Amended in Assembly May 13, 2013

Amended in Assembly May 1, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 50

Introduced by Assembly Member Pan

December 21, 2012

An act to amend Section 15926 of, to amend and repeal Sections 14016.5 and 14016.6 of, and to add Section 14011.66 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 amended, 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.

Existing law requires the California Health and Human Services Agency, in consultation with specified entities, to a establish standardized single, accessible application form and related renewal procedures for state health subsidy programs, as defined, in accordance with specified requirements. Existing law authorizes the form to 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 pursuant to federal law.

begin delete

This bill would instead require the form to include those questions effective January 1, 2015, and would additionally require the form to include questions that are voluntary for applicants to answer regarding sexual orientation and gender identity or expression.

end delete begin insert

This bill would authorize the form to also include questions that are voluntary for applicants to answer regarding sexual orientation and gender identity or expression. The bill would, effective January 1, 2015, require the form to include questions that are voluntary for applicants to answer regarding the demographic data categories specified.

end insert

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 14016.6 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. 4.  

Section 15926 of the Welfare and Institutions Code is
amended to read:

15926.  

(a) The following definitions apply for purposes of
this part:

(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
instructions.

(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
programs.

(D) The form may be used for, but shall not be limited to,
screening.

(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.

begin insert

(F) (i) Except as specified in clause (ii), the form may include
questions that are voluntary for applicants to answer regarding
demographic data categories, including race, ethnicity, primary
language, disability status, sexual orientation, gender identity or
expression, and other categories recognized by the federal
Secretary of Health and Human Services under Section 4302 of
the PPACA.

end insert begin delete

(F)

end delete

begin insert (ii) end insert  Effective January 1, 2015, the form shall include questions
that are voluntary for applicants to answer regarding demographic
data categories, including race, ethnicity, primary language,
disability status, sexual orientation, gender identity or expression,
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
law.

(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
proficient.

(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 program.

(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 discrimination.

(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
screening.

(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.

SEC. 5.  

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.