INTRODUCED BY   Assembly Member Bonilla

                        FEBRUARY 2, 2012

   An act to amend Section 15926 of the Welfare and Institutions
Code, relating to public health.


   AB 1580, Bonilla. Health care: eligibility: enrollment.
   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
establishes the California Health Benefit Exchange (Exchange),
pursuant to the federal Patient Protection and Affordable Care Act
(PPACA), and specifies the duties and powers of the board governing
the Exchange relative to determining eligibility for enrollment in
the Exchange and arranging for coverage under qualified health plans,
and facilitating the purchase of qualified health plans through the
Exchange. Existing law, the Health Care Reform Eligibility,
Enrollment, and Retention Planning Act, operative as provided,
requires the State Department of Health Care Services, in
consultation with specified entities, to establish standardized
single, accessible application forms and related renewal procedures
for state health subsidy programs, as defined, in accordance with
specified requirements. Existing law provides that the application or
case of an individual screened as not eligible for Medi-Cal on the
basis of household income but who may be eligible for Medi-Cal on
another basis shall be forwarded to the Medi-Cal program for an
eligibility determination.
   This bill would make technical and clarifying changes to these


  SECTION 1.  Section 15926 of the Welfare and Institutions Code is
amended to read:
   15926.  (a) The following definitions apply for purposes of this
   (1) "Accessible" means in compliance with Section 11135 of the
Government Code, Section 1557 of the PPACA, and regulations or
guidance adopted pursuant to these statutes.
   (2) "Limited-English-proficient" means not speaking English as one'
s primary language and having a limited ability to read, speak,
write, or understand English.
   (3) "State health subsidy programs" means the programs described
in Section 1413(e) of the PPACA.
   (b) An individual shall have the option to apply for state health
subsidy programs in person, by mail, online, by telephone, or by
other commonly available electronic means.
   (c) (1) A single, accessible, standardized paper, electronic, and
telephone application for state health subsidy programs shall be
developed by the department in consultation with MRMIB and the board
governing the Exchange as part of the stakeholder process described
in subdivision (b) of Section 15925. The application shall be used by
all entities authorized to make an eligibility determination for any
of the state health subsidy programs and by their agents.
   (2) The application shall be tested and operational by the date as
required by the federal Secretary of Health and Human Services.
   (3) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:
   (A) The form shall include simple, user-friendly language and
   (B) The form may not ask for information related to a nonapplicant
that is not necessary to determine eligibility in the applicant's
particular circumstances.
   (C) The form may require only information necessary to support the
eligibility and enrollment processes for state health subsidy
   (D) The form may be used for, but shall not be limited to,
   (E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through a state health subsidy program for the infant's birth, for
the purpose of automatically enrolling the infant into the applicable
program without the family having to complete the application
process for the infant.
   (F) The form may include questions that are voluntary for
applicants to answer regarding demographic data categories, including
race, ethnicity, primary language, disability status, and other
categories recognized by the federal Secretary of Health and Human
Services under Section 4302 of the PPACA.
   (d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for state
health subsidy programs or other health programs that differs from
the application form described in subdivision (c), and related
enrollment procedures.
   (e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of the
applicant in accordance with the state and federal rules governing
state health subsidy programs.
   (f) (1) If the eligibility, enrollment, and retention system has
the ability to prepopulate an application form for insurance
affordability programs with personal information from available
electronic databases, an applicant shall be given the option, with
his or her informed consent, to have the application form
prepopulated. Before a prepopulated renewal form or, if available,
prepopulated application is submitted to the entity authorized to
make eligibility determinations, the individual shall be given the
opportunity to provide additional eligibility information and to
correct any information retrieved from a database.
   (2) All state health subsidy programs may accept self-attestation,
instead of requiring an individual to produce a document, with
respect to all information needed to determine the eligibility of an
applicant or recipient, to the extent permitted by state and federal
   (3) An applicant or recipient shall have his or her information
electronically verified in the manner required by the PPACA and
implementing federal regulations and guidance.
   (4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.
   (5) The eligibility of an applicant shall not be delayed or denied
for any state health subsidy program unless the applicant is given a
reasonable opportunity, of at least the kind provided for under the
Medi-Cal program pursuant to Section 14007.5 and paragraph (7) of
subdivision (e) of Section 14011.2, to resolve discrepancies
concerning any information provided by a verifying entity.
   (6) To the extent federal financial participation is available, an
applicant shall be provided benefits in accordance with the rules of
the state health subsidy program, as implemented in federal
regulations and guidance, for which he or she otherwise qualifies
until a determination is made that he or she is not eligible and all
applicable notices have been provided. Nothing in this section shall
be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.
   (g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for a state health subsidy program in person, over the
telephone, and online, and in a manner that is accessible to
individuals with disabilities and those who are limited English
   (h) (1) During the processing of an application, renewal, or a
transition due to a change in circumstances, an entity making
eligibility determinations for a state health subsidy program shall
ensure that an eligible applicant and recipient of state health
subsidy programs that meets all program eligibility requirements and
complies with all necessary requests for information moves between
programs without any breaks in coverage and without being required to
provide any forms, documents, or other information or undergo
verification that is duplicative or otherwise unnecessary. The
individual shall be informed about how to obtain information about
the status of his or her application, renewal, or transfer to another
program at any time, and the information shall be promptly provided
when requested.
   (2) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross Income
(MAGI) household income but who may be eligible on the basis of being
65 years of age or older, or on the basis of blindness or
disability, shall be forwarded to the Medi-Cal program for an
eligibility determination. During the period this application or case
is processed for a non-MAGI Medi-Cal eligibility determination, if
the applicant or recipient is otherwise eligible for a state health
subsidy program, he or she shall be determined eligible for that
   (3) Renewal procedures shall include all available methods for
reporting renewal information, including, but not limited to,
face-to-face, telephone, and online renewal.
   (4) An applicant who is not eligible for a state health subsidy
program for a reason other than income eligibility, or for any reason
in the case of applicants and recipients residing in a county that
offers a health coverage program for individuals with income above
the maximum allowed for the Exchange premium tax credits, shall be
referred to the county health coverage program in his or her county
of residence.
   (i) Notwithstanding subdivisions (e), (f), and (j), 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, both of the following shall occur:
   (1) The applicant shall be informed of the overpayment penalties
under the federal 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.
   (2) The applicant shall be informed of the penalty for failure to
have minimum essential health coverage.
   (j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among state health subsidy programs using the least
restrictive rules and requirements permitted by federal and state
law. This process shall include the consideration of methodologies
for determining income levels, assets, rules for household size,
citizenship and immigration status, and self-attestation and
verification requirements.
   (k) (1) Forms and notices developed pursuant to this section shall
be accessible and standardized, as appropriate, and shall comply
with federal and state laws, regulations, and guidance prohibiting
   (2) Forms and notices developed pursuant to this section shall be
developed using plain language and shall be provided in a manner that
affords meaningful access to limited-English-proficient individuals,
in accordance with applicable state and federal law, and at a
minimum, provided in the same threshold languages as required for
Medi-Cal managed care plans.
   (l) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall establish a process for
receiving and acting on stakeholder suggestions regarding the
functionality of the eligibility systems supporting the Exchange,
including the activities of all entities providing eligibility
screening to ensure the correct eligibility rules and requirements
are being used. This process shall include consumers and their
advocates, be conducted no less than quarterly, and include the
recording, review, and analysis of potential defects or enhancements
of the eligibility systems. The process shall also include regular
updates on the work to analyze, prioritize, and implement corrections
to confirmed defects and proposed enhancements, and to monitor
   (m) 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 and other federal and state laws are incorporated and followed,
including responses to security breaches.
   (n) Except as otherwise specified, this section shall be operative
on and after January 1, 2014.