Amended in Senate September 3, 2013

Amended in Senate August 15, 2013

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 begin delete add Section 1366.5 to the Health and Safety Code, to add Section 10112.35 to the Insurance Code, to end delete amend Sections 14005.28, 14005.30, 14005.36, 14005.37, 14005.39, 14005.61, 14011.66, 14015.8, 14016.6, 14102, 14132.02, 14154, and 15926 of, and to add begin delete Sections 14005.22, 14148.65, and 14148.67 end delete begin insert Section 14005.22 end insert 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: begin delete eligibility: pregnancy-related and postpartum services. end delete begin insert eligibility. end insert

begin delete

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that makes available qualified health plans to qualified individuals and small employers. Existing state law establishes the California Health Benefit Exchange (Exchange) within state government, specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of qualified health plans through the Exchange by qualified individuals and small employers by January 1, 2014.

end delete

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. Chapters 3 and 4 of the First Extraordinary Session of 2013-14, to be effective on the 91st day after adjournment of that session, implement various provisions of begin delete PPACA end delete begin insert the federal Patient Protection and Affordable Care Act (PPACA) end insert relating to determining eligibility for the Medi-Cal program. begin delete Commencing January 1, 2014, an individual who is 21 years of age and older, does not have minor children eligible for Medi-Cal benefits, would be eligible for Medi-Cal benefits but for a specified 5-year bar, and who is enrolled in coverage through the Exchange with an advanced premium tax credit is eligible for Medi-Cal benefits, as prescribed. Commencing January 1, 2014, the department is also required to pay the beneficiary’s insurance premium costs and cost-sharing charges under these provisions. end delete

This bill would authorize the department to implement some of those provisions by, among other things, all-county letters, until the time any necessary regulations are adopted. The bill would require the department to adopt regulations implementing those provisions by July 1, 2015. This bill would, begin insert effective January 1, 2014, and end insert under specified federal provisions applicable to qualified pregnant begin delete woman end delete begin insert women end insert and children, provide that a woman shall be eligible for begin insert full-scope end insert Medi-Cal benefits if her income is less than 100% of the federal poverty level as determined, counted, and valued in accordance with federal law.

begin delete

This bill would, by April 1, 2014, or after the department determines that the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) has been programmed for implementation of these provisions, require the State Department of Health Care Services to implement a specified option for women eligible for Medi-Cal pregnancy-related and postpartum services who are enrolled or will be enrolled in individual health care coverage through the Exchange. The bill would, except as provided, require the department to pay the beneficiary’s premium costs and the beneficiary’s cost sharing for benefits and services during the beneficiary’s period of eligibility for pregnancy-related and postpartum services under the Medi-Cal program. The bill would require the department to make these premium or cost-sharing payments to the beneficiary’s qualified health plan, as specified. This bill would require health care service plans and insurers providing individual coverage in the Exchange to cooperate with requests from the Exchange to collaborate in the development of, and participate in the implementation of, these premium and cost-sharing payments for eligible Exchange enrollees. Because a willful violation of the bill’s provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program.

end delete begin insert

Because counties are required to make Medi-Cal eligibility determinations and this bill would expand Medi-Cal eligibility, the bill would impose a state-mandated local program.

end insert

Existing law, to be effective on the 91st day after adjournment of the First Extraordinary Session of 2013-14, would, commencing January 1, 2014, require the department to develop a program to implement provisions that would authorize individuals or their authorized representatives to select Medi-Cal managed care plans via begin delete CalHEERS, end delete begin insert the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), end insert as specified. In this regard, the program is required to include training of specialized county employees to carry out the program.

This bill would, instead, require the program to include training of individuals, including county human services staff, to carry out the program.

Existing law requires the department to establish and maintain a County Administrative Cost Control Plan under which costs for county administration for the determination of eligibility for benefits are controlled, as specified. Existing law requires the department to develop and implement a new budgeting methodology for Medi-Cal county administrative costs to be used to reimburse counties for eligibility determinations for applicants and beneficiaries, and requires that the budgeting methodology include identification of the costs of eligibility determinations for applicants, and the costs of eligibility redeterminations and case maintenance activities for recipients, for different groupings of cases.

This bill would instead provide that the budgeting methodology may include identification of the costs of eligibility determinations for applicants, and the costs of eligibility redeterminations and case maintenance activities for recipients, for different groupings of cases. The bill would authorize the development of the new budgeting methodology to include, among other things, county survey of costs, time and motion studies, and in-person observations by department staff. The bill would require that the new budgeting methodology be implemented no sooner than the 2015-16 fiscal year and that it reflect the impact of PPACA implementation on county administrative work.

Existing law requires the California Health and Human Services Agency, in consultation with specified entities, to establish a 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.

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. This bill would make other technical changes.

begin delete

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end delete begin delete

This bill would provide that no reimbursement is required by this act for a specified reason.

end delete begin insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end insert begin insert

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

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: yes.

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

begin delete

SECTION 1.  

Section 1366.5 is added to the Health and Safety
Code, to read:

1366.5.  

(a) A health care service plan providing individual
coverage in the Exchange shall cooperate with requests from the
Exchange to collaborate in the development of, and participate in
the implementation of, the Medi-Cal program’s premium and
cost-sharing payments under Sections 14102 and 14148.65 of the
Welfare and Institutions Code for eligible Exchange enrollees.

(b) For purposes of this section, “Exchange” means the
California Health Benefit Exchange established pursuant to Title
22 (commencing with Section 100500) of the Government Code.

end delete

begin delete

SEC. 2.  

Section 10112.35 is added to the Insurance Code, to
read:

10112.35.  

(a) An insurer providing individual coverage in the
Exchange shall cooperate with requests from the Exchange to
collaborate in the development of, and participate in the
implementation of, the Medi-Cal program’s premium and
cost-sharing payments under Sections 14102 and 14148.65 of the
Welfare and Institutions Code for eligible Exchange enrollees.

(b) For purposes of this section, “Exchange” means the
California Health Benefit Exchange established pursuant to Title
22 (commencing with Section 100500) of the Government Code.

end delete

begin delete SEC. 3. end delete
begin insert SECTION 1. end insert   

Section 14005.22 is added to the Welfare and
Institutions Code, to read:

14005.22.  

(a)  begin delete A end delete begin insert Effective January 1, 2014, a end insert woman shall be
eligible for begin insert full-scope end insert Medi-Cal benefits under Section
1396a(a)(10)(A)(i)(III) of Title 42 of the United States Code if her
income is less than 100 percent of the federal poverty level as
determined, counted, and valued in accordance with the
requirements of Section 1396a(e)(14) of Title 42 of the United
States Code, as added by the federal Patient Protection and
Affordable Care Act (Public Law 111-148) and as amended by
the federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152) and any subsequent amendments, and she
meets all other eligibility requirements.

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. begin delete Thereafter, the end delete
begin insert The end insert department shall adopt regulations begin insert by January 1, 2017, end insert in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code. Beginning six months after the effective date
of this section, notwithstanding Section 10321.5 of the Government
Code, the department shall provide a status report to the Legislature
on a semiannual basis, in compliance with Section 9795 of the
Government Code, until regulations have been adopted.

(c) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

begin delete SEC. 4. end delete
begin insert SEC. 2. end insert   

Section 14005.28 of the Welfare and Institutions Code,
as added by Section 5 of Chapter 4 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.28.  

(a) To the extent federal financial participation is
available pursuant to an approved state plan amendment, the
department shall implement Section 1902(a)(10)(A)(i)(IX) of the
federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(IX))
to provide Medi-Cal benefits to an individual who is in foster care
on his or her 18th birthday until his or her 26th birthday. In
addition, the department shall implement the federal option to
provide Medi-Cal benefits to individuals who were in foster care
and enrolled in Medicaid in any state.

(1) A foster care adolescent who is in foster care in this state
on his or her 18th birthday shall be enrolled to receive benefits
under this section without any interruption in coverage and without
requiring a new application.

(2) The department shall develop procedures to identify and
enroll individuals who meet the criteria for Medi-Cal eligibility
in this subdivision, including, but not limited to, former foster care
adolescents who were in foster care on their 18th birthday and who
lost Medi-Cal coverage as a result of attaining 21 years of age.
The department shall work with counties to identify and conduct
outreach to former foster care adolescents who lost Medi-Cal
coverage during the 2013 calendar year as a result of attaining 21
years of age, to ensure they are aware of the ability to reenroll
under the coverage provided pursuant to this section.

(3) (A) The department shall develop and implement a
simplified redetermination form for this program. A beneficiary
qualifying for the benefits extended pursuant to this section shall
fill out and return this form only if information known to the
department is no longer accurate or is materially incomplete.

(B) The department shall seek federal approval to institute a
renewal process that allows a beneficiary receiving benefits under
this section to remain on Medi-Cal after a redetermination form
is returned as undeliverable and the county is otherwise unable to
establish contact. If federal approval is granted, the recipient shall
remain eligible for services under the Medi-Cal fee-for-service
program until the time contact is reestablished or ineligibility is
established, and to the extent federal financial participation is
available.

(C) The department shall terminate eligibility only after it
determines that the recipient is no longer eligible and all due
process requirements are met in accordance with state and federal
law.

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(c) This section shall be implemented only if and to the extent
that federal financial participation is available.

(d) This section shall become operative January 1, 2014.

begin delete SEC. 5. end delete
begin insert SEC. 3. end insert   

Section 14005.30 of the Welfare and Institutions Code,
as added by Section 4 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.30.  

(a) Medi-Cal benefits under this chapter shall be
provided to individuals eligible for services under Section 1396u-1
of Title 42 of the United States Code.

(b) (1) When determining eligibility under this section, an
applicant’s or beneficiary’s income and resources shall be
determined, counted, and valued in accordance with the
requirements of Section 1396a(e)(14) of Title 42 of the United
States Code, as added by the ACA.

(2) When determining eligibility under this section, an
applicant’s or beneficiary’s assets shall not be considered and
deprivation shall not be a requirement for eligibility.

(c) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec.
401 et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the
federal poverty level requires the department to modify the income
disregard pursuant to subdivision (c) and in which new income
limits for the program established by this section are adopted by
the department.

(d) The MAGI-based income eligibility standard applied under
this section shall conform with the maintenance of effort
requirements of Sections 1396a(e)(14) and 1396a(gg) of Title 42
of the United States Code, as added by the ACA.

(e) For purposes of this section, the following definitions shall
apply:

(1)  “ACA” means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as originally enacted and as
amended by the federal Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152) and any subsequent
amendments.

(2) “MAGI-based income” means income calculated using the
financial methodologies described in Section 1396a(e)(14) of Title
42 of the United States Code, as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148) and as
amended by the federal Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152) and any subsequent
amendments.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(g) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

(h) This section shall become operative on January 1, 2014.

begin delete SEC. 6. end delete
begin insert SEC. 4. end insert   

Section 14005.36 of the Welfare and Institutions Code,
as amended by Section 5 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.36.  

(a) The county shall undertake outreach efforts to
beneficiaries receiving benefits under this chapter, in order to
maintain the most up-to-date home addresses, telephone numbers,
and other necessary contact information, and to encourage and
assist with timely submission of the annual reaffirmation form,
and, when applicable, transitional Medi-Cal program reporting
forms and to facilitate the Medi-Cal redetermination process when
one is required as provided in Section 14005.37. In implementing
this subdivision, a county may collaborate with community-based
organizations, provided that confidentiality is protected.

(b) The department shall encourage and facilitate efforts by
managed care plans to report updated beneficiary contact
information to counties.

(c) (1) The department and each county shall incorporate, in a
timely manner, updated contact information received from managed
care plans pursuant to subdivision (b) into the beneficiary’s
Medi-Cal case file and into all systems used to inform plans of
their beneficiaries’ enrollee status. Updated Medi-Cal beneficiary
contact information shall be limited to the beneficiary’s telephone
number, change of address information, and change of name.

(2) When a managed care plan obtains a beneficiary’s updated
contact information, the managed care plan shall ask the beneficiary
for approval to provide the beneficiary’s updated contact
information to the appropriate county. If the managed care plan
does not obtain approval from the beneficiary to provide the
appropriate county with the updated contact information, the county
shall attempt to verify that the information that it receives from
the plan is accurate, which may include, but is not limited to,
making contact with the beneficiary, before updating the
beneficiary’s case file. The contact shall first be attempted using
the method of contact identified by the beneficiary as the preferred
method of contact, if a method has been identified.

(d) This section shall be implemented only to the extent that
federal financial participation under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.) is available.

(e) To the extent otherwise required by Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code, the department shall adopt emergency
regulations implementing this section no later than July 1, 2015.
The department may thereafter readopt the emergency regulations
pursuant to that chapter. The adoption and readoption, by the
department, of regulations implementing this section shall be
deemed to be an emergency and necessary to avoid serious harm
to the public peace, health, safety, or general welfare for purposes
of Sections 11346.1 and 11349.6 of the Government Code, and
the department is hereby exempted from the requirement that it
describe facts showing the need for immediate action and from
review by the Office of Administrative Law.

begin delete SEC. 7. end delete
begin insert SEC. 5. end insert   

Section 14005.37 of the Welfare and Institutions Code,
as added by Section 7 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.37.  

(a) Except as provided in Section 14005.39, a county
shall perform redeterminations of eligibility for Medi-Cal
beneficiaries every 12 months and shall promptly redetermine
eligibility whenever the county receives information about changes
in a beneficiary’s circumstances that may affect eligibility for
Medi-Cal benefits. The procedures for redetermining Medi-Cal
eligibility described in this section shall apply to all Medi-Cal
beneficiaries.

(b)  Loss of eligibility for cash aid under that program shall not
result in a redetermination under this section unless the reason for
the loss of eligibility is one that would result in the need for a
redetermination for a person whose eligibility for Medi-Cal under
Section 14005.30 was determined without a concurrent
determination of eligibility for cash aid under the CalWORKs
program.

(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.

(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section and a beneficiary’s Medi-Cal eligibility
shall not be terminated under this section until the county makes
a specific determination based on facts clearly demonstrating that
the beneficiary is no longer eligible for Medi-Cal benefits under
any basis and due process rights guaranteed under this division
have been met. For the purposes of this subdivision, for a
beneficiary who is subject to the use of MAGI-based financial
methods, the determination of whether the beneficiary is eligible
for Medi-Cal benefits under any basis shall include, but is not
limited to, a determination of eligibility for Medi-Cal benefits on
a basis that is exempt from the use of MAGI-based financial
methods only if either of the following occurs:

(A) The county assesses the beneficiary as being potentially
eligible under a program that is exempt from the use of
MAGI-based financial methods, including, but not limited to, on
the basis of age, blindness, disability, or the need for long-term
care services and supports.

(B) The beneficiary requests that the county determine whether
he or she is eligible for Medi-Cal benefits on a basis that is exempt
from the use of MAGI-based financial methods.

(e) (1) For purposes of acquiring information necessary to
conduct the eligibility redeterminations described in this section,
a county shall gather information available to the county that is
relevant to the beneficiary’s Medi-Cal eligibility prior to contacting
the beneficiary. Sources for these efforts shall include information
contained in the beneficiary’s file or other information, including
more recent information available to the county, including, but not
limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
beneficiary or of any of his or her immediate family members,
which are open, or were closed within the last 90 days, information
accessed through any databases accessed under Sections 435.948,
435.949, and 435.956 of Title 42 of the Code of Federal
Regulations, and wherever feasible, other sources of relevant
information reasonably available to the county or to the county
via the department.

(2) In the case of an annual redetermination, if, based upon
information obtained pursuant to paragraph (1), the county is able
to make a determination of continued eligibility, the county shall
notify the beneficiary of both of the following:

(A) The eligibility determination and the information it is based
on.

(B) That the beneficiary is required to inform the county via the
Internet, by telephone, by mail, in person, or through other
commonly available electronic means, in counties where such
electronic communication is available, if any information contained
in the notice is inaccurate but that the beneficiary is not required
to sign and return the notice if all information provided on the
notice is accurate.

(3) The county shall make all reasonable efforts not to send
multiple notices during the same time period about eligibility. The
notice of eligibility renewal shall contain other related information
such as if the beneficiary is in a new Medi-Cal program.

(4) In the case of a redetermination due to a change in
circumstances, if a county determines that the change in
circumstances does not affect the beneficiary’s eligibility status,
the county shall not send the beneficiary a notice unless required
to do so by federal law.

(f) (1) In the case of an annual eligibility redetermination, if
the county is unable to determine continued eligibility based on
the information obtained pursuant to paragraph (1) of subdivision
(e), the beneficiary shall be so informed and shall be provided with
an annual renewal form, at least 60 days before the beneficiary’s
annual redetermination date, that is prepopulated with information
that the county has obtained and that identifies any additional
information needed by the county to determine eligibility. The
form shall include all of the following:

(A) The requirement that he or she provide any necessary
information to the county within 60 days of the date that the form
is sent to the beneficiary.

(B) That the beneficiary may respond to the county via the
Internet, by mail, by telephone, in person, or through other
commonly available electronic means if those means are available
in that county.

(C) That if the beneficiary chooses to return the form to the
county in person or via mail, the beneficiary shall sign the form
in order for it to be considered complete.

(D) The telephone number to call in order to obtain more
information.

(2) The county shall attempt to contact the beneficiary via the
Internet, by telephone, or through other commonly available
electronic means, if those means are available in that county, during
the 60-day period after the prepopulated form is mailed to the
beneficiary to collect the necessary information if the beneficiary
has not responded to the request for additional information or has
provided an incomplete response.

(3) If the beneficiary has not provided any response to the
written request for information sent pursuant to paragraph (1)
within 60 days from the date the form is sent, the county shall
terminate his or her eligibility for Medi-Cal benefits following the
provision of timely notice.

(4) If the beneficiary responds to the written request for
information during the 60-day period pursuant to paragraph (1)
but the information provided is not complete, the county shall
follow the procedures set forth in paragraph (3) of subdivision (g)
to work with the beneficiary to complete the information.

(5) (A) The form required by this subdivision shall be developed
by the department in consultation with the counties and
representatives of eligibility workers and consumers.

(B) For beneficiaries whose eligibility is not determined using
MAGI-based financial methods, the county may use existing
renewal forms until the state develops prepopulated renewal forms
to provide to beneficiaries. The department shall develop
prepopulated renewal forms for use with beneficiaries whose
eligibility is not determined using MAGI-based financial methods
by January 1, 2015.

(g) (1) In the case of a redetermination due to change in
circumstances, if a county cannot obtain sufficient information to
redetermine eligibility pursuant to subdivision (e), the county shall
send to the beneficiary a form that is prepopulated with the
information that the county has obtained and that states the
information needed to renew eligibility. The county shall only
request information related to the change in circumstances. The
county shall not request information or documentation that has
been previously provided by the beneficiary, that is not absolutely
necessary to complete the eligibility determination, or that is not
subject to change. The county shall only request information for
nonapplicants necessary to make an eligibility determination or
for a purpose directly related to the administration of the state
Medicaid plan. The form shall advise the individual to provide
any necessary information to the county via the Internet, by
telephone, by mail, in person, or through other commonly available
electronic means and, if the individual will provide the form by
mail or in person, to sign the form. The form shall include a
telephone number to call in order to obtain more information. The
form shall be developed by the department in consultation with
the counties, representatives of consumers, and eligibility workers.
A Medi-Cal beneficiary shall have 30 days from the date the form
is mailed pursuant to this subdivision to respond. Except as
provided in paragraph (2), failure to respond prior to the end of
this 30-day period shall not impact his or her Medi-Cal eligibility.

(2) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in this
subdivision marked as undeliverable shall result in an immediate
notice of action terminating Medi-Cal eligibility.

(3) During the 30-day period after the date of mailing of a form
to the Medi-Cal beneficiary pursuant to this subdivision, the county
shall attempt to contact the beneficiary by telephone, in writing,
or other commonly available electronic means, in counties where
such electronic communication is available, to request the
necessary information if the beneficiary has not responded to the
request for additional information or has provided an incomplete
response. If the beneficiary does not supply the necessary
information to the county within the 30-day limit, a 10-day notice
of termination of Medi-Cal eligibility shall be sent.

(h) Beneficiaries shall be required to report any change in
circumstances that may affect their eligibility within 10 calendar
days following the date the change occurred.

(i) If within 90 days of termination of a Medi-Cal beneficiary’s
eligibility or a change in eligibility status pursuant to this section,
the beneficiary submits to the county a signed and completed form
or otherwise provides the needed information to the county,
eligibility shall be redetermined by the county and if the beneficiary
is found eligible, or the beneficiary’s eligibility status has not
changed, whichever applies, the termination shall be rescinded as
though the form were submitted in a timely manner.

(j) If the information available to the county pursuant to the
redetermination procedures of this section does not indicate a basis
of eligibility, Medi-Cal benefits may be terminated so long as due
process requirements have otherwise been met.

(k) The department shall, with the counties and representatives
of consumers, including those with disabilities, and Medi-Cal
eligibility workers, develop a timeframe for redetermination of
Medi-Cal eligibility based upon disability, including ex parte
review, the redetermination forms described in subdivisions (f)
and (g), timeframes for responding to county or state requests for
additional information, and the forms and procedures to be used.
The forms and procedures shall be as consumer-friendly as possible
for people with disabilities. The timeframe shall provide a
reasonable and adequate opportunity for the Medi-Cal beneficiary
to obtain and submit medical records and other information needed
to establish eligibility for Medi-Cal based upon disability.

(l) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary’s vision has
improved beyond the applicable definition of blindness contained
in the plan.

(m) The county shall consider disability as continuing until the
review team determines that a beneficiary’s disability no longer
meets the applicable definition of disability contained in the plan.

(n) In the case of a redetermination due to a change in
circumstances, if a county determines that the beneficiary remains
eligible for Medi-Cal benefits, the county shall begin a new
12-month eligibility period.

(o)  For individuals determined ineligible for Medi-Cal by a
county following the redetermination procedures set forth in this
section, the county shall determine eligibility for other insurance
affordability programs and if the individual is found to be eligible,
the county shall, as appropriate, transfer the individual’s electronic
account to other insurance affordability programs via a secure
electronic interface.

(p) Any renewal form or notice shall be accessible to persons
who are limited-English proficient and persons with disabilities
consistent with all federal and state requirements.

(q) The requirements to provide information in subdivisions (e)
and (g), and to report changes in circumstances in subdivision (h),
may be provided through any of the modes of submission allowed
in Section 435.907(a) of Title 42 of the Code of Federal
Regulations, including an Internet Web site identified by the
department, telephone, mail, in person, and other commonly
available electronic means as authorized by the department.

(r) Forms required to be signed by a beneficiary pursuant to this
section shall be signed under penalty of perjury. Electronic
signatures, telephonic signatures, and handwritten signatures
transmitted by electronic transmission shall be accepted.

(s) For purposes of this section, “MAGI-based financial
methods” means income calculated using the financial
methodologies described in Section 1396a(e)(14) of Title 42 of
the United States Code, and as added by 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), and any subsequent
amendments.

(t) When contacting a beneficiary under paragraphs (2) and (4)
of subdivision (f), and paragraph (3) of subdivision (g), a county
shall first attempt to use the method of contact identified by the
beneficiary as the preferred method of contact, if a method has
been identified.

(u) The department shall seek federal approval to extend the
annual redetermination date under this section for a three-month
period for those Medi-Cal beneficiaries whose annual
redeterminations are scheduled to occur between January 1, 2014,
and March 31, 2014.

(v) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations by July 1, 2015, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10231.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the
Government Code, until regulations have been adopted.

(w) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

(x) This section shall become operative on January 1, 2014.

begin delete SEC. 8. end delete
begin insert SEC. 6. end insert   

Section 14005.39 of the Welfare and Institutions Code,
as amended by Section 10 of Chapter 4 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.39.  

(a) If a county has facts clearly demonstrating that
a Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an
event, such as death or change of state residency, Medi-Cal benefits
shall be terminated without a redetermination under Section
14005.37.

(b) Whenever Medi-Cal eligibility is terminated without a
redetermination, as provided in subdivision (a), the Medi-Cal
eligibility worker shall record that fact or event causing the
eligibility termination in the beneficiary’s file, along with a
certification that a full redetermination could not result in a finding
of Medi-Cal eligibility. Following this certification, a notice of
action specifying the basis for termination of Medi-Cal eligibility
shall be sent to the beneficiary.

(c) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(d) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et. seq.) is available and
necessary federal approvals have been obtained.

begin delete SEC. 9. end delete
begin insert SEC. 7. end insert   

Section 14005.61 of the Welfare and Institutions Code,
as added by Section 10 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14005.61.  

(a) Except as provided in subdivision (e), individuals
who are enrolled in a Low Income Health Program (LIHP) as of
December 31, 2013, under California’s Bridge to Reform Section
1115(a) Medicaid Demonstration who are at or below 133 percent
of the federal poverty level shall be transitioned directly to the
Medi-Cal program in accordance with the requirements of this
section and pursuant to federal approval.

(b) Except as provided in paragraph (8) of subdivision (c),
individuals who are eligible under subdivision (a) shall be required
to enroll into Medi-Cal managed care health plans.

(c) Except as provided in subdivision (d), with respect to
managed care health plan enrollment, a LIHP enrollee shall be
notified by the department at least 60 days prior to January 1, 2014,
in accordance with the department’s LIHP transition plan of all of
the following:

(1) Which Medi-Cal managed care health plan or plans contain
his or her existing primary care provider, if the department has
this information and the primary care provider is contracted with
a Medi-Cal managed care health plan.

(2) That the LIHP enrollee, subject to his or her ability to change
as described in paragraph (3), will be assigned to a health plan that
includes his or her primary care provider and enrolled effective
January 1, 2014. If the enrollee wants to keep his or her primary
care provider, no additional action will be required if the primary
care provider is contracted with a Medi-Cal managed care health
plan.

(3) That the LIHP enrollee may choose any available Medi-Cal
managed care health plan and primary care provider in his or her
county of residence prior to January 1, 2014, if more than one such
plan is available in the county where he or she resides, and he or
she will receive all provider and health plan information required
to be sent to new enrollees and instructions on how to choose or
change his or her health plan and primary care provider.

(4) That in counties with more than one Medi-Cal managed care
health plan, if the LIHP enrollee does not affirmatively choose a
plan within 30 days of receipt of the notice, he or she shall be
enrolled into the Medi-Cal managed care health plan that contains
his or her LIHP primary care provider as part of the Medi-Cal
managed care contracted primary care network, if the department
has this information about the primary care provider, and the
primary care provider is contracted with a Medi-Cal managed care
health plan. If the primary care provider is contracted with more
than one Medi-Cal managed care health plan, then the LIHP
enrollee will be assigned to one of the health plans containing his
or her primary care provider in accordance with an assignment
process established to ensure the linkage.

(5) That if the LIHP enrollee’s existing primary care provider
is not contracted with any Medi-Cal managed care health plan,
then he or she will receive all provider and health plan information
required to be sent to new enrollees. If the LIHP enrollee does not
affirmatively select one of the available Medi-Cal managed care
plans within 30 days of receipt of the notice, he or she will
automatically be assigned a plan through the department-prescribed
auto-assignment process.

(6) That the LIHP enrollee does not need to take any action to
be transitioned to the Medi-Cal program or to retain his or her
primary care provider, if the primary care provider is available
pursuant to paragraph (2).

(7) That the LIHP enrollee may choose not to transition to the
Medi-Cal program, and what this choice will mean for his or her
health care coverage and access to health care services.

(8) That in counties where no Medi-Cal managed care health
plans are available, the LIHP enrollee will be transitioned into
fee-for-service Medi-Cal, and provided with all information that
is required to be sent to new Medi-Cal enrollees including the
assistance telephone number for fee-for-service beneficiaries, and
that, if a Medi-Cal managed care health plan becomes available
in the residence county, he or she will be enrolled in a Medi-Cal
managed care health plan according to the enrollment procedures
in place at that time.

(d) Individuals who qualify under subdivision (a) who apply
and are determined eligible for LIHP after the date identified by
the department that is not later than October 1, 2013, will be
considered late enrollees. Late enrollees shall be notified in
accordance with subdivision (c), except according to a different
timeframe, but will transition to Medi-Cal coverage on January 1,
2014. Late enrollees after the date identified in this subdivision
shall be transitioned pursuant to the department’s LIHP transition
plan process.

(e) Individuals who qualify under subdivision (a) and are not
denoted as active LIHP enrollees according to the Medi-Cal
Eligibility Data System at any point within the date range identified
by the department that will start not sooner than December 20,
2013, and continue through December 31, 2013, will not be
included in the LIHP transition to the Medi-Cal program. These
individuals may apply for Medi-Cal eligibility separately from the
LIHP transition process.

(f) In conformity with the department’s transition plan,
individuals who are enrolled in a LIHP at any point from
September 2013 through December 2013, under California’s Bridge
to Reform Section 1115(a) Medicaid Demonstration and are above
133 percent of the federal poverty level will be provided
information regarding how to apply for an eligibility determination
for an insurance affordability program, including submission of
an application by telephone, by mail, online, or in person.

(g) A Medi-Cal managed care health plan that receives a LIHP
enrollee during this transition shall assign the LIHP primary care
provider of the enrollee as the Medi-Cal managed care health plan
primary care provider of the enrollee, to the extent possible, if the
Medi-Cal managed care health plan contracts with that primary
care provider, unless the beneficiary has chosen another primary
care provider on his or her choice form. A LIHP enrollee who is
enrolled into a Medi-Cal managed care plan may work through
the Medi-Cal managed care plan to change his or her assigned
primary care provider or other provider, after enrollment and
subject to provider availability, according to the standard processes
that are currently available in Medi-Cal managed care for selecting
providers.

(h) The director may, with federal approval, suspend, delay, or
otherwise modify the requirement for LIHP program eligibility
redeterminations in 2013 to facilitate the process of transitioning
LIHP enrollees to other health coverage in 2014.

(i) The county LIHPs and their designees shall work with the
department and its designees during the 2013 and 2014 calendar
years to facilitate continuity of care and data sharing for the
purposes of delivering Medi-Cal services in the 2014 calendar
year.

(j) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available and
all necessary federal approvals have been obtained.

begin delete SEC. 10. end delete
begin insert SEC. 8. end insert   

Section 14011.66 of the Welfare and Institutions Code,
as added by Section 22 of Chapter 4 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14011.66.  

(a) Effective January 1, 2014, the department shall
provide Medi-Cal benefits during a presumptive eligibility period
to individuals who have been determined eligible on the basis of
preliminary information by a qualified hospital in accordance with
Section 1396a(a)(47)(B) of Title 42 of the United States Code and
as set forth in this section.

(b) A hospital may only make presumptive eligibility
determinations under this section if it complies with all of
following:

(1) It is a participating provider under the state plan or under a
federal waiver under Section 1315 of Title 42 of the United States
Code.

(2) It has notified the department in writing that it has elected
to be a qualified entity for the purpose of making presumptive
eligibility determinations.

(3) It agrees to make presumptive eligibility determinations
consistent with all applicable policies and procedures.

(4) It has not been disqualified to make presumptive eligibility
determinations by the department.

(c) Qualified hospitals may only make presumptive eligibility
determinations based upon income for children, pregnant women,
parents and other caretaker relatives, and other adults, whose
income is calculated using the applicable MAGI-based income
standard.

(d) The department shall establish a process for determining
whether a hospital should be disqualified from being able to make
presumptive eligibility determinations under this section.

(e) For purposes of this section, “MAGI-based income” means
income calculated using the financial methodologies described in
Section 1396a(e)(14) of Title 42 of the United States Code, as
added by the federal Patient Protection and Affordable Care Act
(Public Law 111-148) and as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152)
and any subsequent amendments.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(g) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

begin delete SEC. 11. end delete
begin insert SEC. 9. end insert   

Section 14015.8 of the Welfare and Institutions Code,
as added by Section 18 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14015.8.  

(a) The department, any other government agency
that is determining eligibility for, or enrollment in, the Medi-Cal
program or any other program administered by the department, or
collecting protected health information for those purposes, and the
California Health Benefit Exchange established pursuant to Title
22 (commencing with Section 100500) of the Government Code,
shall share information with each other as necessary to enable them
to perform their respective statutory and regulatory duties under
state and federal law. This information shall include, but not be
limited to, personal information, as defined in subdivision (a) of
Section 1798.3 of the Civil Code, and protected health information,
as defined in Parts 160 and 164 of Title 45 of the Code of Federal
Regulations, regarding individual beneficiaries and applicants.

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

begin delete SEC. 12. end delete
begin insert SEC. 10. end insert   

Section 14016.6 of the Welfare and Institutions Code,
as added by Section 22 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14016.6.  

The State Department of Health Care Services shall
develop a program to implement subdivision (p) of 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, the California Health Benefit Exchange
(Exchange), the California Healthcare Eligibility, Enrollment, and
Retention System (CalHEERS), and entities or persons designated
pursuant to subdivision (g) 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.

(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 individuals, including county human services
staff, to carry out the program.

(e) Monitoring the implementation of the program at any
location, including online at the Exchange or at counties, 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) Notwithstanding any other law, the department, in
consultation with the Exchange, may authorize specific persons
or entities, including counties, to provide information to
beneficiaries concerning their health care options for receiving
Medi-Cal benefits and assistance with enrollment. This subdivision
shall apply in all geographic areas designated by the director. This
subdivision shall be implemented in a manner consistent with
federal law.

(h) To the extent otherwise required by Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code, the department shall adopt emergency
regulations implementing this section no later than July 1, 2015.
The department may thereafter readopt the emergency regulations
pursuant to that chapter. The adoption and readoption, by the
department, of regulations implementing this section shall be
deemed to be an emergency and necessary to avoid serious harm
to the public peace, health, safety, or general welfare for purposes
of Sections 11346.1 and 11349.6 of the Government Code, and
the department is hereby exempted from the requirement that it
describe facts showing the need for immediate action and from
review by the Office of Administrative Law.

(i) This section shall become operative on January 1, 2014.

begin delete SEC. 13. end delete
begin insert SEC. 11. end insert   

Section 14102 of the Welfare and Institutions Code,
as added by Section 25 of Chapter 4 of the First Extraordinary
Session of the Statutes of 2013, is amended to read:

14102.  

(a) Notwithstanding any other law and except as
otherwise provided in this section, any individual who is 21 years
of age or older, who does not have minor children eligible for
Medi-Cal benefits and would be eligible for Medi-Cal benefits
pursuant to Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the
federal Social Security Act (42 U.S.C. Sec.
1396a(a)(10)(A)(i)(VIII)) but for the five-year eligibility limitation
under Section 1613 of Title 8 of the United States Code, and who
is enrolled in coverage through the Exchange with an advanced
premium tax credit shall be eligible for the following:

(1) Those Medi-Cal benefits for which he or she would have
been eligible but for the five-year eligibility limitation only to the
extent that they are not available through his or her individual
health plan.

(2) The department shall pay on behalf of the beneficiary:

(A) The beneficiary’s insurance premium costs for an individual
health plan, minus the beneficiary’s premium tax credit authorized
by Section 36B of Title 26 of the United States Code and its
implementing regulations.

(B) The beneficiary’s cost-sharing charges so that the individual
has the same cost-sharing charges as he or she would have in the
Medi-Cal program.

(b) (1) If an individual is eligible for benefits under subdivision
(a) and he or she is otherwise eligible for state-only funded
full-scope benefits, but (A) he or she is barred from enrolling in
an Exchange qualified health plan because he or she is outside of
an available enrollment period for coverage or (B) the Exchange
and the department do not have the operational capability to
implement the benefits under subdivision (a), he or she shall remain
eligible for those state-only funded benefits subject to paragraph
(2).

(2) On the first date that an individual referenced in paragraph
(1) is eligible for and can enroll in coverage under a qualified
health plan offered through the Exchange, he or she shall be
ineligible for the state-only funded full-scope benefits referenced
in paragraph (1) unless the Exchange and the department do not
have the operational capability to implement the benefits under
subdivision (a).

(c) The department shall inform and assist individuals eligible
under this section on enrolling in coverage through the Exchange
with the premium assistance, cost sharing, and benefits described
in subdivision (a), including, but not limited to, developing
processes to coordinate with the county entities that administer
eligibility for coverage in Medi-Cal and the Exchange.

(d) For purposes of this section, the following definitions shall
apply:

(1) “Cost-sharing charges” means any expenditure required by
or on behalf of an enrollee by his or her individual health plan with
respect to essential health benefits and includes deductibles,
coinsurance, copayments, or similar charges, but excludes
premiums, and spending for noncovered services.

(2) “Exchange” means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.

(e) Benefits for services under this section shall be provided
with state-only funds only if federal financial participation is not
available for those services. The department shall maximize federal
financial participation in implementing this section to the extent
allowable.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations by July 1, 2015, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10321.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the
Government Code, until regulations have been adopted.

(g) This section shall become operative on January 1, 2014.

begin delete SEC. 14. end delete
begin insert SEC. 12. end insert   

Section 14132.02 of the Welfare and Institutions
Code, as added by Section 28 of Chapter 4 of the First
Extraordinary Session of the Statutes of 2013, is amended to read:

14132.02.  

(a) The department shall seek approval from the
United States Secretary of Health and Human Services to provide
individuals made eligible pursuant to Section 14005.60 with the
alternative benefit package option authorized by Section
1396u-7(b)(1)(D) of Title 42 of the United States Code. Effective
January 1, 2014, the alternative benefit package shall provide the
same schedule of benefits provided to full-scope Medi-Cal
beneficiaries qualifying under the modified adjusted gross income
standard pursuant to Section 1396a(e)(14) of Title 42 of the United
States Code, except coverage of long-term services and supports
shall be excluded unless otherwise required by Section
1396u-7(a)(2) of Title 42 of the United States Code or made
available pursuant to subdivision (b). The alternative benefit
package shall also include any benefits otherwise required by
Section 1396u-7 of Title 42 of the United States Code and any
regulations or guidance issued pursuant to that section.

(b) Notwithstanding Section 14005.64, and only to the extent
federal approval is obtained, the department shall provide coverage
for long-term services and supports to only those individuals who
meet the asset requirements imposed under the Medi-Cal program
for receipt of the services.

(c) For purposes of this section, long-term services and supports
include nursing facility services, a level of care in any institution
equivalent to nursing facility services, home- and community-based
services furnished under the state plan or a waiver under Section
1315 or 1396n of Title 42 of the United States Code, home health
services as described in Section 1396d(a)(7) of Title 42 of the
United States Code, and personal care services described in Section
1396d(a)(24) of Title 42 of the United States Code.

(d) The department may seek approval of any necessary state
plan amendments or waivers to implement this section.

(e) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
section by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations
by July 1, 2015, in accordance with the requirements of Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of
Title 2 of the Government Code. Beginning six months after the
effective date of this section, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(f) This section shall be implemented only to the extent that
federal financial participation is available and any necessary federal
approvals have been obtained.

begin delete

SEC. 15.  

Section 14148.65 is added to the Welfare and
Institutions Code, to read:

14148.65.  

(a) (1) It is the intent of the Legislature in adding
this section and Sections 14005.22 and 14148.67, to help prevent
premature delivery and low birth weights, the leading cause of
infant and maternal morbidity and mortality, and to promote
women’s overall health, well-being, and financial security, while
maximizing federal funds.

(2) It is therefore the intent of the Legislature that all Medi-Cal
eligible pregnant women with incomes up to 100 percent of the
federal poverty level are eligible for full-scope benefits through
the Medi-Cal program. In addition, the intent of the Legislature is
to maintain and not to alter, restrict, or limit Medi-Cal
comprehensive pregnancy-related benefits and services currently
available to eligible pregnant women with incomes between 100
percent and 200 percent of the federal poverty level through the
Medi-Cal program.

(3) It is further the intent of the Legislature to maximize federal
funding while making no cost health care coverage available to
pregnant women with incomes between 100 percent and 200
percent of the federal poverty level who are enrolled in a qualified
health plan through the Exchange. To this end, it is the intent of
the Legislature to enact an affordability and benefit wrap for
pregnant women within this income range within the Exchange.
The intent of the Legislature is to enact a wrap within the Exchange
that would provide pregnant women with no share of cost and
supplemental benefits so that pregnant women may receive a
benefit package equal to full-scope, comprehensive benefits that
are provided for Medi-Cal beneficiaries who are pregnant. It is
also the intent of the Legislature that no cost health coverage for
pregnant women between 100 percent and 200 percent of the
federal poverty level means providers and plans are prohibited
from requiring the women to pay any of the costs or charges of
any services, premiums, cost sharing, copayments, or any other
costs at any time. It is further the intent of the Legislature that
providers are prohibited from refusing to provide these
supplemental services to an eligible pregnant woman.

(b) By April 1, 2014, or after the department determines that
CalHEERS has been programmed for implementation of this
section, whichever is later, the department, in coordination with
the Exchange, shall implement the following option for women
eligible for Medi-Cal pregnancy-related and postpartum services
who are or will be enrolled in individual health care coverage
through the Exchange. To promote continuity of care, at the
beneficiary’s option, the department shall allow the beneficiary to
remain enrolled in her Exchange individual qualified health plan
while at the same time ensuring she receives the services and
benefits to which she is entitled as a result of her eligibility for
and enrollment in the Medi-Cal program as provided in this section.

(c) If a beneficiary is only eligible for pregnancy-related and
postpartum services under this chapter and the beneficiary is also
enrolled in coverage under a qualified health plan offered under
the Exchange, the department shall pay both of the following on
behalf of the beneficiary without the beneficiary being billed or
paying any costs for the qualified health plan:

(1) The beneficiary’s premium costs for Exchange coverage,
minus the beneficiary’s premium tax credit authorized by Section
36B of Title 26 of the United States Code and its implementing
regulations, during the beneficiary’s period of eligibility for
pregnancy-related and postpartum services under this chapter.

(2) The beneficiary’s cost sharing for benefits and services under
the Exchange qualified health plan during the beneficiary’s period
of eligibility for pregnancy-related and postpartum services under
this chapter.

(d) The department shall provide beneficiaries who are receiving
benefits under subdivision (c) with only those Medi-Cal benefits
for pregnancy-related and postpartum services that are covered
under the State Plan and that are not available through the
beneficiary’s qualified health plan.

(e) Beneficiaries shall have the right to access Medi-Cal
providers through the Medi-Cal program that are not contracting
with the Exchange qualified health plan as required under state
and federal laws for services that are not available through the
beneficiary’s qualified health plan including, but not limited to,
the right to access Comprehensive Perinatal Services Program
(CPSP) Medi-Cal providers and perinatal specialists, to the extent
services provided by the CPSP providers and perinatal specialists
are not covered by the beneficiary’s qualified health plan.

(f) For purposes of this section, the following definitions shall
apply:

(1) “Beneficiary” means a woman eligible for Medi-Cal
pregnancy-related and postpartum services.

(2) “CalHEERS” means the California Healthcare Eligibility,
Enrollment, and Retention System developed under Section 15926.

(3) “Cost sharing” means the expenditures required by or on
behalf of the beneficiary by her qualified health plan with respect
to essential health benefits and includes deductibles, coinsurance,
copayments, and similar charges, but excludes premiums, and
spending by an eligible beneficiary for benefits or services not
covered by the qualified health plan.

(4) “Exchange” means the California Health Benefit Exchange
established in Title 22 (commencing with Section 100500) of the
Government Code.

(5) “Postpartum services” means those services and benefits
provided during a postpartum period under Section 14005.18.

(g) The department shall consult with the Exchange, Exchange
contracting qualified health plans, and stakeholders, including
consumer advocates and counties, in the implementation of all of
the following:

(1) The development of processes and procedures to inform
beneficiaries and applicants how they can receive the benefits and
services covered through the Exchange coverage and how they
can receive benefits and services under this section.

(2) The development of a simple process for a woman eligible
for the Medi-Cal program based on pregnancy to exercise the
option to remain in or enroll in Exchange coverage and receive
Medi-Cal coverage for pregnancy-related and postpartum services
not covered by the beneficiary’s Exchange qualified health plan
and related assistance for premiums and cost sharing as outlined
in subdivision (c). The process and all options shall be made known
and available to women at the time of applying to the Medi-Cal
program and the Exchange and during their enrollment in Medi-Cal
or Exchange coverage, as applicable.

(3) The development of standardized notices and procedures
that are designed to inform women applying for the Medi-Cal
program and individuals applying for or enrolled in the Exchange
of the option and the process for eligible women to remain enrolled
in Exchange coverage and receive Medi-Cal pregnancy-related
and postpartum coverage under this section.

(4) The development of provider notices to ensure that Medi-Cal
providers are aware of the Medi-Cal pregnancy program for women
enrolled in the Exchange and that providers comply with state and
federal laws applicable to Medi-Cal pregnancy coverage for women
who exercise the option to remain in Exchange coverage.

(h) In addition, the department shall consult with the Exchange
and Exchange contracting qualified health plans in the
implementation of both of the following:

(1) The department shall pay qualified health plans the portion
of the premium for Exchange coverage that would be owed by
beneficiaries under this section if they were enrolled in a qualified
health plan and not Medi-Cal.

(2) The department shall pay qualified health plans for
reductions in beneficiary cost sharing under this section. The
department shall, to the extent feasible, establish processes and
procedures for qualified health plans to report, claim, and receive
reimbursement for the cost-sharing reductions consistent with the
federal process for qualified health plans to report, claim, and
receive federal reimbursement for cost-sharing reductions provided
to Exchange enrollees under 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) and any subsequent amendments.

(i) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations codifying any previous guidance issued by
July 1, 2015, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code. Beginning six months after the effective
date of this section, notwithstanding Section 10321.5 of the
Government Code, the department shall provide a status report to
the Legislature on a semiannual basis, in compliance with Section
9795 of the Government Code, until regulations have been adopted.

(j) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

SEC. 16.  

Section 14148.67 is added to the Welfare and
Institutions Code, to read:

14148.67.  

(a) When implementing the premium and
cost-sharing payments required under Sections 14102 and
14148.65, the department shall make the premium and cost-sharing
payments required under those sections to the beneficiary’s
qualified health plan in conformity with the requirements of this
section and the requirements of subdivision (h) of Section
14148.65.

(b) (1) The beneficiary shall not be required to make any
premium or cost-sharing payments to his or her qualified health
plan or service provider for any services that are subject to premium
or cost-sharing payments under Section 14102 or 14148.65.

(2) If the beneficiary makes any premium or cost-sharing
payments to his or her plan for services that are subject to premium
or cost-sharing payments under Section 14102 or 14148.65 the
department shall reimburse the beneficiary for those payments.

(3) If as a result of reconciliation in a tax year where the
beneficiary was eligible for covered premium payments under
Section 14102 or 14148.65 the beneficiary owes and makes a tax
payment to the federal government to return a portion of the
advanced premium tax credit to which the beneficiary was not
entitled and the beneficiary notifies the department, the department
shall reimburse the beneficiary for the amount of the tax payment
related to the tax credits for covered premium payments under
Section 14102 or 14148.65.

(c) (1) Except as provided in paragraph (2), beneficiaries who
are eligible for benefits under Section 14102 or 14148.65 shall be
eligible for the premium and cost-sharing payments required under
those sections only up to the amount necessary to pay for the
second lowest silver level plan in his or her qualified health plan
pricing region, as modified by cost-sharing reductions.

(2) If a beneficiary wants to select or remain in a metal level
plan that is more expensive than the metal level plan amount limit
required under paragraph (1), the beneficiary may select or remain
in that plan only if he or she agrees to be responsible for paying
all applicable premium and cost-sharing charges that are in excess
of what is covered by the department. The department shall not
be responsible for paying for any premium or cost sharing that is
in excess of the metal level plan amount limit required under
paragraph (1).

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations by July 1, 2015, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, notwithstanding
Section 10321.5 of the Government Code, the department shall
provide a status report to the Legislature on a semiannual basis,
in compliance with Section 9795 of the Government Code, until
regulations have been adopted.

(e) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

end delete

begin delete SEC. 17. end delete
begin insert SEC. 13. end insert   

Section 14154 of the Welfare and Institutions Code
is amended to read:

14154.  

(a) (1) The department shall establish and maintain a
plan whereby costs for county administration of the determination
of eligibility for benefits under this chapter will be effectively
controlled within the amounts annually appropriated for that
administration. The plan, to be known as the County Administrative
Cost Control Plan, shall establish standards and performance
criteria, including workload, productivity, and support services
standards, to which counties shall adhere. The plan shall include
standards for controlling eligibility determination costs that are
incurred by performing eligibility determinations at county
hospitals, or that are incurred due to the outstationing of any other
eligibility function. Except as provided in Section 14154.15,
reimbursement to a county for outstationed eligibility functions
shall be based solely on productivity standards applied to that
county’s welfare department office.

(2) (A) The plan shall delineate both of the following:

(i) The process for determining county administration base costs,
which include salaries and benefits, support costs, and staff
development.

(ii) The process for determining funding for caseload changes,
cost-of-living adjustments, and program and other changes.

(B) The annual county budget survey document utilized under
the plan shall be constructed to enable the counties to provide
sufficient detail to the department to support their budget requests.

(3) The plan shall be part of a single state plan, jointly developed
by the department and the State Department of Social Services, in
conjunction with the counties, for administrative cost control for
the California Work Opportunity and Responsibility to Kids
(CalWORKs), CalFresh, and Medical Assistance (Medi-Cal)
programs. Allocations shall be made to each county and shall be
limited by and determined based upon the County Administrative
Cost Control Plan. In administering the plan to control county
administrative costs, the department shall not allocate state funds
to cover county cost overruns that result from county failure to
meet requirements of the plan. The department and the State
Department of Social Services shall budget, administer, and
allocate state funds for county administration in a uniform and
consistent manner.

(4) The department and county welfare departments shall
develop procedures to ensure the data clarity, consistency, and
reliability of information contained in the county budget survey
document submitted by counties to the department. These
procedures shall include the format of the county budget survey
document and process, data submittal and its documentation, and
the use of the county budget survey documents for the development
of determining county administration costs. Communication
between the department and the county welfare departments shall
be ongoing as needed regarding the content of the county budget
surveys and any potential issues to ensure the information is
complete and well understood by involved parties. Any changes
developed pursuant to this section shall be incorporated within the
state’s annual budget process by no later than the 2011-12 fiscal
year.

(5) The department shall provide a clear narrative description
along with fiscal detail in the Medi-Cal estimate package, submitted
to the Legislature in January and May of each year, of each
component of the county administrative funding for the Medi-Cal
program. This shall describe how the information obtained from
the county budget survey documents was utilized and, where
applicable, modified and the rationale for the changes.

(6) Notwithstanding any other law, the department shall develop
and implement, in consultation with county program and fiscal
representatives, a new budgeting methodology for Medi-Cal county
administrative costs that reflects the impact of PPACA
implementation on county administrative work. The new budgeting
methodology shall be used to reimburse counties for eligibility
processing and case maintenance for applicants and beneficiaries.

(A) The budgeting methodology may include, but is not limited
to, identification of the costs of eligibility determinations for
applicants, and the costs of eligibility redeterminations and case
maintenance activities for recipients, for different groupings of
cases, based on variations in time and resources needed to conduct
eligibility determinations. The calculation of time and resources
shall be based on the following factors: complexity of eligibility
rules, ongoing eligibility requirements, and other factors as
determined appropriate by the department. The development of
the new budgeting methodology may include, but is not limited
to, county survey of costs, time and motion studies, in-person
observations by department staff, data reporting, and other factors
deemed appropriate by the department.

(B) The new budgeting methodology shall be clearly described,
state the necessary data elements to be collected from the counties,
and establish the timeframes for counties to provide the data to
the state.

(C) The new budgeting methodology developed pursuant to this
paragraph shall be implemented no sooner than the 2015-16 fiscal
year. The department may develop a process for counties to phase
in the requirements of the new budgeting methodology.

(D) The department shall provide the new budgeting
methodology to the legislative fiscal committees by March 1 of
the fiscal year immediately preceding the first fiscal year of
implementation of the new budgeting methodology.

(E) To the extent that the funding for the county budgets
developed pursuant to the new budget methodology is not fully
appropriated in any given fiscal year, the department, with input
from the counties, shall identify and consider options to align
funding and workload responsibilities.

(F) For purposes of this paragraph, “PPACA” means 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) and any
subsequent amendments.

(G) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
paragraph by means of all-county letters, plan letters, plan or
provider bulletins, or similar instructions until the time any
necessary regulations are adopted. The department shall adopt
regulations by July 1, 2015, in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. Beginning six
months after the implementation of the new budgeting methodology
pursuant to this paragraph, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.

(b) Nothing in this section, Section 15204.5, or Section 18906
shall be construed so as to limit the administrative or budgetary
responsibilities of the department in a manner that would violate
Section 14100.1, and thereby jeopardize federal financial
participation under the Medi-Cal program.

(c) (1) The Legislature finds and declares that in order for
counties to do the work that is expected of them, it is necessary
that they receive adequate funding, including adjustments for
reasonable annual cost-of-doing-business increases. The Legislature
further finds and declares that linking appropriate funding for
county Medi-Cal administrative operations, including annual
cost-of-doing-business adjustments, with performance standards
will give counties the incentive to meet the performance standards
and enable them to continue to do the work they do on behalf of
the state. It is therefore the Legislature’s intent to provide
appropriate funding to the counties for the effective administration
of the Medi-Cal program at the local level to ensure that counties
can reasonably meet the purposes of the performance measures as
contained in this section.

(2) It is the intent of the Legislature to not appropriate funds for
the cost-of-doing-business adjustment for the 2008-09, 2009-10,
2010-11, 2011-12, and 2012-13 fiscal years.

(d) The department is responsible for the Medi-Cal program in
accordance with state and federal law. A county shall determine
Medi-Cal eligibility in accordance with state and federal law. If
in the course of its duties the department becomes aware of
accuracy problems in any county, the department shall, within
available resources, provide training and technical assistance as
appropriate. Nothing in this section shall be interpreted to eliminate
any remedy otherwise available to the department to enforce
accurate county administration of the program. In administering
the Medi-Cal eligibility process, each county shall meet the
following performance standards each fiscal year:

(1) Complete eligibility determinations as follows:

(A) Ninety percent of the general applications without applicant
errors and are complete shall be completed within 45 days.

(B) Ninety percent of the applications for Medi-Cal based on
disability shall be completed within 90 days, excluding delays by
the state.

(2) (A) The department shall establish best-practice guidelines
for expedited enrollment of newborns into the Medi-Cal program,
preferably with the goal of enrolling newborns within 10 days after
the county is informed of the birth. The department, in consultation
with counties and other stakeholders, shall work to develop a
process for expediting enrollment for all newborns, including those
born to mothers receiving CalWORKs assistance.

(B) Upon the development and implementation of the
best-practice guidelines and expedited processes, the department
and the counties may develop an expedited enrollment timeframe
for newborns that is separate from the standards for all other
applications, to the extent that the timeframe is consistent with
these guidelines and processes.

(3) Perform timely annual redeterminations, as follows:

(A) Ninety percent of the annual redetermination forms shall
be mailed to the recipient by the anniversary date.

(B) Ninety percent of the annual redeterminations shall be
completed within 60 days of the recipient’s annual redetermination
date for those redeterminations based on forms that are complete
and have been returned to the county by the recipient in a timely
manner.

(C) Ninety percent of those annual redeterminations where the
redetermination form has not been returned to the county by the
recipient shall be completed by sending a notice of action to the
recipient within 45 days after the date the form was due to the
county.

(D) When a child is determined by the county to change from
no share of cost to a share of cost and the child meets the eligibility
criteria for the Healthy Families Program established under Section
12693.98 of the Insurance Code, the child shall be placed in the
Medi-Cal-to-Healthy Families Bridge Benefits Program, and these
cases shall be processed as follows:

(i) Ninety percent of the families of these children shall be sent
a notice informing them of the Healthy Families Program within
five working days from the determination of a share of cost.

(ii) Ninety percent of all annual redetermination forms for these
children shall be sent to the Healthy Families Program within five
working days from the determination of a share of cost if the parent
has given consent to send this information to the Healthy Families
Program.

(iii) Ninety percent of the families of these children placed in
the Medi-Cal-to-Healthy Families Bridge Benefits Program who
have not consented to sending the child’s annual redetermination
form to the Healthy Families Program shall be sent a request,
within five working days of the determination of a share of cost,
to consent to send the information to the Healthy Families Program.

(E) Subparagraph (D) shall not be implemented until 60 days
after the Medi-Cal and Joint Medi-Cal and Healthy Families
applications and the Medi-Cal redetermination forms are revised
to allow the parent of a child to consent to forward the child’s
information to the Healthy Families Program.

(e) The department shall develop procedures in collaboration
with the counties and stakeholder groups for determining county
review cycles, sampling methodology and procedures, and data
reporting.

(f) On January 1 of each year, each applicable county, as
determined by the department, shall report to the department on
the county’s results in meeting the performance standards specified
in this section. The report shall be subject to verification by the
department. County reports shall be provided to the public upon
written request.

(g) If the department finds that a county is not in compliance
with one or more of the standards set forth in this section, the
county shall, within 60 days, submit a corrective action plan to the
department for approval. The corrective action plan shall, at a
minimum, include steps that the county shall take to improve its
performance on the standard or standards with which the county
is out of compliance. The plan shall establish interim benchmarks
for improvement that shall be expected to be met by the county in
order to avoid a sanction.

(h) (1) If a county does not meet the performance standards for
completing eligibility determinations and redeterminations as
specified in this section, the department may, at its sole discretion,
reduce the allocation of funds to that county in the following year
by 2 percent. Any funds so reduced may be restored by the
department if, in the determination of the department, sufficient
improvement has been made by the county in meeting the
performance standards during the year for which the funds were
reduced. If the county continues not to meet the performance
standards, the department may reduce the allocation by an
additional 2 percent for each year thereafter in which sufficient
improvement has not been made to meet the performance standards.

(2) No reduction of the allocation of funds to a county shall be
imposed pursuant to this subdivision for failure to meet
performance standards during any period of time in which the
cost-of-doing-business increase is suspended.

(i) The department shall develop procedures, in collaboration
with the counties and stakeholders, for developing instructions for
the performance standards established under subparagraph (D) of
paragraph (3) of subdivision (d), no later than September 1, 2005.

(j) No later than September 1, 2005, the department shall issue
a revised annual redetermination form to allow a parent to indicate
parental consent to forward the annual redetermination form to
the Healthy Families Program if the child is determined to have a
share of cost.

(k) The department, in coordination with the Managed Risk
Medical Insurance Board, shall streamline the method of providing
the Healthy Families Program with information necessary to
determine Healthy Families eligibility for a child who is receiving
services under the Medi-Cal-to-Healthy Families Bridge Benefits
Program.

(l) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
and except as provided in subparagraph (G) of paragraph (6) of
subdivision (a), the department shall, without taking any further
regulatory action, implement, interpret, or make specific this
section and any applicable federal waivers and state plan
amendments by means of all-county letters or similar instructions.

begin delete SEC. 18. end delete
begin insert SEC. 14. end insert   

Section 15926 of the Welfare and Institutions Code,
as amended by Section 26 of Chapter 3 of the First Extraordinary
Session of the Statutes of 2013, 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) “Insurance affordability program” means a program that is
one of the following:

(A) The Medi-Cal program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.).

(B) The state’s children’s health insurance program (CHIP)
under Title XXI of the federal Social Security Act (42 U.S.C. Sec.
1397aa et seq.).

(C) A program that makes available to qualified individuals
coverage in a qualified health plan through the California Health
Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code with advance
payment of the premium tax credit established under Section 36B
of the Internal Revenue Code.

(4) A program that makes available coverage in a qualified
health plan through the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500)
of the Government Code with cost-sharing reductions established
under Section 1402 of PPACA and any subsequent amendments
to that act.

(b) An individual shall have the option to apply for insurance
affordability 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 insurance affordability 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 insurance affordability programs and
by their agents.

(2) The department may develop and require the use of
supplemental forms to collect additional information needed to
determine eligibility on a basis other than the financial
methodologies described in Section 1396a(e)(14) of Title 42 of
the United States Code, as added by the federal Patient Protection
and Affordable Care Act (Public Law 111-148), and as amended
by the federal Health Care and Education Reconciliation Act of
2010 (Public Law 111-152) and any subsequent amendments, as
provided under Section 435.907(c) of Title 42 of the Code of
Federal Regulations.

(3) The application shall be tested and operational by the date
as required by the federal Secretary of Health and Human Services.

(4) 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 insurance affordability
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 an insurance affordability 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.

(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.

(ii) 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.

(G) Until January 1, 2016, the department shall instruct counties
to not reject an application that was in existence prior to January
1, 2014, but to accept the application and request any additional
information needed from the applicant in order to complete the
eligibility determination process. The department shall work with
counties and consumer advocates to develop the supplemental
questions.

(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
insurance affordability programs or other health programs that
differs from the application form described in subdivision (c), and
related enrollment procedures. Nothing in this section shall
preclude the use of a joint application, developed by the department
and the State Department of Social Services, that allows for an
application to be made for multiple programs, including, but not
limited to, CalWORKs, CalFresh, and insurance affordability
programs.

(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 insurance affordability 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 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 insurance affordability programs may accept
self-attestation, instead of requiring an individual to produce a
document, for age, date of birth, family size, household income,
state residence, pregnancy, and any other applicable criteria 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 and state law.

(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 beyond
the timeliness standards as provided in Section 435.912 of Title
42 of the Code of Federal Regulations or denied for any insurance
affordability 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 insurance affordability 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 an insurance affordability program in person, over the
telephone, by mail, online, or through other commonly available
electronic means 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 an insurance affordability program
shall ensure that an eligible applicant and recipient of insurance
affordability 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 an insurance affordability 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, mail, and online renewal or renewal
through other commonly available electronic means.

(4) An applicant who is not eligible for an insurance affordability
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 insurance affordability 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 January 1, 2014.

begin delete

SEC. 19.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.

end delete

begin insert

begin insert SEC. 15. end insert   

end insert begin insert

If the Commission on State Mandates determines that
this act contains costs mandated by the state, reimbursement to
local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division
4 of Title 2 of the Government Code.

end insert

begin delete SEC. 20. end delete
begin insert SEC. 16. end insert   

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.