BILL NUMBER: AB 1296 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 25, 2011
INTRODUCED BY Assembly Member Bonilla
FEBRUARY 18, 2011
An act to add Part 3.8 (commencing with Section 15925) to Division
9 of the Welfare and Institutions Code, relating to public health.
LEGISLATIVE COUNSEL'S DIGEST
AB 1296, as amended, Bonilla. Health Care Eligibility, Enrollment,
and Retention Act.
Existing law provides for various programs to provide health care
coverage to persons with limited financial resources, including the
Medi-Cal program and the Healthy Families Program. Existing law
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care. Existing law, the
federal Patient Protection and Affordable Care Act (PPACA), requires
each state to, by January 1, 2014, establish an American Health
Benefit Exchange that facilitates the purchase of qualified health
plans by qualified individuals and qualified small employers, as
specified, and meets certain other requirements. Existing law, the
California Patient Protection and Affordable Care Act, creates the
California Health Benefit Exchange (Exchange), specifies the powers
and duties of the board governing the Exchange relative to
determining eligibility for enrollment in the Exchange and arranging
for coverage under qualified health plans, and requires the board to
facilitate the purchase of qualified health plans through the
Exchange by qualified individuals and qualified small employers by
January 1, 2014.
This bill would enact the Health Care Eligibility, Enrollment, and
Retention Act, which would require the California Health and Human
Services Agency, in consultation with specified entities, to
establish a standardized single application
form forms and related renewal
procedures for Medi-Cal, the Healthy Families Program, the Exchange,
and county programs, in accordance with specified requirements. The
bill would specify the duties of the agency and the State Department
of Health Care Services under the act, and would require the agency
to report to the Legislature by January April
1, 2012, regarding policy changes needed to implement the
bill, as specified.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Part 3.8 (commencing with Section 15925) is added to
Division 9 of the Welfare and Institutions Code, to read:
PART 3.8. HEALTH CARE ELIGIBILITY, ENROLLMENT, AND RETENTION
ACT
15925. (a) This part shall be known, and may be cited, as the
Health Care Eligibility, Enrollment, and Retention Act.
(b) (1) By January 1, 2012, the California Health and Human
Services Agency, in consultation with the State Department of Health
Care Services (department), Managed Risk Medical Insurance Board
(MRMIB), the California Health Benefit Exchange (Exchange), counties,
health care services plans, consumer advocates, and other
stakeholders shall have undertaken a planning process to develop
plans and procedures to implement this part and the federal Patient
Protection and Affordable Care Act (PPACA) (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152), related to eligibility for, and
enrollment and retention in, public health coverage programs.
(2) The agency shall submit a report to the health committees of
both houses of the Legislature reflecting the process conducted
pursuant to paragraph (1) by April 1, 2012, regarding policy changes
needed to develop the eligibility, enrollment, and retention system
for health coverage in compliance with this part.
(c) The requirement for submitting a report imposed under
subdivision (b) is inoperative on January 1, 2016, pursuant to
Section 10231.5 of the Government Code.
15926. (a) The following definitions apply for purposes of this
part:
(1) "Medi-Cal" includes all Medi-Cal programs, both full scope and
limited scope benefits, and includes Medi-Cal with a share-of-cost.
(2) "Public health coverage programs" means Medi-Cal, the Healthy
Families Program, the Exchange program of premium tax credits and
reduced cost sharing, and county health programs.
(3) "Real-time determination of eligibility" means a final
determination of eligibility made at the time the application or
retention information is submitted online.
(b) An individual shall have the option to apply for public health
coverage programs in person, by mail, online, and by telephone.
(c) A single, standardized paper, electronic, and telephone
application form for public health coverage programs shall be
developed by the department in consultation with MRMIB and the board
governing the Exchange and shall be used by all entities authorized
to make an eligibility determination for any of the public health
coverage programs and by their agents. The application forms shall
satisfy all of the following criteria:
(1) Include simple, user-friendly language and instructions.
(2) Require only that information that is necessary to determine
eligibility for the applicant's particular circumstances.
(3) May be used for screening, but shall not be limited to
screening. The application form instead shall be an application for
public health coverage programs at all stages of submittal, receipt,
or acceptance at any location authorized to receive or accept an
application for any of the public health coverage programs.
(d) All locations of any kind where applications for any of the
public health coverage programs are received or accepted, including
physical and telephone locations and Internet Web portals or other
electronic systems shall treat the applications described in
subdivision (c) as an application for all of the public health
coverage programs. The entity making the eligibility determination
shall enroll the applicant in the most beneficial public health
coverage program for which the applicant is eligible. If an
application is forwarded or transferred between or among entities for
processing, this process shall not require the applicant to submit
any new information that is not necessary to determine her or his
eligibility. The applicant shall be informed at the time of
application how to obtain information about the status of his or her
application at any time and the information shall be promptly
provided when requested.
(e) The application form described in subdivision (c) shall be
designed to identify infants under the age of one year who are deemed
eligible at birth without an application to Medi-Cal under Section
1396a(e)(4) of Title 42 of the United States Code or to the Healthy
Families Program under Section 12693.70 of the Insurance Code. An
infant who is deemed eligible shall be enrolled upon identification,
and the infant's family shall not be required to complete the
application process.
(f) Nothing in this section shall preclude the use of a
provider-based application form for public health coverage programs
that differs from the application form described in subdivision (c)
to comply with any of the following:
(1) The form and procedures used by the Child Health and
Disability Prevention Program (CHDP) Gateway under Section 14011.7 of
the Welfare and Institutions Code and by Medi-Cal's presumptive
eligibility program for pregnant women under Section 14148.7 of the
Welfare and Institutions Code for children and pregnant women in
families with income at or below 200 percent of the federal poverty
level shall be modified in the simplest way permitted by federal law
to do both of the following:
(A) Serve as an application for ongoing coverage to Medi-Cal, and,
for children, to the Healthy Families Program.
(B) Provide for a program of accelerated enrollment through which
children and pregnant women screened eligible are immediately
enrolled from the medical point of service into coverage with
benefits continuing until a final eligibility determination is made.
(2) The department shall adopt a process for prenatal care
providers to submit the application form for pregnant women required
by paragraph (1) online.
(3) The department shall adopt a process for hospitals to enroll
infants deemed eligible for Medi-Cal under Section 1396a(e)(4) of
Title 42 of the United States Code or the Healthy Families Program
under Section 12693.70 of the Insurance Code immediately online,
without an application.
(g) An applicant or recipient for a public health coverage program
shall be given the option, with his or her informed consent, to have
the application or renewal form prepopulated or electronically
verified in real time, or both, using person information from his or
her own public health coverage program or other public benefits case
file or that of a parent or child or electronic databases authorized
by the PPACA.
(1) An applicant or recipient who chooses a prepopulated
application or renewal shall be given an opportunity, before the
application or renewal form is submitted to the entity authorized to
make eligibility determinations, to provide additional eligibility
information and to correct any information retrieved from a database.
(2) An applicant or recipient who chooses electronic real-time
verification shall be permitted to provide additional eligibility
information and to correct information retrieved from a database any
time before or after a final eligibility determination is made. An
applicant shall not be denied eligibility for any public health
coverage program without being given a reasonable opportunity, at
least to the extent provided for under the Medi-Cal program, for
citizenship documentation, to resolve discrepancies concerning any
information provided by a verifying entity. Applicants shall receive
benefits pending this reasonable opportunity period.
(h) (1) Eligible applicants shall be granted eligibility and
immediately enrolled into a public health coverage program whenever
possible. When granting eligibility immediately is not possible for
an applicant who appears to be eligible based on the information
provided in the application, both of the following shall apply to the
fullest extent permitted by federal law with federal financial
participation:
(A) The applicant shall be immediately enrolled into a program of
presumptive eligibility for children, pregnant women, and adults.
(B) Presumptive eligibility shall continue until the applicant is
enrolled in ongoing coverage through a public health coverage
program, or found to be ineligible for all of these programs and
informed of the denial of coverage in accordance with all applicable
due process requirements.
(2) Notwithstanding paragraph (1), before an online applicant who
appears to be eligible for the Exchange with a premium tax credit or
reduction in cost sharing, or both, may be enrolled in the Exchange,
all of the following shall occur:
(A) The applicant shall be clearly informed of the overpayment
penalties under the Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011 (H.R. 4), if
the individual's annual family income increases by a specified amount
or more, calculated on the basis of the individual's current family
size and current income, and that penalties are avoided by prompt
reporting of income increases throughout the year.
(B) The applicant shall be fully informed of the penalty for
failure to have minimum essential health coverage.
(C) The applicant shall be given the option to decline immediate
enrollment while final eligibility is being determined.
(i) The eligibility, enrollment, and retention system shall ensure
that applicants and recipients receive assistance to understand
decisions they may make, including, but not limited to, those
concerning hardship exemptions from the individual mandate, the
premium tax credit and cost-sharing reductions for the Exchange, and
penalties for overpayments, verifications, and plan choice.
Applicants and recipients shall also be given a meaningful
opportunity to provide information on their applications and renewal
forms that ensures their enrollment in, and retention of, health care
coverage, in the most beneficial program for which they are
eligible.
(j) At application, renewal, or a transition due to a change in
circumstances, eligible applicants and recipients of public health
coverage programs shall move seamlessly between programs without any
breaks in coverage and without being required to provide duplicative
or otherwise unnecessary verification, forms, or other information.
(k) The department shall develop procedures to ensure continuity
of coverage at specific transitions, including, but not limited to,
all of the following:
(1) When a consumer reaches 65 years of age.
(2) When a child reaches 19 years of age.
(3) When a foster youth reaches the age upon which his or her
foster care benefits terminate.
(4) When family income, assets, household composition, or other
circumstances affecting eligibility change.
(l) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among Medi-Cal, the Healthy Families Program, and the
Exchange premium tax credit and reduced cost-sharing using the least
restrictive rules and requirements to ensure that all applicants
whose income is less than 400 percent of the federal poverty level
shall be determined eligible for Medi-Cal, the Healthy Families
Program, or the Exchange when they meet the eligibility requirements
and that all entities processing applications use the same least
restrictive methodologies to determine which program is most
beneficial for each applicant. This process shall include
coordination of rules for determining income levels, assets,
household size, citizenship and immigration status, and documentation
and verification requirements, so that all applications of eligible
persons result in coverage in the most beneficial program and
seamless transition between programs.
(m) Renewal procedures shall be coordinated across all public
health coverage programs and among entities that accept and make
eligibility determinations so as to use all relevant information
already included in the individual's Medi-Cal, other public benefits,
the Healthy Families Program, or Exchange case file, or that of the
individual's parent or child, or electronic databases authorized for
data sharing by the PPACA to renew benefits or transfer eligible
recipients seamlessly between programs without a break in coverage
and without requiring a recipient to provide redundant information.
Renewal procedures shall be as simple and user-friendly as possible,
shall require recipients to provide only information which has
changed, if any, and shall use all available methods for reporting
renewal information, including, but not limited to, face-to-face,
telephone, and online renewal. To the maximum extent allowed under
federal law, a recipient shall be permitted to update her or his
eligibility information at any point and thereby restart the period
for her or his annual redetermination. Eligibility for public health
coverage programs shall be automatically renewed whenever any public
benefits program renewal is conducted.
(n) The eligibility, enrollment, and retention system shall be
both transparent and accountable to the public by complying with, but
not limited to, the following:
(1) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall provide a forum in which
the public, including consumers and their advocates, may on a regular
basis, and no less than once a month, give feedback in person on the
implementation of the eligibility, enrollment, and retention system,
including activities of any public or private entity or individual
providing eligibility screening or application or retention
assistance, for timely corrective action by the department, MRMIB,
and the Exchange board.
(2) In designing and implementing the eligibility, enrollment, and
retention system, the department, MRMIB, and the Exchange board
shall do both of the following:
(A) Provide for evaluation of information technology (IT)
programming by an independent expert before implementation. This
evaluation shall be made available to the public sufficiently in
advance of implementation to allow for an opportunity for review and
comment.
(B) Provide for annual postimplementation evaluation by an
independent expert using data points developed in consultation with
stakeholders, including consumers and their advocates. This
evaluation shall be made available to the public within a reasonable
time period.
(3) The duties of the department, the California Health and Human
Services Agency, MRMIB, and the Exchange board under this subdivision
shall include the duty to monitor and oversee private as well as
public entities engaged in screening for eligibility for a public
health coverage program to ensure that the correct eligibility rules
and requirements are being used by the screener when informing an
individual about his or her potential eligibility, that updates to
the eligibility rules and requirements used by the screener are made
correctly and on a timely basis, and that the screener strictly
adheres to the privacy and confidentiality provisions of subdivision
(o).
(o) In designing and implementing the eligibility, enrollment, and
retention system, the department, MRMIB, and the Exchange board
shall ensure that all privacy and confidentiality rights under the
PPACA, other federal and California laws and regulations, the
Medi-Cal Program, and the Healthy Families' Program are strictly
incorporated and followed. This includes, but is not limited to,
adopting and implementing policies and procedures to ensure all of
the following:
(1) Only that information that is strictly necessary for an
eligibility determination for the individual who is seeking
enrollment in or renewal for a public health coverage program shall
be requested in the application, retention, and renewal process for
that program.
(2) Verification from a third party or database shall be sought
only with respect to information required to be obtained or verified
under federal law to determine eligibility for the public health
coverage program at issue for an individual.
(3) Applicants and recipients shall be given clear, complete,
user-friendly information regarding how their personal information
will be used, disseminated, secured, verified, and retained by public
health coverage programs.
(4) An applicant or recipient shall not be required by the
department, MRMIB, the Exchange board, or any public or private
entity or individual providing eligibility screening or application
or retention assistance to agree to the sharing of his or her
personal information without informed consent as a condition of being
screened for, applying to, or renewing eligibility for a public
health coverage program. Applicants and recipients shall have the
option to decline online screening, application, renewal, and
electronic verification and instead may apply or renew in person, by
mail, or by telephone.
(5) Responses to security breaches shall be conducted according to
the strictest requirements of privacy and confidentiality laws,
including, but not limited to, implementation of a plan to directly
provide information about the breach to anyone whose personal
information has been confirmed or suspected to have been compromised,
stolen, or viewed by anyone without authorized access.
(p) All programs shall use standardized forms and notices, as
appropriate, to timely inform recipients in advance of all of the
following:
(1) What information, if any, is required from them for renewal.
(2) Whether transfer to another public health coverage program is
to occur.
(3) How the transfer will affect the recipient's cost, access to
care, delivery system, and responsibilities.
15925. (a) This part shall be known, and may be cited, as the
Health Care Eligibility, Enrollment, and Retention Act.
(b) (1) By January 1, 2014, the California Health and Human
Services Agency, in consultation with the State Department of Health
Care Services (department), Managed Risk Medical Insurance Board, the
California Health Benefit Exchange (Exchange), counties, health care
services plans, consumer advocates, and other stakeholders shall
undertake a planning process to develop plans and procedures to
implement this part and the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152),
related to eligibility for, and enrollment and retention in, public
health coverage programs.
(2) The agency shall submit a report to the Legislature by January
1, 2012, regarding policy changes needed in order to develop the
eligibility, enrollment, and retention system for health coverage in
compliance with this part.
(c) A single, standardized paper application shall be used by all
entities accepting applications for all public health care programs,
including Medi-Cal, the Healthy Families Program, the Exchange, and
county programs. An electronic application and a telephone
application shall also be developed, using the same eligibility
methodologies. All of these applications shall include simple,
user-friendly instructions, and require applicants to answer only
those questions that are necessary to determine eligibility for their
particular circumstances.
(d) All locations, systems, portals, assistors, or entities of any
kind accepting applications for the programs identified in
subdivision (c) shall use and accept the applications described in
subdivision (c) as an application for all of the described programs.
An entity processing applications shall enroll an applicant in the
most beneficial program for which the applicant is eligible. If an
application is forwarded or transferred among entities for
processing, this process shall not impose any burden on the
applicant. The applicant shall be informed of how to get information
about the status of his or her application at any time.
(e) An applicant shall not be required to provide any verification
that is not necessary for the purpose of evaluating eligibility or
that may be verified using reliable databases approved by the
department for the purpose of evaluating eligibility. An applicant
shall be given an opportunity to provide his or her own verifications
if he or she prefers, but shall not be required to do so. An
applicant shall not be denied eligibility for a program specified in
this section without being given an opportunity to correct any
information provided by a verifying entity.
(f) Applications shall be evaluated so as to provide a real-time
determination of eligibility, including applicable cost sharing and
subsidies, whenever possible. When a real-time determination is not
possible, an applicant shall be granted presumptive enrollment to the
fullest extent allowed by federal law. Presumptive enrollment shall
continue until the applicant is enrolled in ongoing coverage under
Medi-Cal, the Exchange, Healthy Families, or a county health program,
or found to be ineligible for all of these programs and informed of
the denial of coverage in accordance with all applicable due process
requirements. For purposes of this part, "real-time determination of
eligibility" means an eligibility determination made at the time the
application is submitted.
(g) The eligibility, enrollment, and retention system shall use a
consumer-mediated approach, pursuant to which consumers shall receive
assistance to understand decisions they may make, including those
concerning subsidies, plan choice, hardship exemptions, and
verifications. This approach shall provide consumers with a
meaningful opportunity to provide information that ensures their
enrollment in, and retention of, health care coverage, in the most
beneficial program for which they are eligible.
(h) At application, renewal, or a transition due to a change in
circumstances, consumers shall move seamlessly between programs
without providing additional verification, application, or other
information.
(i) The department shall develop procedures to ensure continuity
of coverage at specific transitions, including, but not limited to,
all of the following:
(1) When a consumer reaches 65 years of age.
(2) When a qualified alien reaches the five-year bar for receipt
of public benefits, as provided in Section 1613 of Title 8 of the
United States Code.
(3) When a foster youth reaches the age upon which his or her
foster care benefits terminate.
(4) When family income, assets, household composition, or other
circumstances change.
(j) The department shall streamline and coordinate eligibility
rules and requirements among the programs identified in subdivision
(c) to ensure that all applicants whose income is less than 400
percent of the federal poverty level shall be eligible for one of
those programs, and all entities processing applications use the same
methodologies to determine which program is most beneficial for each
applicant. This process shall include coordination of rules for
determining income levels, assets, household size, documentation
requirements, and citizenship and identity information, so that all
applications result in coverage in the most beneficial program and
seamless transition between programs.
(k) The department shall maximize coordination and enrollment in
other public benefits programs, including, but not limited to,
the California Work Opportunity
and Responsibility to Kids (CalWORKs) program, the California Special
Supplemental Food Program for Woman, Infants, and Children (WIC),
and CalFRESH, both by accepting an application and reporting
information from those programs as an application for health
benefits, and by using health benefit applications to initiate
applications for those programs, to the extent allowed by federal
law.
(l) Renewal procedures shall be coordinated across all programs
and entities that accept and process renewal information, so as to
use all available information to renew benefits or transfer
beneficiaries seamlessly between programs without placing a burden on
the beneficiary. Renewal procedures shall be as simple and user
friendly as possible, shall require beneficiaries to provide only
that information which has changed, and shall use all available
methods for renewal, including, but not limited to, face-to-face,
telephone, and online renewal.
(m) All programs shall use standardized forms and notices and
notices to ensure that beneficiaries are fully informed and
understand what information is required from them for renewal, if
any, and are informed of any transfer, and how the transfer will
affect the beneficiary's costs access to care, delivery system, and
responsibilities.
(n) (1) The requirement for submitting a report imposed under
subdivision (b) is inoperative on January 1, 2016, pursuant to
Section 10231.5 of the Government Code.
(2) A report submitted pursuant to subdivision (b) shall be
submitted in compliance with Section 9795 of the Government Code.