BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1296
A
AUTHOR: Bonilla
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AMENDED: June 28, 2011
HEARING DATE: July 6, 2011
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CONSULTANT:
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Bain
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SUBJECT
Health Care Eligibility, Enrollment, and Retention Act
SUMMARY
Enacts the Health Care Eligibility, Enrollment and
Retention Act, requiring state entities who administer
health care coverage programs to undertake a variety of
activities related to eligibility, enrollment and renewal
of health care coverage through Medi-Cal, the Healthy
Families Program (HFP), the California Health Benefits
Exchange (Exchange), and, if enacted, the Basic Health
Program (BHP).
CHANGES TO EXISTING LAW
Existing federal law:
Requires, under the federal Patient Protection and
Affordable Care Act (PPACA) (Public Law 111-148), as
amended by the Health Care Education and Reconciliation Act
of 2010 (Public Law 111-152), each state, by January 1,
2014, to establish an American Health Benefit Exchange
(federal Exchange) that makes qualified health plans
available to qualified individuals and qualified employers.
If a state does not establish a federal Exchange, the
Continued---
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federal government administers the federal Exchange.
Federal law establishes requirements for the federal
Exchange, for health plans participating in the Exchange,
and defines who is eligible to receive coverage in the
federal Exchange. Among other duties, the federal Exchange
is required to inform individuals of eligibility
requirements for the Medicaid program (Medi-Cal in
California), the Children's Health Insurance Program (CHIP
is known as the Healthy Families Program, or HFP, in
California), or any applicable state or local public
program. The federal Exchange is required if, through
screening of the application, the federal Exchange
determines that such individuals are eligible for any such
program, to enroll such individuals in such program.
Allows through PPACA, effective January 1, 2014, eligible
individual taxpayers whose household income equals or
exceeds 100 percent, but does not exceed 400 percent of the
federal poverty level (FPL), an advanceable and refundable
tax credit for a percentage of the cost of premiums for
coverage under a qualified health plan offered in the
Exchange. PPACA also requires a reduction in cost sharing
for individuals with incomes below 250 percent of the FPL,
and a lower maximum limit on out-of-pocket expenses for
individuals whose incomes are between 100 percent and 400
percent of the FPL. Legal immigrants with household
incomes less than 100 percent of the FPL who are ineligible
for Medicaid because of their immigration status are also
eligible for the premium tax credit and the cost sharing
reductions.
Requires, through PPACA, numerous changes to Medicaid,
including simplifying Medicaid enrollment, requiring
coordination with the federal Exchange, expanding Medicaid
eligibility to adults without minor children with incomes
equal to or less than 133 percent of the FPL, disregarding
(or not counting) an additional five percent in income
(making the Medicaid income eligibility effectively 138
percent of the FPL), eliminating the asset test for
individuals under age 65 and switching to a new method for
calculating income known as modified adjusted gross income
(MAGI) for certain populations.
Requires, through PPACA, the federal Secretary of HHS to
establish a system meeting specified requirements under
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which residents of each state can apply for enrollment,
receive a determination of eligibility for participation,
and continue participation in, applicable state health
subsidy programs (defined as Medicaid, CHIP, Exchange, and
the BHP). Requires this system to ensure that if an
individual applying to an Exchange is found through
screening to be eligible for medical assistance under
Medicaid, or eligible for enrollment under CHIP, the
individual to be enrolled for assistance under such plan or
program.
Requires, through PPACA, each individual, with specified
exceptions, and any dependent of the individual, to
maintain minimum essential coverage; provides exemptions
from the individual mandate, such as for affordability,
hardship, and for individuals with incomes below the income
tax filing threshold, and establishes penalties for
violations.
Existing state law:
Provides for the Medi-Cal program, which is administered by
the Department of Health Care Services (DHCS), under which
qualified, low-income individuals receive health care
services.
Establishes the Exchange in state government, and specifies
the duties and authority of the Exchange. Requires the
Exchange be governed by a board that includes the Secretary
of the Health and Human Services Agency (Agency) and four
members with specified expertise who are appointed by the
Governor and the Legislature.
This bill:
Planning process and information to Legislature
Requires, by January 1, 2012, the Agency, in consultation
with DHCS, the Managed Risk Medical Insurance Board
(MRMIB), the Exchange, counties, health care service plans,
consumer advocates, and other stakeholders to have
undertaken a planning process to develop plans and
procedures to implement this bill and federal health care
reform related to eligibility for, and enrollment and
retention in, public health coverage programs. Defines
"public health coverage programs" as Medi-Cal, HFP, the
Exchange program of premium tax credits, reduced-cost
sharing, or both, the Access for Infants and Mothers
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Program (AIM), and, if enacted, the BHP.
Requires the Agency to provide the appropriate fiscal and
policy committees of the Legislature information reflecting
the planning process conducted by April 1, 2012, regarding
policy changes needed to develop the eligibility,
enrollment, and retention system for health coverage in
compliance with this bill.
Coordination and simplification
Requires, at application, renewal, or a transition due to a
change in circumstances, entities making eligibility
determinations for public health coverage programs to
ensure that eligible applicants and recipients of public
health coverage programs 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.
Requires DHCS, in coordination with MRMIB and the Exchange,
to streamline and coordinate all eligibility rules and
requirements among Medi-Cal, HFP, 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 FPL
are determined eligible for Medi-Cal, HFP, or the Exchange
when they meet the eligibility requirements and that all
entities processing applications use the same least
restrictive methodologies. Requires this process to
include coordination of rules for determining income
levels, assets, household size, citizenship and immigration
status, and documentation and verification requirements.
Requires renewal procedures to 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, HFP, or Exchange case
file, or that of the individual's parent or child, or
electronic databases authorized for data sharing by 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.
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Requires renewal procedures to be as simple and
user-friendly as possible, to require recipients to provide
only information that has changed, if any, and to use all
available methods for reporting renewal information,
including, but not limited to, face-to-face, telephone, and
online renewal. Requires that families be able to renew
coverage at the same time for all members of the family
enrolled in any public health coverage program at one time,
including where there are family members enrolled in more
than one public health coverage program. Requires a
recipient to be permitted to update his or her eligibility
information at any point.
Requires a recipient providing an update to his or her
eligibility information in between renewal dates to be
given the option to renew eligibility at the time of the
update.
Requires eligibility for public health coverage programs to
be automatically renewed whenever any public benefits
program renewal is conducted.
Requires the eligibility, enrollment, and retention system
to be both transparent and accountable to the public
including by requiring DHCS, the Agency, MRMIB, and the
Exchange to 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 DHCS, MRMIB, and the Exchange.
Application form for public health coverage programs
Requires a single, accessible, standardized paper,
electronic, and telephone application for public health
coverage programs to be developed by DHCS in consultation
with MRMIB and the Exchange. Requires this application to
be used by all entities authorized to make an eligibility
determination for any of the public health coverage
programs, and by their agents. Requires DHCS to consult
with counties and stakeholders, including consumer
advocates, regarding whether to use the application
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developed by the federal Secretary of the Department of
Health and Human Services (DHHS) on whether to develop a
separate state form. Requires DHCS, if it develops a state
form, to consult with stakeholders in development of the
application, and requires the application to be tested and
operational by July 1, 2013. Requires the application
forms to satisfy all of the following criteria:
§ Include simple, user-friendly language and instructions.
§ Be available in alternative formats and translations,
including, but not limited to, Braille, large-font print,
CD, audio recording and threshold languages, defined as
languages spoken by at least 20,000 or more limited
English proficient (LEP) health consumers in California.
§ Require only that information that is necessary to
determine eligibility for the applicant's particular
circumstances.
§ May be used for screening, but is not limited to
screening.
§ Requires the application to be able to be used as 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.
§ Include questions that are voluntary for applicants to
answer regarding demographic data categories, including
race, ethnicity, sex, primary language, disability
status, and other categories recognized by the federal
DHHS Secretary under a specified provision of PPACA.
Requires 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, to treat
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the application as an application for all of the public
health coverage programs.
Requires the entity making the eligibility determination to
enroll the applicant in the public health coverage program
for which the applicant is eligible. Requires, if an
application is forwarded or transferred between or among
entities for processing, this process does not require the
applicant to submit any new information that is not
necessary to determine her or his eligibility. Requires the
applicant to 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 to be promptly
provided when requested.
Requires the application form to be designed to identify
infants under age one who are deemed eligible for Medi-Cal
at birth without an application to Medi-Cal under federal
law, or HFP. Requires an infant who is deemed eligible to
enroll upon identification, and prohibits the infant's
family from being required to complete the application
process.
Provider-based application and enrollment procedures
Continues to allow the use of provider-based application
forms or enrollment procedures for public health coverage
programs or other health programs that differs from the
application form and related procedures developed under
this bill:
Requires the forms and procedures used by the Child Health
and Disability Prevention Program Gateway (CHDP Gateway)
and by Medi-Cal's presumptive eligibility program for
pregnant women for children and pregnant women in families
with income at or below 200 percent of the FPL to be
modified in the simplest way permitted by federal law to do
both of the following:
§ Serve as an application for ongoing coverage to Medi-Cal,
and, for children, to HFP.
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§ Provide for a program of accelerated enrollment through
which children and pregnant women screened as eligible
are immediately enrolled from the medical point of
service into coverage, with benefits continuing until a
final eligibility determination is made.
Requires DHCS to adopt a process for prenatal care
providers to submit the application form for pregnant women
online.
Requires DHCS to adopt a process for hospitals to enroll
infants deemed eligible for Medi-Cal under federal law or
HFP immediately online, without an application.
Applicant rights
Requires an applicant or recipient of a public health
coverage program to 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
required by PPACA.
Requires an applicant or recipient who chooses a
prepopulated application or renewal to be given an
opportunity, before the application or renewal form is
submitted, to provide additional eligibility information,
and to correct any information retrieved from a database.
Requires an applicant or recipient who chooses electronic
real-time verification to 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.
Prohibits an applicant from being denied eligibility for
any public health coverage program without being given a
reasonable opportunity, of at least the kind provided for
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under the Medi-Cal program for citizenship documentation,
to resolve discrepancies concerning any information
provided by a verifying entity.
Requires applicants to receive the benefits for which they
otherwise qualify, pending this reasonable opportunity
period.
Requires eligible applicants to be granted eligibility and
immediately enrolled into a public health coverage program
whenever possible. Requires, 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 to apply to the fullest
extent permitted by federal law with federal financial
participation:
§ Requires the applicant to be immediately enrolled into a
program of presumptive eligibility (PE) for children,
pregnant women, and adults.
§ Requires PE to continue until the applicant is enrolled
in ongoing coverage through a public health coverage
program, or is found to be ineligible for all of these
programs and informed of the denial of coverage in
accordance with all applicable due process requirements.
Requires, before an online applicant who appears to be
eligible for the Exchange with a premium tax credit or
reduction in cost sharing, or both, can be enrolled in the
Exchange, all of the following to occur:
§ The applicant to be clearly informed of the overpayment
penalties under federal law 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.
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§ The applicant to be fully informed of the penalty for
failure to have minimum essential health coverage.
§ The applicant to be given the option to decline immediate
enrollment while final eligibility is being determined.
Requires an applicant who is not eligible for a public
health coverage program for a reason other than income
eligibility, or for any reason if the individual resides in
a county that offers a health program for individuals with
income above the maximum allowed for the Exchange subsidies
or credits, to be referred to the county health coverage
program in his or her county of residence.
Requires the eligibility, enrollment, and retention system
to ensure that applicants and recipients have available
assistance with their application or renewal for public
health coverage programs. Requires applicants and
recipients to also be given a meaningful opportunity to
provide information on their applications and renewal
forms.
Requires applicants and recipients to be provided with
reasonable accommodations and policy modifications as
necessary to ensure meaningful access to benefits by
persons with disabilities and LEP individuals, including,
but not limited to, the reading aloud of information over
the telephone, assistance with filling out forms, and the
ready availability of information concerning all benefits
programs in alternative formats and translations including
interpretation in any language and translation in threshold
languages. Requires DHCS to effectively communicate notice
of the availability of the assistance exemplified this bill
to all applicants and recipients.
Administrative requirements
Requires DHCS, MRMIB and the Exchange, in designing and
implementing the eligibility, enrollment, and retention
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system, to do all of the following:
§ 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.
Requires this evaluation to be made available to the
public sufficiently in advance of implementation to allow
for an opportunity for review and comment.
§ Provide for annual post-implementation evaluation by an
independent expert using data points developed in
consultation with stakeholders, including consumers and
their advocates.
§ Requires this evaluation to be made available to the
public within a reasonable time period.
Requires the duties of DHCS, Agency, MRMIB, and the
Exchange to 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 in this bill described below.
Requires DHCS, MRMIB and the Exchange, in designing and
implementing the eligibility, enrollment, and retention
system, to ensure that all privacy and confidentiality
rights under PPACA, other federal and California laws and
regulations, the Medi-Cal program, and HFP are strictly
incorporated and followed, including, but not limited to,
adopting and implementing policies and procedures to ensure
all of the following:
§ Only that information that is strictly necessary for an
eligibility determination for the individual who is
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seeking enrollment in or renewal for a public health
coverage program is requested in the application,
retention, and renewal process for that program.
§ Verification from a third party or database is 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.
§ Applicants and recipients are given clear, complete,
user-friendly information regarding how their personal
information will be used, disseminated, secured,
verified, and retained by public health coverage
programs.
§ An applicant or recipient is not required by DHCS, MRMIB,
the Exchange, 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.
Requires applicants and recipients to have the option to
decline online screening, application, renewal, and
electronic verification and to instead apply or renew in
person, by mail, or by telephone.
Requires responses to security breaches to 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.
Requires all programs to use standardized forms and
notices, as appropriate, to timely inform recipients in
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advance of all of the following:
§ What information, if any, is required from them for
renewal.
§ Whether transfer to another public health coverage
program is to occur.
§ How the transfer will affect the recipient's cost, access
to care, delivery system, and responsibilities.
Operative date
Makes this bill operative on January 1, 2014, except as
otherwise specified in this bill.
FISCAL IMPACT
According to the Assembly Appropriations Committee:
1)One-time costs to DHCS to conduct a stakeholder planning
process and develop a report may range from $50,000 to
the hundreds of thousands of dollars, depending upon the
scope and complexity of the stakeholder process. Ongoing
costs related to specific transparency and accountability
measures, including a monthly public forum for entities
operating health programs to receive in-person feedback,
estimated at $100,000 annually.
2)Significant costs for development of IT and business
processes that meet the requirements of this bill,
potentially ranging from the tens to hundreds of millions
of dollars. Most of the significant systems changes
required by this bill are required by PPACA and existing
state law governing the operation of the Exchange, so a
significant systems development cost in the range
specified would be incurred regardless of the passage of
this bill. Federal grant funding and enhanced Medicaid
funding (90 percent federal match) is available for this
purpose.
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3)Unknown, potentially significant costs associated with
the two following provisions in the bill that go beyond
strict conformity with requirements of state and federal
law: (a) presumptive eligibility for public health care
coverage programs; and, (b) the requirement that
recipients move seamlessly between programs without any
breaks in coverage.
BACKGROUND AND DISCUSSION
According to the author, this bill ensures California is in
compliance with PPACA requirements and complements other state
PPACA-implementing legislation by streamlining and simplifying
eligibility and enrollment. This bill implements a statewide
approach to determine eligibility and allow enrollment of
consumers in the most affordable public health program. Last
year, California initiated the process to offer health care
options, by passing AB 1602 (Pérez), Chapter 655, Statutes of
2010 and SB 900 (Alquist), Chapter 659, Statutes of 2010. These
bills created the structure and basic duties of the Exchange.
However, the bills did not establish the system required by
PPACA to determine eligibility for and enrolling consumers in
health coverage. PPACA requires a seamless "no wrong door"
application system so that wherever a consumer applies he/she is
enrolled into the program for which he/she is eligible.
The author states this bill enacts the Health Care Eligibility,
Enrollment, and Retention Act to implement the PPACA requirement
of creating a single, statewide application to be used by all
entities accepting and processing applications, for enrolling
consumers in health coverage. The system must be available to
apply by phone, in person, by mail or online for enrolling into
Medi-Cal, HFP, or the Exchange. Under this bill, DHCS is
required to develop a "no wrong door" policy, regardless of
where a person applies, their application will be evaluated
using the same system and methodologies, ensure all applicants
whose income is less than 400 percent of the FPL are eligible
for coverage, and preserve and streamline citizenship and
identity verification for application and renewals to allow
consumers to move between programs seamlessly.
Federal health care reform and coverage expansions
Federal health care reform makes numerous changes to reduce
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the number of uninsured Americans. According to estimates
in a 2011 study in the health policy journal, Health
Affairs, by Peter Long and Jonathan Gruber, PPACA will
provide health insurance for an additional 3.4 million
people in California in 2016. The authors state this will
mean that nearly 96 percent of documented residents of
California under age 65 will be insured. The authors
estimate enrollment in Medi-Cal is expected to increase by
1.7 million people, while 4.0 million people are expected
to enroll in the state's Exchange. Employer-sponsored
insurance and spending on health insurance will decline
slightly. The authors conclude that low-income households
will experience substantial financial benefits, but
families at the highest income levels will pay more.
PPACA changes to eligibility and enrollment processing
Under state law, counties, except for certain applicants,
perform eligibility and enrollment on behalf of the state
for Medi-Cal. Medi-Cal eligibility is complex, with over
160 different aid codes, and different income and asset
rules for particular groups.
Applicants can apply in person and through the internet.
Unless there is good cause, counties are required to
complete the determination of eligibility as quickly as
possible, but no later than any of the following: (a) 45
days following the date the application, reapplication or
request for restoration is filed, and (b) 90 days following
the date the application, reapplication or request for
restoration is filed when eligibility depends on
establishing disability or blindness. Federal law requires
eligibility determination for participation in a state
Medicaid program to be determined by a public agency.
In addition to the county eligibility process, Medi-Cal
permits a health care provider to "presume" a pregnant
woman is eligible for Medi-Cal based on her answers to a
few income and residency questions through the presumptive
eligibility program. To encourage early prenatal care, a
woman can be presumptively enrolled into Medi-Cal through a
qualified provider or clinic with the agreement that she
will later complete an application for Medi-Cal. The
beneficiary must then start the formal Medi-Cal application
process by the end of the month following the month the
temporary presumptive benefits started. The CHDP Gateway
allows eligible children and youth to receive up to two
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months of full-scope Medi-Cal pre-enrollment eligibility.
CHDP providers can pre-enroll eligible patients into
Medi-Cal using the CHDP Gateway Internet transaction.
MRMIB contracts with enrollment contractors to perform
eligibility and enrollment for the four programs it
administers, and applicants apply by phone and through the
mail (and through the internet for the HFP). MRMIB
establishes application processing timeframes through
regulation (10 to 30 days, depending upon the MRMIB
program).
California does have a common application that can be used
for all public health programs, although the state has a
joint application for children for Medi-Cal and HFP that is
used to screen applicants to determine if they are
income-eligible for either program. Children who complete
the joint application apply through the Single Point of
Entry (SPE), and those that appear eligible for Medi-Cal
receive immediate, accelerated enrollment. Accelerated
enrollment begins on the first day of the month that the
SPE receives the application and continues until the child
is determined eligible for Medi-Cal or the end of the month
in which the child is found ineligible.
PPACA makes numerous changes to simplify enrollment in
public health coverage programs. PPACA requires that an
enrollment system be created that allows state residents to
apply for enrollment, receive an eligibility determination,
and renew participation in state health subsidy programs.
In addition, PPACA requires the Secretary of DHHS to
develop and provide to each state a single, streamlined
form that:
§ May be used to apply for all applicable state health
subsidy programs (Medi-Cal, HFP, Exchange, and the BHP);
§ May be filed online, in person, by mail, or by telephone;
§ May be filed with an Exchange or with state officials
operating one of the other applicable state health
subsidy programs;
§ Is structured to maximize an applicant's ability to
complete the form satisfactorily, taking into account the
characteristics of individuals who qualify for applicable
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state health subsidy programs.
PPACA permits a state to develop and use its own single,
streamlined form as an alternative to the federal form if
the alternative form is consistent with standards
promulgated by the Secretary.
PPACA also requires each state to develop, for all
applicable state health subsidy programs, a secure,
electronic interface allowing an exchange of data,
including information contained in the application forms,
that allows a determination of eligibility for all such
programs based on a single application.
Related bills
AB 714 (Atkins) would establish notification requirements
to individuals who are enrolled in, or who cease to be
enrolled in, publicly funded state health care programs.
Would require an application for coverage to be made on
their behalf through the Exchange, and would allow
individuals to decline health care coverage in a manner to
be prescribed by the Exchange. AB 714 passed this
committee on June 29, 2011 and is scheduled to be heard in
the Senate Judiciary Committee on July 5, 2011.
AB 792 (Bonilla) would require, effective January 1, 2013,
courts, health plans, health insurers, employers, and the
Employment Development Department (EDD) to provide a notice
of the availability of coverage in the Exchange, effective
January 1, 2014. Requires health plans, health insurers,
and employers, for employees or dependents who have
experienced a death, loss of employment or a reduction in
hours, divorce or the loss of dependent status that results
in a loss of health insurance, to transfer information to
the Exchange to initiate an application for enrollment in
the Exchange if the individual consents. Requires an
individual electing to decline coverage from the Exchange
to elect to do so in writing. AB 792 passed this committee
on June 29, 2011 and is scheduled to be heard in the Senate
Judiciary Committee on July 5, 2011.
Prior legislation
SB 900 (Alquist), Chapter 659, Statutes of 2010,
establishes the Exchange as an independent public entity
within state government, and requires the Exchange to be
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governed by a board composed of the Secretary of California
Health and Human Services Agency, or his or her designee,
and four other members appointed by the Governor and the
Legislature who meet specified criteria.
AB 1602 (John A. Pérez), Chapter 655, Statutes of 2010,
specifies the powers and duties of the Exchange relative to
determining eligibility for enrollment in the Exchange and
arranging for coverage under qualified health plans,
requires the Exchange to provide health plan products in
all five of the federal benefit levels (platinum, gold,
silver, bronze and catastrophic), requires health plans
participating in the Exchange to sell at least one product
in all five benefit levels in the Exchange, requires health
plans participating in the Exchange to sell their Exchange
products outside of the Exchange, and requires health plans
that do not participate in the Exchange to sell at least
one standardized product designated by the Exchange in each
of the four levels of coverage, if the Exchange elects to
standardize products.
Arguments in support
This bill is sponsored by the Western Center on Law and
Poverty (WCLP) to establish the framework for the
eligibility, enrollment and retention system for public
health coverage programs, as required by PPACA. WCLP
states that PPACA requires states to have a seamless, "no
wrong door" system for determining eligibility for and
enrolling people into public health coverage programs.
WCLP states this bill would implement these components of
PPACA in a way that works for health care consumers by
requiring:
§ The creation of unified applications - paper, telephone
and online - for Medi-Cal, the Exchange, HFP, AIM and
BHP;
§ Real-time determination of eligibility when possible;
§ Use of the same eligibility rules regardless of which
"application door" a consumer uses;
§ Enrollment of consumers in the most beneficial program
for which they are eligible;
§ Assistance for consumers with their application and the
ability for consumers to correct or update their
information;
§ Seamless renewal between health programs;
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§ Disability and language accessibility standards;
§ Transparency and accountability standards for the IT
system; and
§ Privacy protections for consumers.
WCLP states that the onus is largely on the consumer to
figure out what health coverage program to apply for and to
submit a new application when moving from one health
coverage program to another. For example, a consumer who
applies for California's high risk pools, but is eligible
for Medi-Cal, would have to submit a separate application
to Medi-Cal, and there is currently no mechanism for the
state to transfer an adult's application for one program to
initiate an application for another program. PPACA changes
this by requiring that if someone applies for Medi-Cal but
is eligible for the Exchange, they are enrolled in the
Exchange, and vice versa. WCLP states this will require a
new level of coordination among agencies and departments,
and it is important both that these entities coordinate on
developing and implementing the eligibility, enrollment and
retention system. In addition to making sure that the
initial application process enrolls consumers into the
right program, the programs must also coordinate during
consumers' annual renewal of coverage, and when
circumstances change so that a consumer moves between
health coverage programs seamlessly.
WCLP concludes that California is required to have this new
system tested by June 2013 to allow for enrollment to begin
in mid to late 2013. With less than two and a half years
to make and implement numerous important policy decisions,
develop applications and renewal forms and processes, and
build and test IT components, this legislation is urgently
needed, and significant federal funding (100 percent for
the Exchange and 90 percent for Medi-Cal) is available to
build the health care infrastructure system.
PRIOR ACTIONS
Assembly Health: 13- 6
Assembly Appropriations:12- 5
Assembly Floor: 51- 27
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COMMENTS
1)Effect on mid-year status reports. This bill requires
DHCS to streamline and
coordinate all eligibility rules and requirements among
Medi-Cal, HFP, and the Exchange, for premium tax credits
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 FPL are determined eligible
for Medi-Cal, HFP, or the Exchange, when they meet the
eligibility requirements, and that all entities processing
applications use the same least restrictive methodologies.
One effect of this provision would be to end the current
requirement that adult Medi-Cal beneficiaries file
semiannual status reports, which would result in additional
General Fund expenditures.
2)Eligibility renewal. This bill requires eligibility for
public health coverage program
to be automatically renewed whenever any public benefits
program renewal is conducted. The intent of this provision
is if an individual renews for another public benefit
program, such as Cal Fresh, and that program's renewal form
has the information needed for a Medi-Cal renewal, the
information on that form would be used for the annual
Medi-Cal redetermination. However, as drafted, the current
language could be read as requiring eligibility for public
health coverage programs to be automatically renewed,
irrespective of the outcome of the eligibility
determination for the public benefits program, which is not
the intent. Committee staff recommend that this provision
be clarified.
POSITIONS
Support: Western Center on Law and Poverty (sponsor)
100% Campaign
American Federation of State, County and
Municipal Employees
California Academy of Family Physicians
California Children's Health Initiatives
California Chiropractic Association
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California Communities United Institute
California Coverage & Health Initiatives
California Family Resource Association
California Optometric Association
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation
California School Health Centers Association
Children Now
The Children's Partnership
Congress of California Seniors
Consumers Union
Contra Costa County Board of Supervisors
Disability Rights California
Disability Rights Education and Defense Fund
Disability Rights Legal Center
First 5 Association of California
Having Our Say
Health Access California
Latino Coalition for a Healthy California
Latino Health Alliance
Maternal and Child Health Access Children's
Defense Fund - California
National Alliance on Mental Illness California
National Association of Social Workers,
California Chapter
PICO California
Southeast Asia Resource Action Center
United Nurses Associations of California/Union of
Health Care Professionals
United Ways of California
Youth Law Center
Oppose: None on file
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