BILL NUMBER: AB 617 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 4, 2014
AMENDED IN SENATE AUGUST 13, 2013
AMENDED IN ASSEMBLY APRIL 15, 2013
AMENDED IN ASSEMBLY MARCH 19, 2013
INTRODUCED BY Assembly Member Nazarian
FEBRUARY 20, 2013
An act to add Sections 100501.1, 100506.1, 100506.2, 100506.3,
100506.4, and 100506.5 to the Government Code, and to amend
Sections 10950, 10951, and 10960 of the Welfare and Institutions
Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 617, as amended, Nazarian. California Health Benefit Exchange:
appeals.
Existing federal law, the federal Patient Protection and
Affordable Care Act (PPACA), enacts various health care coverage
market reforms that take effect January 1, 2014. PPACA also requires
each state to, by January 1, 2014, establish an American Health
Benefit Exchange that facilitates the purchase of qualified health
plans by qualified individuals and qualified small employers, as
specified. Existing law establishes the California Health Benefit
Exchange (Exchange) to implement the federal law. Existing law also
requires the Exchange board to establish an appeals process for
prospective and current enrollees of the Exchange that complies with
all requirements of the federal act concerning the role of a state
Exchange in facilitating federal appeals of Exchange-related
determinations.
This bill would require the Exchange board to contract with the
State Department of Social Services to serve as the Exchange appeals
entity designated to hear appeals of eligibility determination or
redetermination for persons in the individual market. The bill would
establish an appeals process for initial
eligibility or enrollment determinations and redeterminations for
insurance affordability programs, as defined, or exemption
determinations within the Exchanges jurisdiction, including an
informal resolution process, as specified, establishing procedures
and timelines for hearings with the appeals entity, and notice
provisions. The bill would also establish continuing eligibility for
individuals during the appeals process. The bill would make
other related changes.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 100501.1 is added to the Government Code, to
read:
100501.1. For purposes of this title, the following definitions
shall apply:
(a) "Insurance affordability program" means a program that is one
of the following:
(1) The state's Medi-Cal program under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(2) The state's children's health insurance program (CHIP) under
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa
et seq.).
(3) A program that makes available to qualified individuals
coverage in a qualified health plan through the Exchange with advance
payment of the premium tax credit established under Section 36B of
the Internal Revenue Code.
(4) A program that makes available coverage in a qualified health
plan through the Exchange with cost-sharing reductions established
under Section 1402 of the federal act.
(b) "MRMIB" means the Managed Risk Medical Insurance Board,
established by Sections 12710 and 12710.1 of the Insurance Code, or
its successor.
(b) "Combined eligibility notice," means an eligibility notice
that informs an individual, or multiple family members of a
household, of eligibility for each of the insurance affordability
programs and for enrollment in a qualified health plan through the
Exchange, for which a determination of eligibility was made.
SEC. 2. Section 100506.1 is added to the Government Code, to read:
100506.1. An applicant or enrollee has the right to appeal any of
the following:
(a) Any action or inaction related to the individual's eligibility
for or enrollment in an insurance affordability program, or for
advance payment of premium tax credits and cost-sharing reductions,
or the amount of the advance payment of the premium tax credit and
level of cost sharing, or eligibility for affordable plan options.
(b) An eligibility determination for an exemption from the
individual responsibility penalty pursuant to Section 1311(d)(4)(H)
of the federal act.
(c) A failure to provide timely or adequate notice of
an eligibility determination or redetermination or an enrollment
related determination.
SEC. 3. Section 100506.2 is added to the Government Code, to read:
100506.2. (a) The entity making an eligibility or enrollment
determination described in Section 100506.1 shall provide notice of
the appeals process at the time of application and at the time of
eligibility or enrollment determination or redetermination.
(b) The entity making an eligibility or enrollment determination
described in Section 100506.1 shall also issue a combined eligibility
notice, as defined by Section 435.4 of Title 42 of the Code
of Federal Regulations. notice. The combined
eligibility notice shall contain all of the following:
(1) Information about each insurance affordability
program for which an eligibility or ineligibility for
Medi-Cal, premium tax credits and cost-sharing reductions, and, if
applicable, eligibility for the Medi-Cal Access Program, for each
individual , or multiple family members of a
household have been determined to be eligible or ineligible
and the effective date of eligibility and enrollment. ,
that has applied, including all of the following:
(A) An explanation of the action reflected in the notice,
including the effective date of the action.
(B) Any factual bases upon which the decision is made.
(C) Citations to, or identification of, the legal authority
supporting the action.
(D) Contact information for available customer service resources,
including local legal aid and welfare rights offices.
(E) The effective date of eligibility and enrollment.
(2) Information regarding all of the bases of
eligibility for non-Modified Adjusted Gross Income
non-modified adjusted gross income (MAGI) Medi-Cal and
the benefits and services afforded to individuals eligible on those
bases, sufficient to enable the individual to make an informed choice
as to whether to appeal the eligibility determination or the date of
enrollment. enrollment, which may be included
with the notice in a separate document.
(3) An explanation that the applicant or enrollee may appeal any
action or inaction related to an individual's eligibility for or
enrollment in an insurance affordability program with which the
applicant or enrollee is dissatisfied by requesting a state fair
hearing consistent with Section 100506.4 this
title and the provisions of Chapter 7 (commencing with Section
10950) of Part 2 of Division 9 of the Welfare and Institutions Code.
(4) Information on the applicant or enrollee's right to represent
himself or herself or to be represented by legal counsel or an
authorized representative as provided in subdivision (f) of Section
100506.4.
(5) An explanation of the circumstances under which the applicant'
s or enrollee's eligibility shall be maintained or reinstated pending
an appeal decision, pursuant to Section 100506.5.
SEC. 4. Section 100506.3 is added to the Government Code, to read:
100506.3. The board shall enter into a contract with the State
Department of Social Services to serve as the Exchange appeals entity
designated to hear appeals of eligibility or enrollment
determination or redetermination for persons in the individual
market, pursuant to Section 100506 and Subpart F of Part 155
of Title 45 of the Code of Federal Regulations. or
exemption determinations within the Exchange's jurisdiction.
Except as otherwise provided in this title, the
this hearing process shall be governed by the Medi-Cal
hearing process established in Chapter 7 (commencing with Section
10950) of Part 2 of Division 9 of the Welfare and Institutions
Code. Code, Section 100506, Subpart F of Part
155 of Title 45 of the Code of Federal Regulations, and Article 7 of
Chapter 12 of Title 10 of the California Code of Regulations to the
extent applicable and consistent with the act that added this
section.
SEC. 5. Section 100506.4 is added to the Government Code, to read:
100506.4. (a) (1) Except as provided in paragraph (2), the State
Department of Social Services, acting as the appeals entity, shall
allow an applicant or enrollee to request an appeal within 90 days of
the date of the notice of an eligibility or enrollment
determination, or exemption determination within the
Exchange's jurisdiction, unless there is good cause as provided
in Section 10951 of the Welfare and Institutions Code.
(2) The appeals entity shall establish and maintain a process for
an applicant or enrollee to request an expedited appeals process
where there is immediate need for health services because a standard
appeal could seriously jeopardize the appellant's life, health, or
the ability to attain, maintain, or regain maximum function. If an
expedited appeal is granted, the decision shall be issued
within three working days or as soon as is required by the appellant'
s condition. no later than five working days unless
the appellant agrees to a delay to submit additional documents for
the appeals record. If an expedited appeal is denied, the
appeals entity shall notify the appellant within two
three days by telephone or through other
commonly available secure electronic means, to be
followed in writing, by a notice in writing,
within five working days. of the denial of an expedited appeal.
If an expedited appeal is denied, the appeal shall be handled
through the standard appeal process.
(b) Appeal requests may be submitted to the appeals entity by
telephone, by mail, in person, through the Internet, through other
commonly available electronic means, or by facsimile.
(c) The staff of the Exchange, the county, or MRMIB
the State Department of Health Care Services or its
designee shall assist the applicant or enrollee in making the
appeal request.
(d) (1) Upon receipt of an appeal, the appeals entity shall send
timely acknowledgment to the appellant that the appeal has been
received. The acknowledgment shall include information relating to
the appellant's eligibility for benefits while the appeal is pending,
an explanation that advance payments of the premium tax credit while
the appeal is pending are may be
subject to reconciliation, reconciliation if
the appeal is unsuccessful, an explanation that the appellant
may participate in informal resolution pursuant to subdivision (g),
and information regarding how to initiate informal
resolution. resolution, and an explanation
that the appellant shall have the opportunity to review his or her
entire eligibility file, including information on how an income
determination was made and all papers, requests, documents, and
relevant information in the possession of the entity that made the
decision that is the subject of the appeal at any time from the date
on which an appeal request is filed t o the date on which
the appeal decision is issued.
(2) Upon receipt of an appeal request, the appeals entity shall
send, via secure electronic interface, means,
timely notice of the appeal to the Exchange and the county
and, if related to the Access for Infants and Mothers or the
Healthy Families Program, MRMIB. , and the State
Department of Health Care Services or its designee if applicable.
(3) Upon receipt of the notice of appeal from the appeals entity,
the entity that made the determination of eligibility or enrollment
being appealed shall transmit, either as a hardcopy or
electronically, the appellant's eligibility and enrollment records
for use in the adjudication of the appeal to the appeals entity.
(e) A member of the board, employee of the Exchange, a county,
MRMIB, the State Department of Health Care
Services or its designee, or the appeals entity shall not limit
or interfere with an applicant applicant's
or enrollee's right to make an appeal or attempt to direct the
individual's decisions regarding the appeal.
(f) An applicant or enrollee may be represented by counsel or
designate an authorized representative to act on his or her behalf,
including, but not limited to, when making an appeal request and
participating in the informal resolution process provided in
subdivision (g).
(g) An applicant or enrollee who files an appeal shall have the
opportunity for informal resolution, prior to a hearing, that
conforms with all of the following:
(1) A representative of the Exchange, the county, or
MRMIB entity that made the eligibility or enrollment
determination shall contact the appellant or the appellant'
s appropriately authorized representative and offer to discuss
the determination with the appellant if he or she agrees.
(2) The appellant's right to a hearing shall be preserved if the
appellant is dissatisfied with the outcome of the informal resolution
process. The appellant or the authorized representative may withdraw
the hearing request voluntarily or may agree to a conditional
withdrawal that shall list the agreed-upon conditions that the
appellant and the Exchange, county, or MRMIB
the State Department of Health Care Services or its designee
shall meet.
(3) If the appeal advances to a hearing, the appellant shall not
be required to provide duplicative information or documentation that
he or she previously provided during the application,
redetermination, enrollment, or informal resolution
processes.
(4) The informal resolution process shall not delay the timeline
for a provision of a hearing.
(5) The informal resolution process is voluntary and neither an
appellant's participation nor nonparticipation in the informal
resolution process shall affect the right to a hearing under this
section.
(6) For eligibility or enrollment determinations for insurance
affordability programs based on modified adjusted gross income
(MAGI), the appellant or the appellant's appropriately
authorized representative may initiate the informal resolution
process with the entity that made the determination, except that all
of the following shall apply:
(A) The Exchange shall conduct informal resolution involving
issues related only to the Exchange, including, but not limited to,
exemption from the individual responsibility penalty pursuant to
Section 1311(d)(4)(H) of the federal act, offers of affordable
employer coverage, special enrollment periods, and eligibility for
affordable plan options.
(B) Counties shall conduct informal resolution involving issues
related to non-MAGI Medi-Cal. Medi-Cal
eligibility or enrollment decisions.
(C) MRMIB shall conduct informal resolution involving issues
related only to the Access for Infants and Mothers Program or the
Healthy Families Program.
(C) The State Department of Health Care Services or its designee
shall conduct informal resolution involving issues related to the
Medi-Cal Access Program.
(7) The staff involved in the informal resolution process shall
try to resolve the issue through a review of case documents, in
person or through electronic means as desired by the appellant, and
shall give the appellant the opportunity to review case documents,
verify the accuracy of submitted documents, and submit updated
information or provide further explanation of previously submitted
documents.
(8) The informal resolution process set forth by the State
Department of Social Services' Manual of Policies and
Procedures Section 22-073 Services for Medi-Cal fair
hearings shall be used for the informal resolutions pursuant to
this subdivision. subdivision and shall
require the Exchange, county representative, or the State Department
of Health Care Services or its designee to do the
following:
(A) Review the file to determine the appropriateness of the action
and whether a hearing is needed.
(B) Attempt to resolve the matter if the action was incorrect.
(C) Determine whether a dual agency appeal is required to resolve
the matter at hearing and notice the other agency if not already
included.
(D) Determine whether interpretation services are necessary and
arrange for those services accordingly.
(E) Inform appellants of other agencies that may also be available
to resolve the controversy.
(h) (1) A position statement, as required by Section 10952.5 of
the Welfare and Institutions Code, shall be electronically
made available at least two working days before
the hearing on the appeal. The position statement shall be made
available electronically by the entity that determined eligibility if
the entity has the capacity to send information
electronically in a secure manner.
(2) The appeals entity shall send written notice, electronically
or in hard copy, to the appellant of the date, time, and location of
the hearing no later than 15 days prior to the date of the hearing.
If the date, time, and location of the hearing are prohibitive of
participation by the appellant, the appeals entity shall make
reasonable efforts to set a reasonable, mutually convenient date,
time, and location. The notice shall explain what format the
hearing shall be held in, via telephone or video conference or in
person, and include the right of the appellant to request that
the hearing be held via telephone or video conference and
or in person. The notice shall
include instructions for submitting the request on the notice, by
telephone or through other commonly available electronic means.
(3) The format of the hearing shall be in person,
hearing format may be held via telephone or video
conference, unless the appellant requests the hearing be held
telephonically or via video conference in
person pursuant to paragraph (2).
(4) The hearing shall be an evidentiary hearing where the
appellant may present evidence, bring witnesses, establish all
relevant facts and circumstances, and question or refute any
testimony or evidence, including, but not limited to, the opportunity
to confront and cross-examine adverse witnesses, if any.
(5) The hearing shall be conducted by one or more impartial
officials who have not been directly involved in the eligibility or
enrollment determination or any prior appeal decision in the same
matter.
(6) The appellant shall have the opportunity to review his or her
appeal record, case file, and all documents to be used by the appeals
entity at the hearing, at a reasonable time before the date of the
hearing as well as during the hearing.
(7) Cases and evidence shall be reviewed de novo by the appeals
entity.
(i) Decisions shall be made within 90 days from the date the
appeal is filed and shall be based exclusively on the application of
the applicable laws and eligibility and enrollment rules to the
information used to make the eligibility or enrollment decision, as
well as any other information provided by the appellant during the
course of the appeal. The content of the decision of appeal shall
include a decision with a plain language description of the effect of
the decision on the appellant's eligibility or enrollment, a summary
of the facts relevant to the appeal, an identification of the legal
basis for the decision, and the effective date of the decision, which
may be retroactive. retroactive at the
election of the appellant if the appellant is otherwise eligible.
(j) Upon adjudication of the appeal, the appeals entity shall
transmit the decision of appeal to the entity that made the
eligibility or enrollment determination via a secure electronic
interface. means.
(k) If an appellant disagrees with the decision of the appeals
entity, he or she may make an appeal request regarding
issues relating to coverage in a qualified health plan
through the Exchange to the federal Department
Health and Human Services Agency within 30 days of
the notice of decision through any of the methods in subdivision
(b).
(l) An appellant may also seek judicial review to the extent
provided by law. Appeal to the federal Department of Health and Human
Services is not a prerequisite for seeking judicial review.
review, nor shall seeking an appeal to the federal
Department of Health and Human Services preclude a judicial review.
(m) Nothing in this section, or in Sections 100506.1 and 100506.2,
shall limit or reduce an appellant's rights to notice, hearing, and
appeal under Medi-Cal, county indigent programs, or any other public
programs.
SEC. 6. Section 100506.5 is added to the Government Code, to read:
100506.5. For appeals of redetermination of Exchange advance
premium tax credits or cost-sharing reductions, upon receipt of
notice from the appeals entity that it has received an appeal, the
entity that made the redetermination shall continue to consider the
applicant or enrollee eligible for the same level of advance premium
tax credits or costing-sharing cost-sharing
reductions while the appeal is pending in accordance with the
level of eligibility immediately before the redetermination being
appealed.
SEC. 7. Section 10950 of the Welfare
and Institutions Code is amended to read:
10950. (a) If any applicant for or
recipient of public social services is dissatisfied with any action
of the county department relating to his or her application for or
receipt of public social services, if his or her application is not
acted upon with reasonable promptness, or if any person who desires
to apply for public social services is refused the opportunity to
submit a signed application therefor, and is dissatisfied with that
refusal, he or she shall, in person or through an authorized
representative, without the necessity of filing a claim with the
board of supervisors, upon filing a request with the State Department
of Social Services or the State Department of Health Care
Services, whichever department administers the public social
service, be accorded an opportunity for a state hearing.
(b) (1) The requirements of Sections 100506.2, 100506.3, 100506.4
of the Government Code apply to state hearings regarding eligibility
for or enrollment in an insurance affordability program administered
by the State Department of Health Care Services to the extent that
those sections conflict with the state hearing requirements under
this chapter.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this subdivision by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, in accordance
with the requirements of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code.
Notwithstanding Section 10231.5 of the Government Code, beginning
July 1, 2015, the department shall provide a semiannual status report
to the Legislature, in compliance with Section 9795 of the
Government Code, until regulations have been adopted.
Priority
(c) Priority in setting and
deciding cases shall be given in those cases in which aid is not
being provided pending the outcome of the hearing. This priority
shall not be construed to permit or excuse the failure to render
decisions within the time allowed under federal and state law.
Notwithstanding
(d) Notwithstanding any other
provision of this code, there is no right to a state hearing when
either (1) state or federal law requires automatic grant adjustments
for classes of recipients unless the reason for an individual request
is incorrect grant computation, or (2) the sole issue is a federal
or state law requiring an automatic change in services or medical
assistance which adversely affects some or all recipients.
For
(e) For the purposes of
administering health care services and medical assistance, the
State Director of Health Care Services
shall have those powers and duties conferred on the Director of
Social Services by this chapter to conduct state hearings in order to
secure approval of a state plan under applicable federal law.
The State
(f) The Director of Health
Care Services may contract with the State Department of Social
Services for the provisions of state hearings in accordance with this
chapter.
As
(g) As used in this chapter,
"recipient" means an applicant for or recipient of public social
services except aid exclusively financed by county funds or aid under
Article 1 (commencing with Section 12000) to Article 6 (commencing
with Section 12250), inclusive, of Chapter 3 of Part 3, and under
Article 8 (commencing with Section 12350) of Chapter 3 of Part 3, or
those activities conducted under Chapter 6 (commencing with Section
18350) of Part 6, and shall include any individual who is an approved
adoptive parent, as described in subdivision (C) of Section 8708 of
the Family Code, and who alleges that he or she has been denied or
has experienced delay in the placement of a child for adoption solely
because he or she lives outside the jurisdiction of the department.
SEC. 8. Section 10951 of the Welfare
and Institutions Code is amended to read:
10951. (a) No A person
shall be is not entitled to a hearing pursuant
to this chapter unless he or she files his or her request for the
same within 90 days after the order or action complained of.
(b) (1) Notwithstanding subdivision (a), a person shall be
entitled to a hearing pursuant to this chapter if he or she files the
request more than 90 days after the order or action complained of
and there is good cause for filing the request beyond the 90-day
period. The director may determine whether good cause exists.
(2) For purposes of this subdivision "good cause" means a
substantial and compelling reason beyond the party's control,
considering the length of the delay, the diligence of the party
making the request, and the potential prejudice to the other party.
The inability of a person to understand an adequate and language
compliant notice, in and of itself, shall not constitute good cause.
In no event shall the The department
shall not grant a request for a hearing where
for good cause if the request is filed more than
180 days after the order or action complained of.
(3) Nothing in this This section
shall not preclude the application of the principles of
equity jurisdiction as otherwise provided by law.
(c) Notwithstanding the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code), the department shall implement this section
through an all-county information notice no later than January 1,
2008. The department may also provide further instructions through
training notes.
SEC. 9. Section 10960 of the Welfare
and Institutions Code is amended to read:
10960. (a) Within 30 days after receiving the decision of the
director, which is the proposed decision of an administrative law
judge adopted by the director as final, a final decision rendered by
an administrative law judge, or a decision issued by the director
himself or herself, the affected county or applicant or recipient may
file a request with the director for a rehearing. The director shall
immediately serve a copy of the request on the other party to the
hearing and that other party may within five days of the service file
with the director a written statement supporting or objecting to the
request. The director shall grant or deny the request no later than
the 35th working day after the request is made to ensure the prompt
and efficient administration of the hearing
process. If the director grants the request,
the rehearing shall be conducted in the same manner and subject to
the same time limits as the original hearing.
(b) The grounds for requesting a rehearing are as follows:
(1) The adopted decision is inconsistent with the law.
(2) The adopted decision is not supported by the evidence in the
record.
(3) The adopted decision is not supported by the findings.
(4) The adopted decision does not address all of the claims or
issues raised by the parties.
(5) The adopted decision does not address all of the claims or
issues supported by the record or evidence.
(6) The adopted decision does not set forth sufficient information
to determine the basis for its legal conclusion.
(7) Newly discovered evidence, that was not in custody or
available to the party requesting rehearing at the time of the
hearing, is now available and the new evidence, had it been
introduced, could have changed the hearing decision.
(8) For any other reason necessary to prevent the abuse of
discretion or an error of law, or for any other reason consistent
with Section 1094.5 of the Code of Civil Procedure.
(c) The notice granting or denying the rehearing request shall
explain the reasons and legal basis for granting or denying the
request for rehearing.
(d) The decision of the director, which is the proposed decision
of an administrative law judge adopted by the director as final, a
final decision rendered by an administrative law judge, or a decision
issued by the director himself or herself, remains final pending a
request for a rehearing. Only after a rehearing is granted is the
decision no longer the final decision in the case.
(e) Notwithstanding any other provision of law, a rehearing
request or decision shall not be a prerequisite to filing an action
under Section 10962.
(f) (1) Notwithstanding subdivision (a), an applicant or recipient
otherwise may be entitled to a rehearing pursuant to this chapter if
he or she files a request more than 30 days after the decision of
the director is issued, or if he or she did not receive a copy of the
decision of the director, or if there is good cause for filing
beyond the 30-day period. The director may determine whether good
cause exists.
(2) For purposes of this subdivision, "good cause" means a
substantial and compelling reason beyond the party's control,
considering the length of the delay, the diligence of the party
making the request, and the potential prejudice to the other party.
The inability of a person to understand an adequate and
language-compliant notice, in and of itself, shall not constitute
good cause. The department shall not grant a request for a
hearing rehearing for good cause if the request
is filed more than 180 days after the order or action complained of.
(3) This section shall not preclude the application of the
principles of equity jurisdiction as otherwise provided by law.
(g) Notwithstanding the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code), the department shall implement this section
through an all-county information notice no later than January 1,
2008. The department may also provide further instructions through
training notes.