BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 720
AUTHOR: Skinner
AMENDED: May 24, 2013
HEARING DATE: June 19, 2013
CONSULTANT: Bain
SUBJECT : Inmates: health care enrollment.
SUMMARY : Requires each county to designate an individual or
agency to complete and submit an application for a health
insurance affordability program application for individuals
detained in county jail for at least 72 hours who appear
potentially eligible for Medi-Cal, the Healthy Families Program,
or federally subsidized coverage in the California Health
Benefit Exchange. Prohibits detained individuals who are
currently enrolled in the Medi-Cal program from being terminated
from Medi-Cal coverage due to their detention unless required by
federal law, or they become ineligible.
Existing law:
1.Establishes the Medi-Cal program, administered by Department
of Health Care Services (DHCS), which provides comprehensive
health benefits to various low-income individuals.
2.Requires, under the federal Patient Protection and Affordable
Care Act (ACA), (Public Law 111-148), as amended by the Health
Care and Education Reconciliation Act of 2010 (Public Law
111-152), states to expand Medicaid coverage of adults under
age 65 who are not currently eligible with incomes up to 138
percent of the FPL (at or below $15,856 in 2013 for an
individual). Allows states, under the June 2012 Supreme Court
decision of National Federation of Independent Business v.
Sebelius, to opt-out of the Medicaid expansion required by the
ACA.
3.Makes inmates of public institutions (including individuals in
prison or county jails) ineligible for Medi-Cal.
4.Requires benefits provided under the Medi-Cal program to an
individual less than 21 years of age who is an inmate of a
public institution to be suspended on the date he or she
becomes an inmate of a public institution. The suspension ends
on the date the individual is no longer an inmate of a public
Continued---
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institution or one year from the date he or she becomes an
inmate of a public institution.
5.Authorizes the California Department of Corrections and
Rehabilitation (CDCR) and DHCS to develop a process to
maximize federal financial participation (FFP) through
Medicaid for the provision of inpatient hospital services
rendered to individuals who, but for their institutional
status as inmates, are otherwise eligible for Medi-Cal or for
the Low Income Health Program.
This bill:
1.Requires each county to designate an individual or agency to
complete and submit an application for a health insurance
affordability program application for inmates in county jail
meeting the criteria in 2) below consistent with federal
requirements. Requires the jail administrator, or his or her
designee, to coordinate with this individual or agency.
2.Requires the individual or agency to complete and submit an
application for a health insurance affordability program on
behalf of an inmate in a county jail at any time before
release if both of the following conditions are met:
a. The inmate has been in detention for at least
72 hours; and,
b. The inmate appears potentially eligible to be
enrolled in the health insurance affordability program
upon release.
3.Defines a "health insurance affordability program" as a
program that is one of the following:
a. The state's Medi-Cal program;
b. The state's children's health insurance
program (CHIP), which is known as the Healthy Families
Program in California; or,
c. A program that makes coverage in a qualified
health plan through the California Health Benefit
Exchange (Covered California) with federally
established advance payment premium tax credits or
cost-sharing reductions.
4.Prohibits, consistent with federal regulations, individuals
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who are currently enrolled in the Medi-Cal program from being
terminated from the Medi-Cal program due to their detention
unless required by federal law, or they become otherwise
ineligible.
5.Requires the state to establish a process to enable counties
to obtain the maximum available FFP for administrative
activities related to this bill.
6.Authorizes the individual or agency in 1) above to act on
behalf of an individual detained in county jail for purposes
of applying, or a determination of eligibility for, a health
insurance affordability program.
7.Permits DHCS to implement this bill by means of all-county
letters or similar instructions, without taking regulatory
action under the Administrative Procedure Act.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1.Significant state-reimbursable local administrative costs,
likely in excess of $4 million, assuming a 50/50 state/federal
share of costs. County jails statewide average about $86,000
per month ($1,032,000 per year). This figure includes bookings
that do not result in more than 72 hours of detention, as well
as multiple releases for the same person. If half of these
releases require a Medi-Cal eligibility determination and an
application, assuming about 30 minutes per inmate, at a cost
of about $30 per hour, the annual cost would be in the range
of $8 million.
To the extent counties are able to access private funding, such
as a recent announcement that the California Endowment will be
awarding close to $20 million to groups assisting in the
implementation of the Affordable Care Act, state costs could
be considerably reduced.
2.To the extent this bill results in providing Medi-Cal services
to individuals who might otherwise not avail themselves of the
program, the cost in most cases will be fully paid by the
federal government for several years, assuming California
adopts Medi-Cal expansion to include childless adults at 138
percent of the federal poverty level, until the reimbursement
ratio settles at 90:10, federal: state.
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PRIOR VOTES :
Assembly Public Safety: 7- 0
Assembly Appropriations: 13- 4
Assembly Floor: 56- 19
COMMENTS :
1.Author's statement. AB 720 would require counties to enroll
eligible inmates into the Medi-Cal program before being
released. This would address one of the main barriers to
re-entry by helping formerly incarcerated inmates access
physical, mental health and substance abuse services. Research
shows that formerly incarcerated individuals who have access
to medical services upon release have reduced recidivism
rates, increasing the likelihood they will become productive
citizens. A 2009 CDCR report showed a 61 percent recidivism
reduction for female inmates who underwent substance abuse
treatment and a 29 percent reduction for male inmates who
underwent such treatment.
2.Medi-Cal expansion under federal health care reform. On March
23, 2010, President Obama signed the ACA into law (Public Law
111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152). The ACA
greatly expands health insurance coverage in California.
Beginning in 2014, millions of low- and middle-income
Californians will gain access to coverage under the expansion
of Medi-Cal through easier enrollment requirements established
for Medi-Cal, and through premium tax credits and cost-sharing
subsidies offered through Covered California. As a result of
the coverage expansions under the ACA, between 89 and 91
percent of non-elderly Californians are predicted to have
health coverage under the ACA, and the number of uninsured is
projected to decrease by between 1.8 and 2.7 million by 2019.
Prior to the enactment of the ACA, adults were generally not
eligible for Medi-Cal coverage unless they were low income and
met categorical eligibility requirements, such as having minor
children living at home, having a disability, being over the
age of 65, or being pregnant. The Medicaid expansion's largest
enrollment impact will be from the expansion to non-disabled
childless adults with incomes at or below 138 percent of the
FPL (for a single adult, 138 percent of the FPL is $1,321 per
month or $15,856 per year in 2013). Among other provisions, AB
X1 1 (John A. P�rez) would implement the Medicaid expansion in
California, and SB X1 1 (Hernandez and Steinberg) would
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establish the benefit package for the expansion population and
augment the benefit package for the current population.
3.Federal guidance to suspend but not terminate Medi-Cal
eligibility. This bill prohibits, individuals who are
currently enrolled in the Medi-Cal program from being
terminated from coverage unless required by federal law, or
they otherwise become ineligible.
Federal guidance indicates that, while states cannot claim
Medicaid funding for services furnished to people who are
incarcerated or served in an Institute for Mental Disease
(IMD), it is not a federal requirement that Medicaid
eligibility be terminated while individuals are in jail or a
mental health facility. Instead, a state may place the person
in suspended status and return the individual to active
Medicaid eligibility upon release from jail (including release
to parole or probation) or discharge from the mental health
facility. In 2004, CMS issued a State Medicaid Director Letter
to clarify federal policy in this arena In this letter, CMS
points out that incarceration or institutionalization:
"? does not affect the eligibility of an individual for the
Medicaid program. Individuals who meet the requirements for
eligibility for Medicaid may be enrolled in the program
before, during, and after the time in which they are held
involuntarily in secure custody of a public institution or
as a resident of an IMD."
Instead of terminating Medicaid eligibility, CMS urged
states to:
"? establish a process under which an eligible inmate or
[IMD] resident is placed
in a suspended status so that the state does not claim FFP
for services the individual receives, but the person
remains on the state's rolls as being eligible for Medicaid
(assuming the person continues to meet all applicable
eligibility requirements). Once discharge from the facility
is anticipated, the state should take whatever steps are
necessary to ensure that an eligible individual is placed
in payment status so that he or she can begin receiving
Medicaid-covered services immediately upon leaving the
facility."
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4.Double referral. This bill is double referred. Should it pass
out of this committee, it will be referred to the Senate
Committee on Public Safety.
5.Previous legislation.
SB 695 (Hancock), Chapter 847, Statutes of 2011, permits
Medi-Cal benefits to be provided to an individual awaiting
adjudication in a county juvenile detention facility if the
individual is eligible for Medi-Cal at admission or is
subsequently determined to be eligible to receive Medi-Cal
benefits, the county agrees to pay the state's share of
Medi-Cal expenditures and administrative costs, and FFP is
available.
SB 1091 (Hancock) of 2010 was similar to SB 695 (Hancock). SB
1091 was vetoed by Governor Schwarzenegger. In his veto
message, the Governor stated this bill was inconsistent with
federal law and exposed the state to potentially significant
costs. The Governor concluded his veto message by stating
that if the author wishes to craft workable legislation that
allows for additional federal funds, but also adheres to
federal Medicaid law and regulations, DHCS would be willing to
assist in that effort next year.
SB 1147 (Calderon), Chapter 546, Statutes of 2007 required, to
the extent permitted under federal law, Medi-Cal benefits
provided to an individual under 21 years of age who is an
inmate of a public institution to be suspended, rather than
terminated.
6.Support. This bill is sponsored by Californians for Safety and
Justice (CSJ) and is designed to take advantage of newly
available Medicaid funds under the ACA, to improve reentry for
thousands of Californians being released from county jails, to
address key drivers of crime, reduce justice system costs and
make communities safer. CSJ argues the first component of this
bill (requiring counties to complete and submit an application
for coverage) is to address individuals being released from
county jails who are uninsured and potentially eligible for
coverage, many of whom have chronic conditions and a higher
prevalence of mental health and substance abuse disorders. The
second portion of the bill (requiring Medi-Cal eligibility be
suspended but not terminated) is to allow for continuity of
care for individuals, to ensure individuals have are covered
upon release, and to provide federal Medicaid matching funds
when incarcerated individuals receive inpatient services from
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a facility outside the jail.
7.Oppose unless amended. The California State Sheriffs
Association (CSSA) writes opposing this bill unless it is
amended, arguing the requirement that counties submit and
complete an application on behalf of an inmate in county jail
who has been held for at least 72 hours and appears
potentially eligible would inadvertently require enrollment
for all inmates held for 72 hours, even those who are
statutorily ineligible to apply, and would go beyond assisting
applicants by authorizing the county to act on the detained
individual's behalf. CSSA argues this bill makes it almost a
certainty that the sheriffs will be burdened with paperwork
requirements needed for the application, and sheriffs will
have to make significant housing/program changes in order to
allow for enrollment take place in county jails prior to
release. CSSA concludes that it does not believe enrolling
people prior to discharge is feasible.
8.Policy issues.
a. Should state law designate which county entity should
complete and submit inmates' applications? This bill requires
each county to designate an individual or agency to complete
and submit an application for a health insurance
affordability program application for inmates in county jail,
and requires the jail administrator (or his or her designee)
to coordinate with this individual or agency. However, this
bill does not specify which individual or entity would make
this designation (for example, the county board of
supervisors, the sheriff or the county department of human
services). The intent of the language in this measure is to
provide counties with the maximum flexibility to determine
the best agency to receive the application and the timing of
the enrollment process.
b. Role of county and the role of the inmate in the
application process. This bill requires the
county-designated individual or agency to complete and
submit an application for a health insurance
affordability program on behalf of an inmate in a county
jail at any time before release if the inmate has been in
detention for at least 72 hours, and the inmate appears
potentially eligible to be enrolled in the health
insurance affordability program upon release. This bill
authorizes the county-designed individual or agency to
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act on behalf of an individual detained in county jail
for purposes of applying, or an eligibility determination
for, health insurance affordability program. Since the
inmate does not appear to be required to be informed or
consent to having an application or submitted on his or
her behalf, this may result in individuals who already
have coverage having applications submitted on their
behalf. One way to address this issue is to require the
inmate be asked whether he or she has health insurance
coverage.
9.Clarifying amendment. This bill prohibits individuals Medi-Cal
eligibility be suspended rather than terminated due to their
detention unless required by federal law, or they become
otherwise ineligible. While this bill deals with county jails,
this provision uses the phrase "detention" and does not
specify that it applies only to county jails (and not state
prisons). The author may wish to clarify the types of
institutions where Medi-Cal individuals would be detained for
purposes of the requirement in this bill that Medi-Cal
eligibility be suspended but not terminated.
SUPPORT AND OPPOSITION :
Support: Californians for Safety and Justice (sponsor)
Latino Coalition for a Healthy California
Western Center on Law and Poverty
Support: Berkeley Organizing Congregations for Action
(prior version)California Attorneys for Criminal Justice
California Pan-Ethnic Health Network
California Public Defenders Association
California State Association of Counties
City and County of San Francisco Office of the Sheriff
Contra Costa County Probation Department
County Alcohol and Drug Program Administrators
Association of California California Nurses
Association
Drug Policy Alliance
Ella Baker Center for Human Rights
Friends Outside
Greenlining Institute
Housing California
Lassen County
Legal Services for Prisoners with Children
Sacramento County Board of Supervisors
Taxpayers for Improving Public Safety
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Urban Strategies Council
Women's Foundation of California
Oppose: California State Sheriffs Association (unless amended)
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