BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 695
S
AUTHOR: Hancock
B
AMENDED: As Introduced
HEARING DATE: April 6, 2011
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CONSULTANT:
9
Bain
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SUBJECT
Medi-Cal: county juvenile detention facilities
SUMMARY
This bill permits Medi-Cal benefits to be provided to an
individual awaiting adjudication in a county juvenile
detention facility if the individual is eligible for
Medi-Cal at admission or is subsequently determined to be
eligible to receive Medi-Cal benefits, the county agrees to
pay the state's share of Medi-Cal expenditures and
administrative costs, and federal financial participation
(FFP) is available.
CHANGES TO EXISTING LAW
Existing federal law:
Defines, in federal Medicaid law, the term "medical
assistance" as payment of the cost of specified care and
services, such as inpatient hospital services, outpatient
hospital services, and physician services. The term
"medical assistance" generally does not include care or
services for an inmate of a public institution, except for
inpatient psychiatric hospital services for individuals
under age 21.
Continued---
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Prohibits, through federal Medicaid regulations, FFP from
being available for services provided to individuals who
are "inmates of public institutions." Exempts from the
definition of "inmate of a public institution" a person who
is in a public institution for a temporary period pending
other arrangements appropriate to his or her needs.
Existing state law:
Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health benefits to low-income children, their
parents or caretaker relatives, pregnant women, elderly,
blind or disabled persons, nursing home residents, and
refugees who meet specified eligibility criteria. Medi-Cal
family income eligibility for children ages 0 to 1 extends
up to 200 percent of the federal poverty level (FPL),
children ages 1 to 5 with family incomes up to 133 percent
of the FPL, and children ages 6 to 19 with family incomes
up to 100 percent of the FPL.
Requires benefits provided under the Medi-Cal program to an
individual under 21 years of age who is an inmate of a
public institution to be suspended on the date he or she
becomes an inmate of a public institution. The suspension
ends on the date the individual is no longer an inmate of a
public institution, or one year from the date he or she
becomes an inmate of a public institution. Health care
services under Medi-Cal are not available to inmates of
public institutions whose Medi-Cal benefits have been
suspended.
This bill:
Permits Medi-Cal benefits to be provided to an individual
awaiting adjudication in a county juvenile detention
facility if the following requirements are met:
§ The individual is eligible to receive Medi-Cal benefits
at the time the individual is admitted to the juvenile
detention facility or the individual is subsequently
determined to be eligible for Medi-Cal benefits;
§ The county agrees to pay the state's share of Medi-Cal
expenditures and the state's administrative costs for
benefits under this bill; and,
§ FFP is available.
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Requires benefits available under this bill to continue
until the date of the individual's adjudication.
Prohibits this bill from being construed to require a
county to pay the state's share of Medi-Cal expenditures or
the state's administrative costs for Medi-Cal benefits that
the state is obligated to provide pursuant to an
administrative action (such as a decision by the federal
government) or court order that is final and no longer
subject to appeal.
Permits DHCS to implement and administer this bill by means
of all-county letters or similar instructions without
taking regulatory action. Thereafter, DHCS is required to
adopt regulations in accordance with the Administrative
Procedure Act.
Implements this bill only if, and to the extent that, both
of the following occur:
§ DHCS receives written confirmation from the federal
Centers for Medicare and Medicaid Services that FFP is
available to implement this bill; and,
§ The DHCS director executes a declaration that states that
implementation of this bill will not jeopardize the
state's ability to receive FFP or any increase in federal
medical assistance percentage (FMAP) available on or
after October 1, 2008, or additional federal funds that
the director, in consultation with the Department of
Finance (DOF), has determined would be advantageous to
the state.
Requires the director of DHCS, if at any time the director
determines that the statement in the declaration executed
above to no longer be accurate, to give notice to the Joint
Legislative Budget Committee and to DOF. If the director
determines, in consultation with DOF, that it is necessary
to cease implementation of this bill in order to receive
FFP, or any increase in FMAP available on or after October
1, 2008, or additional federal funds that the director, in
consultation with DOF, has determined would be advantageous
to the state, the director is required to cease
implementation of this bill and to execute a declaration to
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that effect.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
According to an Assembly Appropriations Committee analysis
last year of a similar measure:
1)Annual increased Medi-Cal costs of $10 million to $15
million (50 percent federal/50 percent local) to the
extent counties opt into the funding mechanism
established by this bill and provide a month of Medi-Cal
health services to youth awaiting adjudication.
2)Unknown administrative workload to DHCS to seek federal
approval and administer the funding mechanism established
by this bill. Counties are required to pay the cost of
the state's administrative workload.
BACKGROUND AND DISCUSSION
According to the author, this bill will enable counties to
receive federal funds through Medi-Cal reimbursement for health
care services to Medi-Cal-eligible individuals entering county
juvenile detention facilities until adjudication. The author
argues every county has an obligation to tend to the health care
needs of the persons detained in its institutions, but this
obligation has been challenging due to the severe reduction in
county revenues. The author continues that experience shows
that children in the juvenile justice system can have
significant behavioral, mental health and medical issues, and
that for many youth, the health care they receive in juvenile
hall may be their first encounter with medical personnel in many
years. The author states providing medical, dental, and mental
health to individuals entering county juvenile detention
facilities comes at a significant cost to counties. For Alameda
County, the cost is approximately $7 million annually, and this
bill will enable counties such as Alameda to receive federal
funds to offset the costs they already incur providing health
care services.
Youth awaiting adjudication
If a county elected the option in this bill, this bill
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would enable federal Medicaid matching funds to be drawn
down to treat youth who are pending adjudication in a
county juvenile detention facility. "Pending adjudication"
is the period of time from when a youth is admitted to a
juvenile detention facility (such as a juvenile hall) and
to when the youth appears before a judge or commissioner to
have his or her case heard. The average daily population
in juvenile halls and camps and other county facilities was
12,274, according to data from the last quarter of 2009
from the California Corrections Standards Authority.
Exemption from counties providing the state match to draw
federal funds
Medi-Cal is funded, with some exceptions, with state
General Fund dollars and federal matching funds. This bill
requires counties electing to provide Medi-Cal benefits to
an individual awaiting adjudication to pay the state's
share of Medi-Cal expenditures and the state's
administrative costs for benefits. This bill contains a
new provision that was not in last year's legislation that
creates an exception from this county-funding requirement
by prohibiting a county from being required to pay the
state's share of Medi-Cal expenditures, or the state's
administrative costs, for Medi-Cal benefits that the state
is obligated to provide pursuant to an administrative
action or court order that is final and no longer subject
to appeal.
This provision is included in this measure at the request
of the City Attorney of the City and County of San
Francisco in response to litigation filed by the Office of
the City Attorney of San Francisco and the County of Santa
Clara against DHCS over the obligation of the state to
provide inpatient psychiatric hospital services for
individuals under age 21. In that case, the Superior Court
issued an order stating that DHCS' policy of denying
Medi-Cal coverage of inpatient psychiatric hospital
services to youth who are in custody violates federal and
state law. That case is currently on appeal. The language
in this bill that creates an exception to the county
funding requirement is not specific to inpatient
psychiatric hospital services and would apply to other
court orders that are final and no longer subject to
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appeal.
Budget Action Last Year
The corrections budget trailer bill from 2010, AB 1628
(Committee on Budget), Chapter 729, Statutes of 2010,
authorizes the California Department of Corrections and
Rehabilitation (CDCR) and DHCS, to the extent that FFP is
not jeopardized and federal approval is obtained, to
develop a process to draw down FFP for inpatient hospital
services provided to state and local inmates who would
otherwise be eligible for Medi-Cal or local Coverage
Expansion and Enrollment Demonstration (CEED) project
projects authorized under the federal section 1115 Medi-Cal
Demonstration Waiver, if these inmates were not
institutionalized. This trailer bill provides an
opportunity to secure federal funds by establishing adult
inmate eligibility for Medi-Cal and local county CEED
projects so that state and county savings can be achieved
by drawing down federal Medicaid matching funds. Federal
law generally prohibits claiming Medicaid funds to
reimburse for health care services provided to inmates
residing in correctional facilities. However, this
prohibition does not apply to inpatient hospital services
provided to an inmate at a medical facility that is not
located on the grounds of the correctional facility (for
example, a "community" hospital), if the inmate is
otherwise eligible for Medi-Cal.
Under AB 1628, CEED projects are required to provide
reimbursement for inpatient hospital services provided to
an inmate whose county of last legal residence participates
in the CEED project. Additionally, AB 1628 permits, to the
extent FFP is available, DHCS to provide Medi-Cal
eligibility and reimbursement for inpatient hospital
services to inmates, as defined. Finally, AB 1628 also
authorizes a county to seek reimbursement from the Medi-Cal
program or the responsible CEED program for the provision
of inpatient hospital services to adults in county
facilities.
Arguments in support
This bill is sponsored by Alameda County, which writes in
support that every county has an obligation to tend to the
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health care needs of the persons detained in its
institutions. Alameda County writes that it takes that
responsibility very seriously and has developed a state of
the art medical clinic within its new Juvenile Justice
Center where every youth who is admitted to this facility
is given a thorough physical examination of their health,
dental, and mental health needs. Alameda County states
this care comes at a significant cost to the county -
approximately $7 million annually - and this bill would
help the county to reduce this amount by almost half by
substituting federal funds for county dollars. There would
be no cost to the state General Fund because the county
would cover not only the state's share of cost, but also
the state's reasonable expenses for administering the
pass-through of the federal funds.
Alameda County argues this approach is consistent with
federal regulations, which allow Medicaid funds to be used
for a person who is detained in an institution "for a
temporary period of time pending other arrangements
appropriate to his needs." This bill would limit the
availability of Medi-Cal services to the period of time
beginning at detention until adjudication. Finally,
Alameda County argues the approach in this bill is not
novel, as New Mexico, Pennsylvania, and Vermont have been
using Medicaid funds to provide health and mental health
services for youths in their juvenile detention facilities
for several years.
Prior legislation
SB 1091 (Hancock) of 2010 was similar to this measure.
That bill was vetoed by Governor Schwarzenegger. In this
veto message, the Governor stated this bill was
inconsistent with federal law and exposed the state to
potentially significant costs. The Governor concluded his
veto message by stating that if the author wishes to craft
workable legislation that allows for additional federal
funds but also adheres to federal Medicaid law and
regulations, DHCS would be willing to assist in that effort
next year.
SB 817 (Hancock) of 2010 was also similar to this measure
except that it only applied to Alameda County. That bill
originally dealt with vote by mail provisions in the
Election Code and was gutted and amended on August 3, 2010
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to require Medi-Cal benefits to be provided to an
individual awaiting adjudication in Alameda County Juvenile
Hall if the individual was receiving Medi-Cal benefits at
the time the individual was admitted to Alameda County
Juvenile Hall or the individual is subsequently determined
to be eligible for Medi-Cal and benefits, and Alameda
County agreed to pay the state's share of Medi-Cal
expenditures and the state's administrative costs for
benefits. SB 817 was never heard in a policy or fiscal
committee in that form.
SB 1147 (Calderon and Yee), Chapter 546, Statutes of 2008,
requires DHCS to develop procedures to ensure that the
Medi-Cal eligibility of minors is not terminated when they
are incarcerated.
SB 648 (Calderon) of 2007 would have required DHCS to
suspend rather than terminate the Medi-Cal benefits of an
incarcerated minor. This bill was referred to Senate
Health Committee but was not heard.
SB 1469 (Cedillo), Chapter 657, Statutes of 2006, requires
county juvenile detention facilities to notify county
welfare departments about the release of a ward so that
eligibility for Medi-Cal can be determined prior to the
release of the inmate.
SB 1616 (Kuehl) of 2006 would have required CDCR to work
with the federal Social Security Administration and DHCS to
ensure that disabled wards are enrolled in Medi-Cal and
that their disability benefits are available to them when
they are released from incarceration at a state
institution. This bill was vetoed by the Governor.
AB 1945 (Coto) of 2006 among other provisions, would have
required a juvenile detention facility, when a minor is
released from custody, to determine if the minor will have
health insurance after release, and if the minor will not,
to evaluate the eligibility of the minor for enrollment in
appropriate need-based programs. This bill was held in the
Assembly Health Committee.
AB 2004 (Yee) of 2006 was identical to SB 648 of 2007. This
bill was vetoed by the Governor.
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AB 470 (Yee) of 2005 was a very similar bill to SB 648 of
2007. The bill failed passage on the Assembly floor.
COMMENTS
1.Federal "statewideness" requirement and veto message from
last session.
This bill authorizes but does not require Medi-Cal benefits
to be provided to an individual awaiting adjudication in
a county juvenile detention facility if certain
conditions are met. In the veto message last session of
SB 1091, Governor Schwarzeneggar stated the bill was
inconsistent with federal law and exposed the state to
potentially significant costs.
The reference to federal law in the veto message refers to
the "statewideness" requirement in federal Medicaid law,
which generally requires states to make their Medicaid
benefits package available to all eligible individuals,
regardless of their residence within the state. There
are exceptions to this general rule, such as for the
targeted case management services benefit, which allows a
state to limit its coverage to particular subpopulations,
such as the chronically mentally ill, but also to
particular geographic areas within the state. Similarly,
the states can obtain waivers of the federal
statewideness requirement so that services can be
restricted to target populations residing in particular
areas within the state, subject to federal approval.
This bill contains language that its provisions are
implemented only if FFP is available.
2.Link to benefit suspension in current law.
This bill requires benefits provided to an individual
pending adjudication to continue until the date of the
individual's adjudication. Staff recommends an amendment
to clarify that following adjudication, if the individual
is incarcerated in a public institution, his or her
benefits be suspended in accordance with existing law.
3.Provider bulletins and regulations.
Subdivision (d) of Section 2 of this bill permits DHCS to
implement and administer the provisions of this bill by
means of all-county letters or similar instructions
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(provider bulletins) without taking regulatory action.
Thereafter, DHCS is required to adopt regulations in
accordance with the Administrative Procedure Act. Staff
recommends an amendment to clarify how long the use of
provider bulletin is allowed before regulations are
required.
POSITIONS
Support: Alameda County (sponsor)
California Alliance of Child and Family Services
California Council of Community Mental Health
Agencies
California Health Executives Association of
California
California State Association of Counties
California State Sheriffs' Association
California Probation, Parole, and Correctional
Association
Chief Probation Officers of California
County Alcohol and Drug Program Administrators
Association of
California
County of Santa Clara Board of Supervisors
Legal Services for Prisoners with Children
Mental Health Association in California
Regional Council of Rural Counties
Urban Counties Caucus
Oppose: None on file.
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