Amended in Senate June 14, 2013

Amended in Senate June 4, 2013

California Legislature—2013–14 First Extraordinary Session

Assembly BillNo. 1


Introduced by Assembly Member John A. Pérez

(Coauthors: Assembly Members Alejo, Blumenfield, Bocanegra, Campos, Eggman, Garcia, Gomez,begin delete Hernandez,end deletebegin insert Roger end insertbegin insertHernández,end insert Pan, V. Manuel Pérez, and Quirk-Silva)

(Coauthors: Senators Calderon, Correa, De León, Hueso, and Lara)

January 28, 2013


An act to amend Section 12698.30 of the Insurance Code, and to amend Sectionsbegin delete 14005.36, 14005.39, 14132,end deletebegin insert 14005.36end insert and 15926 of, to amend and repeal Sections 14005.38,begin delete 14008.85,end delete 14011.16,begin delete andend delete 14011.17begin insert, and 14012end insert of, to amend, repeal, and add Sectionsbegin delete 14005.18, 14005.28, 14005.30, 14005.31, 14005.32, 14005.37, 14007.1, 14007.6, and 14012end deletebegin insert 14005.30, 14005.37, 14016.5, and 14016.6end insert of, to add Sectionsbegin delete 14000.7, 14005.60, 14005.62,14005.63, 14005.64, 14005.65, 14007.15, 14014.5,end deletebegin insert 14005.60, 14005.61, 14005.64, 14013.3,end insert 14015.7,begin insert 14015.8,end insert 14055,begin delete 14057, 14102,end delete 14102.5, andbegin delete 14132.02end deletebegin insert 14103end insert to, and to add and repeal Section 14015.5 of, the Welfare and Institutions Code, relating to health.

LEGISLATIVE COUNSEL’S DIGEST

AB 1, as amended, John A. Pérez. Medi-Cal: eligibility.

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

This bill would, commencing January 1, 2014, implement various provisions of the federal Patient Protection and Affordable Care Act (Affordable Care Act), as amended, by, among other things, modifying provisions relating to determining eligibility for certain groups. The bill would, in this regard, extend Medi-Cal eligibility to specified adultsbegin delete and former foster childrenend delete and would require that income eligibility be determined based on modified adjusted gross income (MAGI), as prescribed. The bill would prohibit the use of an asset or resources test for individuals whose financial eligibility for Medi-Cal is determined based on the application of MAGI.begin delete The bill would also add, commencing January 1, 2014, benefits, services, and coverage included in the essential health benefits package, as adopted by the state and approved by the United States Secretary of Health and Human Services, to the schedule of Medi-Cal benefits.end deletebegin insert The bill would require that individuals who are enrolled in the Low Income Health Program as of December 31, 2013, under a specified waiver who are at or below 133% of the federal poverty level be transitioned directly to the Medi-Cal program, as prescribed. The bill would provide that the implementation of the optional expansion of Medi-Cal benefits to adults who meet specified eligibility requirements shall be contingent on the federal medical assistance percentage (FMAP) payable to the state under the Affordable Care Act is not being reduced below specified percentages, as specified.end 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.

begin delete

This bill would require that a person who wishes to apply for an insurance affordability program, as defined, be allowed to file an application on his or her own behalf or on behalf of his or her family and would authorize a person to be accompanied, assisted, and represented in the application and renewal process by an individual or organization of his or her choice. This bill would also require the department, to the extent required by federal law, to provide assistance to any applicant or beneficiary who requests help with the application or redetermination.

end delete

The bill would require the California Health Benefit Exchange (Exchange) to implement a workflow transfer protocol, as prescribed, for persons calling the customer service center operated by the Exchange for the purpose of applying for an insurance affordability program, to ascertain which individuals are potentially eligible for Medi-Cal. This bill would also prescribe the authority the department, the Exchange, and the counties would have, until July 1, 2015, to perform Medi-Cal eligibility determinations.begin insert The bill would require the department to verify the accuracy of certain information that is provided as part of the application or redetermination process when determiningend insertbegin insert whetend insertbegin inserther an individual is eligible for Medi-Cal benefits, as prescribed. The bill would require 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 information for those purposes, and the Exchange to share specified information with each other as necessary to enable them to perform their respective statutory and regulatory duties under state and federal law.end insert

begin delete

Existing law requires the department to adopt regulations for use by the county in determining whether an applicant is a resident of the state and of the county, subject to the requirements of federal law. Existing law requires that the regulations require that state residency be established only if certain requirements are met, including the requirement that the applicant makes specified declarations under penalty of perjury.

end delete
begin delete

This bill would revise those provisions to, among other things, further prescribe the circumstances under which state residency may be established and to require the department to electronically verify an individual’s state residency using certain sources and would set forth how an individual may establish state residency if the department is unable to electronically verify his or her state residency. The bill would, for purposes of establishing state residency, authorize an individual to make various declarations under penalty of perjury, and would authorize other individuals, such as parents or legal guardians, to make various declarations under penalty of perjury regarding the individual’s state residency if the individual is incapable of indicating intent. By expanding the crime of perjury, the bill would impose a state-mandated local program.

end delete
begin insert

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

end insert
begin insert

This bill would revise these provisions to, among other things, require the department to develop a program to allow individuals or their authorized representatives to select Medi-Cal managed care plans via the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERs).

end insert

Existing law requires Medi-Cal beneficiaries, with some exceptions, to file semiannual status reports to ensure that beneficiaries make timely and accurate reports of any change in circumstance that may affect their eligibility and requires, with some exceptions, a county to promptly redetermine eligibility whenever a county receives information about changes in a beneficiary’s circumstances that may affect eligibility for Medi-Cal benefits.

This bill would, commencing January 1, 2014, revise these provisions to, among other things, delete the semiannual status report requirement and require a county to perform redeterminations every 12 months. The bill would require any forms signed by the beneficiary for purposes of redetermining eligibility to be signed under penalty of perjury. By expanding the crime of perjury, the bill would impose a state-mandated local program.

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.

This bill would provide that with regard to certain mandates no reimbursement is required by this act for a specified reason.

With regard to any other mandates, this bill would provide that, if the Commission on State Mandates determines that the bill contains costs so mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

begin insert

This bill would become operative only if SB 1 of the 2013-14 First Extraordinary Session is enacted and takes effect.

end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

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

P5    1

SECTION 1.  

The Legislature finds and declares all of the
2following:

3(a) The United States is the only industrialized country in the
4world without a universal health insurance system.

5(b) (1) In 2006, the United States Census reported that 46
6million Americans did not have health insurance.

7(2) In California in 2009, according to the UCLA Center for
8Health Policy Research’s “The State of Health Insurance in
9California: Findings from the 2009 California Health Interview
10Survey,” 7.1 million Californians were uninsured in 2009,
11amounting to 21.1 percent of nonelderly Californians who had no
12health insurance coverage for all or some of 2009, up nearly 2
13percentage points from 2007.

14(c) On March 23, 2010, President Obama signed the Patient
15Protection and Affordable Care Act (Public Law 111-148), which
16was amended by the Health Care and Education Reconciliation
17Act of 2010 (Public Law 111-152), and together are referred to as
18the Affordable Care Act of 2010 (Affordable Care Act).

19(d) The Affordable Care Act is the culmination of decades of
20movement toward health reform, and is the most fundamental
21legislative transformation of the United States health care system
22in 40 years.

23(e) As a result of the enactment of the Affordable Care Act,
24according to estimates by the UCLA Center for Health Policy
25Research and the UC Berkeley Labor Center, using the California
26Simulation of Insurance Markets, in 2019, after the Affordable
27Care Act is fully implemented:

28(1) Between 89 and 92 percent of Californians under 65 years
29of age will have health coverage.

30(2) Between 1.2 and 1.6 million individuals will be newly
31enrolled in Medi-Cal.

32(f) It is the intent of the Legislature to ensure full implementation
33of the Affordable Care Act, including the Medi-Cal expansion for
34individuals with incomes below 133 percent of the federal poverty
35level, so that millions of uninsured Californians can receive health
36care coverage.

37

SEC. 2.  

Section 12698.30 of the Insurance Code is amended
38to read:

P6    1

12698.30.  

(a) (1) Subject to paragraph (2), at a minimum,
2coverage shall be provided to subscribers during one pregnancy,
3and for 60 days thereafter, and to children less than two years of
4age who were born of a pregnancy covered under this program to
5a woman enrolled in the program before July 1, 2004.

6(2) Commencing January 1, 2014, at a minimum, coverage shall
7be provided to subscribers during one pregnancy, and until the end
8of the month in which the 60th day thereafter occurs, and to
9children less than two years of age who were born of a pregnancy
10covered under this program to a woman enrolled in the program
11before July 1, 2004.

12(b) Coverage provided pursuant to this part shall include, at a
13minimum, those services required to be provided by health care
14service plans approved by the United States Secretary of Health
15and Human Services as a federally qualified health care service
16plan pursuant to Section 417.101 of Title 42 of the Code of Federal
17Regulations.

18(c) Coverage shall include health education services related to
19tobacco use.

20(d) Medically necessary prescription drugs shall be a required
21benefit in the coverage provided under this part.

begin delete
22

SEC. 3.  

Section 14000.7 is added to the Welfare and
23Institutions Code
, to read:

24

14000.7.  

(a) The department shall provide assistance to any
25applicant or beneficiary that requests help with the application or
26redetermination process to the extent required by federal law.

27(b) The assistance provided under subdivision (a) shall be
28available to the individual in person, over the telephone, and online,
29and in a manner that is accessible to individuals with disabilities
30and those who have limited English proficiency.

31(c) To the extent otherwise required by Chapter 3.5
32(commencing with Section 11340) of Part 1 of Division 3 of Title
332 of the Government Code, the department shall adopt emergency
34regulations implementing this section no later than July 1, 2015.
35The department may thereafter readopt the emergency regulations
36pursuant to that chapter. The adoption and readoption, by the
37department, of regulations implementing this section shall be
38deemed to be an emergency and necessary to avoid serious harm
39to the public peace, health, safety, or general welfare for purposes
40of Sections 11346.1 and 11349.6 of the Government Code, and
P7    1the department is hereby exempted from the requirement that it
2describe facts showing the need for immediate action and from
3review by the Office of Administrative Law.

4(d) This section shall be implemented only if and to the extent
5that federal financial participation is available and any necessary
6federal approvals have been obtained.

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

8

SEC. 4.  

Section 14005.18 of the Welfare and Institutions Code
9 is amended to read:

10

14005.18.  

(a) A woman is eligible, to the extent required by
11federal law, as though she were pregnant, for all pregnancy-related
12and postpartum services for a 60-day period beginning on the last
13day of pregnancy.

14For purposes of this section, “postpartum services” means those
15services provided after childbirth, child delivery, or miscarriage.

16(b) This section shall remain in effect only until January 1, 2014,
17and as of that date is repealed, unless a later enacted statute, that
18is enacted before January 1, 2014, deletes or extends that date.

19

SEC. 5.  

Section 14005.18 is added to the Welfare and
20Institutions Code
, to read:

21

14005.18.  

(a) To help prevent premature delivery and low
22birthweights, the leading causes of infant and maternal morbidity
23and mortality, and to promote women’s overall health, well-being,
24and financial security and that of their families, it is imperative
25that pregnant women enrolled in Medi-Cal be provided with all
26medically necessary services. Therefore, a woman is eligible, to
27the extent required by federal law, as though she were pregnant,
28for all pregnancy-related and postpartum services for a period
29beginning on the last day of pregnancy and continuing until the
30end of the month in which the 60th day of postpartum occurs.

31(b) For purposes of this section, the following definitions shall
32apply:

33(1) “Pregnancy-related services” means, at a minimum, all
34services required under the state plan.

35(2) “Postpartum services” means those services provided after
36child birth, child delivery, or miscarriage.

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

38

SEC. 6.  

Section 14005.28 of the Welfare and Institutions Code
39 is amended to read:

P8    1

14005.28.  

(a) To the extent federal financial participation is
2available pursuant to an approved state plan amendment, the
3department shall exercise its option under Section
41902(a)(10)(A)(ii)(XVII) of the federal Social Security Act (42
5U.S.C. Sec. 1396a(a)(10)(A)(ii)(XVII)) to extend Medi-Cal benefits
6to independent foster care adolescents, as defined in Section
71905(w)(1) of the federal Social Security Act (42 U.S.C. Sec.
81396d(w)(1)).

9(b) Notwithstanding Chapter 3.5 (commencing with Section
1011340) of Part 1 of Division 3 of Title 2 of the Government Code,
11and if the state plan amendment described in subdivision (a) is
12approved by the federal Health Care Financing Administration,
13the department may implement subdivision (a) without taking any
14regulatory action and by means of all-county letters or similar
15instructions. Thereafter, the department shall adopt regulations in
16accordance with the requirements of Chapter 3.5 (commencing
17with Section 11340) of Part 1 of Division 3 of Title 2 of the
18Government Code.

19(c) The department shall implement subdivision (a) on October
201, 2000, but only if, and to the extent that, the department has
21obtained all necessary federal approvals.

22(d) This section shall remain in effect only until January 1, 2014,
23and as of that date is repealed, unless a later enacted statute, that
24is enacted before January 1, 2014, deletes or extends that date.

25

SEC. 7.  

Section 14005.28 is added to the Welfare and
26Institutions Code
, to read:

27

14005.28.  

(a) To the extent federal financial participation is
28available pursuant to an approved state plan amendment, the
29department shall implement Section 1902(a)(10)(A)(i)(IX) of the
30federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(IX))
31to provide Medi-Cal benefits to an individual who is in foster care
32on his or her 18th birthday until his or her 26th birthday. In
33addition, the department shall implement the option in paragraph
34(3) of subdivision (b) of Section 435.150 of Title 42 of the Code
35of Federal Regulations to provide Medi-Cal benefits to individuals
36that were in foster care and enrolled in Medicaid in any state.

37(1) A foster care adolescent who is in foster care on his or her
3818th birthday shall be enrolled to receive benefits under this section
39without any interruption in coverage and without requiring a new
40application.

P9    1(2) The department shall develop procedures to identify and
2enroll individuals who meet the criteria for Medi-Cal eligibility
3in this subdivision, including, but not limited to, former foster care
4adolescents who were in foster care on their 18th birthday and who
5lost Medi-Cal coverage as a result of attaining 21 years of age.
6The department shall work with counties to identify and conduct
7outreach to former foster care adolescents who lost Medi-Cal
8coverage during the 2013 calendar year as a result of attaining 21
9years of age, to ensure they are aware of the ability to reenroll
10under the coverage provided pursuant to this section.

11(3) (A) The department shall develop and implement a
12simplified redetermination form for this program. A beneficiary
13qualifying for the benefits extended pursuant to this section shall
14fill out and return this form only if information known to the
15department is no longer accurate or is materially incomplete.

16(B) The department shall seek federal approval to institute a
17renewal process that allows a beneficiary receiving benefits under
18this section to remain on Medi-Cal after a redetermination form
19is returned as undeliverable and the county is otherwise unable to
20establish contact. If federal approval is granted, the recipient shall
21remain eligible for services under the Medi-Cal fee-for-service
22program until the time contact is reestablished or ineligibility is
23established, and to the extent federal financial participation is
24available.

25(C) The department shall terminate eligibility only after it
26determines that the recipient is no longer eligible and all due
27process requirements are met in accordance with state and federal
28law.

29(b) This section shall be implemented only if and to the extent
30that federal financial participation is available.

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

end delete
32

begin deleteSEC. 8.end delete
33begin insertSEC. 3.end insert  

Section 14005.30 of the Welfare and Institutions Code
34 is amended to read:

35

14005.30.  

(a) (1) To the extent that federal financial
36participation is available, Medi-Cal benefits under this chapter
37shall be provided to individuals eligible for services under Section
381396u-1 of Title 42 of the United States Code, including any
39options under Section 1396u-1(b)(2)(C) made available to and
40exercised by the state.

P10   1(2) The department shall exercise its option under Section
21396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
3less restrictive income and resource eligibility standards and
4methodologies to the extent necessary to allow all recipients of
5benefits under Chapter 2 (commencing with Section 11200) to be
6eligible for Medi-Cal under paragraph (1).

7(3) To the extent federal financial participation is available, the
8department shall exercise its option under Section 1396u-1(b)(2)(C)
9of Title 42 of the United States Code authorizing the state to
10disregard all changes in income or assets of a beneficiary until the
11next annual redetermination under Section 14012. The department
12shall implement this paragraph only if, and to the extent that the
13State Child Health Insurance Program waiver described in Section
1412693.755 of the Insurance Code extending Healthy Families
15Program eligibility to parents and certain other adults is approved
16and implemented.

17(b) To the extent that federal financial participation is available,
18the department shall exercise its option under Section
191396u-1(b)(2)(C) of Title 42 of the United States Code as necessary
20to expand eligibility for Medi-Cal under subdivision (a) by
21establishing the amount of countable resources individuals or
22families are allowed to retain at the same amount medically needy
23individuals and families are allowed to retain, except that a family
24of one shall be allowed to retain countable resources in the amount
25of three thousand dollars ($3,000).

26(c) To the extent federal financial participation is available, the
27department shall, commencing March 1, 2000, adopt an income
28disregard for applicants equal to the difference between the income
29standard under the program adopted pursuant to Section 1931(b)
30of the federal Social Security Act (42 U.S.C. Sec. 1396u-1) and
31the amount equal to 100 percent of the federal poverty level
32applicable to the size of the family. A recipient shall be entitled
33to the same disregard, but only to the extent it is more beneficial
34than, and is substituted for, the earned income disregard available
35to recipients.

36(d) For purposes of calculating income under this section during
37any calendar year, increases in social security benefit payments
38under Title II of the federal Social Security Act (42 U.S.C. Sec.
39401 et seq.) arising from cost-of-living adjustments shall be
40disregarded commencing in the month that these social security
P11   1benefit payments are increased by the cost-of-living adjustment
2through the month before the month in which a change in the
3federal poverty level requires the department to modify the income
4disregard pursuant to subdivision (c) and in which new income
5limits for the program established by this section are adopted by
6the department.

7(e) Subdivision (b) shall be applied retroactively to January 1,
81998.

9(f) Notwithstanding Chapter 3.5 (commencing with Section
1011340) of Part 1 of Division 3 of Title 2 of the Government Code,
11the department shall implement, without taking regulatory action,
12subdivisions (a) and (b) of this section by means of an all-county
13letter or similar instruction. Thereafter, the department shall adopt
14regulations in accordance with the requirements of Chapter 3.5
15(commencing with Section 11340) of Part 1 of Division 3 of Title
162 of the Government Code.

17(g) This section shall remain in effect only until January 1, 2014,
18and as of that date is repealed, unless a later enacted statute, that
19is enacted before January 1, 2014, deletes or extends that date.

20

begin deleteSEC. 9.end delete
21begin insertSEC. 4.end insert  

Section 14005.30 is added to the Welfare and
22Institutions Code
, to read:

23

14005.30.  

(a) (1) begin deleteTo the extent that federal financial
24participation is available, end delete
Medi-Cal benefits under this chapter
25shall be provided to individuals eligible for services under Section
261396u-1 of Title 42 of the United States Codebegin delete, known as the
27Section 1931(b) program, including any options under Section
281396u-1(b)(2)(C) made available to and exercised by the stateend delete
.

begin delete

29(2) The department shall exercise its option under Section
301396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
31less restrictive income and resource eligibility standards and
32methodologies to the extent necessary to allow all recipients of
33benefits under Chapter 2 (commencing with Section 11200) to be
34eligible for Medi-Cal under paragraph (1).

35(b) Commencing January 1, 2014, pursuant to Section
361396a(e)(14)(C) of Title 42 of the United States Code, there shall
37be no assets test and no deprivation test for any individual under
38this section.

end delete
begin insert

39(b) (1) When determining eligibility under this section, an
40applicant’s or beneficiary’s income and resources shall be
P12   1determined, counted, and valued in accordance with the
2requirements of Section 1396a(e)(14) of Title 42 of the United
3States Code, as added by the ACA.

end insert
begin insert

4(2) When determining eligibility under this section, an
5applicant’s or beneficiary’s assets shall not be considered and
6deprivation shall not be a requirement for eligibility.

end insert

7(c) For purposes of calculating income under this section during
8any calendar year, increases in social security benefit payments
9under Title II of the federal Social Security Act (42 U.S.C. Sec.
10401 et seq.) arising from cost-of-living adjustments shall be
11disregarded commencing in the month that these social security
12benefit payments are increased by the cost-of-living adjustment
13through the month before the month in which a change in the
14federal poverty level requires the department to modify the income
15disregard pursuant to subdivision (c) and in which new income
16limits for the program established by this section are adopted by
17the department.

begin insert

18(d) The MAGI-based income eligibility standard applied under
19this section shall conform with the maintenance of effort
20requirements of Sections 1396a(e)(14) and 1396a(gg) of Title 42
21of the United States Code, as added by the ACA.

end insert
begin insert

22(e) For purposes of this section, the following definitions shall
23apply:

end insert
begin insert

24(1)  “ACA” means the federal Patient Protection and Affordable
25Care Act (Public Law 111-148), as originally enacted and as
26amended by the federal Health Care and Education Reconciliation
27Act of 2010 (Public Law 111-152) and any subsequent
28amendments.

end insert
begin insert

29(2) “MAGI-based income” means income calculated using the
30financial methodologies described in Section 1396a(e)(14) of Title
3142 of the United States Code, as added by the federal Patient
32Protection and Affordable Care Act (Public Law 111-148) and as
33amended by the federal Health Care and Education Reconciliation
34Act of 2010 (Public Law 111-152) and any subsequent
35amendments.

end insert
begin insert

36(f) This section shall be implemented only if and to the extent
37that federal financial participation is available and any necessary
38federal approvals have been obtained.

end insert
begin delete

39(d)

end delete

40begin insert(g)end insert This section shall become operativebegin insert onend insert January 1, 2014.

begin delete
P13   1

SEC. 10.  

Section 14005.31 of the Welfare and Institutions Code
2 is amended to read:

3

14005.31.  

(a) (1) Subject to paragraph (2), for any person
4whose eligibility for benefits under Section 14005.30 has been
5determined with a concurrent determination of eligibility for cash
6aid under Chapter 2 (commencing with Section 11200), loss of
7eligibility or termination of cash aid under Chapter 2 (commencing
8with Section 11200) shall not result in a loss of eligibility or
9termination of benefits under Section 14005.30 absent the existence
10of a factor that would result in loss of eligibility for benefits under
11Section 14005.30 for a person whose eligibility under Section
1214005.30 was determined without a concurrent determination of
13eligibility for benefits under Chapter 2 (commencing with Section
1411200).

15(2) Notwithstanding paragraph (1), a person whose eligibility
16would otherwise be terminated pursuant to that paragraph shall
17not have his or her eligibility terminated until the transfer
18procedures set forth in Section 14005.32 or the redetermination
19procedures set forth in Section 14005.37 and all due process
20requirements have been met.

21(b) The department, in consultation with the counties and
22representatives of consumers, managed care plans, and Medi-Cal
23providers, shall prepare a simple, clear, consumer-friendly notice
24to be used by the counties, to inform Medi-Cal beneficiaries whose
25eligibility for cash aid under Chapter 2 (commencing with Section
2611200) has ended, but whose eligibility for benefits under Section
2714005.30 continues pursuant to subdivision (a), that their benefits
28will continue. To the extent feasible, the notice shall be sent out
29at the same time as the notice of discontinuation of cash aid, and
30shall include all of the following:

31(1) A statement that Medi-Cal benefits will continue even though
32cash aid under the CalWORKs program has been terminated.

33(2) A statement that continued receipt of Medi-Cal benefits will
34not be counted against any time limits in existence for receipt of
35cash aid under the CalWORKs program.

36(3) A statement that the Medi-Cal beneficiary does not need to
37fill out monthly status reports in order to remain eligible for
38Medi-Cal, but shall be required to submit a semiannual status report
39and annual reaffirmation forms. The notice shall remind individuals
40whose cash aid ended under the CalWORKs program as a result
P14   1of not submitting a status report that he or she should review his
2or her circumstances to determine if changes have occurred that
3should be reported to the Medi-Cal eligibility worker.

4(4) A statement describing the responsibility of the Medi-Cal
5beneficiary to report to the county, within 10 days, significant
6changes that may affect eligibility.

7(5) A telephone number to call for more information.

8(6) A statement that the Medi-Cal beneficiary’s eligibility
9worker will not change, or, if the case has been reassigned, the
10new worker’s name, address, and telephone number, and the hours
11during which the county’s eligibility workers can be contacted.

12(c) This section shall be implemented on or before July 1, 2001,
13but only to the extent that federal financial participation under
14Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396
15et seq.) is available.

16(d) Notwithstanding Chapter 3.5 (commencing with Section
1711340) of Part 1 of Division 3 of Title 2 of the Government Code,
18the department shall, without taking any regulatory action,
19implement this section by means of all-county letters or similar
20instructions. Thereafter, the department shall adopt regulations in
21accordance with the requirements of Chapter 3.5 (commencing
22with Section 11340) of Part 1 of Division 3 of Title 2 of the
23Government Code. Comprehensive implementing instructions
24shall be issued to the counties no later than March 1, 2001.

25(e) This section shall remain in effect only until January 1, 2014,
26and as of that date is repealed, unless a later enacted statute, that
27is enacted before January 1, 2014, deletes or extends that date.

28

SEC. 11.  

Section 14005.31 is added to the Welfare and
29Institutions Code
, to read:

30

14005.31.  

(a) (1) Subject to paragraph (2), for any person
31whose eligibility for benefits under Section 14005.30 has been
32determined with a concurrent determination of eligibility for cash
33aid under Chapter 2 (commencing with Section 11200), loss of
34eligibility or termination of cash aid under Chapter 2 (commencing
35with Section 11200) shall not result in a loss of eligibility or
36termination of benefits under Section 14005.30 absent the existence
37of a factor that would result in loss of eligibility for benefits under
38Section 14005.30 for a person whose eligibility under Section
3914005.30 was determined without a concurrent determination of
P15   1eligibility for benefits under Chapter 2 (commencing with Section
211200).

3(2) Notwithstanding paragraph (1), a person whose eligibility
4would otherwise be terminated pursuant to that paragraph shall
5not have his or her eligibility terminated until the transfer
6procedures set forth in Section 14005.32 or the redetermination
7procedures set forth in Section 14005.37 and all due process
8requirements have been met.

9(b) The department, in consultation with the counties and
10representatives of consumers, managed care plans, and Medi-Cal
11providers, shall prepare a simple, clear, consumer-friendly notice
12to be used by the counties to inform Medi-Cal beneficiaries whose
13eligibility for cash aid under Chapter 2 (commencing with Section
1411200) has ended, but whose eligibility for benefits under Section
1514005.30 continues pursuant to subdivision (a), that their benefits
16will continue. To the extent feasible, the notice shall be sent out
17at the same time as the notice of discontinuation of cash aid, and
18shall include all of the following:

19(1) A statement that Medi-Cal benefits will continue even though
20cash aid under the CalWORKs program has been terminated.

21(2) A statement that continued receipt of Medi-Cal benefits will
22not be counted against any time limits in existence for receipt of
23cash aid under the CalWORKs program.

24(3) A statement that the Medi-Cal beneficiary does not need to
25fill out monthly status reports in order to remain eligible for
26Medi-Cal, but may be required to submit annual reaffirmation
27forms. The notice shall remind individuals whose cash aid ended
28under the CalWORKs program as a result of not submitting a status
29report that he or she should review his or her circumstances to
30determine if changes have occurred that should be reported to the
31Medi-Cal eligibility worker.

32(4) A statement describing the responsibility of the Medi-Cal
33beneficiary to report to the county, within 10 days, significant
34changes that may affect eligibility.

35(5) A telephone number to call for more information.

36(6) A statement that the Medi-Cal beneficiary’s eligibility
37worker will not change, or, if the case has been reassigned, the
38new worker’s name, address, and telephone number, and the hours
39during which the county’s eligibility workers can be contacted.

40(c)


P16   1Notwithstanding Chapter 3.5 (commencing with Section 11340)
2of Part 1 of Division 3 of Title 2 of the Government Code, the
3department, without taking any further regulatory action, shall
4implement, interpret, or make specific this section by means of
5all-county letters, plan letters, plan or provider bulletins, or similar
6instructions until the time regulations are adopted. Thereafter, the
7department shall adopt regulations in accordance with the
8requirements of Chapter 3.5 (commencing with Section 11340) of
9Part 1 of Division 3 of Title 2 of the Government Code. Beginning
10six months after the effective date of this section, the department
11shall provide a status report to the Legislature on a semiannual
12basis until regulations have been adopted.

13(d)


14This section shall become operative on January 1, 2014.

15

SEC. 12.  

Section 14005.32 of the Welfare and Institutions
16Code
is amended to read:

17

14005.32.  

(a) (1) If the county has evidence clearly
18demonstrating that a beneficiary is not eligible for benefits under
19this chapter pursuant to Section 14005.30, but is eligible for
20benefits under this chapter pursuant to other provisions of law, the
21county shall transfer the individual to the corresponding Medi-Cal
22program. Eligibility under Section 14005.30 shall continue until
23the transfer is complete.

24(2) The department, in consultation with the counties and
25representatives of consumers, managed care plans, and Medi-Cal
26providers, shall prepare a simple, clear, consumer-friendly notice
27to be used by the counties, to inform beneficiaries that their
28Medi-Cal benefits have been transferred pursuant to paragraph (1)
29and to inform them about the program to which they have been
30transferred. To the extent feasible, the notice shall be issued with
31the notice of discontinuance from cash aid, and shall include all
32of the following:

33(A) A statement that Medi-Cal benefits will continue under
34another program, even though aid under Chapter 2 (commencing
35with Section 11200) has been terminated.

36(B) The name of the program under which benefits will continue,
37and an explanation of that program.

38(C) A statement that continued receipt of Medi-Cal benefits will
39not be counted against any time limits in existence for receipt of
40cash aid under the CalWORKs program.

P17   1(D) A statement that the Medi-Cal beneficiary does not need to
2fill out monthly status reports in order to remain eligible for
3Medi-Cal, but shall be required to submit a semiannual status report
4and annual reaffirmation forms. In addition, if the person or persons
5to whom the notice is directed has been found eligible for
6transitional Medi-Cal as described in Section 14005.8 or 14005.85,
7the statement shall explain the reporting requirements and duration
8of benefits under those programs, and shall further explain that,
9at the end of the duration of these benefits, a redetermination, as
10provided for in Section 14005.37 shall be conducted to determine
11whether benefits are available under any other provision of law.

12(E) A statement describing the beneficiary’s responsibility to
13report to the county, within 10 days, significant changes that may
14affect eligibility or share of cost.

15(F) A telephone number to call for more information.

16(G) A statement that the beneficiary’s eligibility worker will
17not change, or, if the case has been reassigned, the new worker’s
18name, address, and telephone number, and the hours during which
19the county’s Medi-Cal eligibility workers can be contacted.

20(b) No later than September 1, 2001, the department shall submit
21a federal waiver application seeking authority to eliminate the
22reporting requirements imposed by transitional medicaid under
23Section 1925 of the federal Social Security Act (Title 42 U.S.C.
24Sec. 1396r-6).

25(c) This section shall be implemented on or before July 1, 2001,
26but only to the extent that federal financial participation under
27Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396
28et seq.) is available.

29(d) Notwithstanding Chapter 3.5 (commencing with Section
3011340) of Part 1 of Division 3 of Title 2 of the Government Code,
31the department shall, without taking any regulatory action,
32implement this section by means of all-county letters or similar
33instructions. Thereafter, the department shall adopt regulations in
34accordance with the requirements of Chapter 3.5 (commencing
35with Section 11340) of Part 1 of Division 3 of Title 2 of the
36Government Code. Comprehensive implementing instructions
37shall be issued to the counties no later than March 1, 2001.

38(e) This section shall remain in effect only until January 1, 2014,
39and as of that date is repealed, unless a later enacted statute, that
40is enacted before January 1, 2014, deletes or extends that date.

P18   1

SEC. 13.  

Section 14005.32 is added to the Welfare and Institutions
2Code
, to read:

3

14005.32.  

(a) (1) If the county has evidence clearly
4demonstrating that a beneficiary is not eligible for benefits under
5this chapter pursuant to Section 14005.30, but is eligible for
6benefits under this chapter pursuant to other provisions of law, the
7county shall transfer the individual to the corresponding Medi-Cal
8program in conformity with and subject to the requirements of
9Section 14005.37. Eligibility under Section 14005.30 shall continue
10until the transfer is complete.

11(2) The department, in consultation with the counties and
12representatives of consumers, managed care plans, and Medi-Cal
13providers, shall prepare a simple, clear, consumer-friendly notice
14to be used by the counties to inform beneficiaries that their
15Medi-Cal benefits have been transferred pursuant to paragraph (1)
16and to inform them about the program to which they have been
17transferred. To the extent feasible, the notice shall be issued with
18the notice of discontinuance from cash aid, and shall include all
19of the following:

20(A) A statement that Medi-Cal benefits will continue under
21another program, even though aid under Chapter 2 (commencing
22with Section 11200) has been terminated.

23(B) The name of the program under which benefits will continue
24and an explanation of that program.

25(C) A statement that continued receipt of Medi-Cal benefits will
26not be counted against any time limits in existence for receipt of
27cash aid under the CalWORKs program.

28(D) A statement that the Medi-Cal beneficiary does not need to
29 fill out monthly status reports in order to remain eligible for
30Medi-Cal, but may be required to submit annual reaffirmation
31forms. In addition, if the person or persons to whom the notice is
32directed has been found eligible for transitional Medi-Cal as
33described in Section 14005.8 or 14005.85, the statement shall
34explain the reporting requirements and duration of benefits under
35those programs and shall further explain that, at the end of the
36duration of these benefits, a redetermination, as provided in Section
3714005.37, shall be conducted to determine whether benefits are
38available under any other law.

P19   1(E) A statement describing the beneficiary’s responsibility to
2report to the county, within 10 days, significant changes that may
3affect eligibility or share of cost.

4(F) A telephone number to call for more information.

5(G) A statement that the beneficiary’s eligibility worker will
6not change, or, if the case has been reassigned, the new worker’s
7name, address, and telephone number, and the hours during which
8the county’s Medi-Cal eligibility workers can be contacted.

9(b)


10Notwithstanding Chapter 3.5 (commencing with Section 11340)
11of Part 1 of Division 3 of Title 2 of the Government Code, the
12department, without taking any further regulatory action, shall
13implement, interpret, or make specific this section by means of
14all-county letters, plan letters, plan or provider bulletins, or similar
15instructions until the time regulations are adopted. Thereafter, the
16department shall adopt regulations in accordance with the
17requirements of Chapter 3.5 (commencing with Section 11340) of
18Part 1 of Division 3 of Title 2 of the Government Code. Beginning
19six months after the effective date of this section, the department
20shall provide a status report to the Legislature on a semiannual
21basis until regulations have been adopted.

22(c)


23This section shall become operative on January 1, 2014.

end delete
24

begin deleteSEC. 14.end delete
25begin insertSEC. 5.end insert  

Section 14005.36 of the Welfare and Institutions Code
26 is amended to read:

27

14005.36.  

(a) The county shall undertake outreach efforts to
28beneficiaries receiving benefits under this chapter, in order to
29maintain the most up-to-date home addresses, telephone numbers,
30and other necessary contact information, and to encourage and
31assist with timely submission of the annual reaffirmation form,
32and, when applicable, transitional Medi-Cal program reporting
33forms and to facilitate the Medi-Cal redetermination process when
34one is required as provided in Section 14005.37. In implementing
35this subdivision, a county may collaborate with community-based
36organizations, provided that confidentiality is protected.

37(b) The department shall encourage and facilitate efforts by
38managed care plans to report updated beneficiary contact
39information to counties.

P20   1(c) begin insert(1)end insertbegin insertend insert The department and each county shall incorporate, in
2a timely manner, updated contact information received from
3managed care plans pursuant to subdivision (b) into the
4beneficiary’s Medi-Cal case file and into all systems used to inform
5plans of their beneficiaries’ enrollee status. Updated Medi-Cal
6beneficiary contact information shall be limited to the beneficiary’s
7telephone number, change of address information, and change of
8name.begin delete The county shall attempt to verify that the information it
9receives from the plan is accurate, which may include, but is not
10limited to, making contact with the beneficiary, before updating
11the beneficiary’s case file.end delete

begin insert

12(2) When a managed care plan obtains a beneficiary’s updated
13contact information, the managed care plan shall ask the
14beneficiary for approval to provide the beneficiary’s updated
15contact information to the appropriate county. If the managed care
16plan does not obtain approval from the beneficiary to provide the
17appropriate county with the updated contact information, the
18county shall attempt to verify the plan is accurate, which may
19include, but is not limited to, making contact with the beneficiary,
20before updating the beneficiary’s case file. The contact shall first
21be attempted using the method of contact identified by the
22beneficiary as the preferred method of contact, if a method has
23been identified.

end insert

24(d) This section shall be implemented only to the extent that
25federal financial participation under Title XIX of the federal Social
26Security Act (42 U.S.C. Sec. 1396 et seq.) is available.

27(e) To the extent otherwise required by Chapter 3.5
28(commencing with Section 11340) of Part 1 of Division 3 of Title
292 of the Government Code, the department shall adopt emergency
30regulations implementing this section no later than July 1, 2015.
31The department may thereafter readopt the emergency regulations
32pursuant to that chapter. The adoption and readoption, by the
33department, of regulations implementing this section shall be
34deemed to be an emergency and necessary to avoid serious harm
35to the public peace, health, safety, or general welfare for purposes
36of Sections 11346.1 and 11349.6 of the Government Code, and
37the department is hereby exempted from the requirement that it
38describe facts showing the need for immediate action and from
39review by the Office of Administrative Law.

P21   1

begin deleteSEC. 15.end delete
2begin insertSEC. 6.end insert  

Section 14005.37 of the Welfare and Institutions Code
3 is amended to read:

4

14005.37.  

(a) Except as provided in Section 14005.39,
5whenever a county receives information about changes in a
6beneficiary’s circumstances that may affect eligibility for Medi-Cal
7benefits, the county shall promptly redetermine eligibility. The
8procedures for redetermining Medi-Cal eligibility described in this
9section shall apply to all Medi-Cal beneficiaries.

10(b)  Loss of eligibility for cash aid under that program shall not
11result in a redetermination under this section unless the reason for
12the loss of eligibility is one that would result in the need for a
13redetermination for a person whose eligibility for Medi-Cal under
14Section 14005.30 was determined without a concurrent
15determination of eligibility for cash aid under the CalWORKs
16program.

17(c) A loss of contact, as evidenced by the return of mail marked
18in such a way as to indicate that it could not be delivered to the
19intended recipient or that there was no forwarding address, shall
20require a prompt redetermination according to the procedures set
21forth in this section.

22(d) Except as otherwise provided in this section, Medi-Cal
23eligibility shall continue during the redetermination process
24described in this section. A Medi-Cal beneficiary’s eligibility shall
25not be terminated under this section until the county makes a
26specific determination based on facts clearly demonstrating that
27the beneficiary is no longer eligible for Medi-Cal under any basis
28and due process rights guaranteed under this division have been
29met.

30(e) For purposes of acquiring information necessary to conduct
31the eligibility determinations described in subdivisions (a) to (d),
32inclusive, a county shall make every reasonable effort to gather
33information available to the county that is relevant to the
34beneficiary’s Medi-Cal eligibility prior to contacting the
35beneficiary. Sources for these efforts shall include, but are not
36limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
37beneficiary or of any of his or her immediate family members,
38which are open or were closed within the last 45 days, and
39wherever feasible, other sources of relevant information reasonably
40available to the counties.

P22   1(f) If a county cannot obtain information necessary to
2redetermine eligibility pursuant to subdivision (e), the county shall
3attempt to reach the beneficiary by telephone in order to obtain
4this information, either directly or in collaboration with
5community-based organizations so long as confidentiality is
6protected.

7(g) If a county’s efforts pursuant to subdivisions (e) and (f) to
8obtain the information necessary to redetermine eligibility have
9failed, the county shall send to the beneficiary a form, which shall
10highlight the information needed to complete the eligibility
11determination. The county shall not request information or
12documentation that has been previously provided by the
13beneficiary, that is not absolutely necessary to complete the
14eligibility determination, or that is not subject to change. The form
15shall be accompanied by a simple, clear, consumer-friendly cover
16letter, which shall explain why the form is necessary, the fact that
17it is not necessary to be receiving CalWORKs benefits to be
18receiving Medi-Cal benefits, the fact that receipt of Medi-Cal
19benefits does not count toward any time limits imposed by the
20CalWORKs program, the various bases for Medi-Cal eligibility,
21including disability, and the fact that even persons who are
22employed can receive Medi-Cal benefits. The cover letter shall
23include a telephone number to call in order to obtain more
24information. The form and the cover letter shall be developed by
25the department in consultation with the counties and representatives
26of consumers, managed care plans, and Medi-Cal providers. A
27Medi-Cal beneficiary shall have no less than 20 days from the date
28the form is mailed pursuant to this subdivision to respond. Except
29as provided in subdivision (h), failure to respond prior to the end
30of this 20-day period shall not impact his or her Medi-Cal
31eligibility.

32(h) If the purpose for a redetermination under this section is a
33loss of contact with the Medi-Cal beneficiary, as evidenced by the
34return of mail marked in such a way as to indicate that it could not
35be delivered to the intended recipient or that there was no
36forwarding address, a return of the form described in subdivision
37(g) marked as undeliverable shall result in an immediate notice of
38action terminating Medi-Cal eligibility.

39(i) If, within 20 days of the date of mailing of a form to the
40Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary
P23   1does not submit the completed form to the county, the county shall
2send the beneficiary a written notice of action stating that his or
3her eligibility shall be terminated 10 days from the date of the
4notice and the reasons for that determination, unless the beneficiary
5submits a completed form prior to the end of the 10-day period.

6(j) If, within 20 days of the date of mailing of a form to the
7Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
8submits an incomplete form, the county shall attempt to contact
9the beneficiary by telephone and in writing to request the necessary
10information. If the beneficiary does not supply the necessary
11information to the county within 10 days from the date the county
12contacts the beneficiary in regard to the incomplete form, a 10-day
13notice of termination of Medi-Cal eligibility shall be sent.

14(k) If, within 30 days of termination of a Medi-Cal beneficiary’s
15eligibility pursuant to subdivision (h), (i), or (j), the beneficiary
16submits to the county a completed form, eligibility shall be
17determined as though the form was submitted in a timely manner
18and if a beneficiary is found eligible, the termination under
19subdivision (h), (i), or (j) shall be rescinded.

20(l) If the information reasonably available to the county pursuant
21to the redetermination procedures of subdivisions (d), (e), (g), and
22(m) does not indicate a basis of eligibility, Medi-Cal benefits may
23be terminated so long as due process requirements have otherwise
24been met.

25(m) The department shall, with the counties and representatives
26of consumers, including those with disabilities, and Medi-Cal
27providers, develop a timeframe for redetermination of Medi-Cal
28eligibility based upon disability, including ex parte review, the
29redetermination form described in subdivision (g), timeframes for
30responding to county or state requests for additional information,
31and the forms and procedures to be used. The forms and procedures
32shall be as consumer-friendly as possible for people with
33disabilities. The timeframe shall provide a reasonable and adequate
34opportunity for the Medi-Cal beneficiary to obtain and submit
35medical records and other information needed to establish
36eligibility for Medi-Cal based upon disability.

37(n) This section shall be implemented on or before July 1, 2001,
38but only to the extent that federal financial participation under
39Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396
40et seq.) is available.

P24   1(o) Notwithstanding Chapter 3.5 (commencing with Section
211340) of Part 1 of Division 3 of Title 2 of the Government Code,
3the department shall, without taking any regulatory action,
4implement this section by means of all-county letters or similar
5instructions. Thereafter, the department shall adopt regulations in
6accordance with the requirements of Chapter 3.5 (commencing
7with Section 11340) of Part 1 of Division 3 of Title 2 of the
8Government Code. Comprehensive implementing instructions
9shall be issued to the counties no later than March 1, 2001.

10(p) This section shall remain in effect only until January 1, 2014,
11and as of that date is repealed, unless a later enacted statute, that
12is enacted before January 1, 2014, deletes or extends that date.

13

begin deleteSEC. 16.end delete
14begin insertSEC. 7.end insert  

Section 14005.37 is added to the Welfare and
15Institutions Code
, to read:

16

14005.37.  

(a) Except as provided in Section 14005.39, a county
17shall perform redeterminations of eligibility for Medi-Cal
18beneficiaries every 12 months and shall promptly redetermine
19eligibility whenever the county receives information about changes
20in a beneficiary’s circumstances that may affect eligibility for
21Medi-Cal benefits. The procedures for redetermining Medi-Cal
22eligibility described in this section shall apply to all Medi-Cal
23beneficiaries.

24(b)  Loss of eligibility for cash aid under that program shall not
25result in a redetermination under this section unless the reason for
26the loss of eligibility is one that would result in the need for a
27redetermination for a person whose eligibility for Medi-Cal under
28Section 14005.30 was determined without a concurrent
29determination of eligibility for cash aid under the CalWORKs
30program.

31(c) A loss of contact, as evidenced by the return of mail marked
32in such a way as to indicate that it could not be delivered to the
33intended recipient or that there was no forwarding address, shall
34require a prompt redetermination according to the procedures set
35forth in this section.

36(d) Except as otherwise provided in this section, Medi-Cal
37eligibility shall continue during the redetermination process
38described in this section and a beneficiary’s Medi-Cal eligibility
39shall not be terminated under this section until the county makes
40a specific determination based on facts clearly demonstrating that
P25   1the beneficiary is no longer eligible for Medi-Cal benefits under
2any basis and due process rights guaranteed under this division
3have been met.begin insert For the purposes of this subdivision, for a
4beneficiary who is subject to the use of MAGI-based financial
5methods, the determination of whether the beneficiary is eligible
6for Medi-Cal benefits under any basis shall include, but is not
7limited to, a determination of eligibility for Medi-Cal benefits on
8a basis that is exempt from the use of MAGI-based financial
9methods only if either of the following occurs:end insert

begin insert

10(A) The county assesses the beneficiary as being potentially
11eligible under a program that is exempt from the use of
12MAGI-based financial methods, including, but not limited to, on
13the basis of age, blindness, disability, or the need for long-term
14care services and supports.

end insert
begin insert

15(B) The beneficiary requests that the county determine whether
16he or she is eligible for Medi-Cal benefits on a basis that is exempt
17from the use of MAGI-based financial methods.

end insert

18(e) (1) For purposes of acquiring information necessary to
19conduct the eligibility redeterminations described in this section,
20a county shall gather information available to the county that is
21relevant to the beneficiary’s Medi-Cal eligibility prior to contacting
22the beneficiary. Sources for these efforts shall include information
23contained in the beneficiary’s file or other information, including
24more recent information available to the county, including, but not
25limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
26beneficiary or of any of his or her immediate family members,
27which are openbegin insert,end insert or were closed within the lastbegin delete 45end deletebegin insert 90end insert days,
28information accessed through any databases accessed under
29Sections 435.948, 435.949, and 435.956 of Title 42 of the Code
30of Federal Regulations, and wherever feasible, other sources of
31relevant information reasonably available to the countybegin insert or to the
32county via the departmentend insert
.

33(2) In the case of an annual redetermination, if, based upon
34information obtained pursuant to paragraph (1), the county is able
35to make a determination of continued eligibility, the county shall
36notify the beneficiary of both of the following:

37(A) The eligibility determination and the information it is based
38on.

39(B) That the beneficiary is required to inform the county via the
40Internet, by telephone, by mail, in person, or through other
P26   1commonly available electronic means, in counties where such
2electronic communication is available, if any information contained
3in the notice is inaccurate but that the beneficiary is not required
4to sign and return the notice if all information provided on the
5notice is accurate.

6(3) The county shall make all reasonable efforts not to send
7multiple notices during the same time period about eligibility. The
8notice of eligibility renewal shall contain other related information
9such as if the beneficiary is in a new Medi-Cal program.

10(4) In the case of a redetermination due to a change in
11circumstances, if a county determines that the change in
12circumstances does not affect the beneficiary’s eligibility status,
13the county shall not send the beneficiary a notice unless required
14to do so by federal law.

15(f) (1) In the case of an annual eligibility redetermination, if
16the county is unable to determine continued eligibility based on
17the information obtained pursuant to paragraph (1) of subdivision
18(e), the beneficiary shall be so informed and shall be provided with
19an annual renewal formbegin insert, at least 60 days before the beneficiary’s
20annual redetermination date,end insert
that is prepopulated with information
21that the county has obtained and that identifies any additional
22information needed by the county to determine eligibility. The
23form shall begin delete be accompanied by a cover letter advising the
24beneficiary ofend delete
begin insert include end insert all of the following:

25(A) The requirement that he or she provide any necessary
26information to the county within 60 days of the date that the form
27is sent to the beneficiary.

28(B) That the beneficiary may respond to the county via the
29Internet, by mail, by telephone, in person, or through other
30commonly available electronic means if those means are available
31in that county.

32(C) That if the beneficiary chooses to return the form to the
33county in person or via mail, the beneficiary shall sign the form
34in order for it to be considered complete.

35(D) Thebegin delete phoneend deletebegin insert telephoneend insert number to call in order to obtain more
36information.

37(2) The county shall attempt to contact the beneficiary via the
38Internet, by telephone, or through other commonly available
39electronic means, if those means are available in that county, during
40the 60-day periodbegin insert after the prepopulated form is mailed to the
P27   1beneficiaryend insert
to collect the necessary informationbegin insert if the beneficiary
2has not responded to the request for additional information or has
3provided an incomplete responseend insert
.

4(3) If the beneficiary has not provided any response to the
5written request for information sent pursuant to paragraph (1)
6within 60 days from the date the form is sent, the county shall
7terminate his or her eligibility for Medi-Cal benefits following the
8provision of timely notice.

9(4) If the beneficiary responds to the written request for
10information during the 60-day period pursuant to paragraph (1)
11but the information provided is not complete, the county shall
12follow the procedures set forth inbegin insert paragraph (3) ofend insert subdivision (g)
13to work with the beneficiary to complete the information.

14(5) (A) The formbegin delete and cover letterend delete required by this subdivision
15shall be developed by the department in consultation with the
16counties and representatives of eligibility workers and consumers.

17(B) For beneficiaries whose eligibility is not determined using
18MAGI-based financial methods, the county may use existing
19renewal forms until the state develops prepopulated renewal forms
20to provide to beneficiaries. The department shall develop
21prepopulated renewal forms for use with beneficiaries whose
22eligibility is not determined using MAGI-based financial methods
23by January 1, 2015.

24 (g) (1) In the case of a redetermination due to change in
25circumstances, if a county cannot obtain sufficient information to
26redetermine eligibility pursuant to subdivision (e),begin delete the county shall
27attempt to reach the beneficiary by telephone and other commonly
28available electronic means, in counties where such electronic
29communication is available, in order to obtain this information,
30either directly or in collaboration with community-based
31organizations so long as confidentiality is protected.end delete

begin delete32(2) If a county’s efforts pursuant to subdivision (e) and
33paragraph (1) of this subdivision to obtain the information
34necessary to redetermine eligibility have failed,end delete
the county shall
35send to the beneficiary a formbegin delete statingend deletebegin insert that is prepopulated with
36the information that the county has obtained and that statesend insert
the
37information needed to renew eligibility. The county shall only
38request information related to the change in circumstances. The
39county shall not request information or documentation that has
40been previously provided by the beneficiary, that is not absolutely
P28   1necessary to complete the eligibility determination, or that is not
2subject to change. The county shall only request information for
3nonapplicants necessary to make an eligibility determination or
4for a purpose directly related to the administration of the state
5Medicaid plan. The form shall advise the individual to provide
6any necessary information to the county via the Internet, by
7 telephone, by mail, in person, or through other commonly available
8electronic means and, if the individual will provide the form by
9mail or in person, to sign the form. The form shall include a
10telephone number to call in order to obtain more information. The
11form shall be developed by the department in consultation with
12the counties, representatives of consumers, and eligibility workers.
13A Medi-Cal beneficiary shall havebegin delete no less than 20end deletebegin insert 30end insert days from
14the date the form is mailed pursuant to this subdivision to respond.
15Except as provided in paragraphbegin delete (3)end deletebegin insert (2)end insert, failure to respond prior
16to the end of thisbegin delete 20-dayend deletebegin insert 30-dayend insert period shall not impact his or her
17Medi-Cal eligibility.

begin delete

18(3)

end delete

19begin insert(end insertbegin insert2)end insert If the purpose for a redetermination under this section is a
20loss of contact with the Medi-Cal beneficiary, as evidenced by the
21return of mail marked in such a way as to indicate that it could not
22be delivered to the intended recipient or that there was no
23forwarding address, a return of the form described in this
24subdivision marked as undeliverable shall result in an immediate
25notice of action terminating Medi-Cal eligibility.

begin delete

26(4) If, within 20 days of the date of mailing of a form to the
27Medi-Cal beneficiary pursuant to this subdivision, a beneficiary
28does not submit the completed form to the county or otherwise
29provide the needed information to the county, the county shall
30send the beneficiary a written notice of action stating that his or
31her eligibility shall be terminated 10 days from the date of the
32notice and the reasons for that determination, unless the beneficiary
33submits a completed form or otherwise provides the needed
34information to the county prior to the end of the 10-day period.

end delete
begin delete

35(5) If, within 20 days of

end delete

36begin insert(end insertbegin insert3)end insertbegin insertend insertbegin insertDuring the 30-day period after end insertthe date of mailing of a form
37to the Medi-Cal beneficiary pursuant to this subdivision, begin delete the
38beneficiary submits an incomplete form,end delete
the county shall attempt
39to contact the beneficiary by telephone, in writing, or other
40commonly available electronic means, in counties where such
P29   1electronic communication is available, to request the necessary
2informationbegin insert if the beneficiary has not responded to the request for
3additional information or has provided an incomplete responseend insert
.
4If the beneficiary does not supply the necessary information to the
5county withinbegin delete 10 days from the date the county contacts the
6beneficiary in regard to the incomplete formend delete
begin insert the 30-day limitend insert, a
710-day notice of termination of Medi-Cal eligibility shall be sent.

begin insert

8(h) Beneficiaries shall be required to report any change in
9circumstances that may affect their eligibility within 10 calendar
10days following the date the change occurred.

end insert
begin delete

11(h)

end delete

12begin insert(end insertbegin inserti)end insert If within 90 days of

13termination of a Medi-Cal beneficiary’s eligibility or a change
14in eligibility status pursuant to this section, the beneficiary submits
15to the county a signed and completed form or otherwise provides
16the needed information to the county, eligibility shall be
17redetermined by the county and if the beneficiary is found eligible,
18begin insert or the beneficiaryend insertbegin insert’s status has not changed, whichever applies,end insert
19 the termination shall be rescindedbegin insert as though the form were
20submitted in a timely mannerend insert
.

begin delete

21(i)

end delete

22begin insert(end insertbegin insertj)end insert If the information available to the county pursuant to the
23redetermination procedures of this section does not indicate a basis
24of eligibility, Medi-Cal benefits may be terminated so long as due
25process requirements have otherwise been met.

begin delete

26(j)

end delete

27begin insert(end insertbegin insertk)end insert The department shall, with the counties and representatives
28of consumers, including those with disabilities, and Medi-Cal
29eligibility workers, develop a timeframe for redetermination of
30Medi-Cal eligibility based upon disability, including ex parte
31review, the redetermination forms described in subdivisions (f)
32and (g), timeframes for responding to county or state requests for
33additional information, and the forms and procedures to be used.
34The forms and procedures shall be as consumer-friendly as possible
35for people with disabilities. The timeframe shall provide a
36reasonable and adequate opportunity for the Medi-Cal beneficiary
37to obtain and submit medical records and other information needed
38to establish eligibility for Medi-Cal based upon disability.

begin delete

39(k)

end delete

P30   1begin insert(end insertbegin insertl)end insert The county shall consider blindness as continuing until the
2reviewing physician determines that a beneficiary’s vision has
3improved beyond the applicable definition of blindness contained
4in the plan.

begin delete

5(l)

end delete

6begin insert(end insertbegin insertm)end insert The county shall consider disability as continuing until the
7review team determines that a beneficiary’s disability no longer
8meets the applicable definition of disability contained in the plan.

begin delete

9(m) If a county has enough information available to it to renew
10eligibility with respect to all eligibility criteria, the county shall
11begin a new 12-month eligibility period.

end delete
begin insert

12(n) In the case of a redetermination due to a change in
13circumstances, if a county determines that the beneficiary remains
14eligible for Medi-Cal benefits, the county shall begin a new
1512-month eligibility period.

end insert
begin delete

16(n)

end delete

17begin insert(end insertbegin inserto)end insert  For individuals determined ineligible for Medi-Cal by a
18county following the redetermination procedures set forth in this
19section, the county shall determine eligibility for other insurance
20affordability programs and if the individual is found to be eligible,
21the county shall, as appropriate, transfer the individual’s electronic
22account to other insurance affordability programs via a secure
23electronic interface.

begin delete

24(o)

end delete

25begin insert(end insertbegin insertp)end insert Any renewal form or notice shall be accessible to persons
26who are limited-English proficient and persons with disabilities
27consistent with all federal and state requirements.

begin delete

28(p)

end delete

29begin insert(end insertbegin insertq)end insert The requirements to provide information inbegin delete subdivision (b)end delete
30begin insert subdivisions (e) and (g),end insert and to report changes in circumstances
31in subdivisionbegin delete (c)end deletebegin insert (h),end insert may be provided through any of the modes
32of submission allowed in Section 435.907(a) of Title 42 of the
33Code of Federal Regulations, including an Internet Web site
34identified by the department, telephone, mail, in person, and other
35commonly available electronic means as authorized by the
36department.

begin delete

37(q)

end delete

38begin insert(end insertbegin insertr)end insert Forms required to be signed by a beneficiary pursuant to this
39section shall be signed under penalty of perjury. Electronic
P31   1signatures, telephonic signatures, and handwritten signatures
2transmitted by electronic transmission shall be accepted.

begin delete

3(r)

end delete

4begin insert(end insertbegin inserts)end insert For purposes of this section, “MAGI-based financial
5methods” means income calculated using the financial
6methodologies described in Section 1396a(e)(14) of Title 42 of
7the United States Code, and as added by the federal Patient
8Protection and Affordable Care Act (Public Law 111-148), as
9amended by the federal Health Care and Education Reconciliation
10Act of 2010 (Public Law 111-152), and any subsequent
11amendments.

begin insert

12(t) When contacting a beneficiary under paragraphs (2) and
13(4) of subdivision (f), and paragraph (3) of subdivision (g), a
14county shall first attempt to use the method of contact identified
15by the beneficiary as the preferred method of contact, if a method
16has been identified.

end insert
begin insert

17(u) The department shall seek federal approval to extend the
18annual redetermination date under this section for a three-month
19period for those Medi-Cal beneficiaries whose annual
20redeterminations are scheduled to occur between January 1, 2014,
21and March 31, 2014.

end insert
begin insert

22(v) Notwithstanding Chapter 3.5 (commencing with Section
2311340) of Part 1 of Division 3 of Title 2 of the Government Code,
24the department, without taking any further regulatory action, shall
25implement, interpret, or make specific this section by means of
26all-county letters, plan letters, plan or provider bulletins, or similar
27instructions until the time regulations are adopted. Thereafter, the
28department shall adopt regulations in accordance with the
29requirements of Chapter 3.5 (commencing with Section 11340) of
30Part 1 of Division 3 of Title 2 of the Government Code. Beginning
31six months after the effective date of this section, and
32notwithstanding Section 10231.5 of the Government Code, the
33department shall provide a status report to the Legislature on a
34semiannual basis until regulations have been adopted.

end insert
begin delete

35(s)

end delete

36begin insert(end insertbegin insertw)end insert This section shall be implemented only if and to the extent
37that federal financial participation is available and any necessary
38federal approvals have been obtained.

begin delete

39(t)

end delete

40begin insert(end insertbegin insertx)end insert This section shall become operativebegin insert onend insert January 1, 2014.

P32   1

begin deleteSEC. 17.end delete
2begin insertSEC. 8.end insert  

Section 14005.38 of the Welfare and Institutions Code
3 is amended to read:

4

14005.38.  

(a) To the extent feasible, the department shall use
5the redetermination form required by subdivision (g) of Section
614005.37 as the annual reaffirmation form.

7(b) This section shall remain in effect only until January 1, 2014,
8and as of that date is repealed, unless a later enacted statute, that
9is enacted before January 1, 2014, deletes or extends that date.

begin delete
10

SEC. 18.  

Section 14005.39 of the Welfare and Institutions
11Code
is amended to read:

12

14005.39.  

(a) If a county has facts clearly demonstrating that
13a Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an
14event, such as death or change of state residency, Medi-Cal benefits
15shall be terminated without a redetermination under Section
1614005.37.

17(b) Whenever Medi-Cal eligibility is terminated without a
18redetermination, as provided in subdivision (a), the Medi-Cal
19eligibility worker shall record that fact or event causing the
20eligibility termination in the beneficiary’s file, along with a
21 certification that a full redetermination could not result in a finding
22of Medi-Cal eligibility. Following this certification, a notice of
23action specifying the basis for termination of Medi-Cal eligibility
24shall be sent to the beneficiary.

25(c) This section shall be implemented only if and to the extent
26that federal financial participation under Title XIX of the federal
27Social Security Act (42 U.S.C. Sec. 1396 et. seq.) is available and
28necessary federal approvals have been obtained.

29(d) Notwithstanding Chapter 3.5 (commencing with Section
3011340) of Part 1 of Division 3 of Title 2 of the Government Code,
31the department shall, without taking any regulatory action,
32implement this section by means of all-county letters or similar
33instructions. Thereafter, the department shall adopt regulations in
34accordance with the requirements of Chapter 3.5 (commencing
35with Section 11340) of Part 1 of Division 3 of Title 2 of the
36Government Code.

37

SEC. 19.  

Section 14005.60 is added to the Welfare and
38Institutions Code
, to read:

39

14005.60.  

(a) Commencing January 1, 2014, the department
40shall provide eligibility for Medi-Cal benefits for any person who
P33   1meets the eligibility requirements of Section
21902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security
3Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)).

4(b) Persons who qualify under subdivision (a) and are currently
5enrolled in a Low Income Health Program (LIHP) under
6California’s Bridge to Reform Section 1115(a) Medicaid
7Demonstration shall be transitioned to the Medi-Cal program under
8this section in accordance with the transition plan as approved by
9the federal Centers for Medicare and Medicaid Services. With
10respect to plan enrollment, a LIHP enrollee shall be simultaneously
11notified by the department at least 60 days prior to January 1, 2014,
12of all of the following:

13(1) Which Medi-Cal health plan or plans contain his or her
14existing medical home provider.

15(2) That the LIHP enrollee, subject to his or her ability to choose
16or change plans as described in paragraph (3), will be assigned to
17a health plan that includes his or her medical home and will be
18enrolled effective January 1, 2014. If the enrollee wants to keep
19his or her medical home, no additional action will be required.

20(3) The opportunity to choose a different health plan prior to
21January 1, 2014, if there is more than one plan available in the
22county where he or she resides. Instructions on how to choose or
23change plans shall be included in the notice, along with a packet
24of information about the available plans in the LIHP enrollee’s
25county.

26(4) If his or her existing medical home provider is not contracted
27with any Medi-Cal managed care health plan, he or she will receive
28all provider and health plan information required to be sent to new
29 enrollees. If he or she does not affirmatively select one of the
30available Medi-Cal managed care plans within 30 days of receipt
31of the notice, he or she will automatically be assigned a plan
32through the department prescribed auto-assignment process.

33(c) In counties where no Medi-Cal managed care health plans
34are available, LIHP enrollees shall be (1) notified that they will
35be transitioned to fee-for-service Medi-Cal as of January 1, 2014,
36(2) informed if their LIHP medical home provider is a Medi-Cal
37fee-for-service provider, (3) provided instructions on how to access
38services, (4) given a list of Medi-Cal fee-for-service providers by
39area of practice with contact information for each provider, and
P34   1(5) provided any other information that is required to be sent to
2new enrollees.

3(d) The department shall consult with stakeholders in developing
4the notice required by this section, including representatives of
5Medi-Cal beneficiaries, representatives of public hospitals, and
6representatives of county social service departments.

7(e) In order to ensure that no persons lose health care coverage
8in the course of the transition, the department shall require that
9notices of the January 1, 2014, change be sent to LIHP enrollees
10upon their LIHP redetermination in 2013 and again at least 90 days
11prior to the transition. Pursuant to Section 1902(k)(1) and Section
121937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
131396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
14shall seek approval from the United States Secretary of Health and
15Human Services to establish a benchmark benefit package that
16includes the same benefits, services, and coverage that are provided
17to all other full-scope Medi-Cal enrollees, supplemented by any
18benefits, services, and coverage included in the essential health
19benefits package adopted by the state pursuant to Section 1367.005
20of the Health and Safety Code and Section 10112.27 of the
21Insurance Code and approved by the United States Secretary of
22Health and Human Services under Section 18022 of Title 42 of
23the United States Code, and any successor essential health benefit
24package adopted by the state.

25

SEC. 20.  

Section 14005.62 is added to the Welfare and
26Institutions Code
, to read:

27

14005.62.  

Commencing January 1, 2014, the department shall
28accept an individual’s attestation of information and verify
29information pursuant to Section 15926.2.

end delete
30begin insert

begin insertSEC. 9.end insert  

end insert

begin insertSection 14005.60 is added to the end insertbegin insertWelfare and
31Institutions Code
end insert
begin insert, to read:end insert

begin insert
32

begin insert14005.60.end insert  

(a) Commencing January 1, 2014, the department
33shall provide Medi-Cal benefits for individuals who meet eligibility
34requirements of Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the
35federal Social Security Act (42 U.S.C. Sec.
361396a(a)(10)(A)(i)(VIII)).

37(b) An individual eligible under this section shall not have
38income that exceeds 133 percent of the federal poverty level as
39determined, counted, and valued in accordance with the
40requirements of Section 1396a(e)(14) of Title 42 of the United
P35   1States Code, as added by the federal Patient Protection and
2Affordable Care Act (Public Law 111-148), and as amended by
3the federal Health Care and Education Reconciliation Act of 2010
4(Public Law 111-152) and any subsequent amendments.

5(c) (1) Individuals who are eligible under this section shall be
6required to mandatorily enroll into a Medi-Cal managed care
7health plan in those counties where a Medi-Cal managed care
8health plan is available.

9(2) (A) Individuals residing in a county where no Medi-Cal
10managed care health plan is available shall be provided services
11under the Medi-Cal fee-for-service delivery system subject to
12subparagraph (B).

13(B) If a Medi-Cal managed care health plan becomes available
14to individuals referenced in subparagraph (A), those individuals
15shall be enrolled in a Medi-Cal managed care health plan.

16(d) Notwithstanding Chapter 3.5 (commencing with Section
1711340) of Part 1 of Division 3 of Title 2 of the Government Code,
18 the department, without taking any further regulatory action, shall
19implement, interpret, or make specific this section by means of
20all-county letters, plan letters, plan or provider bulletins, or similar
21instructions until the time regulations are adopted. Thereafter, the
22department shall adopt regulations in accordance with the
23requirements of Chapter 3.5 (commencing with Section 11340) of
24Part 1 of Division 3 of Title 2 of the Government Code. Beginning
25six months after the effective date of this section, and
26notwithstanding Section 10231.5 of the Government Code, the
27department shall provide a status report to the Legislature on a
28semiannual basis until regulations have been adopted.

29(e) This section shall be implemented only if and to the extent
30that federal financial participation under Title XIX of the federal
31Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available.

end insert
32begin insert

begin insertSEC. 10.end insert  

end insert

begin insertSection 14005.61 is added to the end insertbegin insertWelfare and
33Institutions Code
end insert
begin insert, to read:end insert

begin insert
34

begin insert14005.61.end insert  

(a) Except as provided in subdivision (e), individuals
35who are enrolled in a Low Income Health Program (LIHP) as of
36December 31, 2013, under California’s Bridge to Reform Section
371115(a) Medicaid Demonstration who are at or below 133 percent
38of the federal poverty level shall be transitioned directly to the
39Medi-Cal program in accordance with the requirements of this
40section and pursuant to federal approval.

P36   1(b) Except as provided in paragraph (8) of subdivision (c),
2individuals who are eligible under subdivision (a) shall be required
3to enroll into Medi-Cal managed care health plans.

4(c) Except as provided in subdivision (d), with respect to
5managed care health plan enrollment, a LIHP enrollee shall be
6notified by the department at least 60 days prior to January 1,
72014, in accordance with the department’s LIHP transition plan
8of all of the following:

9(1) Which Medi-Cal managed care health plan or plans contain
10his or her existing primary care provider, if the department has
11this information and the primary care provider is contracted with
12a Medi-Cal managed care health plan.

13(2) That the LIHP enrollee, subject to his or her ability to
14change as described in paragraph (3), will be assigned to a health
15plan that includes his or her primary care provider and enrolled
16effective January 1, 2014. If the enrollee wants to keep his or her
17primary care provider, no additional action will be required if the
18primary care provider is contracted with a Medi-Cal managed
19care health plan.

20(3) That the LIHP enrollee may choose any available Medi-Cal
21managed care health plan and primary care provider in his or her
22county of residence prior to January 1, 2014, if more than one
23such plan is available in the county where he or she resides, and
24he or she will receive all provider and health plan information
25required to be sent to new enrollees and instructions on how to
26choose or change his or her health plan and primary care provider.

27(4) That in counties with more than one Medi-Cal managed
28care health plan, if the LIHP enrollee does not affirmatively choose
29a plan within 30 days of receipt of the notice, he or she shall be
30enrolled into the Medi-Cal managed care health plan that contains
31his or her LIHP primary care provider as part of the Medi-Cal
32managed care contracted primary care network, if the department
33has this information about the primary care provider, and the
34primary care provider is contracted with a Medi-Cal managed
35care health plan. If the primary care provider is contracted with
36more than one Medi-Cal managed care health plan, then the LIHP
37enrollee will be assigned to one of the health plans containing his
38or her primary care provider in accordance with an assignment
39process established to ensure the linkage.

P37   1(5) That if the LIHP enrollee’s existing primary care provider
2is not contracted with any Medi-Cal managed care health plan,
3then he or she will receive all provider and health plan information
4required to be sent to new enrollees. If the LIHP enrollee does not
5affirmatively select one of the available Medi-Cal managed care
6plans within 30 days of receipt of the notice, he or she will
7automatically be assigned a plan through the
8department-prescribed auto-assignment process.

9(6) That the LIHP enrollee does not need to take any action to
10be transitioned to the Medi-Cal program or to retain his or her
11primary care provider, if the primary care provider is available
12pursuant to paragraph (2).

13(7) That the LIHP enrollee may choose not to transition to the
14Medi-Cal program, and what this choice will mean for his or her
15health care coverage and access to health care services.

16(8) That in counties where no Medi-Cal managed care health
17plans are available, the LIHP enrollee will be transitioned into
18fee-for-service Medi-Cal, and provided with all information that
19is required to be sent to new Medi-Cal enrollees including the
20assistance telephone number for fee-for-service beneficiaries, and
21that, if a Medi-Cal managed care health plan becomes available
22in the residence county, he or she will be enrolled in a Medi-Cal
23managed care health plan according to the enrollment procedures
24in place at that time.

25(d) Individuals who qualify under subdivision (a) who apply
26and are determined eligible for LIHP after the date identified by
27the department that is not later than October 1, 2013, will be
28considered late enrollees. Late enrollees shall be notified in
29accordance with subdivision (c), except according to a different
30timeframe, but will transition to Medi-Cal coverage on January
311, 2014. Late enrollees after the date identified in this subdivision
32shall be transitioned pursuant to the department’s LIHP transition
33plan process.

34(e) Individuals who qualify under subdivision (a) and are not
35denoted as active LIHP enrollees according to the Medi-Cal
36Eligibility Data System at any point within the date range identified
37by the department that will start not sooner than December 20,
382013, and continue through December 31, 2013, will not be
39included in the LIHP transition to the Medi-Cal program. These
P38   1individuals may apply for Medi-Cal eligibility separately from the
2LIHP transition process.

3(f) In conformity with the department’s transition plan,
4individuals who are enrolled in a LIHP at any point from
5September 2013 through December 2013, under California’s
6Bridge to Reform Section 1115(a) Medicaid Demonstration and
7are above 133 percent of the federal poverty level will be provided
8information regarding how to apply for an insurance affordability
9program, including submission of an application by telephone, by
10mail, online, or in person.

11(g) A Medi-Cal managed care health plan that receives a LIHP
12enrollee during this transition shall assign the LIHP primary care
13provider of the enrollee as the Medi-Cal managed care health plan
14primary care provider of the enrollee, to the extent possible, if the
15Medi-Cal managed care health plan contracts with that primary
16care provider, unless the beneficiary has chosen another primary
17care provider on his or her choice form. A LIHP enrollee who is
18enrolled into a Medi-Cal managed care plan may work through
19the Medi-Cal managed care plan to change his or her assigned
20primary care provider or other provider, after enrollment and
21subject to provider availability, according to the standard
22processes that are currently available in Medi-Cal managed care
23for selecting providers.

24(h) The director may, with federal approval, suspend, delay, or
25otherwise modify the requirement for LIHP program eligibility
26redeterminations in 2013 to facilitate the process of transitioning
27LIHP enrollees to other health coverage in 2014.

28(i) The county LIHPs and their designees shall work with the
29department and its designees during the 2013 and 2014 calendar
30years to facilitate continuity of care and data sharing for the
31purposes of delivering Medi-Cal services in the 2014 calendar
32year.

33(j) This section shall be implemented only if and to the extent
34that federal financial participation under Title XIX of the federal
35Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available and
36all necessary federal approvals have been obtained.

end insert
begin delete
37

SEC. 21.  

Section 14005.63 is added to the Welfare and
38Institutions Code
, to read:

39

14005.63.  

(a) A person who wishes to apply for an insurance
40affordability program shall be allowed to file an application on his
P39   1or her own behalf or on behalf of his or her family. Subject to the
2requirements of Section 14014.5, an individual also may be
3accompanied, assisted, and represented in the application and
4renewal process by an individual or organization of his or her own
5choice. If the individual, for any reason, is unable to apply or renew
6on his or her own behalf, any of the following persons may assist
7in the application process or during a renewal of eligibility:

8(1) The individual’s guardian, conservator, a person authorized
9to make health care decisions on behalf of the individual pursuant
10to an advance health care directive, or executor or administrator
11of the individual’s estate.

12(2) A public agency representative.

13(3) The individual’s legal counsel, relative, friend, or other
14spokesperson of his or her choice.

15(b) A person who wishes to challenge a decision concerning his
16or her eligibility for or receipt of benefits from an insurance
17affordability program has the right to represent himself or herself
18or use legal counsel, a relative, a friend, or other spokesperson of
19his or her choice subject to the requirements of Section 14014.5.

20(c) To the extent otherwise required by Chapter 3.5
21(commencing with Section 11340) of Part 1 of Division 3 of Title
222 of the Government Code, the department shall adopt emergency
23regulations implementing this section no later than July 1, 2015.
24 The department may thereafter readopt the emergency regulations
25pursuant to that chapter. The adoption and readoption, by the
26department, of regulations implementing this section shall be
27deemed to be an emergency and necessary to avoid serious harm
28to the public peace, health, safety, or general welfare for purposes
29of Sections 11346.1 and 11349.6 of the Government Code, and
30the department is hereby exempted from the requirement that it
31describe facts showing the need for immediate action and from
32review by the Office of Administrative Law.

33(d) This section shall be implemented on October 1, 2013, or
34when all necessary federal approvals have been obtained,
35whichever is later, and only if and to the extent that federal
36financial participation is available.

37

SEC. 22.  

Section 14005.64 is added to the Welfare and
38Institutions Code
, to read:

39

14005.64.  

(a) This section implements Section 1902(e)(14)(C)
40of the federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(C))
P40   1and Section 435.603(g) of Title 42 of the Code of Federal
2Regulations, which prohibits the use of an assets test for individuals
3whose income eligibility is determined based on modified adjusted
4gross income (MAGI), and Section 2002 of the federal Patient
5Protection and Affordable Care Act (Affordable Care Act) (42
6U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of Title 42
7of the Code of Federal Regulations, which requires a 5-percent
8income disregard for individuals whose income eligibility is
9determined based on MAGI.

10(b) In the case of individuals whose financial eligibility for
11Medi-Cal is determined based on the application of MAGI pursuant
12to Section 435.603 of Title 42 of the Code of Federal Regulations,
13the eligibility determination shall not include any assets or
14resources test.

15(c) The department shall implement the 5-percent income
16disregard for individuals whose income eligibility is determined
17based on MAGI in Section 2002 of the Affordable Care Act (42
18U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of Title 42
19of the Code of Federal Regulations.

20(d) The department shall adopt an equivalent income level for
21each eligibility group whose income level will be converted to
22MAGI. The equivalent income level shall not be less than the dollar
23amount of all income exemptions, exclusions, deductions, and
24disregards in effect on March 23, 2010, plus the existing income
25level expressed as a percent of the federal poverty level for each
26eligibility group so as to ensure that the use of MAGI income
27methodology does not result in populations who would have been
28eligible under this chapter and Part 6.3 (commencing with Section
2912695) of Division 2 of the Insurance Code losing coverage.

30(e)


31The department shall include individuals under 19 years of age,
32or in the case of full-time students, under 21 years of age, in the
33household for purposes of determining eligibility under Section
341396a(e)(14) of Title 42 of the United States Code, as added by
35the federal Patient Protection and Affordable Care Act (Public
36Law 111-148), and as amended by the federal Health Care and
37Education Reconciliation Act of 2010 (Public Law 111-152) and
38any subsequent amendments, as provided in Section 435.603(f)(3)
39of Title 42 of the Code of Federal Regulations.

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

  

P41   1

SEC. 23.  

Section 14005.65 is added to the Welfare and
2Institutions Code
, to read:

3

14005.65.  

In accordance with the state’s options under Section
4435.603(h) of Title 42 of the Code of Federal Regulations, the
5department shall adopt procedures to take into account projected
6future changes in income and family size, for individuals whose
7Medi-Cal income eligibility is determined using MAGI-based
8methods, in order to grant or maintain eligibility for those
9individuals who may be ineligible or become ineligible if only the
10current monthly income and family size are considered.

11(a) For current beneficiaries whose eligibility has already been
12approved, the department shall base financial eligibility on
13projected annual household income for the remainder of the current
14calendar year if the current monthly income would render the
15beneficiary ineligible due to fluctuating income.

16(b) For applicants, the department shall, in determining the
17current monthly household income and family size, base an initial
18determination of eligibility on the projected annual household
19income and family size for the upcoming year if considering the
20current monthly income and family size in isolation would render
21an applicant ineligible.

22(c) In the procedures adopted pursuant to this section, the
23department shall implement a reasonable method to account for a
24reasonably predictable decrease in income and increase in family
25size, as evidenced by a history of predictable fluctuations in income
26or other clear indicia of a future decrease in income and increase
27in family size. The department shall not assume potential future
28increases in income or decreases in family size to make an applicant
29or beneficiary ineligible in the current month.

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

end delete
31begin insert

begin insertSEC. 11.end insert  

end insert

begin insertSection 14005.64 is added to the end insertbegin insertWelfare and
32Institutions Code
end insert
begin insert, to read:end insert

begin insert
33

begin insert14005.64.end insert  

(a) Effective January 1, 2014, and notwithstanding
34any other provision of law, when determining eligibility for
35Medi-Cal benefits, an applicant’s or beneficiary’s income and
36resources shall be determined, counted, and valued in accordance
37with the requirements of Section 1902(e)(14) of the federal Social
38Security Act (42 U.S.C. 1396a(e)(14)), as added by the ACA, which
39prohibits the use of an assets or resources test for individuals
P42   1whose income eligibility is determined based on modified adjusted
2gross income.

3(b) When determining the eligibility of applicants and
4beneficiaries using the MAGI-based financial methods, the
55-percent income disregard required under Section
61902(e)(14)(B)(I) of the federal Social Security Act (42 U.S.C.
7Sec. 1396a(e)(14)(B)(I)) shall be applied.

8(c) (1) The department shall establish income eligibility
9thresholds for those Medi-Cal eligibility groups whose eligibility
10will be determined using MAGI-based financial methods. The
11income eligibility thresholds shall be developed using the financial
12methodologies described in Section 1396a(e)(14) of Title 42 of the
13United States Code and in conformity with Section 1396a(gg) of
14Title 42 of the United States Code as added by the ACA.

15(2) In utilizing state data or the national standard methodology
16with Survey of Income and Program Participation data to develop
17the converted modified adjusted gross income standard for
18Medi-Cal applicants and beneficiaries, the department shall ensure
19that the financial methodology used for identifying the equivalent
20income eligibility threshold preserves Medi-Cal eligibility for
21 applicants and beneficiaries to the extent required by federal law.
22The department shall report to the Legislature on the expected
23changes in income eligibility thresholds using the chosen
24methodology for individuals whose income is determined on the
25basis of a converted dollar amount or federal poverty level
26percentage. The department shall convene stakeholders, including
27the Legislature, counties, and consumer advocates regarding the
28results of the converted standards and shall review with them the
29information used for the specific calculations before adopting its
30final methodology for the equivalent income eligibility threshold
31level.

32(d) The department shall include individuals under 19 years of
33age, or in the case of full-time students, under 21 years of age, in
34the household for purposes of determining eligibility under Section
351396a(e)(14) of Title 42 of the United States Code, as added by
36the ACA.

37(e) For purposes of this section, the following definitions shall
38apply:

39(1) “ACA” means the federal Patient Protection and Affordable
40Care Act (Public Law 111-148) as originally enacted and as
P43   1amended by the federal Health Care and Education Reconciliation
2Act of 2010 (Public Law 111-152) and any subsequent
3amendments.

4(2) “MAGI-based financial methods” means income calculated
5using the financial methodologies described in Section
61396a(e)(14) of Title 42 of the United States Code, and as added
7by the ACA.

8(f) Notwithstanding Chapter 3.5 (commencing with Section
911340) of Part 1 of Division 3 of Title 2 of the Government Code,
10the department, without taking any further regulatory action, shall
11implement, interpret, or make specific this section by means of
12all-county letters, plan letters, plan or provider bulletins, or similar
13instructions until the time regulations are adopted. Thereafter, the
14department shall adopt regulations in accordance with the
15requirements of Chapter 3.5 (commencing with Section 11340) of
16Part 1 of Division 3 of Title 2 of the Government Code. Beginning
17six months after the effective date of this section, and
18notwithstanding Section 10231.5 of the Government Code, the
19department shall provide a status report to the Legislature on a
20semiannual basis until regulations have been adopted.

21(g) This section shall be implemented only if and to the extent
22that federal financial participation is available and any necessary
23federal approvals have been obtained.

end insert
begin delete
24

SEC. 24.  

Section 14007.1 of the Welfare and Institutions Code
25 is amended to read:

26

14007.1.  

(a) The department shall adopt regulations for use
27by the county welfare department in determining whether an
28applicant is a resident of this state and of the county subject to the
29requirements of federal law. The regulations shall require that state
30residency is not established unless the applicant does both of the
31following:

32(1) The applicant produces one of the following:

33(A) A recent California rent or mortgage receipt or utility bill
34in the applicant’s name.

35(B) A current California motor vehicle driver’s license or
36California Identification Card issued by the Department of Motor
37Vehicles in the applicant’s name.

38(C) A current California motor vehicle registration in the
39applicant’s name.

P44   1(D) A document showing that the applicant is employed in this
2state.

3(E) A document showing that the applicant has registered with
4a public or private employment service in this state.

5(F) Evidence that the applicant has enrolled his or her children
6in a school in this state.

7(G) Evidence that the applicant is receiving public assistance
8in this state.

9(H) Evidence of registration to vote in this state.

10(2) The applicant declares, under penalty of perjury, that all of
11the following apply:

12(A) The applicant does not own or lease a principal residence
13outside this state.

14(B) The applicant is not receiving public assistance outside this
15state. As used in this subdivision, “public assistance” does not
16include unemployment insurance benefits.

17(b) A denial of a determination of residency may be appealed
18in the same manner as any other denial of eligibility. The
19Administrative Law Judge shall receive any proof of residency
20offered by the applicant and may inquire into any facts relevant
21to the question of residency. A determination of residency shall
22not be granted unless a preponderance of the credible evidence
23supports the applicant’s intent to remain indefinitely in this state.

24(c) This section shall remain in effect only until January 1, 2014,
25and as of that date is repealed, unless a later enacted statute, that
26is enacted before January 1, 2014, deletes or extends that date.

27

SEC. 25.  

Section 14007.1 is added to the Welfare and
28Institutions Code
, to read:

29

14007.1.  

(a) The department shall electronically verify an
30individual’s state residency using information from the federal
31Supplemental Nutrition Assistance Program, the CalWORKS
32program, the California Health Benefit Exchange, the Franchise
33Tax Board, the Department of Motor Vehicles, the state agency
34administering the state’s unemployment compensation laws, and
35the electronic service established in accordance with Section
36435.949 of Title 42 of the Code of Federal Regulations, and other
37available sources. If the department is unable to electronically
38verify an individual’s state residency using these electronic data
39sources, an individual may establish state residency as set forth in
40this section.

P45   1(b) If the individual is 21 years of age or older, is capable of
2indicating intent, and is not residing in an institution, state
3residency is established when the individual does both of the
4following.

5(1) The individual provides one of the following:

6(A)


7A recent California rent or mortgage receipt or utility bill in
8the individual’s name.

9(B)


10A current California motor vehicle driver’s license or California
11Identification Card issued by the Department of Motor Vehicles
12in the individual’s name.

13(C)


14A current California motor vehicle registration in the
15individual’s name.

16(D)


17A document showing that the individual is employed in this
18state or is seeking employment in the state.

19(E)


20A document showing that the individual has registered with a
21public or private employment service in this state.

22(F)


23Evidence that the individual has enrolled his or her children in
24a school in this state.

25(G)


26Evidence that the individual is receiving public assistance in
27this state.

28(H)


29Evidence of registration to vote in this state.

30(I)


31A declaration by the individual under penalty of perjury that
32he or she intends to reside in this state and does not have a fixed
33address and cannot provide any of the documents identified in
34subparagraphs (A) to (H), inclusive.

35(J)


36A declaration by the individual under penalty of perjury that
37he or she has entered the state with a job commitment or is seeking
38employment in the state and cannot provide any of the documents
39identified in subparagraphs (A) to (H), inclusive.

P46   1(2) The individual declares, under penalty of perjury, that both
2of the following apply:

3(A) The individual does not own or lease a principal residence
4outside this state.

5(B) The individual is not receiving public assistance outside
6this state. For purposes of this subdivision, “public assistance”
7shall not include unemployment insurance benefits.

8(c) If the individual is 21 years or age or older, is incapable of
9indicating intent, and is not residing in an institution, state
10residency is established when the parent, legal guardian of the
11individual, or any other person with knowledge declares, under
12penalty of perjury, that the individual is residing in this state.

13(d) If the individual is 21 years of age or older, is residing in an
14institution, and became incapable of indicating intent before
15reaching 21 years of age, state residency is established by any of
16the following:

17(1) When the parent applying for Medi-Cal on the individual’s
18behalf (A) declares under penalty of perjury that the individual’s
19parents reside in separate states and (B) establishes that he or she
20(the parent) is a resident of this state in accordance with the
21requirements of this section.

22(2) When the legal guardian applying for Medi-Cal on the
23individual’s behalf (A) declares under penalty of perjury that
24parental rights have been terminated and (B) establishes that he
25or she (the legal guardian) is a resident of this state in accordance
26with the requirements of this section.

27(3) When the parent or parents applying for Medi-Cal on the
28individual’s behalf establishes in accordance with the requirements
29of this section that he, she, or they (the parent or parents), were a
30resident of this state at the time the individual was placed in the
31institution.

32(4) When the legal guardian applying for Medi-Cal on the
33individual’s behalf (A) declares under penalty of perjury that
34parental rights have been terminated and (B) establishes in
35accordance with the requirements of this section that he or she (the
36legal guardian) was a resident of this state at the time the individual
37was placed in the institution.

38(5) When the parent, or parents, applying for Medi-Cal on the
39individual’s behalf (A) provides a document from the institution
40that demonstrates that the individual is institutionalized in this
P47   1state and (B) establishes in accordance with the requirements of
2this section that he, she, or they (the parent or parents), are a
3resident of this state.

4(6) When the legal guardian applying for Medi-Cal on the
5individual’s behalf (A) provides a document from the institution
6that demonstrates that the individual is institutionalized in this
7state, (B) declares under penalty of perjury that parental rights
8have been terminated, and (C) establishes in accordance with the
9requirements of this section that he or she (the legal guardian) is
10a resident of this state.

11(7) When the individual or party applying for Medi-Cal on the
12individual’s behalf (A) provides a document from the institution
13that demonstrates that the individual is institutionalized in this
14state, (B) declares under penalty of perjury that the individual has
15 been abandoned by his or her parents and does not have a legal
16guardian, and (C) establishes that he or she (the individual or party
17applying for Medi-Cal on the individual’s behalf) is a resident of
18this state in accordance with the requirements of this section.

19(e) Except when another state has placed the individual in the
20institution, if the individual is 21 years of age or older, is residing
21in an institution, and became incapable of indicating intent on or
22after reaching 21 years of age, state residency is established when
23the person filing the application on the individual’s behalf provides
24a document from the institution that demonstrates that the
25individual is institutionalized in this state.

26(f) If the individual is 21 years of age or older, is capable of
27indicating intent, and is residing in an institution, state residency
28is established when the individual (1) provides a document from
29the institution that demonstrates that the individual is
30institutionalized in this state, and (2) declares under penalty of
31perjury that he or she intends to reside in this state.

32(g) If the individual is under 21 years of age, is married or
33emancipated from his or her parents, is capable of indicating intent,
34and is not residing in an institution, state residency is established
35in accordance with subdivision (b).

36(h) If the individual is under 21 years of age, is not living in an
37institution, and is not described in subdivision (g), state residency
38is established by any of the following:

39(1) When the individual resides with his or her parent or parents
40and the parent or parents establish that he, she, or they (the parent
P48   1or parents), as the case may be, are a resident of this state in
2accordance with the requirements of subdivision (b).

3(2) When the individual resides with a caretaker relative and
4the caretaker relative establishes that he, she, or they (the caretaker
5relative or caretaker relatives), are a resident of this state in
6accordance with the requirements of subdivision (b).

7(3) When the person with whom the individual is residing is
8not the individual’s parent or caretaker relative and he or she (A)
9declares under penalty of perjury that the individual is residing
10with him or her, and (B) establishes that he or she (the person with
11whom the individual is residing) is a resident of this state in
12accordance with the requirements of subdivision (b).

13(4) When the individual does not reside with his or her parents
14or with a caretaker relative and he or she declares under penalty
15of perjury that he or she is living in this state.

16(i) If the individual is under 21 years of age, is institutionalized,
17and is not married or emancipated, state residency is established
18in accordance with paragraphs (3), (4), (5), (6) and (7) of
19subdivision (d).

20(j) A denial of a determination of residency may be appealed
21in the same manner as any other denial of eligibility. The
22administrative law judge shall receive any proof of residency
23offered by the individual and may inquire into any facts relevant
24to the question of residency. A determination of residency shall
25not be granted unless a preponderance of the credible evidence
26supports that the individual is a resident of this state under Section
2714007.15.

28(k) To the extent otherwise required by Chapter 3.5
29(commencing with Section 11340) of Part 1 of Division 3 of Title
302 of the Government Code, the department shall adopt emergency
31regulations implementing this section no later than July 1, 2015.
32The department may thereafter readopt the emergency regulations
33pursuant to that chapter. The adoption and readoption, by the
34department, of regulations implementing this section shall be
35deemed to be an emergency and necessary to avoid serious harm
36to the public peace, health, safety, or general welfare for purposes
37of Sections 11346.1 and 11349.6 of the Government Code, and
38the department is hereby exempted from the requirement that it
39describe facts showing the need for immediate action and from
40review by the Office of Administrative Law.

P49   1(l) For purposes of this section, the definitions in subdivision
2(i) of Section 14007.15 shall apply.

3(m) This section shall be implemented only if and to the extent
4that federal financial participation is available and any necessary
5federal approvals have been obtained.

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

7

SEC. 26.  

Section 14007.15 is added to the Welfare and
8Institutions Code
, immediately following Section 14007.1, to read:

9

14007.15.  

(a) Except as provided in subdivision (f), an
10individual is a resident of this state if he or she is 21 years of age
11or older, is not residing in an institution, is living in the state, and
12any of the following apply:

13(1) The individual intends to reside in this state, including
14individuals who do not have a fixed address.

15(2) The individual has entered this state with a job commitment
16or is seeking employment in this state, regardless of whether he
17or she is currently employed.

18(3) The individual is incapable of indicating intent.

19(b) Except as provided in subdivision (f), an individual that is
2021 years of age or older, is residing in an institution, and became
21incapable of indicating intent before reaching 21 years of age is a
22resident of this state if any of the following apply:

23(1) The individual’s parents reside in separate states and the
24parent applying for Medi-Cal on the individual’s behalf is a resident
25of this state under this section.

26(2) The parental rights have been terminated and a legal guardian
27has been appointed for the individual and the legal guardian
28applying for Medi-Cal on the individual’s behalf is a resident of
29this state under this section.

30(3) The individual’s parent or parents, or legal guardian if
31parental rights have been terminated, was a resident of this state
32under this section at the time the individual was placed in the
33 institution.

34(4) The individual is institutionalized in this state and the parent
35or parents, or legal guardian if parental rights have been terminated,
36applying for Med-Cal on the individual’s behalf is a resident of
37this state under this section.

38(5) The individual is institutionalized in this state, has been
39abandoned by his or her parent or parents, does not have a legal
40guardian, and the individual or party that filed the Medi-Cal
P50   1application on the individual’s behalf is a resident of this state
2under this section.

3(c) Except as provided in subdivision (f) and except where
4another state has placed the individual in the institution, an
5individual is a resident of this state if he or she is 21 years of age
6or older, is institutionalized in this state, and became incapable of
7indicating intent on or after reaching 21 years of age.

8(d) Except as provided in subdivision (f), an individual is a
9resident of this state if he or she is 21 years of age or older, is
10institutionalized in this state, and intends to reside in this state.

11(e) Except as provided in subdivision (f), an individual that is
12under 21 years of age is a resident of this state if one of the
13following apply:

14(1) The individual is not residing in an institution, is capable of
15 indicating intent, is married or is emancipated from his or her
16parents, is living in this state, and one of the following apply:

17(A) The individual intends to reside in this state, which includes
18an individual who does not have a fixed address.

19(B) The individual has entered this state with a job commitment
20or is seeking employment in this state, regardless of whether he
21or she is currently employed.

22(2) The individual is not described in paragraph (1) and is not
23living in an institution, and any of the following apply:

24(A) The individual resides in this state, including without a fixed
25address.

26(B) The individual resides with his or her parent or parents or
27a caretaker relative who is a resident of this state under this section.

28(3) The individual is institutionalized, is not married or
29emancipated, and any of the following apply:

30(A) The individual’s parent or parents, or legal guardian if
31parental rights have been terminated, was a resident of this state
32under this section at the time of placement in the institution.

33(B) The individual is institutionalized in this state and his or
34her parent or parents, or legal guardian if parental rights have been
35terminated, who files the application on the individual’s behalf is
36a resident of this state under this section.

37(C) The individual is institutionalized in this state, has been
38abandoned by his or her parents, does not have a legal guardian,
39and the individual or party that files the application on the
40individual’s behalf is a resident of this state under this section.

P51   1(f) An individual who is receiving a state supplementary
2payment (SSP) is a resident of the state paying the SSP.

3(g) An individual who lives in this state and is receiving foster
4 care or adoption assistance under Title IV-E of the federal Social
5Security Act is a resident of this state.

6(h) (1) If this state or an agent of this state arranges for an
7individual to be placed in an institution located in another state,
8the individual is a resident of this state.

9(2) The following actions do not constitute a placement by this
10state:

11(A) Providing basic information to the individual about another
12state’s Medicaid program and information about the availability
13of health care services and facilities in another state.

14(B) Assisting an individual to locate an institution in another
15state when the individual is capable of indicating intent and
16independently decides to move to the other state.

17(3) When a competent individual leaves the facility in which
18he or she was placed by this state, that individual’s state of
19residence is the state where the individual is physically located.

20(4) If this state initiates a placement in another state because it
21lacks an appropriate facility to provide services to the individual,
22the individual is a resident of this state.

23(i) For the purposes of this section and Section 14007.1, the
24following definitions apply:

25(1) “Incapable of indicating intent” means when an individual
26is considered to be any of the following:

27(A) Determined to have an I.Q. of 49 or less or to have a mental
28age of 7 years or younger based upon tests administered by a
29properly licensed mental health or developmental disabilities
30professional.

31(B) Found to be incapable of indicating intent based on medical
32documentation provided by a physician, psychologist, or other
33person licensed by the state in the field of mental health or
34developmental disabilities.

35(C) Been judicially determined to be legally incompetent.

36(2) “Institution” shall have the same meaning as that term is
37defined in Section 435.1010 of Title 42 of the Code of Federal
38Regulations. For the purposes of determining residency under
39subdivision (h), the term also includes licensed foster care homes
P52   1providing food, shelter, and supportive services to one or more
2persons unrelated to the proprietor.

3(j) To the extent otherwise required by Chapter 3.5 (commencing
4with Section 11340) of Part 1 of Division 3 of Title 2 of the
5Government Code, the department shall adopt emergency
6regulations implementing this section no later than July 1, 2015.
7The department may thereafter readopt the emergency regulations
8pursuant to that chapter. The adoption and readoption, by the
9department, of regulations implementing this section shall be
10deemed to be an emergency and necessary to avoid serious harm
11to the public peace, health, safety, or general welfare for purposes
12of Sections 11346.1 and 11349.6 of the Government Code, and
13the department is hereby exempted from the requirement that it
14describe facts showing the need for immediate action and from
15review by the Office of Administrative Law.

16(k) This section shall be implemented only if and to the extent
17that federal financial participation is available and any necessary
18federal approvals have been obtained.

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

20

SEC. 27.  

Section 14007.6 of the Welfare and Institutions Code
21 is amended to read:

22

14007.6.  

(a) A recipient who maintains a residence outside of
23this state for a period of at least two months shall not be eligible
24for services under this chapter where the county has made inquiry
25of the recipient pursuant to Section 11100, and where the recipient
26has not responded to this inquiry by clearly showing that he or she
27has (1) not established residence elsewhere; and (2) been prevented
28by illness or other good cause from returning to this state.

29(b) If a recipient whose services are terminated pursuant to
30subdivision (a) reapplies for services, services shall be restored
31provided all other eligibility criteria are met if this individual can
32prove both of the following:

33(1) His or her permanent residence is in this state.

34(2) That residence has not been established in any other state
35which can be considered to be of a permanent nature.

36(c) This section shall remain in effect only until January 1, 2014,
37and as of that date is repealed unless a later enacted statute, that
38is enacted before January 1, 2014, deletes or extends that date.

39

SEC. 28.  

Section 14007.6 is added to the Welfare and
40Institutions Code
, to read:

P53   1

14007.6.  

(a) A recipient who maintains a residence outside of
2this state for a period of at least two months shall not be eligible
3for services under this chapter where the county has made inquiry
4of the recipient pursuant to Section 11100, and where the recipient
5has not responded to this inquiry by clearly showing that he or she
6has (1) not established residence elsewhere; or (2) been prevented
7by illness or other good cause from returning to this state.

8(b) If a recipient whose services are terminated pursuant to
9subdivision (a) reapplies for services, services shall be restored
10provided all other eligibility criteria are met and the individual is
11considered a resident pursuant to Section 14007.15.

12(c) To the extent otherwise required by Chapter 3.5
13(commencing with Section 11340) of Part 1 of Division 3 of Title
142 of the Government Code, the department shall adopt emergency
15regulations implementing this section no later than July 1, 2015.
16The department may thereafter readopt the emergency regulations
17pursuant to that chapter. The adoption and readoption, by the
18department, of regulations implementing this section shall be
19deemed to be an emergency and necessary to avoid serious harm
20to the public peace, health, safety, or general welfare for purposes
21of Sections 11346.1 and 11349.6 of the Government Code, and
22the department is hereby exempted from the requirement that it
23describe facts showing the need for immediate action and from
24review by the Office of Administrative Law.

25(d) This section shall be implemented only if and to the extent
26that federal financial participation is available and any necessary
27federal approvals have been obtained.

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

29

SEC. 29.  

Section 14008.85 of the Welfare and Institutions
30Code
is amended to read:

31

14008.85.  

(a) To the extent federal financial participation is
32available, a parent who is the principal wage earner shall be
33considered an unemployed parent for purposes of establishing
34eligibility based upon deprivation of a child where any of the
35following applies:

36(1) The parent works less than 100 hours per month as
37determined pursuant to the rules of the Aid to Families with
38Dependent Children program as it existed on July 16, 1996,
39including the rule allowing a temporary excess of hours due to
40intermittent work.

P54   1(2) The total net nonexempt earned income for the family is not
2more than 100 percent of the federal poverty level as most recently
3calculated by the federal government. The department may adopt
4additional deductions to be taken from a family’s income.

5(3) The parent is considered unemployed under the terms of an
6existing federal waiver of the 100-hour rule for recipients under
7the program established by Section 1931(b) of the federal Social
8Security Act (42 U.S.C. Sec. 1396u-1).

9(b) Notwithstanding Chapter 3.5 (commencing with Section
1011340) of Part 1 of Division 3 of Title 2 of the Government Code,
11the department shall implement this section by means of an
12all-county letter or similar instruction without taking regulatory
13action. Thereafter, the department shall adopt regulations in
14accordance with the requirements of Chapter 3.5 (commencing
15with Section 11340) of Part 1 of Division 3 of Title 2 of the
16Government Code.

17(c) This section shall remain in effect only until January 1, 2014,
18and as of that date is repealed, unless a later enacted statute, that
19is enacted before January 1, 2014, deletes or extends that date.

end delete
20

begin deleteSEC. 30.end delete
21begin insertSEC. 12.end insert  

Section 14011.16 of the Welfare and Institutions
22Code
is amended to read:

23

14011.16.  

(a) Commencing August 1, 2003, the department
24shall implement a requirement for beneficiaries to file semiannual
25status reports as part of the department’s procedures to ensure that
26beneficiaries make timely and accurate reports of any change in
27circumstance that may affect their eligibility. The department shall
28develop a simplified form to be used for this purpose. The
29department shall explore the feasibility of using a form that allows
30a beneficiary who has not had any changes to so indicate by
31checking a box and signing and returning the form.

32(b) Beneficiaries who have been granted continuous eligibility
33under Section 14005.25 shall not be required to submit semiannual
34status reports. To the extent federal financial participation is
35available, all children under 19 years of age shall be exempt from
36the requirement to submit semiannual status reports.

37(c) For any period of time that the continuous eligibility period
38described in paragraph (1) of subdivision (a) of Section 14005.25
39is reduced to six months, subdivision (b) shall become inoperative,
P55   1and all children under 19 years of age shall be required to file
2semiannual status reports.

3(d) Beneficiaries whose eligibility is based on a determination
4of disability or on their status as aged or blind shall be exempt
5from the semiannual status report requirement described in
6subdivision (a). The department may exempt other groups from
7the semiannual status report requirement as necessary for simplicity
8of administration.

9(e) When a beneficiary has completed, signed, and filed a
10semiannual status report that indicated a change in circumstance,
11eligibility shall be redetermined.

12(f) Notwithstanding Chapter 3.5 (commencing with Section
1311340) of Part 1 of Division 3 of Title 2 of the Government Code,
14the department shall implement this section by means of all-county
15letters or similar instructions without taking regulatory action.
16Thereafter, the department shall adopt regulations in accordance
17with the requirements of Chapter 3.5 (commencing with Section
1811340) of Part 1 of Division 3 of Title 2 of the Government Code.

19(g) This section shall be implemented only if and to the extent
20federal financial participation is available.

21(h) This section shall remain in effect only until January 1, 2014,
22and as of that date is repealed, unless a later enacted statute, that
23is enacted before January 1, 2014, deletes or extends that date.

24

begin deleteSEC. 31.end delete
25begin insertSEC. 13.end insert  

Section 14011.17 of the Welfare and Institutions
26Code
is amended to read:

27

14011.17.  

The following persons shall be exempt from the
28semiannual reporting requirements described in Section 14011.16:

29(a) Pregnant women whose eligibility is based on pregnancy.

30(b) Beneficiaries receiving Medi-Cal through Aid for Adoption
31of Children Program.

32(c) Beneficiaries who have a public guardian.

33(d) Medically indigent children who are not living with a parent
34or relative and who have a public agency assuming their financial
35responsibility.

36(e) Individuals receiving minor consent services.

37(f) Beneficiaries in the Breast and Cervical Cancer Treatment
38Program.

39(g) Beneficiaries who are CalWORKs recipients and custodial
40parents whose children are CalWORKs recipients.

P56   1(h) This section shall remain in effect only until January 1, 2014,
2and as of that date is repealed, unless a later enacted statute, that
3is enacted before January 1, 2014, deletes or extends that date.

4

begin deleteSEC. 32.end delete
5begin insertSEC. 14.end insert  

Section 14012 of the Welfare and Institutions Code
6 is amended to read:

7

14012.  

(a) Reaffirmation shall be filed annually and may be
8required at other times in accordance with general standards
9established by the department.

10(b) This section shall remain in effect only until January 1, 2014,
11and as of that date is repealed, unless a later enacted statute, that
12is enacted before January 1, 2014, deletes or extends that date.

begin delete
13

SEC. 33.  

Section 14012 is added to the Welfare and Institutions
14Code
, to read:

15

14012.  

(a) This section implements Section 435.916(a)(1) of
16Title 42 of the Code of Federal Regulations, which applies to the
17eligibility of Medi-Cal beneficiaries whose financial eligibility is
18determined using modified adjusted gross income (MAGI) based
19income.

20(b) To the extent required by federal law or regulations, the
21eligibility of Medi-Cal beneficiaries whose financial eligibility is
22determined using a MAGI-based income shall be renewed once
23every 12 months, and no more frequently than every 12 months.

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

25

SEC. 34.  

Section 14014.5 is added to the Welfare and
26Institutions Code
, to read:

27

14014.5.  

(a) It is the intent of the Legislature to protect
28individual privacy and the integrity of Medi-Cal and other
29insurance affordability programs by restricting the disclosure of
30personal identifying information to prevent identity theft, abuse,
31or fraud in situations where an insurance affordability program
32applicant or beneficiary appoints an authorized representative to
33assist him or her in obtaining health care benefits.

34(b) The department, in consultation with the California Health
35Benefit Exchange, shall implement policies and prescribe forms,
36notices, and other safeguards to ensure the privacy and protection
37of the rights of applicants who appoint an authorized representative
38consistent with the provisions of Section 1902 of the federal Social
39Security Act (42 U.S.C. Sec. 1396a) and Section 435.908 of Title
4042 of the Code of Federal Regulations.

P57   1(c) All insurance affordability programs shall obtain completed
2authorization forms pursuant to subdivision (b) prior to making
3the final determination concerning the eligibility or renewal to
4which the authorization applies.

5(d) An authorization pursuant to this section shall do both of
6the following:

7(1) Specify what authority the applicant or beneficiary is
8granting to the authorized representative and what notices, if any,
9should be sent to the authorized representative in addition to the
10applicant or beneficiary.

11(2) Be effective until the applicant or beneficiary cancels or
12modifies the authorization or appoints a new authorized
13 representative, or the authorized representative informs the agency
14that he or she is no longer acting in that capacity or there is a
15change in the legal authority on which the authority was based.
16The notice shall conform to all federal requirements.

17(e) An authorization pursuant to this section may be canceled
18or modified at any time for any reason by the insurance
19affordability program applicant or beneficiary by submitting notice
20of cancellation or modification to the appropriate insurance
21affordability program in accordance with policies and forms
22developed pursuant to subdivision (b).

23(f) The agency shall accept electronic, including telephonically
24recorded, signatures, and handwritten signatures transmitted by
25facsimile or other electronic transmission.

26(g) For purposes of this section all of the following definitions
27shall apply:

28(1) “Authorized representative” means:

29(A) (i) Any individual appointed in writing, on a form
30designated by the department, by a competent person that is an
31applicant for or beneficiary of any insurance affordability program,
32to act in place or on behalf of the applicant or beneficiary for
33purposes related to the insurance affordability program, including,
34but not limited to, accompanying, assisting, or representing the
35applicant in the application process or the beneficiary in the
36redetermination of eligibility process, as specified by the applicant
37or beneficiary.

38(ii) Legal documentation of authority to act on behalf of the
39applicant or beneficiary under state law, including, but not limited
40to, a court order establishing legal guardianship or a valid power
P58   1of attorney to make health care decisions, shall service in place of
2a written appointment by the applicant or beneficiary.

3(2) “Competent” means being able to act on one’s own behalf
4in business and personal matters.

5(h) An authorized representative of an applicant or beneficiary
6of an insurance affordability program who also is employed by or
7is a contractor for any type of health care provider or facility shall
8fully disclose in writing to the applicant or beneficiary that the
9authorized representative is employed by or contracting with such
10a provider or facility and of any potential conflicts of interest.

11(i) All notices regarding the insurance affordability program,
12including, but not limited to, those related to the application,
13redetermination, or actions taken by the agency, shall be sent to
14the applicant or beneficiary, and to the authorized representative
15if authorized by the applicant or beneficiary.

16(j) (1) If an applicant or beneficiary is not competent and has
17not appointed an appropriately authorized representative pursuant
18to this section or that appointment is no longer effective, any of
19the individuals identified in subparagraphs (A) to (C), inclusive,
20may be recognized by the hearing officer as the authorized
21representative to represent the applicant or beneficiary at the state
22hearing regarding a notice of action if, at the hearing, he or she
23demonstrates that the applicant or beneficiary is not competent
24and that lack of competency is the reason that he or she has not
25been authorized by the applicant or beneficiary to act as the
26applicant’s or beneficiary’s authorized representative. The
27individuals that may be recognized are:

28(A) A relative of the applicant or beneficiary or a person
29appointed by the relative.

30(B) A person with knowledge of the applicant’s or beneficiary’s
31circumstances that completed and signed the Statement of Facts
32on the applicant’s or beneficiary’s behalf.

33(C) An applicant’s or beneficiary’s legal counsel or advocate
34working under the supervision of an attorney.

35(2) If an applicant or beneficiary is not competent and has not
36appointed an appropriately authorized representative pursuant to
37this section or that appointment is no longer effective, the hearing
38officer may allow an individual with knowledge about the
39applicant’s or beneficiary’s circumstances to represent the applicant
40or beneficiary at the hearing if (A) the hearing officer determines
P59   1that the representation is in the applicant or beneficiary’s best
2interests and (B) there is not a person who qualifies under
3paragraph (1) that is available to represent the applicant or
4beneficiary.

5(k) (1) Pursuant to Section 435.923(e) of Title 42 of the Code
6of Federal Regulations, a provider or staff member or volunteer
7of an organization who intends to serve as an authorized
8representative shall provide a signed written agreement that he or
9she will adhere to requirements set forth in the Code of Federal
10Regulations for authorized representatives, including Section
11447.10 of Title 42, subpart F of Part 431 of Title 45, and Section
12155.260(f) of Title 45. The department shall work with counties
13and consumer advocates to develop a standard agreement form
14that may be used for this purpose.

15(2) Pursuant to 435.923(e) of Title 45 of the Code of Federal
16Regulations, the regulations developed pursuant to this section
17shall require authorized representatives to comply with all
18applicable state and federal laws regarding conflicts of interest
19and confidentiality of information.

20(3)


21The standard agreement form developed pursuant to paragraph
22(1) shall include a notification regarding the requirements of this
23subdivision and a statement that by signing the agreement, the
24individual named as an authorized representative agrees to abide
25by those requirements.

26(l) To the extent otherwise required by Chapter 3.5 (commencing
27with Section 11340) of Part 1 of Division 3 of Title 2 of the
28Government Code, the department shall adopt emergency
29regulations implementing this section no later than July 1, 2015.
30The department may thereafter readopt the emergency regulations
31pursuant to that chapter. The adoption and readoption, by the
32department, of regulations implementing this section shall be
33deemed to be an emergency and necessary to avoid serious harm
34to the public peace, health, safety, or general welfare for purposes
35of Sections 11346.1 and 11349.6 of the Government Code, and
36the department is hereby exempted from the requirement that it
37describe facts showing the need for immediate action and from
38review by the Office of Administrative Law.

P60   1(m) This section shall be implemented only if and to the extent
2that federal financial participation is available and any necessary
3federal approvals have been obtained.

4(n) This section shall be implemented on October 1, 2013, or
5when all necessary federal approvals have been obtained,
6whichever is later.

end delete
7begin insert

begin insertSEC. 15.end insert  

end insert

begin insertSection 14013.3 is added to the end insertbegin insertWelfare and
8Institutions Code
end insert
begin insert, to read:end insert

begin insert
9

begin insert14013.3.end insert  

(a) When determining whether an individual is
10eligible for Medi-Cal benefits, the department shall verify the
11accuracy of the information identified in this section that is
12provided as a part of the application or redetermination process
13in conformity with this section.

14(b) Prior to requesting additional verification from an applicant
15or beneficiary for information he or she provides as part of the
16application or redetermination process, the department shall obtain
17information about an individual that is available electronically
18from other state and federal agencies and programs in determining
19an individual’s eligibility for Medi-Cal benefits or for potential
20eligibility for an insurance affordability program offered through
21the California Health Benefit Exchange established pursuant to
22Title 22 (commencing with Section 100500) of the Government
23Code. Needed information shall be obtained from the following
24sources, as well as any other source the department determines is
25useful:

26(1) Information related to wages, net earnings from
27self-employment, unearned income, and resources from any of the
28following:

29(A) The State Wage Information Collection Agency.

30(B) The federal Internal Revenue Service.

31(C) The federal Social Security Administration.

32(D) The Employment Development Department.

33(E) The state administered supplementary payment program
34under Section 1382e of Title 42 of the United States Code.

35(F) Any state program administered under a plan approved
36under Titles I, X, XIV, or XVI of the federal Social Security Act.

37(2) Information related to eligibility or enrollment from any of
38the following:

39(A) The CalFresh program pursuant to Chapter 10 (commencing
40with Section 18900) of Part 6.

P61   1(B) The CalWORKS program.

2(C) The state’s children’s health insurance program under Title
3XXI of the federal Social Security Act (42 U.S.C. 1397aa et seq.).

4(D) The California Health Benefit Exchange established
5pursuant Title 22 (commencing with Section 100500) of the
6Government Code.

7(E) The electronic service established in accordance with
8Section 435.949 of Title 42 of the Code of Federal Regulations.

9(c) (1) If the income information obtained by the department
10pursuant to subdivision (b) is reasonably compatible with the
11information provided by or on behalf of the individual, the
12department shall accept the information provided by or on behalf
13of the individual as being accurate.

14(2) If the income information obtained by the department is not
15reasonably compatible with the information provided by or on
16behalf of the individual, the department shall require that the
17individual provide additional information that reasonably explains
18the discrepancy.

19(3) For the purposes of this subdivision, income information
20 obtained by the department is reasonably compatible with
21information provided by or on behalf of an individual if any of the
22following conditions are met:

23(A) Both state that the individual’s income is above the
24applicable income standard or other relevant income threshold
25for eligibility.

26(B) Both state that the individual’s income is at or below the
27applicable income standard or other relevant income threshold
28for eligibility.

29(C) The information provided by or on behalf of the individual
30states that the individual’s income is above, and the information
31obtained by the department states that the individual’s income is
32at or below, the applicable income standard or other relevant
33income threshold for eligibility.

34(4) If subparagraph (C) of paragraph (3) applies, the individual
35shall be informed that the income information provided by him or
36her was higher than the information that was electronically verified
37and that he or she may request a reconciliation of the difference.
38This paragraph shall be implemented no later than January 1,
392015.

P62   1(d) (1) The department shall accept the attestation of the
2individual regarding whether she is pregnant unless the department
3has information that is not reasonably compatible with the
4attestation.

5(2) If the information obtained by the department is not
6reasonably compatible with the information provided by or on
7behalf of the individual under paragraph (1), the department shall
8require that the individual provide additional information that
9reasonably explains the discrepancy.

10(e) If any information not described in subdivision (c) or (d)
11that is needed for an eligibility determination or redetermination
12and is obtained by the department is not reasonably compatible
13with the information provided by or on behalf of the individual,
14the department shall require that the individual provide additional
15information that reasonably explains the discrepancy.

16(f) The department shall develop, and update as it is modified,
17a verification plan describing the verification policies and
18procedures adopted by the department to verify eligibility
19information. If the department determines that any state or federal
20agencies or programs not previously identified in the verification
21plan are useful in determining an individual’s eligibility for
22Medi-Cal benefits or for potential eligibility, for an insurance
23affordability program offered through the California Health Benefit
24Exchange, the department shall update the verification plan to
25identify those additional agencies or programs. The development
26and modification of the verification plan shall be undertaken in
27consultation with representatives from county human services
28departments, legal aid advocates, and the Legislature. This
29verification plan shall conform to all federal requirements and
30shall be posted on the department’s Internet Web site.

31(g) Notwithstanding Chapter 3.5 (commencing with Section
3211340) of Part 1 of Division 3 of Title 2 of the Government Code,
33the department, without taking any further regulatory action, shall
34implement, interpret, or make specific this section by means of
35all-county letters, plan letters, plan or provider bulletins, or similar
36instructions until the time regulations are adopted. Thereafter, the
37department shall adopt regulations in accordance with the
38requirements of Chapter 3.5 (commencing with Section 11340) of
39Part 1 of Division 3 of Title 2 of the Government Code. Beginning
40six months after the effective date of this section, and
P63   1notwithstanding Section 10231.5 of the Government Code, the
2department shall provide a status report to the Legislature on a
3semiannual basis until regulations have been adopted.

4(h) This section shall be implemented only if and to the extent
5that federal financial participation is available and any necessary
6federal approvals have been obtained.

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

end insert
8

begin deleteSEC. 35.end delete
9begin insertSEC. 16.end insert  

Section 14015.5 is added to the Welfare and
10Institutions Code
, to read:

11

14015.5.  

(a) Notwithstanding any other provision of state law,
12the department shall retain or delegate the authority to perform
13Medi-Cal eligibility determinations as set forth in this section.

14(b) If after an assessment and verification for potential eligibility
15for Medi-Cal benefits using the applicable MAGI-based income
16standard of all persons that apply through an electronic or a paper
17application processed by CalHEERS, which is jointly managed
18by the department and the Exchange, and to the extent required
19by federal law and regulation is completed, the Exchange and the
20departmentbegin delete mayend deletebegin insert is able toend insert electronically determine the applicant’s
21eligibility for Medi-Cal benefits using only the information initially
22provided online, or through the written application submitted by,
23or on behalf of, the applicant, and without further staff review to
24verify the accuracy of the submitted information, the Exchange
25and the department shall determine that applicant’s eligibility for
26the Medi-Cal program using the applicable MAGI-based income
27standard.

28(c) Except as provided in subdivision (b) and Section 14015.7,
29the county of residence shall be responsible for eligibility
30determinations and ongoing case management for the Medi-Cal
31program.

32(d) (1) Notwithstanding any other provision of state law, the
33Exchange shall be authorized to provide information regarding
34available Medi-Cal managed health care plan selection options to
35applicants determined to be eligible for Medi-Cal benefits using
36the MAGI-based income standard and allow those applicants to
37choose an available managed health care plan.

38(2) The Exchange is authorized to record an applicant’s health
39plan selection into CalHEERS for reporting to the department.
P64   1CalHEERS shall have the ability to report to the department the
2results of an applicant’s health plan selection.

3(e) Notwithstanding Chapter 3.5 (commencing with Section
411340) of Part 1 of Division 3 of Title 2 of the Government Code,
5the department, without taking any further regulatory action, shall
6implement, interpret, or make specific this section by means of
7all-county letters, plan letters, plan or provider bulletins, or similar
8instructions until the time regulations are adopted. Thereafter, the
9department shall adopt regulations in accordance with the
10requirements of Chapter 3.5 (commencing with Section 11340) of
11Part 1 of Division 3 of Title 2 of the Government Code. Beginning
12six months after the effective date of this section,begin insert and
13notwithstanding Section 10231.5 of the Government Code,end insert
the
14department shall provide a status report to the Legislature on a
15semiannual basis until regulations have been adopted.

16(f) For the purposes of this section, the following definitions
17shall apply:

18(1) “ACA” means the federal Patient Protection and Affordable
19Care Act (Public Law 111-148), as amended by the federal Health
20Care and Education Reconciliation Act of 2010 (Public Law
21111-152).

22(2) “CalHEERS” means the California Healthcare Eligibility,
23Enrollment, and Retention System developed under Section 15926.

24(3) “Exchange” means the California Health Benefit Exchange
25established pursuant to Section 100500 of the Government Code.

26(4) “MAGI-based income” means income calculated using the
27financial methodologies described in Section 1396a(e)(14) of Title
2842 of the United States Code as added by ACA and any subsequent
29amendments.

30(g) This section shall be implemented only if and to the extent
31that federal financial participation is available and any necessary
32federal approvals have been obtained.

33(h) This section shall become operative on October 1, 2013.

begin delete

34(i) This section shall become inoperative on July 1, 2015, and,
35as of January 1, 2016, is repealed, unless a later enacted statute,
36that becomes operative on or before January 1, 2016, deletes or
37extends the dates on which it becomes inoperative and is repealed.

end delete
begin insert

38(i) This section shall remain in effect only until July 1, 2015,
39and as of that date is repealed, unless a later enacted statute, that
40is enacted before July 1, 2015, deletes or extends that date.

end insert
P65   1

begin deleteSEC. 36.end delete
2begin insertSEC. 17.end insert  

Section 14015.7 is added to the Welfare and
3Institutions Code
, to read:

4

14015.7.  

(a) (1) Notwithstanding any otherbegin insert provision ofend insert law,
5for persons who call the customer service center operated by the
6Exchange for the purpose of applying for an insurance affordability
7program, the Exchange shall implement a workflow transfer
8protocol that consists of only those questions that are essential to
9reliably ascertain whether the caller’s household appears to include
10any individuals who are potentially eligible for Medi-Cal benefits
11and to determine an appropriate point ofbegin delete referralend deletebegin insert transferralend insert. The
12workflow transfer protocol andbegin delete referralend deletebegin insert transferralend insert procedures
13used by the Exchange shall be developed and implemented in
14conjunction with and subject to review and approval by the
15department.

16(2) (A) Except as provided in paragraph (3), if, after applying
17the transfer protocol specified in paragraph (1), the Exchange
18determines that the caller’s household appears to include one or
19more individuals who are potentially eligible for Medi-Cal benefits
20using the applicable MAGI-based income standard, the Exchange
21shallbegin delete referend deletebegin insert transferend insert the caller to his or her county of residence or
22other appropriate county resource for completion of the federally
23required assessment. The county shall proceed with the assessment
24and also perform any required eligibility determination.

25(B) Subject to any income limitations that may be imposed by
26the Exchange, and subject to review and approval from the
27department, if after applying the transfer protocol specified in
28paragraph (1) the Exchange determines that the caller’s household
29appears to include an individual who is pregnant, or who is
30potentially eligible for Medi-Cal benefits on a basis other than
31using a MAGI-based income standard because an applicant is
32potentially disabled, 65 years of age or older, or potentially in need
33of long-term care services, the Exchange shallbegin delete referend deletebegin insert transferend insert the
34caller to his or her county of residence or other appropriate county
35resource for completion of the federally required assessment. The
36county shall proceed with the assessment and also perform any
37required eligibility determination.

38(3) Notwithstanding any otherbegin insert provision ofend insert law, only during the
39initial open enrollment period established by the Exchange, and
40in no case after June 30, 2014, if after applying the transfer protocol
P66   1specified in paragraph (1) the Exchange determines that the caller’s
2household appears to include both individuals who are potentially
3eligible for Medi-Cal benefits using the applicable MAGI-based
4income standard and individuals who are not potentially eligible
5for Medi-Cal benefits, the Exchange shall proceed with its
6assessment and if it is subsequently determined that an applicant
7or applicants are potentially eligible for Medi-Cal benefits using
8the applicable MAGI-based income standard, the Exchange shall
9initially determine thebegin delete applicant or applicantsend deletebegin insert applicant’s or
10applicantsend insert
begin insertend insert eligibility for Medi-Cal benefits. If determined eligible,
11the applicant’s or applicants’ coverage shall start on January 1,
122014, or on the date of the determination, whichever is later. The
13county of residence shall be responsible for final confirmation of
14eligibility determinations relying on data provided by and
15verifications done by the Exchange and the county shall perform
16only that additional work that is necessary for the county to prepare
17and send out the required notice to the applicant regarding the
18result of the eligibility determination and shall not impose any
19additional burdens upon the applicant. The county of residence
20shall be responsible for sending out the required notices of all
21Medi-Cal eligibility determinations.

22(4) Notwithstanding any otherbegin insert provision ofend insert law, if after applying
23the transfer protocol specified in paragraph (1) the Exchange
24determines that the caller’s household appears to only include
25individuals who are not potentially eligible for Medi-Cal benefits,
26the Exchange shall proceed with its assessment of eligibility. If it
27is subsequently determined that an applicant or applicants are
28potentially eligible for Medi-Cal benefits using the applicable
29MAGI-based income standard, the Exchange shall initially
30determine the applicant or applicants eligibility for Medi-Cal
31benefits. If determined eligible, the applicant’s or applicants’
32coverage shall start on January 1, 2014, or on the date of the
33determination, whichever is later. The county of residence shall
34be responsible for final confirmation of eligibility determinations
35relying on data provided by and verifications done by the Exchange
36and the county shall perform only that additional work that is
37necessary for the county to prepare and send out the required notice
38to the applicant regarding the result of the eligibility determination
39and shall not impose any additional burdens upon the applicant.
P67   1The county of residence shall be responsible for sending out the
2required notices of all Medi-Cal eligibility determinations.

3(5) Subject to any income limitations that may be imposed by
4the Exchange, and subject to review and approval from the
5department, if after assessing the potential eligibility of an
6applicant, which shall include enrolling the individual in
7Exchange-based coverage if eligible and, if the determination is
8being made pursuant tobegin delete subdivisionend deletebegin insert paragraphend insert (3),begin insert initiallyend insert
9 determining begin deleteinitialend delete eligibility for MAGI-based Medi-Cal, the
10Exchange determines that the applicant is pregnant, or is potentially
11eligible for Medi-Cal benefits on a basis other than using a
12MAGI-based income standard because the applicant is potentially
13disabled, 65 years of age or older, or potentially in need of
14long-term care services, or if the applicant requests a full Medi-Cal
15eligibility determination, the Exchange shall, consistent with
16federal law and regulations, transmit all information provided by
17or on behalf of the applicant, and any information obtained or
18verified by the Exchange, to the applicant’s county of residence
19or other appropriate county resource via secure electronic interface,
20promptly and without undue delay, for a full Medi-Cal eligibility
21determination.

22(6) Except as otherwise provided in this section and subdivision
23 (b) of Section 14015.5, the county of residence shall be responsible
24for eligibility determinations and ongoing case management for
25the Medi-Cal program.

26(7) Implementation of the protocols andbegin delete referralend deletebegin insert transferralend insert
27 procedures in this subdivision shall be subject to the terms specified
28in the agreements established under subdivision (b).

29(b) The department, Exchange, and each county consortia shall
30jointly enter into an interagency agreement that specifies the
31operational parameters and performance standards pertaining to
32the transfer protocol. After consulting with counties, consumer
33advocates, and labor organizations that represent employees of the
34customer service center operated by the Exchange and employees
35of county customer service centers, the Exchange and the
36department shall determine and implement the performance
37standards that shall be incorporated into these agreements.

38(c) Prior to October 1, 2014, the Exchange and the department,
39in consultation with counties, consumer advocates, and labor
40organizations that represent employees of the customer service
P68   1center operated by the Exchange and employees of county customer
2service centers, shall review and determine the efficacy of the
3enrollment procedures established in this section.

4(d) Notwithstanding Chapter 3.5 (commencing with Section
511340) of Part 1 of Division 3 of Title 2 of the Government Code,
6the department, without taking any further regulatory action, shall
7implement, interpret, or make specific this section by means of
8all-county letters, plan letters, plan or provider bulletins, or similar
9 instructions until the time regulations are adopted. Thereafter, the
10department shall adopt regulations in accordance with the
11requirements of Chapter 3.5 (commencing with Section 11340) of
12Part 1 of Division 3 of Title 2 of the Government Code. Beginning
13six months after the effective date of this section,begin insert and
14notwithstanding Section 10231.5 of the Government Code,end insert
the
15department shall provide a status report to the Legislature on a
16semiannual basis until regulations have been adopted.

17(e) For the purposes of this section, the following definitions
18shall apply:

19(1) “ACA” means the federal Patient Protection and Affordable
20Care Act (Public Law 111-148), as amended by the federal Health
21Care and Education Reconciliation Act of 2010 (Public Law
22111-152).

23(2) “CalHEERS” means the California Healthcare Eligibility,
24Enrollment, and Retention System developed under Section 15926.

25(3) “Exchange” means the California Health Benefit Exchange
26established pursuant to Section 100500 of the Government Code.

27(4) “MAGI-based income” means income calculated using the
28financial methodologies described in Section 1396a(e)(14) of Title
2942 of the United States Code as added by ACA and any subsequent
30amendments.

31(f) This section shall be implemented only if and to the extent
32that federal financial participation is available and any necessary
33federal approvals have been obtained.

begin insert

34(g) The state shall be responsible for providing the
35administrative funding to the counties for work associated with
36this section. Funding shall be subject to the annual state budget
37process.

end insert
begin delete

38(g)

end delete

39begin insert(end insertbegin inserth)end insert This section shall become operative on October 1, 2013.

P69   1begin insert

begin insertSEC. 18.end insert  

end insert

begin insertSection 14015.8 is added to the end insertbegin insertWelfare and
2Institutions Code
end insert
begin insert, to read:end insert

begin insert
3

begin insert14015.8.end insert  

The department, any other government agency that
4is determining eligibility for, or enrollment in, the Medi-Cal
5program or any other program administered by the department,
6or collecting protected health information for those purposes, and
7the California Health Benefit Exchange established pursuant to
8Title 22 (commencing with Section 100500) of the Government
9Code, shall share information with each other as necessary to
10enable them to perform their respective statutory and regulatory
11duties under state and federal law. This information shall include,
12but not be limited to, personal information, as defined in
13subdivision (a) of Section 1798.3 of the Civil Code, and protected
14health information, as defined in Parts 160 and 164 of Title 45 of
15the Code of Federal Regulations, regarding individual beneficiaries
16and applicants.

end insert
17begin insert

begin insertSEC. 19.end insert  

end insert

begin insertSection 14016.5 of the end insertbegin insertWelfare and Institutions Codeend insert
18begin insert is amended to read:end insert

19

14016.5.  

(a) At the time of determining or redetermining the
20eligibility of a Medi-Cal program or Aid to Families with
21Dependent Children (AFDC) program applicant or beneficiary
22who resides in an area served by a managed health care plan or
23pilot program in which beneficiaries may enroll, each applicant
24or beneficiary shall personally attend a presentation at which the
25applicant or beneficiary is informed of the managed care and
26fee-for-service options available regarding methods of receiving
27Medi-Cal benefits. The county shall ensure that each beneficiary
28or applicant attends this presentation.

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

31(1) Each beneficiary or eligible applicant shall be informed that
32he or she may choose to continue an established patient-provider
33relationship in the fee-for-service sector.

34(2) Each beneficiary or eligible applicant shall be provided with
35the name, address, telephone number, and specialty, if any, of each
36primary care provider, and each clinic participating in each prepaid
37managed health care plan, pilot project, or fee-for-service case
38management provider option. This information shall be provided
39under geographic area designations, in alphabetical order by the
40name of the primary care provider and clinic. The name, address,
P70   1and telephone number of each specialist participating in each
2prepaid managed health care plan, pilot project, or fee-for-service
3case management provider option shall be made available by
4contacting either the health care options contractor or the prepaid
5 managed health care plan, pilot project, or fee-for-service case
6management provider.

7(3) Each beneficiary or eligible applicant shall be informed that
8he or she may choose to continue an established patient-provider
9relationship in a managed care option, if his or her treating provider
10is a primary care provider or clinic contracting with any of the
11prepaid managed health care plans, pilot projects, or fee-for-service
12case management provider options available, has available capacity,
13and agrees to continue to treat that beneficiary or applicant.

14(4) In areas specified by the director, each beneficiary or eligible
15applicant shall be informed that if he or she fails to make a choice,
16or does not certify that he or she has an established relationship
17with a primary care provider or clinic, he or she shall be assigned
18to, and enrolled in, a prepaid managed health care plan, pilot
19 project, or fee-for-service case management provider.

20(c) No later than 30 days following the date a Medi-Cal or
21AFDC beneficiary or applicant is determined eligible, the
22beneficiary or applicant shall indicate his or her choice in writing,
23as a condition of coverage for Medi-Cal benefits, of either of the
24following health care options:

25(1) To obtain benefits by receiving a Medi-Cal card, which may
26be used to obtain services from individual providers, that the
27beneficiary would locate, who choose to provide services to
28Medi-Cal beneficiaries.

29The department may require each beneficiary or eligible
30applicant, as a condition for electing this option, to sign a statement
31certifying that he or she has an established patient-provider
32relationship, or in the case of a dependent, the parent or guardian
33shall make that certification. This certification shall not require
34the acknowledgment or guarantee of acceptance, by any indicated
35Medi-Cal provider or health facility, of any beneficiary making a
36certification under this section.

37(2) (A) To obtain benefits by enrolling in a prepaid managed
38health care plan, pilot program, or fee-for-service case management
39provider that has agreed to make Medi-Cal services readily
40available to enrolled Medi-Cal beneficiaries.

P71   1(B) At the time the beneficiary or eligible applicant selects a
2prepaid managed health care plan, pilot project, or fee-for-service
3case management provider, the department shall, when applicable,
4encourage the beneficiary or eligible applicant to also indicate, in
5writing, his or her choice of primary care provider or clinic
6contracting with the selected prepaid managed health care plan,
7pilot project, or fee-for-service case management provider.

8(d) (1) In areas specified by the director, a Medi-Cal or AFDC
9beneficiary or eligible applicant who does not make a choice, or
10who does not certify that he or she has an established relationship
11with a primary care provider or clinic, shall be assigned to and
12enrolled in an appropriate Medi-Cal managed care plan, pilot
13project, or fee-for-service case management provider providing
14service within the area in which the beneficiary resides.

15(2) If it is not possible to enroll the beneficiary under a Medi-Cal
16managed care plan, pilot project, or a fee-for-service case
17management provider because of a lack of capacity or availability
18of participating contractors, the beneficiary shall be provided with
19a Medi-Cal card and informed about fee-for-service primary care
20providers who do all of the following:

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

22(B) The providers provide information about the provider’s
23willingness to accept Medi-Cal patients as described in Section
2414016.6.

25(C) The providers provide services within the area in which the
26beneficiary resides.

27(e) If a beneficiary or eligible applicant does not choose a
28primary care provider or clinic, or does not select any primary care
29provider who is available, the managed health care plan, pilot
30project, or fee-for-service case management provider that was
31selected by or assigned to the beneficiary shall ensure that the
32beneficiary selects a primary care provider or clinic within 30 days
33after enrollment or is assigned to a primary care provider within
3440 days after enrollment.

35(f) (1) The managed care plan shall have a valid Medi-Cal
36contract, adequate capacity, and appropriate staffing to provide
37health care services to the beneficiary.

38(2) The department shall establish standards for all of the
39following:

P72   1(A) The maximum distances a beneficiary is required to travel
2to obtain primary care services from the managed care plan,
3fee-for-service case management provider, or pilot project in which
4the beneficiary is enrolled.

5(B) The conditions under which a primary care service site shall
6be accessible by public transportation.

7(C) The conditions under which a managed care plan,
8fee-for-service case management provider, or pilot project shall
9provide nonmedical transportation to a primary care service site.

10(3) In developing the standards required by paragraph (2), the
11department shall take into account, on a geographic basis, the
12means of transportation used and distances typically traveled by
13Medi-Cal beneficiaries to obtain fee-for-service primary care
14services and the experience of managed care plans in delivering
15services to Medi-Cal enrollees. The department shall also consider
16the provider’s ability to render culturally and linguistically
17appropriate services.

18(g) To the extent possible, the arrangements for carrying out
19subdivision (d) shall provide for the equitable distribution of
20Medi-Cal beneficiaries among participating managed care plans,
21fee-for-service case management providers, and pilot projects.

22(h) If, under the provisions of subdivision (d), a Medi-Cal
23beneficiary or applicant does not make a choice or does not certify
24that he or she has an established relationship with a primary care
25provider or clinic, the person may, at the option of the department,
26be provided with a Medi-Cal card or be assigned to and enrolled
27in a managed care plan providing service within the area in which
28the beneficiary resides.

29(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with
30the provider or managed care plan, pilot project, or fee-for-service
31case management provider shall be allowed to select or be assigned
32to another provider or managed care plan, pilot project, or
33fee-for-service case management provider.

34(j) The department or its contractor shall notify a managed care
35plan, pilot project, or fee-for-service case management provider
36when it has been selected by or assigned to a beneficiary. The
37managed care plan, pilot project, or fee-for-service case
38management provider that has been selected by, or assigned to, a
39beneficiary, shall notify the primary care provider or clinic that it
40has been selected or assigned. The managed care plan, pilot project,
P73   1or fee-for-service case management provider shall also notify the
2beneficiary of the managed care plan, pilot project, or
3fee-for-service case management provider or clinic selected or
4assigned.

5(k) (1) The department shall ensure that Medi-Cal beneficiaries
6eligible under Title XVI of the Social Security Act are provided
7with information about options available regarding methods of
8receiving Medi-Cal benefits as described in subdivision (c).

9(2) (A) The director may waive the requirements of subdivisions
10(c) and (d) until a means is established to directly provide the
11presentation described in subdivision (a) to beneficiaries who are
12eligible for the federal Supplemental Security Income for the Aged,
13Blind, and Disabled Program (Subchapter 16 (commencing with
14Section 1381) of Chapter 7 of Title 42 of the United States Code).

15(B) The director may elect not to apply the requirements of
16subdivisions (c) and (d) to beneficiaries whose eligibility under
17the Supplemental Security Income program is established before
18January 1, 1994.

19(l) In areas where there is no prepaid managed health care plan
20or pilot program that has contracted with the department to provide
21services to Medi-Cal beneficiaries, and where no other enrollment
22requirements have been established by the department, no explicit
23choice need be made, and the beneficiary or eligible applicant shall
24receive a Medi-Cal card.

25(m) The following definitions contained in this subdivision shall
26control the construction of this section, unless the context requires
27otherwise:

28(1) “Applicant,” “beneficiary,” and “eligible applicant,” in the
29case of a family group, mean any person with legal authority to
30make a choice on behalf of dependent family members.

31(2) “Fee-for-service case management provider” means a
32provider enrolled and certified to participate in the Medi-Cal
33fee-for-service case management program the department may
34elect to develop in selected areas of the state with the assistance
35of and in cooperation with California physician providers and other
36interested provider groups.

37(3) “Managed health care plan” and “managed care plan” mean
38a person or entity operating under a Medi-Cal contract with the
39department under this chapter or Chapter 8 (commencing with
40Section 14200) to provide, or arrange for, health care services for
P74   1Medi-Cal beneficiaries as an alternative to the Medi-Cal
2fee-for-service program that has a contractual responsibility to
3manage health care provided to Medi-Cal beneficiaries covered
4by the contract.

5(n) (1) Whenever a county welfare department notifies a public
6assistance recipient or Medi-Cal beneficiary that the recipient or
7beneficiary is losing Medi-Cal eligibility, the county shall include,
8in the notice to the recipient or beneficiary, notification that the
9loss of eligibility shall also result in the recipient’s or beneficiary’s
10disenrollment from Medi-Cal managed health care or dental plans,
11if enrolled.

12(2) (A) Whenever the department or the county welfare
13department processes a change in a public assistance recipient’s
14or Medi-Cal beneficiary’s residence or aid code that will result in
15the recipient’s or beneficiary’s disenrollment from the managed
16health care or dental plan in which he or she is currently enrolled,
17a written notice shall be given to the recipient or beneficiary.

18(B) This paragraph shall become operative and the department
19shall commence sending the notices required under this paragraph
20on or before the expiration of 12 months after the effective date
21of this section.

22(o) This section shall be implemented in a manner consistent
23with any federal waiver required to be obtained by the department
24in order to implement this section.

begin insert

25(p) This section shall remain in effect only until January 1, 2014,
26and as of that date is repealed, unless a later enacted statute, that
27is enacted before January 1, 2014, deletes or extends that date.

end insert
28begin insert

begin insertSEC. 20.end insert  

end insert

begin insertSection 14016.5 is added to the end insertbegin insertWelfare and
29Institutions Code
end insert
begin insert, to read:end insert

begin insert
30

begin insert14016.5.end insert  

(a) At the time of determining or redetermining the
31eligibility of a Medi-Cal program or Aid to Families with
32Dependent Children (AFDC) program applicant or beneficiary
33who resides in an area served by a managed health care plan or
34pilot program in which beneficiaries may enroll, each applicant
35or beneficiary shall be informed of the managed care and
36fee-for-service options available regarding methods of receiving
37Medi-Cal benefits.

38(b) The information described in subdivision (a) shall include
39all of the following elements:

P75   1(1) Each beneficiary or eligible applicant shall be informed that
2he or she may choose to continue an established patient-provider
3 relationship in the fee-for-service sector.

4(2) Each beneficiary or eligible applicant shall be provided
5with the name, address, telephone number, and specialty, if any,
6of each primary care provider, and each clinic participating in
7each prepaid managed health care plan, pilot project, or
8fee-for-service case management provider option. This information
9shall be provided under geographic area designations, in
10alphabetical order by the name of the primary care provider and
11clinic. The name, address, and telephone number of each specialist
12participating in each prepaid managed health care plan, pilot
13project, or fee-for-service case management provider option shall
14be made available by contacting either the health care options
15contractor or the prepaid managed health care plan, pilot project,
16or fee-for-service case management provider.

17(3) Each beneficiary or eligible applicant shall be informed that
18he or she may choose to continue an established patient-provider
19relationship in a managed care option, if his or her treating
20provider is a primary care provider or clinic contracting with any
21of the prepaid managed health care plans, pilot projects, or
22fee-for-service case management provider options available, has
23available capacity, and agrees to continue to treat that beneficiary
24or applicant.

25(4) In areas specified by the director, each beneficiary or
26eligible applicant shall be informed that if he or she fails to make
27a choice, or does not certify that he or she has an established
28relationship with a primary care provider or clinic, he or she shall
29be assigned to, and enrolled in, a prepaid managed health care
30plan, pilot project, or fee-for-service case management provider.

31(c) No later than 30 days following the date a Medi-Cal or
32AFDC beneficiary or applicant is determined eligible, the
33beneficiary or applicant shall indicate his or her choice in writing,
34as a condition of coverage for Medi-Cal benefits, of either of the
35following health care options:

36(1) To obtain benefits by receiving a Medi-Cal card, which may
37be used to obtain services from individual providers, that the
38beneficiary would locate, that choose to provide services to
39Medi-Cal beneficiaries.

P76   1The department may require each beneficiary or eligible
2applicant, as a condition for electing this option, to sign a
3statement certifying that he or she has an established
4patient-provider relationship, or in the case of a dependent, the
5parent or guardian shall make that certification. This certification
6shall not require the acknowledgment or guarantee of acceptance,
7by any indicated Medi-Cal provider or health facility, of any
8beneficiary making a certification under this section.

9(2) (A) To obtain benefits by enrolling in a prepaid managed
10health care plan, pilot program, or fee-for-service case
11management provider that has agreed to make Medi-Cal services
12readily available to enrolled Medi-Cal beneficiaries.

13(B) At the time the beneficiary or eligible applicant selects a
14prepaid managed health care plan, pilot project, or fee-for-service
15case management provider, the department shall, when applicable,
16encourage the beneficiary or eligible applicant to also indicate,
17in writing, his or her choice of primary care provider or clinic
18contracting with the selected prepaid managed health care plan,
19pilot project, or fee-for-service case management provider.

20(d) (1) In areas specified by the director, a Medi-Cal or AFDC
21beneficiary or eligible applicant who does not make a choice, or
22who does not certify that he or she has an established relationship
23with a primary care provider or clinic, shall be assigned to and
24enrolled in an appropriate Medi-Cal managed care plan, pilot
25project, or fee-for-service case management provider providing
26service within the area in which the beneficiary resides.

27(2) If it is not possible to enroll the beneficiary under a Medi-Cal
28managed care plan, pilot project, or a fee-for-service case
29management provider because of a lack of capacity or availability
30of participating contractors, the beneficiary shall be provided with
31a Medi-Cal card and informed about fee-for-service primary care
32providers who do all of the following:

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

34(B) The providers provide information about the provider’s
35 willingness to accept Medi-Cal patients as described in Section
3614016.6.

37(C) The providers provide services within the area in which the
38beneficiary resides.

39(e) If a beneficiary or eligible applicant does not choose a
40primary care provider or clinic, or does not select any primary
P77   1care provider who is available, the managed health care plan,
2pilot project, or fee-for-service case management provider that
3was selected by or assigned to the beneficiary shall ensure that
4the beneficiary selects a primary care provider or clinic within 30
5days after enrollment or is assigned to a primary care provider
6within 40 days after enrollment.

7(f) (1) The managed care plan shall have a valid Medi-Cal
8contract, adequate capacity, and appropriate staffing to provide
9health care services to the beneficiary.

10(2) The department shall establish standards for all of the
11following:

12(A) The maximum distances a beneficiary is required to travel
13to obtain primary care services from the managed care plan,
14fee-for-service case management provider, or pilot project in which
15the beneficiary is enrolled.

16(B) The conditions under which a primary care service site shall
17be accessible by public transportation.

18(C) The conditions under which a managed care plan,
19fee-for-service case management provider, or pilot project shall
20provide nonmedical transportation to a primary care service site.

21(3) In developing the standards required by paragraph (2), the
22department shall take into account, on a geographic basis, the
23means of transportation used and distances typically traveled by
24Medi-Cal beneficiaries to obtain fee-for-service primary care
25services and the experience of managed care plans in delivering
26services to Medi-Cal enrollees. The department shall also consider
27the provider’s ability to render culturally and linguistically
28appropriate services.

29(g) To the extent possible, the arrangements for carrying out
30subdivision (d) shall provide for the equitable distribution of
31Medi-Cal beneficiaries among participating managed care plans,
32fee-for-service case management providers, and pilot projects.

33(h) If, under the provisions of subdivision (d), a Medi-Cal
34beneficiary or applicant does not make a choice or does not certify
35that he or she has an established relationship with a primary care
36provider or clinic, the person may, at the option of the department,
37be provided with a Medi-Cal card or be assigned to and enrolled
38in a managed care plan providing service within the area in which
39the beneficiary resides.

P78   1(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with
2the provider or managed care plan, pilot project, or fee-for-service
3case management provider shall be allowed to select or be assigned
4to another provider or managed care plan, pilot project, or
5fee-for-service case management provider.

6(j) The department or its contractor shall notify a managed care
7plan, pilot project, or fee-for-service case management provider
8when it has been selected by or assigned to a beneficiary. The
9managed care plan, pilot project, or fee-for-service case
10management provider that has been selected by, or assigned to, a
11beneficiary, shall notify the primary care provider or clinic that
12it has been selected or assigned. The managed care plan, pilot
13project, or fee-for-service case management provider shall also
14notify the beneficiary of the managed care plan, pilot project, or
15fee-for-service case management provider or clinic selected or
16assigned.

17(k) (1) The department shall ensure that Medi-Cal beneficiaries
18eligible under Title XVI of the federal Social Security Act are
19provided with information about options available regarding
20methods of receiving Medi-Cal benefits as described in subdivision
21(c).

22(2) (A) The director may waive the requirements of subdivisions
23(c) and (d) until a means is established to directly provide the
24information described in subdivision (a) to beneficiaries who are
25eligible for the federal Supplemental Security Income for the Aged,
26Blind, and Disabled Program (Subchapter 16 (commencing with
27Section 1381) of Chapter 7 of Title 42 of the United States Code).

28(B) The director may elect not to apply the requirements of
29subdivisions (c) and (d) to beneficiaries whose eligibility under
30the Supplemental Security Income program is established before
31January 1, 1994.

32(l) In areas where there is no prepaid managed health care plan
33or pilot program that has contracted with the department to provide
34services to Medi-Cal beneficiaries, and where no other enrollment
35requirements have been established by the department, no explicit
36choice need be made, and the beneficiary or eligible applicant
37shall receive a Medi-Cal card.

38(m) The following definitions contained in this subdivision shall
39control the construction of this section, unless the context requires
40otherwise:

P79   1(1) “Applicant,” “beneficiary,” and “eligible applicant,” in
2the case of a family group, mean any person with legal authority
3to make a choice on behalf of dependent family members.

4(2) “Fee-for-service case management provider” means a
5provider enrolled and certified to participate in the Medi-Cal
6fee-for-service case management program the department may
7elect to develop in selected areas of the state with the assistance
8of and in cooperation with California physician providers and
9other interested provider groups.

10(3) “Managed health care plan” and “managed care plan”
11mean a person or entity operating under a Medi-Cal contract with
12the department under this chapter or Chapter 8 (commencing with
13Section 14200) to provide, or arrange for, health care services for
14Medi-Cal beneficiaries as an alternative to the Medi-Cal
15fee-for-service program that has a contractual responsibility to
16manage health care provided to Medi-Cal beneficiaries covered
17by the contract.

18(n) (1) Whenever a county welfare department notifies a public
19assistance recipient or Medi-Cal beneficiary that the recipient or
20beneficiary is losing Medi-Cal eligibility, the county shall include,
21in the notice to the recipient or beneficiary, notification that the
22loss of eligibility shall also result in the recipient’s or beneficiary’s
23disenrollment from Medi-Cal managed health care or dental plans,
24if enrolled.

25(2) Whenever the department or the county welfare department
26processes a change in a public assistance recipient’s or Medi-Cal
27beneficiary’s residence or aid code that will result in the recipient’s
28or beneficiary’s disenrollment from the managed health care or
29dental plan in which he or she is currently enrolled, a written
30notice shall be given to the recipient or beneficiary.

31(o) This section shall be implemented in a manner consistent
32with any federal waiver required to be obtained by the department
33in order to implement this section.

34(p) (1)  If the functionality is available in the California
35Healthcare Eligibility, Enrollment, and Retention System
36(CalHEERS), individuals or their authorized representatives may
37select Medi-Cal managed care plans via CalHEERS.

38(A) Any person that assists a Medi-Cal beneficiary who is
39eligible for the program based on modified adjusted gross income
40(MAGI) to select a Medi-Cal managed care plan via CalHEERS
P80   1shall complete a training program that includes all of the
2following:

3(i) The right to select a plan, to designate a plan at a later date,
4to have plan choice materials sent by mail, and that if the person
5does not select a plan, one will be selected for them.

6(ii) All plan enrollment options and requirements with regard
7to MAGI Medi-Cal eligibility.

8(iii) Any applicable timeframes in which the plan choice must
9be designated and the mechanism for designating plan choice.

10(iv) How to use provider directories, how to identify which
11providers are in a particular plan network, and the applicable
12characteristics of primary care and specialty care providers and
13providers of other services, such as languages spoken, whether
14they are accepting new patients, and office locations.

15(v) To the extent applicable, how to access Medi-Cal services
16prior to plan enrollment, including the right to retroactive
17Medi-Cal benefits.

18(B) Any person that assists a Medi-Cal beneficiary who is not
19eligible for Medi-Cal on the basis of MAGI to select a Medi-Cal
20managed care plan shall complete a training program that includes
21all of the following:

22(i) All of the information included in the training program
23described in subparagraph (A).

24(ii) The enrollment options and requirements with regard to
25each Medi-Cal eligibility category, including whether enrollment
26is mandatory, how to obtain medical exemptions and continuity
27of care, waiver programs, carved-out services, and the California
28Children’s Services Program, as applicable.

29(2) The department shall consult with a group of stakeholders
30through either a group currently in existence or convened for this
31purpose that includes representatives of plans, providers, consumer
32advocates, counties, eligibility workers, CalHEERS, the California
33Health Benefit Exchange (Exchange), and the Legislature to review
34process, timelines, scripts, training curricula, monitoring and
35oversight plans, and plan marketing and informational materials.

36(3) In developing materials, scripts, and processes, the
37department and the Exchange shall consult with or test the
38materials, scripts, and processes with stakeholders that have
39expertise in health plan selection, and in assisting populations of
40diverse demographic characteristics such as race, ethnicity,
P81   1language spoken, geographic region, sexual orientation, and
2gender identity or preference.

3(4) The department, CalHEERS, the Exchange, and counties
4may adopt the recommendations of the advisory body convened
5in paragraph (2) and specify the reasons if the recommendations
6are not adopted.

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

end insert
8begin insert

begin insertSEC. 21.end insert  

end insert

begin insertSection 14016.6 of the end insertbegin insertWelfare and Institutions Codeend insert
9begin insert is amended to read:end insert

10

14016.6.  

The State Department of Healthbegin insert Careend insert Services shall
11develop a program to implement Section 14016.5 and to provide
12information and assistance to enable Medi-Cal beneficiaries to
13understand and successfully use the services of the Medi-Cal
14managed care plans in which they enroll. The program shall
15include, but not be limited to, the following components:

16(a) (1) Development of a method to inform beneficiaries and
17applicants of all of the following:

18(A) Their choices for receiving Medi-Cal benefits including the
19use of fee-for-service sector managed health care plans, or pilot
20programs.

21(B) The availability of staff and information resources to
22Medi-Cal managed health care plan enrollees described in
23subdivision (f).

24(2) (A) Marketing and informational materials including printed
25materials, films, and exhibits, to be provided to Medi-Cal
26beneficiaries and applicants when choosing methods of receiving
27health care benefits.

28(B) The department shall not be responsible for the costs of
29developing material required by subparagraph (A).

30(C) (i) The department may prescribe the format and edit the
31informational materials for factual accuracy, objectivity and
32comprehensibility .

33(ii) The department shall use the edited materials in informing
34beneficiaries and applicants of their choices for receiving Medi-Cal
35benefits.

36(b) Provision of information that is necessary to implement this
37program in a manner that fairly and objectively explains to
38beneficiaries and applicants their choices for methods of receiving
39Medi-Cal benefits, including information prepared by the
40department emphasizing the benefits and limitations to
P82   1beneficiaries of enrolling in managed health care plans and pilot
2projects as opposed to the fee-for-service system.

3(c) Provision of information about providers who will provide
4services to Medi-Cal beneficiaries. This may be information about
5provider referral services of a local provider professional
6organization. The information shall be made available to Medi-Cal
7beneficiaries and applicants at the same time the beneficiary or
8applicant is being informed of the options available for receiving
9care.

10(d) Training of specialized county employees to carry out the
11program.

12(e) Monitoring the implementation of the program in those
13county welfare offices where choices are made available in order
14to assure that beneficiaries and applicants may make a
15well-informed choice, without duress.

16(f) Staff and information resources dedicated to directly assist
17Medi-Cal managed health care plan enrollees to understand how
18to effectively use the services of, and resolve problems or
19complaints involving, their managed health care plans.

20(g) The responsibilities outlined in this section shall, at the
21option of the department, be carried out by a specially trained
22county or state employee or by an independent contractor paid by
23the department. If a county sponsored prepaid health plan or pilot
24program is offered, the responsibilities outlined in this section shall
25be carried out either by a specially trained state employee or by
26an independent contractor paid by the department.

27(h) The department shall adopt any regulations as are necessary
28to ensure that the informing of beneficiaries of their health care
29options is a part of the eligibility determination process.

begin insert

30(i) This section shall remain in effect only until January 1, 2014,
31and as of that date is repealed, unless a later enacted statute, that
32is enacted before January 1, 2014, deletes or extends that date.

end insert
33begin insert

begin insertSEC. 22.end insert  

end insert

begin insertSection 14016.6 is added to the end insertbegin insertWelfare and
34Institutions Code
end insert
begin insert, to read:end insert

begin insert
35

begin insert14016.6.end insert  

The State Department of Health Care Services shall
36develop a program to implement subdivision (p) of Section 14016.5
37and to provide information and assistance to enable Medi-Cal
38beneficiaries to understand and successfully use the services of
39the Medi-Cal managed care plans in which they enroll. The
P83   1program shall include, but not be limited to, the following
2components:

3(a) (1) Development of a method to inform beneficiaries and
4applicants of all of the following:

5(A) Their choices for receiving Medi-Cal benefits including the
6use of fee-for-service sector managed health care plans, or pilot
7programs.

8(B) The availability of staff and information resources to
9Medi-Cal managed health care plan enrollees described in
10subdivision (f).

11(2) (A) Marketing and informational materials, including
12printed materials, films, and exhibits, to be provided to Medi-Cal
13beneficiaries and applicants when choosing methods of receiving
14health care benefits.

15(B) The department shall not be responsible for the costs of
16developing material required by subparagraph (A).

17(C) (i) The department may prescribe the format and edit the
18informational materials for factual accuracy, objectivity, and
19comprehensibility .

20(ii) The department, the California Health Benefit Exchange
21(Exchange), the California Healthcare Eligibility, Enrollment, and
22Retention System (CalHEERS), and entities or persons designated
23pursuant to subdivision (g) shall use the edited materials in
24informing beneficiaries and applicants of their choices for
25receiving Medi-Cal benefits.

26(b) Provision of information that is necessary to implement this
27program in a manner that fairly and objectively explains to
28beneficiaries and applicants their choices for methods of receiving
29Medi-Cal benefits, including information prepared by the
30department.

31(c) Provision of information about providers who will provide
32services to Medi-Cal beneficiaries. This may be information about
33provider referral services of a local provider professional
34organization. The information shall be made available to Medi-Cal
35beneficiaries and applicants at the same time the beneficiary or
36applicant is being informed of the options available for receiving
37 care.

38(d) Training of specialized county employees to carry out the
39program.

P84   1(e) Monitoring the implementation of the program at any
2location, including online at the Exchange or at counties, where
3choices are made available in order to assure that beneficiaries
4and applicants may make a well-informed choice, without duress.

5(f) Staff and information resources dedicated to directly assist
6Medi-Cal managed health care plan enrollees to understand how
7to effectively use the services of, and resolve problems or
8complaints involving, their managed health care plans.

9(g) Notwithstanding any other provision of state law, the
10department, in consultation with the Exchange, may authorize
11specific persons or entities, including counties, to provide
12information to beneficiaries concerning their health care options
13for receiving Medi-Cal benefits and assistance with enrollment.
14This subdivision shall apply in all geographic areas designated
15by the director. This subdivision shall be implemented in a manner
16consistent with federal law.

17(h) To the extent otherwise required by Chapter 3.5
18(commencing with Section 11340) of Part 1 of Division 3 of Title
192 of the Government Code, the department shall adopt emergency
20regulations implementing this section no later than July 1, 2015.
21The department may thereafter readopt the emergency regulations
22pursuant to that chapter. The adoption and readoption, by the
23department, of regulations implementing this section shall be
24deemed to be an emergency and necessary to avoid serious harm
25to the public peace, health, safety, or general welfare for purposes
26of Sections 11346.1 and 11349.6 of the Government Code, and
27the department is hereby exempted from the requirement that it
28describe facts showing the need for immediate action and from
29review by the Office of Administrative Law.

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

end insert
31

begin deleteSEC. 37.end delete
32begin insertSEC. 23.end insert  

Section 14055 is added to the Welfare and Institutions
33Code
, to read:

34

14055.  

(a) For the purposes of this chapter, “caretaker relative”
35means a relative of a dependent child by blood, adoption, or
36marriage with whom the child is living, who assumes primary
37responsibility for the child’s care, and who is one of the following:

38(1) The child’s father, mother, grandfather, grandmother,
39brother, sister, stepfather, stepmother, stepbrother, stepsister, great
40grandparent, uncle, aunt, nephew, niece, great-great grandparent,
P85   1great uncle or aunt, first cousin, great-great-great grandparent,
2great-great uncle or aunt, or first cousin once removed.

3(2) The spouse or registered domestic partner of one of the
4relatives identified in paragraph (1), even after the marriage is
5terminated by death or divorce or the domestic partnership has
6been legally terminated.

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

begin delete
8

SEC. 38.  

Section 14057 is added to the Welfare and Institutions
9Code
, to read:

10

14057.  

(a) For the purposes of this chapter, “insurance
11affordability program” means a program that is one of the
12following:

13(1) The state’s Medi-Cal program under Title XIX of the federal
14Social Security Act (42 U.S.C. Sec. 1396 et seq.).

15(2) The state’s children’s health insurance program (CHIP)
16under Title XXI of the federal Social Security Act (42 U.S.C. Sec.
171397aa et seq.).

18(3) A program that makes available to qualified applicants
19coverage in a qualified health plan through the California Health
20Benefit Exchange, established pursuant to Title 22 (commencing
21with Section 100500) of the Government Code, with advance
22 payment of the premium tax credit established under Section 36B
23of the Internal Revenue Code.

24(4) A program that makes available coverage in a qualified
25health plan through the California Health Benefit Exchange,
26established pursuant to Title 22 (commencing with Section 100500)
27of the Government Code, with cost-sharing reductions established
28under Section 1402 of the federal Patient Protection and Affordable
29Care Act (Public Law 111-148), and any subsequent amendments
30to that act.

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

32

SEC. 39.  

Section 14102 is added to the Welfare and Institutions
33Code
, to read:

34

14102.  

(a) (1) Notwithstanding any other law and except as
35otherwise provided in this section, any individual who is 21 years
36of age or older, who does not have minor children eligible for
37Medi-Cal, and would be eligible for full-scope Medi-Cal benefits
38pursuant to Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the
39federal Social Security Act (42 U.S.C. Sec.
401396a(a)(10)(A)(i)(VIII)) but for the five-year eligibility limitation
P86   1under Section 1613 of Title 8 of the United States Code and who
2is otherwise eligible for state-only funded full-scope benefits shall
3be ineligible for those state-only funded benefits if he or she is
4eligible for, and is not barred from enrolling in because he or she
5is outside of an available enrollment period for coverage with an
6advanced premium tax credit offered through the Exchange.

7(2) On or after January 1, 2015, if an individual is eligible for
8and does not enroll in coverage offered through the Exchange with
9an advanced premium tax credit during his or her first available
10enrollment period, that individual shall be ineligible for the
11state-only funded benefits referenced in paragraph (1), except as
12provided in paragraph (3).

13(3) An individual shall be ineligible for Medi-Cal pursuant to
14this section only if and when he or she is able to receive the
15premium assistance, cost sharing, and benefits described in
16subdivision (c). Disenrollment from state-only Medi-Cal shall only
17occur during an available enrollment period in the Exchange.

18(4) The department shall inform and assist such individuals on
19enrolling in coverage through the Exchange with the premium
20assistance, cost sharing, and benefits described in subdivision (c)
21and the process for disenrollment from Medi-Cal, if applicable, in
22a way that ensures seamless transition between coverage, including,
23but not limited to, developing processes to coordinate with the
24county entities that administer eligibility for coverage in Medi-Cal
25and the Exchange.

26(b) (1) An individual who is a state-only Medi-Cal person as
27defined in Section 14052 shall not be subject to subdivision (a) or
28(c).

29(c) An individual subject to subdivision (a) who is enrolled in
30coverage through the Exchange with an advanced premium tax
31credit shall be eligible for the following:

32(1) Those Medi-Cal benefits for which he or she would have
33been eligible but for the five-year eligibility limitation only to the
34extent that they are not available through his or her individual
35health plan.

36(2) The department shall pay on behalf of the beneficiary:

37(A) The beneficiary’s insurance premium costs for an individual
38health plan, minus the beneficiary’s premium tax credit authorized
39by Section 36B of Title 26 of the United States Code and its
40implementing regulations.

P87   1(B) The beneficiary’s cost-sharing charges so that the individual
2has the same cost-sharing charges as he or she would have in the
3Medi-Cal program.

4(d) For purposes of this section, the following definitions shall
5apply:

6(1) “Cost-sharing charges” means any expenditure required by
7or on behalf of an enrollee by his or her individual health plan with
8respect to essential health benefits and includes deductibles,
9coinsurance, copayments, or similar charges, but excludes
10premiums, and spending for noncovered services.

11(2) “Exchange” means the California Health Benefit Exchange
12established pursuant to Section 100500 of the Government Code.

13(e) Benefits for services under this section shall be provided
14with state-only funds only if federal financial participation is not
15 available for those services. The department shall maximize federal
16financial participation in implementing this section to the extent
17allowable.

18(f) Notwithstanding Chapter 3.5 (commencing with Section
1911340) of Part 1 of Division 3 of Title 2 of the Government Code,
20the department, without taking any further regulatory action, shall
21implement, interpret, or make specific this section by means of
22all-county letters, plan letters, plan or provider bulletins, or similar
23instructions until the time regulations are adopted. Thereafter, the
24department shall adopt regulations in accordance with the
25requirements of Chapter 3.5 (commencing with Section 11340) of
26Part 1 of Division 3 of Title 2 of the Government Code. Beginning
27six months after the effective date of this section, the department
28shall provide a status report to the Legislature on a semiannual
29basis until regulations have been adopted.

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

end delete
31

begin deleteSEC. 40.end delete
32begin insertSEC. 24.end insert  

Section 14102.5 is added to the Welfare and
33Institutions Code
, to read:

34

14102.5.  

(a) The department shall, in collaboration with the
35Exchange, the counties, consumer advocates, and the Statewide
36Automated Welfare System consortia, develop and prepare one or
37more reports that shall be issued on at least a quarterly basis and
38shall be made publicly available within 30 days following the end
39of each quarter, for the purpose of informing the California Health
40and Human Services Agency, the Exchange, the Legislature, and
P88   1the public about the enrollment process for all insurance
2affordability programs. The reports shall comply with federal
3reporting requirements and shall, at a minimum, include the
4following information, to be derived from, as appropriate
5depending on the data element, CalHEERS, MEDS, or the
6Statewide Automated Welfare System:

7(1) For applications received for insurance affordability
8programs through any venue, all of the following:

9(A) The number of applications received through each venue.

10(B) The number of applicants included on those applications.

11(C) Applicant demographics, including, but not limited to,
12gender, age, race, ethnicity, and primary language.

13(D) The disposition of applications, including all of the
14following:

15(i) The number of eligibility determinations that resulted in an
16approval for coverage.

17(ii) The program or programs for which the individuals in clause
18(i) were determined eligible.

19(iii) The number of applications that were denied for any
20coverage and the reason or reasons for the denials.

21(E) The number of days for eligibility determinationsbegin insert to be
22completedend insert
.

23(2) With regard to health plan selection, all of the following:

24(A) The health plans that are selected by applicants enrolled in
25an insurance affordability program, reported by the program.

26(B) The number of Medi-Cal enrollees who do not select a health
27plan but are defaulted into a plan.

28(3) For annual redeterminations conducted for beneficiaries, all
29of the following:

30(A) The number of redeterminations processed.

31(B) The number of redeterminations that resulted in continued
32eligibility for the samebegin insert insurance affordabilityend insert program.

33(C) The number of redeterminations that resulted in a change
34in eligibility to a differentbegin insert insurance affordabilityend insert program.

35(D) The number of redeterminations that resulted in a finding
36of ineligibility for any program and the reason or reasons for the
37findings of ineligibility.

38(E) The number of days for redeterminations to be completed.

39(4) With regard to disenrollments not related to a
40redetermination of eligibility, all of the following:

P89   1(A) The number of beneficiary disenrollments.

2(B) The reasons for the disenrollments.

3(C) The number of disenrollments that are caused by an
4individual disenrolling from one insurance affordability program
5and enrolling into another.

6(5) The number of applications for insurance affordability
7programs that were filed with the help of an assister or navigator.

8(6) The total number of grievances and appeals filed by
9applicants and enrollees regarding eligibility for insurance
10affordability programs, the basis for the grievance, and the
11outcomes of the appeals.

12(b) The department shall collect the information necessary for
13these reports and develop these reports using data obtained from
14the Statewide Automated Welfare System, CalHEERS, MEDS,
15and any other appropriate state information management systems.

16(c) For purposes of this section, the following definitions shall
17apply:

18(1) “CalHEERS” means the California Healthcare Eligibility,
19Enrollment, and Retention System developed under Section 15926.

20(2) “Exchange” means the California Health Benefit Exchange
21established pursuant to Title 22 (commencing with Section 100500)
22of the Government Code.

23(3) “Statewide Automated Welfare System” means the system
24developed pursuant to Section 10823.

25(4) “MEDS” means the Medi-Cal Eligibility Data Systembegin insert that
26is maintained by the departmentend insert
.

27(d) Notwithstanding Chapter 3.5 (commencing with Section
2811340) of Part 1 of Division 3 of Title 2 of the Government Code,
29the department, without taking any further regulatory action, shall
30implement, interpret, or make specific this section by means of
31all-county letters, plan letters, plan or provider bulletins, or similar
32instructions until the time regulations are adopted. Thereafter, the
33department shall adopt regulations in accordance with the
34requirements of Chapter 3.5 (commencing with Section 11340) of
35Part 1 of Division 3 of Title 2 of the Government Code. Beginning
36six months after the effective date of this section,begin insert and
37notwithstanding Section 10231.5 of the Government Code,end insert
the
38department shall provide a status report to the Legislature on a
39semiannual basis until regulations have been adopted.

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

begin delete
P90   1

SEC. 41.  

Section 14132 of the Welfare and Institutions Code is
2amended to read:

3

14132.  

The following is the schedule of benefits under this
4chapter:

5(a) Outpatient services are covered as follows:

6Physician, hospital or clinic outpatient, surgical center,
7respiratory care, optometric, chiropractic, psychology, podiatric,
8occupational therapy, physical therapy, speech therapy, audiology,
9acupuncture to the extent federal matching funds are provided for
10acupuncture, and services of persons rendering treatment by prayer
11or healing by spiritual means in the practice of any church or
12religious denomination insofar as these can be encompassed by
13federal participation under an approved plan, subject to utilization
14controls.

15(b) (1) Inpatient hospital services, including, but not limited
16to, physician and podiatric services, physical therapy and
17occupational therapy, are covered subject to utilization controls.

18(2) For Medi-Cal fee-for-service beneficiaries, emergency
19services and care that are necessary for the treatment of an
20emergency medical condition and medical care directly related to
21the emergency medical condition. This paragraph shall not be
22construed to change the obligation of Medi-Cal managed care
23plans to provide emergency services and care. For the purposes of
24this paragraph, “emergency services and care” and “emergency
25medical condition” shall have the same meanings as those terms
26are defined in Section 1317.1 of the Health and Safety Code.

27(c) Nursing facility services, subacute care services, and services
28provided by any category of intermediate care facility for the
29developmentally disabled, including podiatry, physician, nurse
30practitioner services, and prescribed drugs, as described in
31subdivision (d), are covered subject to utilization controls.
32Respiratory care, physical therapy, occupational therapy, speech
33therapy, and audiology services for patients in nursing facilities
34and any category of intermediate care facility for the
35developmentally disabled are covered subject to utilization controls.

36(d) (1) Purchase of prescribed drugs is covered subject to the
37Medi-Cal List of Contract Drugs and utilization controls.

38(2) Purchase of drugs used to treat erectile dysfunction or any
39off-label uses of those drugs are covered only to the extent that
40federal financial participation is available.

P91   1(3) (A) To the extent required by federal law, the purchase of
2outpatient prescribed drugs, for which the prescription is executed
3by a prescriber in written, nonelectronic form on or after April 1,
42008, is covered only when executed on a tamper resistant
5prescription form. The implementation of this paragraph shall
6conform to the guidance issued by the federal Centers for Medicare
7and Medicaid Services but shall not conflict with state statutes on
8the characteristics of tamper resistant prescriptions for controlled
9substances, including Section 11162.1 of the Health and Safety
10Code. The department shall provide providers and beneficiaries
11with as much flexibility in implementing these rules as allowed
12by the federal government. The department shall notify and consult
13with appropriate stakeholders in implementing, interpreting, or
14making specific this paragraph.

15(B) Notwithstanding Chapter 3.5 (commencing with Section
1611340) of Part 1 of Division 3 of Title 2 of the Government Code,
17the department may take the actions specified in subparagraph (A)
18by means of a provider bulletin or notice, policy letter, or other
19similar instructions without taking regulatory action.

20(4) (A) (i) For the purposes of this paragraph, nonlegend has
21the same meaning as defined in subdivision (a) of Section
2214105.45.

23(ii) Nonlegend acetaminophen-containing products, with the
24exception of children’s acetaminophen-containing products,
25selected by the department are not covered benefits.

26(iii) Nonlegend cough and cold products selected by the
27department are not covered benefits. This clause shall be
28implemented on the first day of the first calendar month following
2990 days after the effective date of the act that added this clause,
30or on the first day of the first calendar month following 60 days
31after the date the department secures all necessary federal approvals
32to implement this section, whichever is later.

33(iv) Beneficiaries under the Early and Periodic Screening,
34Diagnosis, and Treatment Program shall be exempt from clauses
35(ii) and (iii).

36(B) Notwithstanding Chapter 3.5 (commencing with Section
3711340) of Part 1 of Division 3 of Title 2 of the Government Code,
38the department may take the actions specified in subparagraph (A)
39by means of a provider bulletin or notice, policy letter, or other
40similar instruction without taking regulatory action.

P92   1(e) Outpatient dialysis services and home hemodialysis services,
2including physician services, medical supplies, drugs and
3equipment required for dialysis, are covered, subject to utilization
4controls.

5(f) Anesthesiologist services when provided as part of an
6outpatient medical procedure, nurse anesthetist services when
7rendered in an inpatient or outpatient setting under conditions set
8forth by the director, outpatient laboratory services, and X-ray
9services are covered, subject to utilization controls. Nothing in
10this subdivision shall be construed to require prior authorization
11for anesthesiologist services provided as part of an outpatient
12medical procedure or for portable X-ray services in a nursing
13facility or any category of intermediate care facility for the
14developmentally disabled.

15(g) Blood and blood derivatives are covered.

16(h) (1) Emergency and essential diagnostic and restorative
17dental services, except for orthodontic, fixed bridgework, and
18partial dentures that are not necessary for balance of a complete
19artificial denture, are covered, subject to utilization controls. The
20utilization controls shall allow emergency and essential diagnostic
21and restorative dental services and prostheses that are necessary
22to prevent a significant disability or to replace previously furnished
23prostheses which are lost or destroyed due to circumstances beyond
24the beneficiary’s control. Notwithstanding the foregoing, the
25director may by regulation provide for certain fixed artificial
26dentures necessary for obtaining employment or for medical
27conditions that preclude the use of removable dental prostheses,
28and for orthodontic services in cleft palate deformities administered
29by the department’s California Children Services Program.

30(2) For persons 21 years of age or older, the services specified
31in paragraph (1) shall be provided subject to the following
32conditions:

33(A) Periodontal treatment is not a benefit.

34(B) Endodontic therapy is not a benefit except for vital
35pulpotomy.

36(C) Laboratory processed crowns are not a benefit.

37(D) Removable prosthetics shall be a benefit only for patients
38as a requirement for employment.

P93   1(E) The director may, by regulation, provide for the provision
2of fixed artificial dentures that are necessary for medical conditions
3that preclude the use of removable dental prostheses.

4(F) Notwithstanding the conditions specified in subparagraphs
5(A) to (E), inclusive, the department may approve services for
6persons with special medical disorders subject to utilization review.

7(3) Paragraph (2) shall become inoperative July 1, 1995.

8(i) Medical transportation is covered, subject to utilization
9controls.

10(j) Home health care services are covered, subject to utilization
11controls.

12(k) Prosthetic and orthotic devices and eyeglasses are covered,
13subject to utilization controls. Utilization controls shall allow
14replacement of prosthetic and orthotic devices and eyeglasses
15necessary because of loss or destruction due to circumstances
16beyond the beneficiary’s control. Frame styles for eyeglasses
17replaced pursuant to this subdivision shall not change more than
18once every two years, unless the department so directs.

19Orthopedic and conventional shoes are covered when provided
20by a prosthetic and orthotic supplier on the prescription of a
21physician and when at least one of the shoes will be attached to a
22prosthesis or brace, subject to utilization controls. Modification
23of stock conventional or orthopedic shoes when medically
24indicated, is covered subject to utilization controls. When there is
25a clearly established medical need that cannot be satisfied by the
26modification of stock conventional or orthopedic shoes,
27custom-made orthopedic shoes are covered, subject to utilization
28controls.

29Therapeutic shoes and inserts are covered when provided to
30beneficiaries with a diagnosis of diabetes, subject to utilization
31controls, to the extent that federal financial participation is
32available.

33(l) Hearing aids are covered, subject to utilization controls.
34Utilization controls shall allow replacement of hearing aids
35necessary because of loss or destruction due to circumstances
36beyond the beneficiary’s control.

37(m) Durable medical equipment and medical supplies are
38covered, subject to utilization controls. The utilization controls
39shall allow the replacement of durable medical equipment and
40medical supplies when necessary because of loss or destruction
P94   1due to circumstances beyond the beneficiary’s control. The
2utilization controls shall allow authorization of durable medical
3equipment needed to assist a disabled beneficiary in caring for a
4child for whom the disabled beneficiary is a parent, stepparent,
5foster parent, or legal guardian, subject to the availability of federal
6financial participation. The department shall adopt emergency
7regulations to define and establish criteria for assistive durable
8medical equipment in accordance with the rulemaking provisions
9of the Administrative Procedure Act (Chapter 3.5 (commencing
10 with Section 11340) of Part 1 of Division 3 of Title 2 of the
11Government Code).

12(n) Family planning services are covered, subject to utilization
13controls.

14(o) Inpatient intensive rehabilitation hospital services, including
15respiratory rehabilitation services, in a general acute care hospital
16are covered, subject to utilization controls, when either of the
17following criteria are met:

18(1) A patient with a permanent disability or severe impairment
19requires an inpatient intensive rehabilitation hospital program as
20described in Section 14064 to develop function beyond the limited
21amount that would occur in the normal course of recovery.

22(2) A patient with a chronic or progressive disease requires an
23inpatient intensive rehabilitation hospital program as described in
24Section 14064 to maintain the patient’s present functional level as
25long as possible.

26(p) (1) Adult day health care is covered in accordance with
27Chapter 8.7 (commencing with Section 14520).

28(2) Commencing 30 days after the effective date of the act that
29added this paragraph, and notwithstanding the number of days
30previously approved through a treatment authorization request,
31adult day health care is covered for a maximum of three days per
32week.

33(3) As provided in accordance with paragraph (4), adult day
34health care is covered for a maximum of five days per week.

35(4) As of the date that the director makes the declaration
36described in subdivision (g) of Section 14525.1, paragraph (2)
37shall become inoperative and paragraph (3) shall become operative.

38(q) (1) Application of fluoride, or other appropriate fluoride
39treatment as defined by the department, other prophylaxis treatment
40for children 17 years of age and under, are covered.

P95   1(2) All dental hygiene services provided by a registered dental
2hygienist in alternative practice pursuant to Sections 1768 and
31770 of the Business and Professions Code may be covered as
4long as they are within the scope of Denti-Cal benefits and they
5are necessary services provided by a registered dental hygienist
6in alternative practice.

7(r) (1) Paramedic services performed by a city, county, or
8special district, or pursuant to a contract with a city, county, or
9special district, and pursuant to a program established under Article
103 (commencing with Section 1480) of Chapter 2.5 of Division 2
11of the Health and Safety Code by a paramedic certified pursuant
12to that article, and consisting of defibrillation and those services
13specified in subdivision (3) of Section 1482 of the article.

14(2) All providers enrolled under this subdivision shall satisfy
15all applicable statutory and regulatory requirements for becoming
16a Medi-Cal provider.

17(3) This subdivision shall be implemented only to the extent
18funding is available under Section 14106.6.

19(s) In-home medical care services are covered when medically
20appropriate and subject to utilization controls, for beneficiaries
21who would otherwise require care for an extended period of time
22in an acute care hospital at a cost higher than in-home medical
23care services. The director shall have the authority under this
24section to contract with organizations qualified to provide in-home
25medical care services to those persons. These services may be
26provided to patients placed in shared or congregate living
27arrangements, if a home setting is not medically appropriate or
28available to the beneficiary. As used in this section, “in-home
29medical care service” includes utility bills directly attributable to
30continuous, 24-hour operation of life-sustaining medical equipment,
31to the extent that federal financial participation is available.

32As used in this subdivision, in-home medical care services,
33include, but are not limited to:

34(1) Level of care and cost of care evaluations.

35(2) Expenses, directly attributable to home care activities, for
36materials.

37(3) Physician fees for home visits.

38(4) Expenses directly attributable to home care activities for
39shelter and modification to shelter.

P96   1(5) Expenses directly attributable to additional costs of special
2diets, including tube feeding.

3(6) Medically related personal services.

4(7) Home nursing education.

5(8) Emergency maintenance repair.

6(9) Home health agency personnel benefits which permit
7coverage of care during periods when regular personnel are on
8vacation or using sick leave.

9(10) All services needed to maintain antiseptic conditions at
10stoma or shunt sites on the body.

11(11) Emergency and nonemergency medical transportation.

12(12) Medical supplies.

13(13) Medical equipment, including, but not limited to, scales,
14gurneys, and equipment racks suitable for paralyzed patients.

15(14) Utility use directly attributable to the requirements of home
16care activities which are in addition to normal utility use.

17(15) Special drugs and medications.

18(16) Home health agency supervision of visiting staff which is
19medically necessary, but not included in the home health agency
20rate.

21(17) Therapy services.

22(18) Household appliances and household utensil costs directly
23attributable to home care activities.

24(19) Modification of medical equipment for home use.

25(20) Training and orientation for use of life-support systems,
26including, but not limited to, support of respiratory functions.

27(21) Respiratory care practitioner services as defined in Sections
283702 and 3703 of the Business and Professions Code, subject to
29prescription by a physician and surgeon.

30Beneficiaries receiving in-home medical care services are entitled
31to the full range of services within the Medi-Cal scope of benefits
32as defined by this section, subject to medical necessity and
33applicable utilization control. Services provided pursuant to this
34 subdivision, which are not otherwise included in the Medi-Cal
35schedule of benefits, shall be available only to the extent that
36federal financial participation for these services is available in
37accordance with a home- and community-based services waiver.

38(t) Home- and community-based services approved by the
39United States Department of Health and Human Services may be
40covered to the extent that federal financial participation is available
P97   1for those services under waivers granted in accordance with Section
21396n of Title 42 of the United States Code. The director may
3seek waivers for any or all home- and community-based services
4approvable under Section 1396n of Title 42 of the United States
5Code. Coverage for those services shall be limited by the terms,
6conditions, and duration of the federal waivers.

7(u) Comprehensive perinatal services, as provided through an
8agreement with a health care provider designated in Section
914134.5 and meeting the standards developed by the department
10pursuant to Section 14134.5, subject to utilization controls.

11The department shall seek any federal waivers necessary to
12implement the provisions of this subdivision. The provisions for
13which appropriate federal waivers cannot be obtained shall not be
14implemented. Provisions for which waivers are obtained or for
15which waivers are not required shall be implemented
16notwithstanding any inability to obtain federal waivers for the
17other provisions. No provision of this subdivision shall be
18implemented unless matching funds from Subchapter XIX
19(commencing with Section 1396) of Chapter 7 of Title 42 of the
20United States Code are available.

21(v) Early and periodic screening, diagnosis, and treatment for
22any individual under 21 years of age is covered, consistent with
23the requirements of Subchapter XIX (commencing with Section
241396) of Chapter 7 of Title 42 of the United States Code.

25(w) Hospice service which is Medicare-certified hospice service
26is covered, subject to utilization controls. Coverage shall be
27available only to the extent that no additional net program costs
28are incurred.

29(x) When a claim for treatment provided to a beneficiary
30includes both services which are authorized and reimbursable
31under this chapter, and services which are not reimbursable under
32this chapter, that portion of the claim for the treatment and services
33authorized and reimbursable under this chapter shall be payable.

34(y) Home- and community-based services approved by the
35United States Department of Health and Human Services for
36beneficiaries with a diagnosis of AIDS or ARC, who require
37intermediate care or a higher level of care.

38Services provided pursuant to a waiver obtained from the
39Secretary of the United States Department of Health and Human
40Services pursuant to this subdivision, and which are not otherwise
P98   1included in the Medi-Cal schedule of benefits, shall be available
2only to the extent that federal financial participation for these
3services is available in accordance with the waiver, and subject to
4the terms, conditions, and duration of the waiver. These services
5shall be provided to individual beneficiaries in accordance with
6the client’s needs as identified in the plan of care, and subject to
7medical necessity and applicable utilization control.

8The director may under this section contract with organizations
9qualified to provide, directly or by subcontract, services provided
10for in this subdivision to eligible beneficiaries. Contracts or
11agreements entered into pursuant to this division shall not be
12subject to the Public Contract Code.

13(z) Respiratory care when provided in organized health care
14systems as defined in Section 3701 of the Business and Professions
15Code, and as an in-home medical service as outlined in subdivision
16(s).

17(aa) (1) There is hereby established in the department, a
18program to provide comprehensive clinical family planning
19services to any person who has a family income at or below 200
20percent of the federal poverty level, as revised annually, and who
21is eligible to receive these services pursuant to the waiver identified
22in paragraph (2). This program shall be known as the Family
23Planning, Access, Care, and Treatment (Family PACT) Program.

24(2) The department shall seek a waiver in accordance with
25Section 1315 of Title 42 of the United States Code, or a state plan
26amendment adopted in accordance with Section
271396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code,
28which was added to Section 1396a of Title 42 of the United States
29Code by Section 2303(a)(2) of the federal Patient Protection and
30Affordable Care Act (PPACA) (Public Law 111-148), for a
31program to provide comprehensive clinical family planning
32services as described in paragraph (8). Under the waiver, the
33program shall be operated only in accordance with the waiver and
34the statutes and regulations in paragraph (4) and subject to the
35terms, conditions, and duration of the waiver. Under the state plan
36amendment, which shall replace the waiver and shall be known as
37the Family PACT successor state plan amendment, the program
38shall be operated only in accordance with this subdivision and the
39statutes and regulations in paragraph (4). The state shall use the
40standards and processes imposed by the state on January 1, 2007,
P99   1including the application of an eligibility discount factor to the
2extent required by the federal Centers for Medicare and Medicaid
3Services, for purposes of determining eligibility as permitted under
4Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States
5Code. To the extent that federal financial participation is available,
6the program shall continue to conduct education, outreach,
7enrollment, service delivery, and evaluation services as specified
8under the waiver. The services shall be provided under the program
9only if the waiver and, when applicable, the successor state plan
10amendment are approved by the federal Centers for Medicare and
11Medicaid Services and only to the extent that federal financial
12participation is available for the services. Nothing in this section
13shall prohibit the department from seeking the Family PACT
14successor state plan amendment during the operation of the waiver.

15(3) Solely for the purposes of the waiver or Family PACT
16successor state plan amendment and notwithstanding any other
17provision of law, the collection and use of an individual’s social
18security number shall be necessary only to the extent required by
19federal law.

20(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005,
21and 24013, and any regulations adopted under these statutes shall
22apply to the program provided for under this subdivision. No other
23provision of law under the Medi-Cal program or the State-Only
24Family Planning Program shall apply to the program provided for
25under this subdivision.

26(5) Notwithstanding Chapter 3.5 (commencing with Section
2711340) of Part 1 of Division 3 of Title 2 of the Government Code,
28the department may implement, without taking regulatory action,
29the provisions of the waiver after its approval by the federal Health
30Care Financing Administration and the provisions of this section
31by means of an all-county letter or similar instruction to providers.
32Thereafter, the department shall adopt regulations to implement
33this section and the approved waiver in accordance with the
34requirements of Chapter 3.5 (commencing with Section 11340) of
35Part 1 of Division 3 of Title 2 of the Government Code. Beginning
36six months after the effective date of the act adding this
37subdivision, the department shall provide a status report to the
38Legislature on a semiannual basis until regulations have been
39adopted.

P100  1(6) In the event that the Department of Finance determines that
2the program operated under the authority of the waiver described
3in paragraph (2) or the Family PACT successor state plan
4amendment is no longer cost effective, this subdivision shall
5become inoperative on the first day of the first month following
6the issuance of a 30-day notification of that determination in
7writing by the Department of Finance to the chairperson in each
8house that considers appropriations, the chairpersons of the
9committees, and the appropriate subcommittees in each house that
10considers the State Budget, and the Chairperson of the Joint
11Legislative Budget Committee.

12(7) If this subdivision ceases to be operative, all persons who
13have received or are eligible to receive comprehensive clinical
14family planning services pursuant to the waiver described in
15paragraph (2) shall receive family planning services under the
16Medi-Cal program pursuant to subdivision (n) if they are otherwise
17eligible for Medi-Cal with no share of cost, or shall receive
18comprehensive clinical family planning services under the program
19established in Division 24 (commencing with Section 24000) either
20if they are eligible for Medi-Cal with a share of cost or if they are
21otherwise eligible under Section 24003.

22(8) For purposes of this subdivision, “comprehensive clinical
23family planning services” means the process of establishing
24objectives for the number and spacing of children, and selecting
25the means by which those objectives may be achieved. These
26means include a broad range of acceptable and effective methods
27and services to limit or enhance fertility, including contraceptive
28methods, federal Food and Drug Administration approved
29contraceptive drugs, devices, and supplies, natural family planning,
30abstinence methods, and basic, limited fertility management.
31Comprehensive clinical family planning services include, but are
32not limited to, preconception counseling, maternal and fetal health
33counseling, general reproductive health care, including diagnosis
34and treatment of infections and conditions, including cancer, that
35threaten reproductive capability, medical family planning treatment
36and procedures, including supplies and followup, and
37informational, counseling, and educational services.
38Comprehensive clinical family planning services shall not include
39abortion, pregnancy testing solely for the purposes of referral for
40abortion or services ancillary to abortions, or pregnancy care that
P101  1is not incident to the diagnosis of pregnancy. Comprehensive
2clinical family planning services shall be subject to utilization
3control and include all of the following:

4(A) Family planning related services and male and female
5sterilization. Family planning services for men and women shall
6include emergency services and services for complications directly
7related to the contraceptive method, federal Food and Drug
8Administration approved contraceptive drugs, devices, and
9supplies, and followup, consultation, and referral services, as
10indicated, which may require treatment authorization requests.

11(B) All United States Department of Agriculture, federal Food
12and Drug Administration approved contraceptive drugs, devices,
13and supplies that are in keeping with current standards of practice
14and from which the individual may choose.

15(C) Culturally and linguistically appropriate health education
16and counseling services, including informed consent, that include
17all of the following:

18(i) Psychosocial and medical aspects of contraception.

19(ii) Sexuality.

20(iii) Fertility.

21(iv) Pregnancy.

22(v) Parenthood.

23(vi) Infertility.

24(vii) Reproductive health care.

25(viii) Preconception and nutrition counseling.

26(ix) Prevention and treatment of sexually transmitted infection.

27(x) Use of contraceptive methods, federal Food and Drug
28Administration approved contraceptive drugs, devices, and
29supplies.

30(xi) Possible contraceptive consequences and followup.

31(xii) Interpersonal communication and negotiation of
32relationships to assist individuals and couples in effective
33contraceptive method use and planning families.

34(D) A comprehensive health history, updated at the next periodic
35visit (between 11 and 24 months after initial examination) that
36includes a complete obstetrical history, gynecological history,
37contraceptive history, personal medical history, health risk factors,
38and family health history, including genetic or hereditary
39conditions.

P102  1(E) A complete physical examination on initial and subsequent
2periodic visits.

3(F) Services, drugs, devices, and supplies deemed by the federal
4Centers for Medicare and Medicaid Services to be appropriate for
5inclusion in the program.

6(9) In order to maximize the availability of federal financial
7participation under this subdivision, the director shall have the
8discretion to implement the Family PACT successor state plan
9amendment retroactively to July 1, 2010.

10(ab) (1) Purchase of prescribed enteral nutrition products is
11covered, subject to the Medi-Cal list of enteral nutrition products
12and utilization controls.

13(2) Purchase of enteral nutrition products is limited to those
14products to be administered through a feeding tube, including, but
15not limited to, a gastric, nasogastric, or jejunostomy tube.
16Beneficiaries under the Early and Periodic Screening, Diagnosis,
17and Treatment Program shall be exempt from this paragraph.

18(3) Notwithstanding paragraph (2), the department may deem
19an enteral nutrition product, not administered through a feeding
20tube, including, but not limited to, a gastric, nasogastric, or
21jejunostomy tube, a benefit for patients with diagnoses, including,
22but not limited to, malabsorption and inborn errors of metabolism,
23if the product has been shown to be neither investigational nor
24experimental when used as part of a therapeutic regimen to prevent
25serious disability or death.

26(4) Notwithstanding Chapter 3.5 (commencing with Section
2711340) of Part 1 of Division 3 of Title 2 of the Government Code,
28the department may implement the amendments to this subdivision
29made by the act that added this paragraph by means of all-county
30letters, provider bulletins, or similar instructions, without taking
31regulatory action.

32(5) The amendments made to this subdivision by the act that
33added this paragraph shall be implemented June 1, 2011, or on the
34first day of the first calendar month following 60 days after the
35date the department secures all necessary federal approvals to
36implement this section, whichever is later.

37(ac) Diabetic testing supplies are covered when provided by a
38pharmacy, subject to utilization controls.

39(ad) Commencing January 1, 2014, any benefits, services, and
40coverage not otherwise described in this chapter that are included
P103  1in the essential health benefits package adopted by the state
2pursuant to Section 1367.005 of the Health and Safety Code and
3Section 10112.27 of the Insurance Code and approved by the
4United States Secretary of Health and Human Services under
5Section 18022 of Title 42 of the United States Code, and any
6successor essential health benefit package adopted by the state.

7

SEC. 42.  

Section 14132.02 is added to the Welfare and
8Institutions Code
, to read:

9

14132.02.  

(a) Pursuant to Sections 1902(k)(1) and
101937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
111396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
12shall seek approval from the United States Secretary of Health and
13Human Services to establish a benchmark benefit package that
14includes the same benefits, services, and coverage as is provided
15to all other full-scope Medi-Cal enrollees, supplemented by any
16benefits, services, and coverage included in the essential health
17benefits package adopted by the state pursuant to Section 1367.005
18of the Health and Safety Code and Section 10112.27 of the
19Insurance Code and approved by the secretary under Section 18022
20of Title 42 of the United States Code, and any successor essential
21health benefit package adopted by the state.

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

end delete
23begin insert

begin insertSEC. 25.end insert  

end insert

begin insertSection 14103 is added to the end insertbegin insertWelfare and Institutions
24Code
end insert
begin insert, to read:end insert

begin insert
25

begin insert14103.end insert  

(a) The implementation of the optional expansion of
26Medi-Cal benefits to adults who meet the eligibility requirements
27of Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social
28Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), shall be
29contingent upon the following:

30(1) If the federal medical assistance percentage payable to the
31state under the ACA for the optional expansion of Medi-Cal
32benefits to adults is reduced below 90 percent, that reduction shall
33be addressed in a timely manner through the annual state budget
34or legislative process. Upon receiving notification of any reduction
35in federal assistance pursuant to this paragraph, the Director of
36Finance shall immediately notify the Chairpersons of the Senate
37and Assembly Health Committees and the Chairperson of the Joint
38Legislative Budget Committee.

39(2) If, prior to January 1, 2018, the federal medical assistance
40percentage payable to the state under the ACA for the optional
P104  1expansion of Medi-Cal benefits to adults is reduced to 70 percent
2or less, the implementation of any provision in this chapter
3authorizing the optional expansion of Medi-Cal benefits to adults
4shall cease 12 months after the effective date of the federal law or
5other action reducing the federal medical assistance percentage.

6(b) For purposes of this section, “ACA” means the federal
7Patient Protection and Affordable Care Act (Public Law 111-148)
8as originally enacted and as amended by the federal Health Care
9and Education Reconciliation Act of 2010 (Public Law 111-152)
10and any subsequent amendments.

end insert
11

begin deleteSEC. 43.end delete
12begin insertSEC. 26.end insert  

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

14

15926.  

(a) The following definitions apply for purposes of
15this part:

16(1) “Accessible” means in compliance with Section 11135 of
17the Government Code, Section 1557 of the PPACA, and regulations
18or guidance adopted pursuant to these statutes.

19(2) “Limited-English-proficient” means not speaking English
20as one’s primary language and having a limited ability to read,
21speak, write, or understand English.

22(3) “Insurance affordability program” means a program that is
23one of the following:

24(A) The Medi-Cal program under Title XIX of the federal Social
25Security Act (42 U.S.C. Sec. 1396 et seq.).

26(B) Thebegin delete Healthy Families Programend deletebegin insert state’s children’s health
27insurance program (CHIP)end insert
under Title XXI of the federal Social
28Security Act (42 U.S.C. Sec. 1397aa et seq.).

29(C) A program that makes available to qualified individuals
30coverage in a qualified health plan through the California Health
31Benefit Exchange established pursuant to Title 22 (commencing
32with Section 100500) of the Government Code with advance
33payment of the premium tax credit established under Section 36B
34of the Internal Revenue Code.

35(4) A program that makes available coverage in a qualified
36health plan through the California Health Benefit Exchange
37established pursuant to Title 22 (commencing with Section 100500)
38of the Government Code with cost-sharing reductions established
39under Section 1402 of PPACA and any subsequent amendments
40to that act.

P105  1(b) An individual shall have the option to apply for insurance
2affordability programs in person, by mail, online, by telephone,
3or by other commonly available electronic means.

4(c) (1) A single, accessible, standardized paper, electronic, and
5telephone application for insurance affordability programs shall
6be developed by the department in consultation with MRMIB and
7the board governing the Exchange as part of the stakeholder process
8described in subdivision (b) of Section 15925. The application
9shall be used by all entities authorized to make an eligibility
10determination for any of the insurance affordability programs and
11by their agents.

begin insert

12(2) The department may develop and require the use of
13supplemental forms to collect additional information needed to
14determine eligibility on a basis other than the financial
15methodologies described in Section 1396a(e)(14) of Title 42 of the
16United States Code, as added by the federal Patient Protection
17and Affordable Care Act (Public Law 111-148), and as amended
18by the federal Health Care and Education Reconciliation Act of
192010 (Public Law 111-152) and any subsequent amendments, as
20provided under Section 435.907(c) of Title 42 of the Code of
21Federal Regulations.

end insert
begin delete

22(2)

end delete

23begin insert(end insertbegin insert3)end insert The application shall be tested and operational by the date
24as required by the federal Secretary of Health and Human Services.

begin delete

25(3)

end delete

26begin insert(end insertbegin insert4)end insert The application form shall, to the extent not inconsistent
27with federal statutes, regulations, and guidance, satisfy all of the
28following criteria:

29(A) The form shall include simple, user-friendly language and
30instructions.

31(B) The form may not ask for information related to a
32nonapplicant that is not necessary to determine eligibility in the
33applicant’s particular circumstances.

34(C) The form may require only information necessary to support
35the eligibility and enrollment processes for insurance affordability
36programs.

37(D) The form may be used for, but shall not be limited to,
38screening.

39(E) The form may ask, or be used otherwise to identify, if the
40mother of an infant applicant under one year of age had coverage
P106  1through an insurance affordability program for the infant’s birth,
2for the purpose of automatically enrolling the infant into the
3applicable program without the family having to complete the
4application process for the infant.

5(F) The form may include questions that are voluntary for
6applicants to answer regarding demographic data categories,
7including race, ethnicity, primary language, disability status, and
8other categories recognized by the federal Secretary of Health and
9Human Services under Section 4302 of the PPACA.

10(G) Until January 1, 2016, the department shall instruct counties
11to not reject an application that was in existence prior to January
121, 2014, but to accept the application and request any additional
13information needed from the applicant in order to complete the
14eligibility determination process. The department shall work with
15counties and consumer advocates to develop the supplemental
16questions.

17(d) Nothing in this section shall preclude the use of a
18provider-based application form or enrollment procedures for
19insurance affordability programs or other health programs that
20differs from the application form described in subdivision (c), and
21related enrollment procedures. Nothing in this section shall
22preclude the use of a joint application, developed by the department
23and the State Department of Social Services, that allows for an
24application to be made for multiple programs, including, but not
25limited to, CalWORKs, CalFresh, and insurance affordability
26programs.

27(e) The entity making the eligibility determination shall grant
28eligibility immediately whenever possible and with the consent of
29the applicant in accordance with the state and federal rules
30governing insurance affordability programs.

31(f) (1) If the eligibility, enrollment, and retention system has
32the ability to prepopulate an application form for insurance
33affordability programs with personal information from available
34electronic databases, an applicant shall be given the option, with
35his or her informed consent, to have the application form
36prepopulated. Before a prepopulated application is submitted to
37the entity authorized to make eligibility determinations, the
38individual shall be given the opportunity to provide additional
39eligibility information and to correct any information retrieved
40from a database.

P107  1(2) All insurance affordability programsbegin delete shallend deletebegin insert mayend insert accept
2self-attestation, instead of requiring an individual to produce a
3document, for age, date of birth, family size, household income,
4state residence, pregnancy, and any other applicable criteria needed
5to determine the eligibility of an applicant or recipient, to the extent
6permitted by state and federal law.

7(3) An applicant or recipient shall have his or her information
8electronically verified in the manner required by the PPACA and
9implementing federal regulations and guidancebegin insert and state lawend insert.

10(4) Before an eligibility determination is made, the individual
11shall be given the opportunity to provide additional eligibility
12information and to correct information.

13(5) The eligibility of an applicant shall not be delayedbegin insert beyond
14the timeliness standards as provided in Section 435.912 of Title
1542 of the Code of Federal Regulationsend insert
or denied for any insurance
16affordability program unless the applicant is given a reasonable
17opportunity, of at least the kind provided for under the Medi-Cal
18program pursuant to Section 14007.5 and paragraph (7) of
19subdivision (e) of Section 14011.2, to resolve discrepancies
20concerning any information provided by a verifying entity.

21(6) To the extent federal financial participation is available, an
22applicant shall be provided benefits in accordance with the rules
23of the insurance affordability program, as implemented in federal
24regulations and guidance, for which he or she otherwise qualifies
25until a determination is made that he or she is not eligible and all
26applicable notices have been provided. Nothing in this section
27shall be interpreted to grant presumptive eligibility if it is not
28otherwise required by state law, and, if so required, then only to
29the extent permitted by federal law.

30(g) The eligibility, enrollment, and retention system shall offer
31an applicant and recipient assistance with his or her application or
32renewal for an insurance affordability program in person, over the
33telephone, by mail, online, or through other commonly available
34electronic means and in a manner that is accessible to individuals
35with disabilities and those who are limited-English proficient.

36(h) (1) During the processing of an application, renewal, or a
37transition due to a change in circumstances, an entity making
38eligibility determinations for an insurance affordability program
39shall ensure that an eligible applicant and recipient of insurance
40affordability programs that meets all program eligibility
P108  1requirements and complies with all necessary requests for
2information moves between programs without any breaks in
3coverage and without being required to provide any forms,
4documents, or other information or undergo verification that is
5duplicative or otherwise unnecessary. The individual shall be
6informed about how to obtain information about the status of his
7or her application, renewal, or transfer to another program at any
8time, and the information shall be promptly provided when
9requested.

10(2) The application or case of an individual screened as not
11eligible for Medi-Cal on the basis of Modified Adjusted Gross
12Income (MAGI) household income but who may be eligible on
13the basis of being 65 years of age or older, or on the basis of
14blindness or disability, shall be forwarded to the Medi-Cal program
15for an eligibility determination. During the period this application
16or case is processed for a non-MAGI Medi-Cal eligibility
17determination, if the applicant or recipient is otherwise eligible
18for an insurance affordability program, he or she shall be
19determined eligible for that program.

20(3) Renewal procedures shall include all available methods for
21reporting renewal information, including, but not limited to,
22face-to-face, telephone, mail, and online renewal or renewal
23through other commonly available electronic means.

24(4) An applicant who is not eligible for an insurance affordability
25program for a reason other than income eligibility, or for any reason
26in the case of applicants and recipients residing in a county that
27offers a health coverage program for individuals with income above
28the maximum allowed for the Exchange premium tax credits, shall
29be referred to the county health coverage program in his or her
30county of residence.

31(i) Notwithstanding subdivisions (e), (f), and (j), before an online
32applicant who appears to be eligible for the Exchange with a
33premium tax credit or reduction in cost sharing, or both, may be
34enrolled in the Exchange, both of the following shall occur:

35(1) The applicant shall be informed of the overpayment penalties
36under the federal Comprehensive 1099 Taxpayer Protection and
37Repayment of Exchange Subsidy Overpayments Act of 2011
38(Public Law 112-9), if the individual’s annual family income
39increases by a specified amount or more, calculated on the basis
40of the individual’s current family size and current income, and that
P109  1penalties are avoided by prompt reporting of income increases
2throughout the year.

3(2) The applicant shall be informed of the penalty for failure to
4have minimum essential health coverage.

5(j) The department shall, in coordination with MRMIB and the
6Exchange board, streamline and coordinate all eligibility rules and
7requirements among insurance affordability programs using the
8least restrictive rules and requirements permitted by federal and
9state law. This process shall include the consideration of
10methodologies for determining income levels, assets, rules for
11household size, citizenship and immigration status, and
12self-attestation and verification requirements.

13(k) (1) Forms and notices developed pursuant to this section
14shall be accessible and standardized, as appropriate, and shall
15comply with federal and state laws, regulations, and guidance
16prohibiting discrimination.

17(2) Forms and notices developed pursuant to this section shall
18be developed using plain language and shall be provided in a
19manner that affords meaningful access to limited-English-proficient
20individuals, in accordance with applicable state and federal law,
21and at a minimum, provided in the same threshold languages as
22required for Medi-Cal managed care plans.

23(l) The department, the California Health and Human Services
24Agency, MRMIB, and the Exchange board shall establish a process
25for receiving and acting on stakeholder suggestions regarding the
26 functionality of the eligibility systems supporting the Exchange,
27including the activities of all entities providing eligibility screening
28to ensure the correct eligibility rules and requirements are being
29used. This process shall include consumers and their advocates,
30be conducted no less than quarterly, and include the recording,
31review, and analysis of potential defects or enhancements of the
32eligibility systems. The process shall also include regular updates
33on the work to analyze, prioritize, and implement corrections to
34confirmed defects and proposed enhancements, and to monitor
35screening.

36(m) In designing and implementing the eligibility, enrollment,
37and retention system, the department, MRMIB, and the Exchange
38board shall ensure that all privacy and confidentiality rights under
39the PPACA and other federal and state laws are incorporated and
40followed, including responses to security breaches.

P110  1(n) Except as otherwise specified, this section shall be operative
2on January 1, 2014.

3

begin deleteSEC. 44.end delete
4begin insertSEC. 27.end insert  

No reimbursement is required by this act pursuant to
5Section 6 of Article XIII B of the California Constitution for certain
6costs that may be incurred by a local agency or school district
7because, in that regard, this act creates a new crime or infraction,
8eliminates a crime or infraction, or changes the penalty for a crime
9or infraction, within the meaning of Section 17556 of the
10Government Code, or changes the definition of a crime within the
11meaning of Section 6 of Article XIII B of the California
12Constitution.

13However, if the Commission on State Mandates determines that
14this act contains other costs mandated by the state, reimbursement
15to local agencies and school districts for those costs shall be made
16pursuant to Part 7 (commencing with Section 17500) of Division
174 of Title 2 of the Government Code.

18begin insert

begin insertSEC. 28.end insert  

end insert

begin insertThis act shall become operative only if Senate Bill 1
19of the 2013-14 First Extraordinary Session is enacted and takes
20effect. end insert



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