Medi-Cal through the Child Health and Disability Program, children who apply for free lunches through the National School Lunch program and for children enrolling through the single point of entry, a centralized administrative entity. Establishes the Healthy Families program to provide low-cost insurance, including health, dental and vision coverage to children who do not have health insurance, do not qualify for free Medi-Cal and are in families at or below 250 percent of the federal poverty level. Provides that the Managed Risk Medical Insurance Board (MRMIB) administers Healthy Families. This bill: Requires MRMIB to transfer eligibility determination to counties beginning January 1, 2011 and requires MRMIB and stakeholders to consult regarding the procedure for transferring eligibility determinations. Authorizes MRMIB to continue to contract with a private entity for other administrative activities. Requires DHCS to exercise the option for accelerated enrollment for pregnant women and children who apply for Medi-Cal at a county welfare office, provided that federal financial participation is available. Directs DHCS to seek federal approval for any state plan amendments required to implement this bill. Allows DHCS to implement this bill through all-county letters initially and then adopt regulations for any subsequent actions. STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 3 Directs a county, if it determines that a pregnant woman or a child appears eligible for Medi-Cal, to grant them accelerated enrollment into Medi-Cal. Requires counties to perform a complete eligibility determination and, if the pregnant woman or child is found to be ineligible, report that to DHCS so that benefits can be discontinued. FISCAL IMPACT Unknown. BACKGROUND AND DISCUSSION According to the author, this bill seeks to expand access to health care services by streamlining enrollment in the state's Medi-Cal program. The author argues that this bill will accelerate and simplify enrollment by allowing the county welfare office to immediately enroll children who appear to meet the eligibility requirements. The author points out that accelerated enrollment is allowed through the state's single point of entry, the Child Health and Disability Program and between the Healthy Families and Medi-Cal programs. Ironically, the traditional point of entry for many applying for Medi-Cal is the one place where they cannot get the accelerated enrollment, the county welfare office. Uninsured children There are approximately 700,000 children in California who are not covered by health insurance, according to researchers. Many of these uninsured children come from low-income working families. As a result of the lack of insurance, they are less likely to visit a doctor, less likely to receive preventive services, and may delay seeking necessary care. Often when they seek care, they have more serious conditions and require more extensive and costly treatment. According to the UCLA Center for Health Policy Research, of the nearly 700,000 children who are uninsured, over half are eligible for two of California's public health insurance programs; approximately 200,000 for Medi-Cal and STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 4 180,000 for Healthy Families. Another 150,000 are eligible for local children's programs, although these are not offered in all counties. Approximately the same number are not eligible for either of the state programs because of income or immigration status. Studies have reported that when parents of uninsured children who are potentially eligible for Medi-Cal were asked why their children were not enrolled, only eight percent reported being unsure about their children's eligibility as the reason for not applying, and less than one percent did not know the program existed. However, parents of about one in eight uninsured eligible children objected to some characteristics of the program, particularly the onerous paperwork. Consequences of being uninsured Again, according to a report by the UCLA Center for Health Policy Research, uninsured children reported slightly lower health status than those enrolled in Medi-Cal or Healthy Families. Over three-fourths of insured children or their parents reported their health as "excellent" or "very good," while less than half of uninsured children reported the same. Uninsured children were also more than three times as likely to report their health status as "fair" or "poor" than those with job-based coverage. Nearly half of the uninsured reported no usual source of care and were only half as likely as those with Medi-Cal to list a doctor's office or health maintenance organization as their usual source of care and only one-third as likely as those with job-based coverage or individually purchased private insurance. Over 50 percent of the uninsured cited lack of insurance or cost as a reason for not having a usual source of care, compared to about 33 percent of those with Medi-Cal or other public coverage and less than one percent of those with job-based or individually purchased coverage. Previous efforts to ease program requirements The state has implemented a number of eligibility streamlining changes for children that this bill would build on. For example, the Child Health and Disability Prevention Program (CHDP) "Gateway" provides access for uninsured children to the Medi-Cal or the Healthy Families STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 5 program through an automated pre-enrollment process. Another effort to streamline enrollment that the state has embarked on is "Express Enrollment." This concept was established after it was noted that many children eligible for, but not enrolled in, health insurance programs, were participating in existing public programs such as School Lunches, Food Stamps, and Women, Infants, and Children (WIC). Under the state's Express Enrollment program, the application for the school lunch program is used, when the parent or guardian consents, for determining Medi-Cal eligibility. If the child is eligible for free lunches, the application is forwarded to the county, and a determination is made regarding eligibility for no-cost Medi-Cal. If the child is eligible only for reduced-cost lunches, no Medi-Cal determination is made. Related legislation SB 1 (Steinberg), among its other provisions, would have established presumptive eligibility for children in families applying for Medi-Cal at county eligibility offices. This bill is in Senate Health Committee. Prior legislation SB 1459 (Yee) of 2008, among its other provisions, would have established presumptive eligibility for children in families applying for Medi-Cal at county eligibility offices. This bill was held in Senate Appropriations Committee. SB 32 (Steinberg) of 2008 among its other provisions, would have established presumptive eligibility for children in families applying for Medi-Cal at county eligibility offices. SB 32 was held in the Assembly. AB 1 (Laird) of 2008 among its other provisions, would have established presumptive eligibility for children in families applying for Medi-Cal at county eligibility offices. AB 1 was held in the Assembly. SB 437 (Escutia), Chapter 328, Statutes of 2006, established the Healthy Families Presumptive Eligibility Program and would have required the DHCS to implement a process for self-certification of assets and income for various eligibility categories under the Medi-Cal program. STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 6 AB 624 (Monta?ez) of 2005 would have required the DHS and the MRMIB to, by July 1, 2007, include an application process to be used at the option of the person applying on the child's behalf, to simultaneously pre-enroll and apply for enrollment into the Healthy Families or Medi-Cal programs. This bill was vetoed by Governor Schwarzenegger. Arguments in support The California Nurses Association, the bill's sponsor, states that two-thirds of the children in California that are uninsured are eligible for one of the state's public programs. They argue that SB 438 will close those ranks by allowing counties to grant accelerated enrollment of children and pregnant women into Medi-Cal. They also point out that full eligibility determinations will still be done to ensure if benefits will be continued. The Western Center on Law and Poverty (WCLP) points out that there is currently a strange anomaly whereby if a child applies through the state's single point of entry, they can get Medi-Cal in a few days. However, if that same child applies through a county welfare office and provides the same information, the process is slower. WCLP argues that the current screen done by the single point of entry is incomplete because it looks at eligibility for only a few of the many eligibility categories of Medi-Cal. WCLP states that counties are best equipped to accurately make Medi-Cal determinations, apply the program's many complex eligibility rules, and sort through the program's varying income level and rules. County Welfare Directors of California argues that this bill will create equity for children and pregnant women whose applications for Medi-Cal are filed directly with the county human services departments rather than mailed in through the single point of entry. They point out that this process is already in use by other entities than counties. COMMENTS 1. The author is proposing an amendment to eliminate provisions of the bill related to Healthy Families. As currently drafted the bill would require the Managed Risk Medical Insurance Board to shift eligibility determinations for Healthy Families to the county welfare offices. The STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 7 author proposes to amend the bill by deleting those provisions. Proposed amendment Page 3, delete lines 4 through 25.
SEC. 2. Section 12693.766 is added to the Insurance Code, to read: 12693.766. (a) Notwithstanding any other provision of this part, on or before July 1, 2010, the board, in consultation with the State Department of Health Care Services, shall begin the transfer of initial and ongoing eligibility determinations for the program to the county departments. The counties shall assume full responsibility for the eligibility determinations for the program by January 1, 2011. (b) The board and the department shall consult with stakeholders, including counties and advocates for program clients, in the development of procedures for transferring the responsibility for determinations to the county level. (c) Upon transfer of program eligibility determinations to the county level, the collection of family contributions and participating health plan selection may continue to be contracted to a private entity. In order to maximize efficiency, it is the intent of the Legislature that plan selection and collection of contributions be incorporated, to the extent possible, into the Medi-Cal managed care enrollment broker contract administered by the State Department of Health Care Services.Technical amendment Page 9, beginning line 20 (f) Upon the receipt of an application for a child directly from the parent pregnant womanor from another source on behalf of the child, or an applicationfor a pregnant woman directly from the pregnant woman parentor another source on behalf of the pregnant woman, the county shall determine whether the child or pregnant woman appears eligible for Medi-Cal benefits and, if so, grant accelerated enrollment to the child or pregnant woman. Upon the granting of accelerated enrollment for a child or pregnant woman, the county shall determine whether the child or pregnant woman is eligible for Medi-Cal benefits. If the county determines that the child or pregnant woman does not meet the eligibility requirements for participation in the Medi-Cal program, the county shall report this finding to the Medical Eligibility Data System so that accelerated enrollment coverage benefits are discontinued. If the STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 8 county determines that the child is eligible for the Medi-Cal program with a share of cost, the county shall enroll the child in the Medi-Cal program and forward the application to the Managed Risk Medical Insurance Board for an evaluation of the child's eligibility for the Healthy Families Program. POSITIONS Support: California Nurses Association (sponsor) County Welfare Directors of California Western Center on Law and Poverty Previous version of bill American Federation of State, County and Municipal Employees California Medical Association California Primary Care Association California Psychological Association Oppose: None received -- END --