BILL NUMBER: AB 1296	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MAY 27, 2011
	AMENDED IN ASSEMBLY  MAY 10, 2011
	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 standardized single application forms and related renewal
procedures for Medi-Cal, the Healthy Families Program,  and 
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
April 1, 2012, regarding policy changes needed to implement the bill
 ,   . The bill would otherwise be operative
January 1, 2014, except  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 service 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,  or  the Exchange program of premium tax
 credits and reduced cost sharing, or county health programs.
  credits and reduced cost sharing. 
   (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 
 or  by telephone.
   (c) A single, standardized paper, electronic, and telephone
application 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 department shall consult with
counties and stakeholders, including consumer  advocates, in
the development of the application. The application  
advocates, regarding whether to use the application developed by the
federal Secretary of Health and Human Services, pursuant to Section
1413 of the PPACA (42 U.S.C. Sec. 18083), or whether to develop a
separate state form. If developing a sta   te form, the
department shall consult with stakeholders in development of the
application. The application shall be tested and operational by July
1, 2013. 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 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 of 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 personal 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   required  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, of at
least the kind provided for under the Medi-Cal program for
citizenship documentation, to resolve discrepancies concerning any
information provided by a verifying entity. Applicants shall receive
the benefits for which they otherwise qualify 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 (Public Law
112-9), 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. 
   (3) An applicant who is not eligible for a public health coverage
program shall be referred to the county health coverage program in
his or her county of residence. 
   (i) The eligibility, enrollment, and retention system shall ensure
that applicants and recipients receive assistance with their
application or renewal for public health coverage programs  ,
including, but not limited to, assistance with 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.  
applications and renewal forms. 
   (j) At application, renewal, or a transition due to a change in
circumstances,  entities making eligibility determinations for
public health coverage programs shall ensure that  eligible
applicants and recipients of public health coverage programs 
shall   meeting all program eligibility requirements
 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) 
    (k)  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.
  requirements.  
   (m) 
    (l)  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 that 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. A recipient shall
be permitted to update his or her eligibility information at any
point.
   (1) A recipient providing an update to his or her eligibility
information in between renewal dates shall be given the option to
renew eligibility at the time of the update.
   (2) Eligibility for public health coverage programs shall be
automatically renewed whenever any public benefits program renewal is
conducted. 
   (n) 
   (m)  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  , by
testing functionality, compliance with eligibility rules, and
accuracy of enrollment decisions  . 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)   (n)  . 
   (o) 
    (n)  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) 
    (o)  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. 
   15927.  Except as otherwise specified, this part shall become
operative on January 1, 2014.