BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 50
AUTHOR: Pan
AMENDED: August 15, 2013
HEARING DATE: August 21, 2013
CONSULTANT: Bain
SUBJECT : Medi-Cal: eligibility: pregnancy-related and postpartum
services. Urgency
SUMMARY : Expands the benefit package to Medi-Cal-eligible
pregnant women with family incomes under 100 percent of the
federal poverty level to full scope Medi-Cal benefits. Permits
the Department of Health Care Services to initially implement
specified Medi-Cal provisions of the recently enacted AB X1 1
(John A. Perez), Chapter 3, Statutes of 2013-14, and SB X1 1
(Hernandez and Steinberg), Chapter 4, Statutes of 2013-14, by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions, followed by a requirement
that Department of Health Care Services adopt regulations by
July 1, 2015. Requires, by January 1, 2015, the CalHEERS
application form for Medi-Cal and Covered California coverage,
to include questions that are voluntary for applicants to answer
on applicant demographics.
Existing law:
1.Establishes the Medi-Cal program, which is administered by
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2.Requires DHCS to provide Medi-Cal eligibility to pregnant
women and infants with family incomes up to 200 percent, of
the federal poverty level (FPL). The scope of Medi-Cal
benefits provided to pregnant women (full scope benefits
versus pregnancy-only benefits) depends upon several factors,
including her income, immigration status, assets, and whether
she is otherwise Medi-Cal eligible.
3.Requires DHCS to develop and implement, in consultation with
county program and fiscal representatives, a new budgeting
methodology for Medi-Cal county administrative costs. Requires
the new budgeting methodology be used to reimburse counties
for eligibility determinations for applicants and
beneficiaries, including one-time eligibility processing and
Continued---
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ongoing case maintenance. Requires DHCS to provide the new
budgeting methodology to the legislative fiscal committees by
March 1, 2012, and permits inclusion of the methodology in the
May 2012 Medi-Cal Local Assistance Estimate for the 2012-13
fiscal year and each fiscal year thereafter.
4.Requires a single, accessible, standardized paper, electronic,
and telephone application for insurance affordability programs
be developed by DHCS in consultation with the Managed Risk
Medical Insurance Board and the Covered California board.
Requires the application to be used by all entities authorized
to make an eligibility determination for any of the insurance
affordability programs and by their agents.
5.Permits 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 (HHS) under a specified
provision of the Affordable Care Act (ACA).
This bill:
1.Makes women with income less than 100 percent of the FPL
eligible for full scope Medi-Cal benefits under a specified
provision of federal and if she meets all other eligibility
requirements. Implements this provision only if and to the
extent that federal financial participation is available and
any necessary federal approvals have been obtained.
2.Permits DHCS to implement the below-listed provisions of the
recently enacted Medi-Cal-related provisions implementing the
ACA of AB X1 1 and SB X1 1 by means of all-county letters,
plan letters, plan or provider bulletins, or similar
instructions until the time any necessary regulations are
adopted. Requires DHCS to adopt regulations by July 1, 2015,
in accordance with the requirements of the rulemaking
requirements of the Administrative Procedure Act. Requires
DHCS to provide a status report to the Legislature on a
semiannual basis until regulations have been adopted.
a. The Medi-Cal expansion to former foster youth
up to age 26;
b. The requirements involving Medi-Cal
eligibility redeterminations and termination of
benefits (known as "SB 87" after the implementing
statute);
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c. The implementation of the adoption of a
different income counting methodology using Modified
Adjusted Gross Income in Medi-Cal, the elimination of
the asset test, the elimination of the deprivation
requirement and the implementation of a specified
ACA-required Medicaid maintenance of effort
eligibility requirement;
d. The provision of Medi-Cal benefits during a
presumptive eligibility period who have been
determined eligible by a qualified hospital in
accordance with a specified provision of federal law
enacted by the ACA;
e. The requirement that DHCS and any other
governmental agencies determining eligibility for, or,
enrollment in Medi-Cal or any other program
administered by DHCS, and Covered California share
information with each other as necessary to perform
their respective statutory and regulatory duties under
state and federal law;
f. The implementation of the benefit and
affordability wrap for legal immigrant adults who are
not eligible for Medi-Cal benefits because of the five
year federal bar;
g. The implementation of the Medi-Cal benefit
package for the Medicaid expansion population; and,
h. The implementation of the new budgeting
methodology for Medi-Cal county administrative costs.
3.Permits, rather than requires under existing law, the
budgeting methodology for county Medi-Cal eligibility
determination to include specified costs. Requires the new
budgeting methodology to be implemented no sooner than the
2015-16 fiscal year, to reflect the impact of ACA
implementation on county administrative work, and to be
provided to the legislative fiscal committees by March 1 of
the fiscal year immediately preceding the first fiscal year of
implementation.
4.Permits, until January 1, 2015, the California Healthcare
Eligibility, Enrollment, and Retention System (CalHEERS)
application form for Medi-Cal and Covered California coverage
to include additional questions that are voluntary for
applicants to answer on sexual orientation and gender identity
or expression.
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5.Requires, by January 1, 2015, the CalHEERS application form to
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 HHS.
6.Requires the training of "individuals, including county human
services staff," (instead of "specialized county employees")
in carrying out a DHCS program, to provide information and
assistance to Medi-Cal beneficiaries to understand and
successfully use the services of Medi-Cal managed care plans.
7.Makes other clarifying changes to the recently the recently
enacted Medi-Cal-related provisions implementing the ACA in AB
X1 1 and SB X1 1.
FISCAL EFFECT : The current version of this bill has not been
analyzed by a fiscal committee.
PRIOR VOTES : Not relevant
COMMENTS :
1.Author's statement. According to the author, AB 50 is needed
to supplement AB X1 1 and SB X1 1 by providing DHCS with
time-limited authority to use all county letters or similar
instructions to implement many of the recent Medi-Cal changes,
but requiring the adoption of regulations by a date certain so
as to ensure public input, clear program rules and
accountability in implementation of the Medi-Cal changes. In
addition, this bill would require DHCS to provide full-scope
coverage to pregnant women in Medi-Cal to promote women's
overall health, well-being and financial security, instead of
pregnancy-only coverage for certain women under existing law.
AB 50 also requires the CalHEERS application for Medi-Cal and
Covered California to ask demographic questions that are
voluntary for applicants to answer, beginning in 2015. The
author states that, in order to meet the requirements of the
ACA and for the new enrollment system to be operational by
October 1, 2013, a decision was made to omit these items from
the initial system design. However, the author argues, this
demographic information will be crucial and therefore should
begin to be collected in the future. The author points out
that it will be needed to assess whether outreach and
enrollment strategies to target certain populations are
needed. This data will also be crucial in identifying and
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reducing health disparities. Finally, this bill contains
changes to the county budgeting methodology for eligibility
determinations agreed to by DHCS and the County Welfare
Directors Association.
2.Medi-Cal benefits for low-income pregnant women. State law
requires Medi-Cal to cover pregnant women without a share of
cost with incomes below 200 percent of the FPL. However, the
scope of coverage a woman receives (full scope Medi-Cal
coverage versus Medi-Cal coverage for pregnancy-only services)
depends upon her income, immigration status, assets, and
whether she meets other criteria (for example, a pregnant
woman can only receive full scope coverage if she has
"linkage" to Medi-Cal for specified reasons). DHCS indicates a
low-income pregnant woman in her first or second trimester
with income between 59 and 100 percent of the FPL is eligible
for pregnancy only Medi-Cal coverage and does not qualify for
full-scope Medi-Cal unless she is otherwise linked to Medi-Cal
(such as being on CalWORKS) until she reaches her third
trimester.
Under federal law, the Medicaid expansion to single adults up to
138 percent of the FPL does not include women who are pregnant
at the time of application. AB X1 1 and SB X1 1 originally
proposed to provide full scope Medi-Cal coverage to pregnant
women up to 200 percent of the FPL, but these provisions were
removed from the final legislative package so that additional
time could be given to instead provide a benefit and
affordability wrap for pregnant women with incomes between 100
and 200 percent of the FPL who are currently eligible for
pregnancy-only Medi-Cal and who may also be eligible for
premium and cost-sharing subsidies in Covered California. The
benefit and affordability wrap contained in this bill is being
removed from this measure as proposed to be amended following
stakeholder objection.
Under this bill, women who are citizens or legal immigrants with
family incomes below 100 of the FPL (effectively, women with
incomes between 59 percent and 100 percent of the FPL or
income between $11,523 and $19,530 for a family of three in
2013) would be eligible for full-scope Medi-Cal coverage. This
would address an anomaly in the federal Medicaid expansion
that provides single adult women and men with broader coverage
than would be provided to pregnant women who are currently
eligible for pregnancy-only services.
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3.DHCS use of provider bulletins followed by regulations. The
use of provider bulletins in lieu of regulations has been an
on-going issue of dispute between the Legislature and DHCS.
While the Legislature has authorized the exemption from the
rule-making provisions of the Administrative Procedure Act.
(APA) when urgent action is needed (such as to immediately
implement budget savings proposals) or for ease of program
implementation, the requirements set forth in the APA are
designed to provide the public with a meaningful opportunity
to participate in the adoption of state regulations and to
ensure that regulations are clear, necessary and legally
valid, and broadly available to the public. In addition, many
Medi-Cal policies and program rules are contained in statute,
all-county letters and regulations, making it difficult to
discern the complex eligibility and related requirements for
this program. This bill adopts a compromise in initially
allowing the Medi-Cal-related health reform provisions to be
adopted by all-county letters or similar instructions but
requires the adoption of regulations by July 1, 2015.
4.Medi-Cal county budgeting methodology changes. County social
service departments determine Medi-Cal eligibility on behalf
of the state. DHCS is responsible for determining allocation
for funding county social service costs associated with
Medi-Cal eligibility determinations. AB 102 (Committee on
Budget), Chapter 29, Statutes of 2011, required DHCS to
develop and implement a new budgeting methodology for Medi-Cal
county administrative costs. This bill makes changes to those
provisions agreed to by the County Welfare Directors
Association and DHCS, including requiring the budgeting
methodology to reflect the impact of ACA implementation on
county administrative work, and requiring the methodology be
implemented no sooner than the 2015-16 fiscal year.
5.Prior legislation.
a. SB 900 (Alquist), Chapter 659, Statutes of 2010,
establishes Covered California as an independent public
entity within state government, and requires Covered
California to be governed by a board composed of the
Secretary of California Health and Human Services Agency,
or his or her designee, and four other members appointed by
the Governor and the Legislature who meet specified
criteria.
b. AB 1602 (John A. P�rez), Chapter 655, Statutes of 2010,
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specifies the powers and duties of Covered California
relative to determining eligibility for enrollment in the
Covered California and arranging for coverage under
qualified health plans, requires Covered California to
provide health plan products in all five of the federal
benefit levels (platinum, gold, silver, bronze and
catastrophic), requires health plans participating in
Covered California to sell at least one product in all five
benefit levels in Covered California, requires health plans
participating in Covered California to sell their Covered
California products outside of Covered California, and
requires health plans that do not participate in the
Covered California to sell at least one standardized
product designated by the Covered California in each of the
four levels of coverage, if Covered California elects to
standardize products.
c. AB 1296 (Bonilla), Chapter 641, Statutes of 2011, the
Health Care Eligibility, Enrollment, and Retention Act,
requires the California Health and Human Services Agency,
in consultation with other state departments and
stakeholders, to undertake a planning process to develop
plans and procedures regarding these provisions relating to
enrollment in state health programs and federal law. AB
1296 also established the requirements for the CalHEERS
application form.
6.Proposed author's amendments. The author is proposing to
remove Sections 1, 2, 15 and 16 from this bill as amended on
August 15, 2013, which would delete provisions establishing a
benefit and affordability wrap for pregnant women with incomes
between 100 and 200 percent of the FPL.
7.Support. Groups representing health care providers,
low-income consumers and women's health advocates, such as the
American Congress of Obstetricians and Gynecologists, write in
support of the expansion to 100 percent of the FPL but would
argue this expansion should also apply to women with incomes
up to 138 percent of FPL. In addition, these groups seek
amendments to change the pregnancy benefit and cost-sharing
wrap provisions that are being removed from this bill. Since
these provisions are being removed from the bill, the current
position of these groups is unknown.
.
8.Opposition. The California Primary Care Association (CPCA)
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writes that it is opposed unless amended and seeks changes to
the provisions being removed from this bill by the proposed
author's amendments, and because the bill does not contain a
provision entitling newly qualified immigrants to full-scope
Medi-Cal benefits, including Federally Qualified Health
Centers (FQHC) services provided at the enhanced FQHC Medi-Cal
rate. Because these provisions are being removed from the bill
or were not in the bill to begin with, the current position of
CPCA is unknown.
9.Recommended amendments. This bill permits DHCS to implement
the expansion of Medi-Cal coverage for pregnant women with
incomes below 100 percent of the FPL through the use of
provider bulletins but does not specify a date by which
regulations must be adopted consistent with the other
provisions of this bill. In addition, staff recommends that
the Medi-Cal pregnancy related benefits include the phrase
"full scope" to clarify the intent of this section.
SUPPORT AND OPPOSITION :
Positions below are based on the August 15, 2013 version of this
bill; the author is removing the benefit and affordability wrap
that many groups commented on, sought changes to, and were the
principle basis for their amendments and position on the
measure.
Support: Planned Parenthood Affiliates of California (and
seeks amendments)
Western Center on Law & Poverty (and seeks
amendments)
Support if amended:American Congress of Obstetricians and
Gynecologists
California Nurse-Midwives Association
Maternal and Child Health Access
National Health Law Program
National Organization for Women California
Oppose: California Primary Care Association (unless
amended)
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