BILL NUMBER: AB 50 INTRODUCED
BILL TEXT
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.
(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.
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 Care 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.
(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.
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.