California Legislature—2013–14 Regular Session

Assembly Bill No. 50

Introduced by Assembly Member Pan

December 21, 2012

An act to amend and repeal Sections 14016.5 and 14016.6 of, and to add Sections 14011.66, 14016.54, and 15926.6 to, the Welfare and Institutions Code, relating to health care coverage, and declaring the urgency thereof, to take effect immediately.

LEGISLATIVE COUNSEL’S DIGEST

AB 50, as introduced, Pan. Health care coverage: Medi-Cal: eligibility: enrollment.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

This bill would require the department to establish a process in accordance with federal law to allow a hospital that is a participating Medi-Cal provider to elect to be a qualified entity for purposes of determining whether any individual is eligible for Medi-Cal and providing the individual with medical assistance during the presumptive eligibility period.

Existing law requires an applicant or beneficiary, as specified, who resides in an area served by a managed health care plan or pilot program in which beneficiaries may enroll, to personally attend a presentation at which the applicant or beneficiary is informed of managed care and fee-for-service options for receiving Medi-Cal benefits. Existing law requires the applicant or beneficiary to indicate in writing his or her choice of health care options and provides that if the applicant or beneficiary does not make a choice he or she shall be assigned to and enrolled in an appropriate Medi-Cal managed care plan, pilot project, or fee-for-service case management provider providing service within the area in which the beneficiary resides. Existing law requires the department to develop a program, as specified, to implement these provisions.

This bill would repeal these provisions on January 1, 2015, and would require the department to implement a new process by January 1, 2015, to inform Medi-Cal enrollees of their options with regard to the delivery of Medi-Cal services, including fee-for-service, if available, and all managed care options. The bill would, in this regard, prohibit the department from extending, or exercising any options to extend, the term of any existing contracts under which a nongovernmental entity has responsibility for performing functions under the Medi-Cal Managed Health Care Options program, including enrolling or informing an applicant or enrollee of managed care plan choices, assigning an applicant or enrollee to a managed care plan, or informing applicants of, or processing applications or requests for, exemptions to enrollment.

Existing law requires the California Health and Human Services Agency, 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.

This bill would require that an applicant or recipient of benefits under a state health subsidy program be given an option, with his or her informed consent, to have an application for renewal form prepopulated or electronically verified in real time, or both, as specified.

This bill would declare that it is to take effect immediately as an urgency statute.

Vote: ²⁄₃. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

Section 14011.66 is added to the Welfare and
Institutions Code, to read:

14011.66.  

The department shall establish a process in
accordance with Section 1396a(a)(47)(B) of Title 42 of the United
States Code, effective January 1, 2014, to allow a hospital that is
a participating provider under the state plan to elect to be a
qualified entity for purposes of determining, on the basis of
preliminary information, whether any individual is eligible for
Medi-Cal under the state plan or under a federal waiver for
purposes of providing the individual with medical assistance during
the presumptive eligibility period.

SEC. 2.  

Section 14016.5 of the Welfare and Institutions Code
is amended to read:

14016.5.  

(a) At the time of determining or redetermining the
eligibility of a Medi-Cal program or Aid to Families with
Dependent Children (AFDC) program applicant or beneficiary
who resides in an area served by a managed health care plan or
pilot program in which beneficiaries may enroll, each applicant
or beneficiary shall personally attend a presentation at which the
applicant or beneficiary is informed of the managed care and
fee-for-service options available regarding methods of receiving
Medi-Cal benefits. The county shall ensure that each beneficiary
or applicant attends this presentation.

(b) The health care options presentation described in subdivision
(a) shall include all of the following elements:

(1) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in the fee-for-service sector.

(2) Each beneficiary or eligible applicant shall be provided with
the name, address, telephone number, and specialty, if any, of each
primary care provider, and each clinic participating in each prepaid
managed health care plan, pilot project, or fee-for-service case
management provider option. This information shall be provided
under geographic area designations, in alphabetical order by the
name of the primary care provider and clinic. The name, address,
and telephone number of each specialist participating in each
prepaid managed health care plan, pilot project, or fee-for-service
case management provider option shall be made available by
contacting either the health care options contractor or the prepaid
managed health care plan, pilot project, or fee-for-service case
management provider.

(3) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating provider
is a primary care provider or clinic contracting with any of the
prepaid managed health care plans, pilot projects, or fee-for-service
case management provider options available, has available capacity,
and agrees to continue to treat that beneficiary or applicant.

(4) In areas specified by the director, each beneficiary or eligible
applicant shall be informed that if he or she fails to make a choice,
or does not certify that he or she has an established relationship
with a primary care provider or clinic, he or she shall be assigned
to, and enrolled in, a prepaid managed health care plan, pilot
project, or fee-for-service case management provider.

(c) No later than 30 days following the date a Medi-Cal or
AFDC beneficiary or applicant is determined eligible, the
beneficiary or applicant shall indicate his or her choice in writing,
as a condition of coverage for Medi-Cal benefits, of either of the
following health care options:

(1) To obtain benefits by receiving a Medi-Cal card, which may
be used to obtain services from individual providers, that the
beneficiary would locate, who choose to provide services to
Medi-Cal beneficiaries.

The department may require each beneficiary or eligible
applicant, as a condition for electing this option, to sign a statement
certifying that he or she has an established patient-provider
relationship, or in the case of a dependent, the parent or guardian
shall make that certification. This certification shall not require
the acknowledgment or guarantee of acceptance, by any indicated
Medi-Cal provider or health facility, of any beneficiary making a
certification under this section.

(2) (A) To obtain benefits by enrolling in a prepaid managed
health care plan, pilot program, or fee-for-service case management
provider that has agreed to make Medi-Cal services readily
available to enrolled Medi-Cal beneficiaries.

(B) At the time the beneficiary or eligible applicant selects a
prepaid managed health care plan, pilot project, or fee-for-service
case management provider, the department shall, when applicable,
encourage the beneficiary or eligible applicant to also indicate, in
writing, his or her choice of primary care provider or clinic
contracting with the selected prepaid managed health care plan,
pilot project, or fee-for-service case management provider.

(d) (1) In areas specified by the director, a Medi-Cal or AFDC
beneficiary or eligible applicant who does not make a choice, or
who does not certify that he or she has an established relationship
with a primary care provider or clinic, shall be assigned to and
enrolled in an appropriate Medi-Cal managed care plan, pilot
project, or fee-for-service case management provider providing
service within the area in which the beneficiary resides.

(2) If it is not possible to enroll the beneficiary under a Medi-Cal
managed care plan, pilot project, or a fee-for-service case
management provider because of a lack of capacity or availability
of participating contractors, the beneficiary shall be provided with
a Medi-Cal card and informed about fee-for-service primary care
providers who do all of the following:

(A) The providers agree to accept Medi-Cal patients.

(B) The providers provide information about the provider’s
willingness to accept Medi-Cal patients as described in Section
14016.6.

(C) The providers provide services within the area in which the
beneficiary resides.

(e) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select any primary care
provider who is available, the managed health care plan, pilot
project, or fee-for-service case management provider that was
selected by or assigned to the beneficiary shall ensure that the
beneficiary selects a primary care provider or clinic within 30 days
after enrollment or is assigned to a primary care provider within
40 days after enrollment.

(f) (1) The managed care plan shall have a valid Medi-Cal
contract, adequate capacity, and appropriate staffing to provide
health care services to the beneficiary.

(2) The department shall establish standards for all of the
following:

(A) The maximum distances a beneficiary is required to travel
to obtain primary care services from the managed care plan,
fee-for-service case management provider, or pilot project in which
the beneficiary is enrolled.

(B) The conditions under which a primary care service site shall
be accessible by public transportation.

(C) The conditions under which a managed care plan,
fee-for-service case management provider, or pilot project shall
provide nonmedical transportation to a primary care service site.

(3) In developing the standards required by paragraph (2), the
department shall take into account, on a geographic basis, the
means of transportation used and distances typically traveled by
Medi-Cal beneficiaries to obtain fee-for-service primary care
services and the experience of managed care plans in delivering
services to Medi-Cal enrollees. The department shall also consider
the provider’s ability to render culturally and linguistically
appropriate services.

(g) To the extent possible, the arrangements for carrying out
subdivision (d) shall provide for the equitable distribution of
Medi-Cal beneficiaries among participating managed care plans,
fee-for-service case management providers, and pilot projects.

(h) If, under the provisions of subdivision (d), a Medi-Cal
beneficiary or applicant does not make a choice or does not certify
that he or she has an established relationship with a primary care
provider or clinic, the person may, at the option of the department,
be provided with a Medi-Cal card or be assigned to and enrolled
in a managed care plan providing service within the area in which
the beneficiary resides.

(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with
the provider or managed care plan, pilot project, or fee-for-service
case management provider shall be allowed to select or be assigned
to another provider or managed care plan, pilot project, or
fee-for-service case management provider.

(j) The department or its contractor shall notify a managed care
plan, pilot project, or fee-for-service case management provider
when it has been selected by or assigned to a beneficiary. The
managed care plan, pilot project, or fee-for-service case
management provider that has been selected by, or assigned to, a
beneficiary, shall notify the primary care provider or clinic that it
has been selected or assigned. The managed care plan, pilot project,
or fee-for-service case management provider shall also notify the
beneficiary of the managed care plan, pilot project, or
fee-for-service case management provider or clinic selected or
assigned.

(k) (1) The department shall ensure that Medi-Cal beneficiaries
eligible under Title XVI of the Social Security Act are provided
with information about options available regarding methods of
receiving Medi-Cal benefits as described in subdivision (c).

(2) (A) The director may waive the requirements of subdivisions
(c) and (d) until a means is established to directly provide the
presentation described in subdivision (a) to beneficiaries who are
eligible for the federal Supplemental Security Income for the Aged,
Blind, and Disabled Program (Subchapter 16 (commencing with
Section 1381) of Chapter 7 of Title 42 of the United States Code).

(B) The director may elect not to apply the requirements of
subdivisions (c) and (d) to beneficiaries whose eligibility under
the Supplemental Security Income program is established before
January 1, 1994.

(l) In areas where there is no prepaid managed health care plan
or pilot program that has contracted with the department to provide
services to Medi-Cal beneficiaries, and where no other enrollment
requirements have been established by the department, no explicit
choice need be made, and the beneficiary or eligible applicant shall
receive a Medi-Cal card.

(m) The following definitions contained in this subdivision shall
control the construction of this section, unless the context requires
otherwise:

(1) “Applicant,” “beneficiary,” and “eligible applicant,” in the
case of a family group, mean any person with legal authority to
make a choice on behalf of dependent family members.

(2) “Fee-for-service case management provider” means a
provider enrolled and certified to participate in the Medi-Cal
fee-for-service case management program the department may
elect to develop in selected areas of the state with the assistance
of and in cooperation with California physician providers and other
interested provider groups.

(3) “Managed health care plan” and “managed care plan” mean
a person or entity operating under a Medi-Cal contract with the
department under this chapter or Chapter 8 (commencing with
Section 14200) to provide, or arrange for, health care services for
Medi-Cal beneficiaries as an alternative to the Medi-Cal
fee-for-service program that has a contractual responsibility to
manage health care provided to Medi-Cal beneficiaries covered
by the contract.

(n) (1) Whenever a county welfare department notifies a public
assistance recipient or Medi-Cal beneficiary that the recipient or
beneficiary is losing Medi-Cal eligibility, the county shall include,
in the notice to the recipient or beneficiary, notification that the
loss of eligibility shall also result in the recipient’s or beneficiary’s
disenrollment from Medi-Cal managed health care or dental plans,
if enrolled.

(2) (A) Whenever the department or the county welfare
department processes a change in a public assistance recipient’s
or Medi-Cal beneficiary’s residence or aid code that will result in
the recipient’s or beneficiary’s disenrollment from the managed
health care or dental plan in which he or she is currently enrolled,
a written notice shall be given to the recipient or beneficiary.

(B) This paragraph shall become operative and the department
shall commence sending the notices required under this paragraph
on or before the expiration of 12 months after the effective date
of this section.

(o) This section shall be implemented in a manner consistent
with any federal waiver required to be obtained by the department
in order to implement this section.

begin insert

(p) This section shall remain in effect only until January 1, 2015,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2015, deletes or extends that date.

end insert

SEC. 3.  

Section 14016.54 is added to the Welfare and
Institutions Code, to read:

14016.54.  

(a) On or before January 1, 2015, the department
shall implement a new process to inform Medi-Cal enrollees of
their options with regard to the delivery of Medi-Cal services,
including fee-for-service, if available, and all managed care options.
The process shall include a mechanism to allow enrollees to make
an informed choice and to pick a health plan and a primary care
provider. In developing the process, the department shall convene
public meetings to allow for input from stakeholders and other
members of the public, consult with counties and the Legislature,
and coordinate with the California Health Benefit Exchange.

(b) For purposes of implementing subdivision (a), the
department shall not extend, or exercise any options to extend the
term of any existing contracts under which a nongovernmental
entity has responsibility for performing functions under the
Medi-Cal Managed Health Care Options program, including
enrolling or informing an applicant or enrollee of managed care
plan choices, assigning an applicant or enrollee to a managed care
plan, or informing applicants of, or processing applications or
requests for, exemptions to enrollment.

SEC. 4.  

Section 14016.6 of the Welfare and Institutions Code
is amended to read:

14016.6.  

The State Department of Health begin insert Care end insert Services shall
develop a program to implement Section 14016.5 and to provide
information and assistance to enable Medi-Cal beneficiaries to
understand and successfully use the services of the Medi-Cal
managed care plans in which they enroll. The program shall
include, but not be limited to, the following components:

(a) (1) Development of a method to inform beneficiaries and
applicants of all of the following:

(A) Their choices for receiving Medi-Cal benefits including the
use of fee-for-service sector managed health care plans, or pilot
programs.

(B) The availability of staff and information resources to
Medi-Cal managed health care plan enrollees described in
subdivision (f).

(2) (A) Marketing and informational materials including printed
materials, films, and exhibits, to be provided to Medi-Cal
beneficiaries and applicants when choosing methods of receiving
health care benefits.

(B) The department shall not be responsible for the costs of
developing material required by subparagraph (A).

(C) (i) The department may prescribe the format and edit the
informational materials for factual accuracy, objectivity and
comprehensibility .

(ii) The department shall use the edited materials in informing
beneficiaries and applicants of their choices for receiving Medi-Cal
benefits.

(b) Provision of information that is necessary to implement this
program in a manner that fairly and objectively explains to
beneficiaries and applicants their choices for methods of receiving
Medi-Cal benefits, including information prepared by the
department emphasizing the benefits and limitations to
beneficiaries of enrolling in managed health care plans and pilot
projects as opposed to the fee-for-service system.

(c) Provision of information about providers who will provide
services to Medi-Cal beneficiaries. This may be information about
provider referral services of a local provider professional
organization. The information shall be made available to Medi-Cal
beneficiaries and applicants at the same time the beneficiary or
applicant is being informed of the options available for receiving
care.

(d) Training of specialized county employees to carry out the
program.

(e) Monitoring the implementation of the program in those
county welfare offices where choices are made available in order
to assure that beneficiaries and applicants may make a
well-informed choice, without duress.

(f) Staff and information resources dedicated to directly assist
Medi-Cal managed health care plan enrollees to understand how
to effectively use the services of, and resolve problems or
complaints involving, their managed health care plans.

(g) The responsibilities outlined in this section shall, at the
option of the department, be carried out by a specially trained
county or state employee or by an independent contractor paid by
the department. If a county sponsored prepaid health plan or pilot
program is offered, the responsibilities outlined in this section shall
be carried out either by a specially trained state employee or by
an independent contractor paid by the department.

(h) The department shall adopt any regulations as are necessary
to ensure that the informing of beneficiaries of their health care
options is a part of the eligibility determination process.

begin insert

(i) This section shall remain in effect only until January 1, 2015,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2015, deletes or extends that date.

end insert

SEC. 5.  

Section 15926.6 is added to the Welfare and
Institutions Code, to read:

15926.6.  

(a) An applicant or recipient of benefits under a state
health subsidy program shall be given the option, with his or her
informed consent, to have an application for renewal form
prepopulated or electronically verified in real time, or both, using
personal information from his or her own state health subsidy
program or other public benefits case file, a case file of that
individual’s parent or child, or other electronic databases required
by the PPACA.

(1) An applicant or recipient who chooses to have an application
for renewal form prepopulated shall be given an opportunity, before
the application for 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 to have an application
for renewal form electronically verified in real time shall be given
an opportunity, before or after a final eligibility determination is
made, to provide additional eligibility information and to correct
information retrieved from a database. An applicant or recipient
shall not be denied eligibility for any state health subsidy 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 or recipients
shall receive the benefits for which they would otherwise qualify
pending this reasonable-opportunity period.

(b) Renewal procedures shall be coordinated across all state
health subsidy programs and among entities that accept and make
eligibility determinations so that all relevant information already
included in the individual’s Medi-Cal or other public benefits case
file, his or her California Health Benefit Exchange case file, a case
file of the individual’s parent or child, or other electronic databases
authorized for data sharing under the PPACA can be used to renew
benefits or transfer eligible recipients between programs without
a break in coverage and without requiring a recipient to provide
redundant information. Renewal procedures shall be as simple,
user-friendly, and accessible as possible, shall require recipients
to provide only the 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. Families shall be able to renew coverage at the same time
for all family members enrolled in any state health subsidy
program, including if family members are enrolled in more than
one state health subsidy program. A recipient shall be permitted
to update his or her eligibility information at any time.

SEC. 6.  

This act is an urgency statute necessary for the
immediate preservation of the public peace, health, or safety within
the meaning of Article IV of the Constitution and shall go into
immediate effect. The facts constituting the necessity are:

In order to implement provisions of the federal Patient Protection
and Affordable Care Act (Public Law 111-148), as amended by
the federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), it is necessary that this act take effect
immediately.