BILL ANALYSIS Ó
SB 695
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Date of Hearing: June 14, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 695 (Hancock) - As Amended: May 23, 2011
SUBJECT : Medi-Cal: county juvenile detention facilities.
SUMMARY : Authorizes Medi-Cal benefits to be provided to a
Medi-Cal eligible individual awaiting adjudication in a county
juvenile detention facility if the county agrees to pay the
state's share of Medi-Cal expenditures and administrative costs.
Specifically, this bill :
1)Provides that benefits shall be provided until the date of
adjudication and requires benefits to be suspended if the
individual is placed in an institution.
2)Limits eligibility to an individual who is receiving Medi-Cal
benefits at the time of admission or is subsequently
determined to be eligible.
3)Specifies that this bill shall not be construed to require a
county to pay for the costs of Medi-Cal benefits that the
state is obligated to provide under administrative action or
final court order.
4)Authorizes initial implementation by all-county letter and
requires the Department of Health Care Services (DHCS) to
adopt regulations by 2015.
5)Conditions implementation on receipt of written confirmation
from the federal Centers for Medicare and Medicaid Services
(CMS) that federal financial participation (FFP) is available
and the execution of a declaration by the director of DHCS
that implementation will not jeopardize the state's ability to
receive FFP including any increase in the federal assistance
percentage (FMAP) available as specified.
6)Authorizes the Director of DHCS to cease operation if a
determination is made that the declaration specified in 5)
above is no longer accurate, authorizes implementation by
all-county-letter or similar instructions and requires notice
to the Joint Legislative Budget Committee, the Department of
Finance and posted on the DHCS Web site.
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EXISTING LAW :
1)Establishes the Medi-Cal Program, administered by DHCS, to
provide comprehensive health care services and long-term care
to pregnant women, children, and people who are aged, blind,
and disabled.
2)Establishes a schedule of benefits under the Medi-Cal Program
but excludes from the definition of "health care services,"
care or services for any individual who is an inmate of an
institution (except as a patient in a medical institution),
except to the extent permitted by federal law.
3)Allows, under federal law, continued Medicaid (Medi-Cal in
California) eligibility even when an inmate of a public
institution is prohibited from receiving benefits, and states
that an individual is not considered to be living in a public
institution if the individual is in a public institution for a
temporary period pending other arrangements.
4)Provides that a juvenile who is an inmate of a public
institution shall have their Medi-Cal benefits suspended, as
specified.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
1)Federal funds match to counties for Medi-Cal benefits likely
in the millions of dollars annually.
2)DHCS administrative cost likely up to $100,000 annually.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
intended to enable counties to use dollars they are already
spending for medical and mental health services they provide
to eligible youth in their detention facilities as the match
for federal Medicaid funds. The author argues that this bill
would help counties reduce the amount they already spend by
almost half by substituting federal funds for county dollars.
The author states that counties that choose to participate
will match the state's share through an intergovernmental
transfer of funds.
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The sponsor, Alameda County, points out that every county has an
obligation to tend to the health care needs of the detained
persons. However, this obligation had been challenging due to
severe reduction in county revenues. This bill, according to
the sponsor is intended to take advantage of federal authority
to use federal Medicaid funds to reduce the cost the county is
already incurring for the first 30 days of a youth's stay in
juvenile hall. According to the sponsor, the average length
of stay is 24 days.
2)BACKGROUND . Medi-Cal regulations make individuals who are
inmates of public institutions ineligible for Medi-Cal.
However, a 1997 letter from the federal Department of Health
and Human Services indicates FFP is available through Medicaid
when an inmate becomes a patient in a medical institution on
an inpatient basis. Additionally, a 2004 letter to State
Medicaid directors from CMS encourages states to "suspend" and
not "terminate" benefits while a person is in a public
institution or Institute for Mental Disease, noting the
payment exclusion (known as the "inmate exception") under
Medicaid does not affect the eligibility of an individual for
the Medicaid program. This policy was codified with regard to
juveniles in SB 1147 (Calderon and Yee), Chapter 546, Statutes
of 2008. DHCS indicated that the necessary protocols were
issued in March 2010.
3)TEMPORARY CUSTODY . Federal regulations also appear to allow
states to claim FFP for all Medicaid services provided to a
person in a public institution for a temporary period pending
other arrangements as an exception to unavailability of FFP
for services provided to inmates. Supporting material
supplied by the sponsor indicates that Pennsylvania and New
Mexico have taken advantage of this opportunity.
Specifically, a letter from the New Mexico Human Services
Department in 2005 interpreted this to mean that an individual
is temporarily placed until adjudication or up to 60 days
whichever occurs first. A bulletin from the Pennsylvania
Department of Public Welfare in 2001 also indicates that FFP
is available for Medicaid benefits for juveniles placed
"temporarily" in juvenile detention centers while other
arrangements are made.
4)BERNALILLO COUNTY, NM . According to the Juvenile Offenders
Community Health Services Project, Medicaid is a critical
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funding source for an onsite mental health clinic at the
Bernalillo County (NM) Juvenile Detention and Youth Services
Center, where rates of recidivism a year after release among
youth in need of mental health treatment fell from 88% to 22%.
In 2000, the detention center convinced the state Medicaid
office to interpret detention as a temporary period of custody
pending other arrangements, so that juveniles in detention are
not considered inmates of a government institution. With this
change, the detention center can keep youths covered under
Medicaid for up to 60 days-which is longer than most juveniles
are in detention.
At booking, detention center staff verifies juveniles' Medicaid
status and enroll those juveniles who are eligible but not yet
enrolled. The detention center bills Medicaid roughly
$370,000 a year for health care services provided to youth in
detention. The detention center closed several residential
units in response to a drop in its population. Staff members
affected by the closures were trained as case managers for
juveniles, acting as liaisons between the juvenile court, the
probation office, and the mental health clinic. These case
managers also work with youth in the community after they are
released from the detention center. The reduction in
recidivism occurred after this new case management program was
implemented.
5)MENTAL HEALTH SERVICES . Federal regulations also provide that
FFP is available for an individual under the age of 22
receiving inpatient psychiatric services. A lawsuit brought
by San Francisco and Santa Clara in 2007, ( City and County of
San Francisco, County of Santa Clara v. State of California,
California Department of Health Care Services , Case No.
CGC-07-468241 (Cal. Super. Ct. Oct. 16, 2007)), challenged the
state's practice and policy of denying Medi-Cal coverage of
inpatient psychiatric hospital services provided to youths who
are in custody. (The lawsuit also challenged the legality of
terminating wards because of their status as inmates. This
cause of action is moot due to the passage of SB 1147.) On
April 5, 2010, the County of San Francisco Superior Court
ruled that this practice violates federal and state law and
ordered the state to provide Medi-Cal coverage of inpatient
psychiatric hospital services for individuals under age 21
regardless of their status as detainees. The case is
currently on appeal. To preserve the ruling in this case,
this bill provides that it shall not be construed to require a
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county to pay for services that are the obligation of the
state.
6)SUPPORT . Alameda County, sponsor of this bill, writes in
support that the current cost to the county of providing
medical and mental health services to this population is $7
million annually and is provided through a system of full
service health, dental, and mental health services and
facilities. According to the Alameda Department of Health, up
to 80% of the population is eligible for Medi-Cal and the
average length of stay is 24 days. Allowing matching funds
would therefore reduce the costs to the county by almost half.
In addition, the county points to the New Mexico experience
and the fact that 80% of juvenile hospitalizations are
psychiatric to make the case that providing mental health
services and medications will save additional funds by
reducing recidivism. These funds, they argue, can be used to
enhance medical and mental health services similarly to the
New Mexico experience. The City and County of San Francisco
writes in support that its Department of Public Health (DPH)
currently spends $4.9 million annually to provide primary care
and behavioral health services to youth incarcerated at the
Youth Guidance Center. Based on the services provided in
2008-09 and an assumption that at least half would be eligible
for Medi-Cal, DPH would, at a minimum, receive $1.2 million in
matching federal funds at no cost to the state. The County
Alcohol and Drug Program Administrators Association of
California writes in support that for many youths, the care
they receive in juvenile hall may be their first opportunity
to revise substance use disorder treatment. Providing
treatment comes at a significant cost to the counties.
Enabling counties to access federal funds in order to help
offset the costs they already spend to deliver these services
is cost-effective and good public policy.
7)PRIOR AND RELATED LEGISLATION :
a) AB 396 (Mitchell), introduced this year, requires the
DHCS to develop a process to allow participating counties
and the state Department of Corrections and Rehabilitation
(CDCR) to receive any available FFP for health care
services provided to juvenile detainees who are admitted as
inpatients in a medical institution. AB 396 is set for
hearing in Senate Health Committee on June 15, 2011.
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b) SB 817 (Hancock) of 2010 was also similar to this
measure except that it only applied to Alameda County. SB
817 originally dealt with vote by mail provisions in the
Election Code and was gutted and amended on August 3, 2010
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.
c) 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 Low Income
Health Plan Demonstration project projects authorized
under the federal section 1115 Medi-Cal Demonstration
Waiver, if these inmates were not institutionalized.
d) 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.
e) SB 648 (Calderon) of 2007 would have required DHCS to
suspend rather than terminate the Medi-Cal benefits of an
incarcerated minor. SB 648 was referred to Senate Health
Committee but was not heard.
f) SB 1469 (Cedillo), Chapter 657, Statutes of 2007,
requires county juvenile detention facilities, following
the issuance of an order of the juvenile court committing a
county ward to a juvenile hall, camp, or ranch for 30 days
or longer, to provide the county welfare department with
the ward's name, his or her scheduled or actual release
date, any known information regarding the ward's Medi-Cal
status prior to disposition, and sufficient information,
when available, for the county welfare department to begin
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the process of determining the ward's Medi-Cal eligibility.
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. SB 1616 was vetoed by the Governor.
g) 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. AB 1945 was
held in the Assembly Health Committee.
h) AB 2004 (Yee) of 2006 was identical to SB 648 of 2007.
AB 2004 was vetoed by the Governor.
i) AB 470 (Yee) of 2005 was a very similar bill to SB 648
of 2007. AB 470 failed passage on the Assembly floor.
8)POLICY ISSUE . Federal Medicaid law 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 this 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.
This bill is nearly identical to AB 1091 (Hancock) of 2010
which was vetoed by Governor Schwarzenegger. The veto message
is as follows:
"I am returning Senate Bill 1091 without my signature.
This bill, while well-intentioned, is inconsistent
with federal law and exposes the state to potentially
significant costs. If the author wishes to craft
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workable legislation that allows for additional
federal funds but also adheres to federal Medicaid law
and regulations, the Department of Health Care
Services would be willing to assist in that effort
next year."
According to the sponsor, no additional guidance has been
provided by DHCS. However, the author would like to move
this bill forward and continue to seek the assistance of
DHCS in crafting workable legislation.
REGISTERED SUPPORT / OPPOSITION :
Support
Alameda County (sponsor)
California Council of Community Mental Health Agencies
California Medical Association
California Probation, Parole and Correctional Association
California State Association of Counties
California State Sheriffs' Association
California Youth Connection
Chief Probation Officers of California
Children's Advocacy Institute
City and County of San Francisco
County Alcohol and Drug Program Administrators Association of
California
County Health Executives Association of California
Legal Services for Prisoners with Children
Little Hoover Commission
Mental Health Association in California
National Association of Social workers - California Chapter
Regional Council of Rural Counties
Santa Clara County Board of Supervisors
Urban Counties Caucus
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097
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