BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 396
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AUTHOR: Mitchell
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AMENDED: May 12, 2011
HEARING DATE: June 22, 2011
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REFFERRAL: Public Safety
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CONSULTANT:
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Bain
SUBJECT
Medi-Cal: juvenile detention facilities
SUMMARY
This bill requires the Department of Health Care Services
(DHCS) to develop processes to allow counties and the
Division of Juvenile Facilities (DJF) within the California
Department of Corrections and Rehabilitation (CDCR) to
receive federal financial participation (FFP) through
Medicaid for health care services provided to juvenile
detainees or detained youth, as applicable, who are
admitted as inpatients in a medical institution.
CHANGES TO EXISTING LAW
Existing state law:
Establishes the Medi-Cal program, administered by DHCS,
which provides comprehensive health benefits to various
groups, including low-income children who meet specified
eligibility criteria. Medi-Cal family income eligibility
for children ages 0 to 1 extends up to 200 percent of the
federal poverty level (FPL), for children ages 1 to 5 with
up to 133 percent of the FPL, and for children ages 6 to 19
up to 100 percent of the FPL.
Continued---
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Requires benefits provided under the Medi-Cal program to an
individual under 21 years of age who is an inmate of a
public institution to be suspended on the date he or she
becomes an inmate of a public institution. The suspension
ends on the date the individual is no longer an inmate of a
public institution or one year from the date he or she
becomes an inmate of a public institution. Health care
services under Medi-Cal are not available to inmates of
public institutions whose Medi-Cal benefits have been
suspended.
Authorizes the California Department of Corrections and
Rehabilitation (CDCR) and DHCS to develop a process to
maximize federal financial participation (FFP) through
Medicaid for the provision of inpatient hospital services
rendered to individuals who, but for their institutional
status as inmates, are otherwise eligible for Medi-Cal or
for the Coverage Expansion and Enrollment Demonstration
(CEED) Project established under SB 208 (Steinberg),
Chapter 714, Statutes of 2010.
This bill:
Requires DHCS, in consultation with counties, to develop a
process to allow counties and DJF in CDCR to receive FFP
for health care services provided to juvenile detainees who
are admitted as inpatients in a medical institution.
Requires this process to be coordinated, to the extent
possible, with the processes and procedures established to
drawn down FFP for inpatient hospital services provided to
inmates under existing law. Prohibits this provision from
being construed to alter or abrogate any obligation of the
state pursuant to an administrative action or a final court
order to fund and reimburse counties for any medical
services provided to a juvenile detainee.
Requires DHCS to seek any federal approvals necessary to
implement the process developed. Implements this bill only
if and to the extent that any necessary federal approval is
obtained, and only to the extent that existing levels of
FFP are not otherwise jeopardized.
Prohibits a juvenile detainee who is an inpatient in a
medical institution from being denied Medi-Cal eligibility
because of his or her status as a detainee of a public
STAFF ANALYSIS OF ASSEMBLY BILL 396 (Mitchell) Page
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institution. Prohibits any youth detained in DJF who is
an inpatient in a medical institution from being denied
Medi-Cal eligibility because of his or her institutional
status as a ward committed to, or a youth housed in, DJF.
Permits DHCS to exempt juvenile detainees from enrollment
into new or existing managed care health plans.
Requires the process developed under this bill to be
implemented in DJF and in only those counties that
voluntarily elect to provide the nonfederal share of
expenditures for health care services to juvenile detainees
who, but for their inpatient status, would be ineligible
for Medi-Cal as detainees of a public institution.
Requires the FFP received under this bill to be paid to
participating counties and CDCR for services rendered to
the juvenile detainees.
Requires DHCS, if a federal audit disallowance and interest
results from claims made under the process, to recoup from
the county that received the disallowed funds the amount of
the disallowance and any applicable interest.
Permits DHCS to implement the county-related provisions of
this bill without taking any regulatory action by means of
all-county letters or similar instructions.
FISCAL IMPACT
According to the Assembly Appropriations Committee
analysis:
1)One-time administrative costs to DHCS, in the range of
$100,000 (50 percent General Fund (GF)), to develop and
obtain federal approval for a process to allow the state
and counties to leverage federal Medi-Cal funds for
juvenile detainees. In addition, there would be minor
ongoing administrative costs to oversee the program. The
bill does not require counties to cover the state's
administrative costs of implementing the program.
2)If federal approval is granted:
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a. Counties report they would see significant cost
savings by leveraging federal funds. Estimates from
Los Angeles County indicate that cost savings to
counties could be in the range of several million to
over $10 million statewide.
b. Potential cost savings to the state by leveraging
federal funds in the range of $2.5 million (50 percent
GF).
BACKGROUND AND DISCUSSION
According to the author, this bill would allow the counties and
state to seek reimbursement for treatment of minors who are
outside of a county or state detention facility or camp for more
than 24 hours. The author argues that counties and the state
have been paying the full cost of health services for minors
detained in juvenile detention facilities or camps when they are
treated outside of the facility. This bill would allow counties
to seek reimbursement from the federal government through
Medicaid for these health care services.
Budget action last year
Under federal Medicaid law, payments for care and services
provided to inmates of a public institution is not
considered "medical assistance" (and thus is not eligible
for federal financial participation through Medicaid)
unless the inmate is a "patient in a medical institution."
The corrections budget trailer bill from 2010, AB 1628
(Committee on Budget), Chapter 729, Statutes of 2010,
authorizes CDCR and DHCS, to the extent that FFP is not
jeopardized and federal approval is obtained, to develop a
process to draw down FFP for inpatient hospital services
provided to state and local inmates who would otherwise be
eligible for Medi-Cal, or local CEED project projects
authorized under the federal section 1115 Medi-Cal
Demonstration Waiver, if these inmates were not
institutionalized. This trailer bill provides an
opportunity to draw down federal funds by establishing
inmate eligibility for Medi-Cal and local county CEED
projects so that state and county savings can be achieved
by funding health care services with federal Medicaid
STAFF ANALYSIS OF ASSEMBLY BILL 396 (Mitchell) Page
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matching funds.
Under AB 1628, CEED projects are required to provide
reimbursement for inpatient hospital services provided to
an inmate whose county of last legal residence participates
in the CEED project. Additionally, AB 1628 permits, to the
extent FFP is available, DHCS to provide Medi-Cal
eligibility and reimbursement for inpatient hospital
services to inmates, as defined. Finally, AB 1628 also
authorizes a county to seek reimbursement from the Medi-Cal
program or the responsible CEED program for the provision
of inpatient hospital services to adults in county
facilities.
DHCS began processing Medi-Cal applications under this
trailer bill provision on April 1, 2011. As of June 3,
2011, DHCS indicates it has received 49 applications, and
18 applications have been approved. CDCR staff indicates
it estimates that approximately 50 percent of inmates
refuse to sign the Medi-Cal application, which prevents the
state from drawing down federal Medicaid matching funds.
CDCR indicates it is pursuing trailer bill language that
authorizes CDCR or its designee to act on behalf of an
inmate for purposes of applying for, or redeterminations
of, Medi-Cal.
Relationship to court order and actions on state
reimbursement of counties
Medi-Cal is funded, with some exceptions, with state GF
dollars and federal matching funds. This bill requires
DHCS to develop a process to allow counties to receive FFP
for health care services provided to juvenile detainees who
are admitted as inpatients in a medical institution. This
bill also states that this provision cannot be construed to
alter or abrogate any obligation of the state pursuant to
an administrative action or a court order that is final and
no longer subject to appeal to fund and reimburse counties
for any medical services provided to a juvenile detainee.
This provision is included in this measure at the request
of the City Attorney of the City and County of San
Francisco in response to litigation filed by the Office of
the City Attorney of San Francisco and the County of Santa
Clara against DHCS over the obligation of the state to
provide inpatient psychiatric hospital services for
individuals under age 21. In that case, the Superior Court
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issued an order stating that DHCS' policy of denying
Medi-Cal coverage of inpatient psychiatric hospital
services to youth who are in custody violates federal and
state law. That case is currently on appeal. The language
in this bill is not specific to inpatient psychiatric
hospital services and would apply to other court orders
that are final and no longer subject to appeal.
Related bills
SB 695 (Hancock) permits Medi-Cal benefits to be provided
to an individual awaiting adjudication in a county juvenile
detention facility if the individual is eligible for
Medi-Cal at admission or is subsequently determined to be
eligible to receive Medi-Cal benefits, the county agrees to
pay the state's share of Medi-Cal expenditures and
administrative costs, and federal financial participation
(FFP) is available. SB 695 passed the Senate on June 1,
2011 by a 40 to 0 vote.
Prior legislation
SB 1091 (Hancock) of 2010 was similar to SB 695 (Hancock).
SB 1091 was vetoed by Governor Schwarzenegger. In his veto
message, the Governor stated this bill was inconsistent
with federal law and exposed the state to potentially
significant costs. The Governor concluded his veto message
by stating that if the author wishes to craft workable
legislation that allows for additional federal funds, but
also adheres to federal Medicaid law and regulations, DHCS
would be willing to assist in that effort next year.
SB 817 (Hancock) of 2010 was also similar to SB 1091 except
that it only applied to Alameda County. That bill
originally dealt with vote by mail provisions in the
Election Code and was gutted and amended on August 3, 2010
to require Medi-Cal benefits to be provided to an
individual awaiting adjudication in Alameda County Juvenile
Hall if the individual was receiving Medi-Cal benefits at
the time the individual was admitted to Alameda County
Juvenile Hall or the individual is subsequently determined
to be eligible for Medi-Cal and benefits, and Alameda
County agreed to pay the state's share of Medi-Cal
expenditures and the state's administrative costs for
benefits. SB 817 was never heard in a policy or fiscal
committee in that form.
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SB 1147 (Calderon and Yee), Chapter 546, Statutes of 2008,
requires DHCS to develop procedures to ensure that the
Medi-Cal eligibility of minors is not terminated when they
are incarcerated.
SB 648 (Calderon) of 2007 would have required DHCS to
suspend rather than terminate the Medi-Cal benefits of an
incarcerated minor. This bill was referred to Senate
Health Committee but was not heard.
SB 1469 (Cedillo), Chapter 657, Statutes of 2006, requires
county juvenile detention facilities to notify county
welfare departments about the release of a ward so that
eligibility for Medi-Cal can be determined prior to the
release of the inmate.
SB 1616 (Kuehl) of 2006 would have required CDCR to work
with the federal Social Security Administration and DHCS to
ensure that disabled wards are enrolled in Medi-Cal and
that their disability benefits are available to them when
they are released from incarceration at a state
institution. This bill was vetoed by the Governor.
AB 1945 (Coto) of 2006 among other provisions, would have
required a juvenile detention facility, when a minor is
released from custody, to determine if the minor will have
health insurance after release, and if the minor will not,
to evaluate the eligibility of the minor for enrollment in
appropriate need-based programs. This bill was held in the
Assembly Health Committee.
AB 2004 (Yee) of 2006 was identical to SB 648 of 2007. This
bill was vetoed by the Governor.
AB 470 (Yee) of 2005 was a very similar bill to SB 648 of
2007. The bill failed passage on the Assembly floor.
Arguments in support
The Los Angeles County Board of Supervisors, the sponsor of
this bill, writes that this bill would allow counties to
draw down federal matching funds to reimburse them for the
medical treatment of minors who are hospitalized and
outside of the County's detention facility for more than 24
hours. According to the sponsor, the Los Angeles County
Probation Department operates three juvenile detention
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facilities and 18 juvenile camps. The sponsor states that
most of the minors taken into custody are from low-income
families, which make them eligible for Medi-Cal. The
sponsor also states that minors detained in local detention
facilities often require medical care which is outside the
scope of medical services available at the facility.
According to the sponsor, medical conditions requiring
hospitalization include complications from asthma,
diabetes, epilepsy, or heart problems. The sponsor
concludes that, in cases where minors require
hospitalization for a contagious or communicable disease,
care at a medical facility is vital not only for their
health and well-being, but for the other detainees and
probation staff before the minor returns to the detention
facility.
PRIOR ACTIONS
Assembly Public Safety:7- 0
Assembly Health: 18- 0
Assembly Appropriations:17- 0
Assembly Floor: 75- 0
COMMENTS
1. Refusal to sign Medi-Cal applications. In implementing
AB 1628, CDCR staff estimates that approximately 50 percent
of inmates refused to sign the Medi-Cal application, which
prevents the state from drawing down federal Medicaid
matching funds for hospital services provided to them. To
address this issue, the legislative budget subcommittees
have adopted trailer bill language proposed by CDCR that
authorizes CDCR or its designee to act on behalf of an
inmate for purposes of applying for or redeterminations of
Medi-Cal. To address this issue in the event juveniles
and/or their families refuse to sign the Medi-Cal
application form, the author may wish to consider similar
language for this measure to ensure the state and counties
can draw down federal Medicaid matching funds.
POSITIONS
Support: Los Angeles County Board of Supervisors (sponsor)
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American Federation of State, County and
Municipal Employees
California Association of Public Hospitals and
Health Systems
California Medical Association
California Psychiatric Association
California Public Defenders Association
California State Association of Counties
Chief Probation Officers of California
County Health Executives Association of
California
Los Angeles County Probation Officers Union
National Association of Social Workers,
California
Riverside Sheriffs' Association
Sacramento County Board of Supervisors
Santa Clara County Board of Supervisors
Oppose: None on file.
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