BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    THIRD READING


          Bill No:  AB 720
          Author:   Skinner (D), et al.
          Amended:  9/3/13 in Senate
          Vote:     21

           
           SENATE HEALTH COMMITTEE  :  7-2, 6/19/13
          AYES:  Hernandez, Beall, De León, DeSaulnier, Monning, Pavley,  
            Wolk
          NOES:  Anderson, Nielsen

           SENATE PUBLIC SAFETY COMMITTEE  :  7-0, 7/2/13
          AYES:  Hancock, Anderson, Block, De León, Knight, Liu, Steinberg

           SENATE APPROPRIATIONS COMMITTEE  :  6-1, 8/30/13
          AYES:  De León, Gaines, Hill, Lara, Padilla, Steinberg
          NOES:  Walters

           ASSEMBLY FLOOR  :  56-19, 5/29/13 - See last page for vote


           SUBJECT  :    Inmates:  health care enrollment

           SOURCE  :     Californians for Safety and Justice


           DIGEST  :    This bill requires the board of supervisors in each  
          county to designate an entity to assist certain jail inmates to  
          apply for a health insurance affordability program, as defined.   
          Prohibits county jail inmates who are currently enrolled in the  
          Medi-Cal from being terminated from the program due to their  
          detention, unless required by federal law or they become  
          otherwise ineligible, as specified. Requires the Department of  
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          Health Care Services (DHCS) to establish, subject to federal  
          law, a process to enable counties to obtain federal financial  
          participation (FFP) for these provisions.

           ANALYSIS  :    

          Existing law:

          1.Establishes the Medi-Cal program, administered by DHCS, which  
            provides comprehensive health benefits to various low-income  
            individuals.

          2.Requires, under the federal Patient Protection and Affordable  
            Care Act (ACA), states to expand Medicaid coverage of adults  
            under age 65 who are not currently eligible with incomes up to  
            138% of the federal poverty level (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.  Prohibits  
            federal financial participation (FFP) for medical care  
            provided to inmates of a public institution, except when the  
            inmate is a patient in a medical institution.

          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/she becomes  
            an inmate of a public institution. The suspension ends on the  
            date the individual is no longer an inmate of a public  
            institution or one year from the date he/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 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.

          6.Requires the Secretary of Health and Human Services, under  
            federal law, to develop and provide to each state a single,  

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            streamlined form that may be used to apply for all state  
            health subsidy programs, as defined, within the state.

          This bill:

          1.Allows the board of supervisors in each county, in  
            consultation with the county sheriff, to designate an entity  
            to assist county jail inmates, as defined, with submitting an  
            application for a health insurance affordability program  
            consistent with federal requirements.

          2.Prohibits the board of supervisors from designating the county  
            sheriff as the entity to assist with submitting an application  
            for a health insurance affordability program for county jail  
            inmates, as defined, unless the county sheriff agrees to  
            perform this function.

          3.Requires, if the board of supervisors designates a  
            community-based organization as the entity to assist with  
            submitting an application for a health insurance affordability  
            program for county jail inmates, the designation to be subject  
            to approval by the jail administrator, or his/her designee.

          4.Permits the jail administrator, or his/her designee, to  
            coordinate with the designated entity.

          5.Allows the designated entity to assist a county jail inmate  
            with submitting an application for a health insurance  
            affordability program if all of the following conditions are  
            met:

             A.   The inmate has been in detention for at least 72 hours  
               following remand into custody by a court or magistrate.

             B.   The inmate appears potentially eligible to be enrolled  
               in the health insurance affordability program upon release.

             C.   The inmate does not currently have health care coverage.

          1.Specifies that county jail inmates who are currently enrolled  
            in the Medi-Cal program shall remain eligible for, and not be  
            terminated from the program due to their detention unless  
            required by federal law, or they become otherwise ineligible.


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          2.Notwithstanding any other provision of law, and only to the  
            extent that federal law allows, requires DHCS to establish a  
            process to enable counties to obtain the maximum available FFP  
            for services they provide related to this bill.

          3.Notwithstanding any other state law, and only to the extent  
            federal law allows, and for Medi-Cal program purposes, federal  
            financial participation is available, the designated entity is  
            authorized to act on behalf of a county jail inmate who meets  
            all specified conditions, for the limited purpose of applying  
            for or determining eligibility for a health insurance  
            affordability program, including, but not limited to, the  
            Medi-Cal program.  Prohibits the entity from determining or  
            redetermining Medi-Cal eligibility, unless the entity is the  
            county human services agency.  Provides that the fact that an  
            applicant is an inmate shall not preclude a county human  
            services agency from processing that application.

          4.Permits an involuntarily detained or incarcerated adult in a  
            county facility to refuse to authorize the designated entity  
            to apply for or determine eligibility for a health insurance  
            affordability program, in which case the entity is prohibited  
            from acting on that person's behalf.  Requires the person to  
            be informed of this right before the entity submits an  
            application on his/her behalf.

           5. Defines, for purposes of this bill, "health insurance  
             affordability program"  to mean a program that is one of the  
             following:

             A.   The state's Medi-Cal program.

             B.   The state's children's health insurance program.

             C.   A program that makes coverage in a qualified health plan  
               (QHP) through the California Health Benefit Exchange  
               (Covered California) with advance payment of the premium  
               tax credit, as defined.

             D.   A program that makes available coverage in a QHP through  
               Covered California.

           1. Permits DHCS to implement this bill by means of all-county  
             letters or similar instructions, without taking regulatory  

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             action.

           2. Deletes the age restriction relating to Medi-Cal benefits  
             provided to an inmate of a public institution.

           3. Requires DHCS to determine whether federal financial  
             participation is jeopardized by this bill and implement the  
             provisions of this bill only if, and to the extent that,  
             federal financial participation is not jeopardized.

           Background
           
           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. 

          According to the Senate Health Committee analysis, 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.

           Prior Legislation
           
          SB 695 (Hancock), Chapter 847, Statutes of 2011, permitted  
          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  

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          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.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  Yes

          According to the Senate Appropriations Committee, unknown  
          increase in Medi-Cal expenditures for former inmates,  
          potentially in the low hundreds of millions per year (General  
          Fund and federal funds). 

          By assisting inmates with the application process, the bill is  
          likely to increase enrollment in Medi-Cal, at least in the short  
          term. Because of the individual mandate to have health care  
          coverage in the Affordable Care Act and the general increase in  
          public awareness of new health care coverage options after 2014,  
          it is likely that many current jail inmates will apply for  
          coverage at some point after leaving jail. Under the bill, this  
          process will be accelerated and therefore the Medi-Cal program  
          is likely to incur costs to provide coverage sooner for eligible  
          former inmates.  For example, assuming that 25% of inmates who  
          are eligible for assistance under the bill are eligible for  
          Medi-Cal and that applying for coverage before release  
          accelerates the average inmate's enrollment in Medi-Cal by six  
          months, total additional Medi-Cal costs would be about $150  
          million per year. 

          In addition, under the bill, jail inmates who are enrolled in  
          Medi-Cal at the time of incarceration would be suspended from  
          the program, but would not be terminated from the program.  Upon  
          their release, Medi-Cal benefits would be immediately  
          reactivated. This provision will increase Medi-Cal enrollment,  
          because former inmates would not have to re-apply for Medi-Cal  
          upon their release.  If 10% of the jail population is enrolled  
          in Medi-Cal upon incarceration and is kept in the program due to  
          changes in the bill, the annual costs from the bill would likely  
          be in the low tens of millions per year.

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          Some inmates impacted by this bill would be eligible for the  
          current Medi-Cal program upon release, provided they are a  
          caretaker to a child and are eligible based on family income.   
          Other inmates may be eligible for expanded Medi-Cal (which  
          provides coverage for childless adults).  Individuals eligible  
          for traditional Medi-Cal would be funded 50% from the General  
          Fund and 50% from federal funds. For individuals who are  
          eligible for the Medi-Cal expansion, the federal government  
          would pay 100% of the costs initially, dropping to 90% of costs  
          by 2020. 

           SUPPORT  :   (Verified  9/3/13)

          Californians for Safety and Justice (source) 
          American Civil Liberties Union
          American Federation of State, County and Municipal Employees 
          Berkeley Organizing Congregations for Action
          Board of Supervisors County of Santa Clara
          California Association of Alcohol and Drug Program Executives 
          California Attorneys for Criminal Justice
          California Council of Community Mental Health Agencies 
          California Latinas for Reproductive Justice 
          California Nurses Association
          California Pan-Ethnic Health Network
          California Primary Care Association
          California Public Defenders Association
          California State Association of Counties
          California State Conference of the National Association for the  
          Advancement of Colored People
          California State Sheriffs' Association 
          Californians for Safety and Justice
          Chief Probation Officers of California
          Chief Probation Officers of Contra Costa County
          County Alcohol and Drug Program Administrators of California
          County of Lassen
          County of Sacramento
          County of San Diego
          Drug Policy Alliance
          Ella Baker Center for Human Rights
          Friends Outside
          Greenlining Institute
          Housing California
          Legal Services for Prisoners with Children

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          Local Health Plans of California
          Los Angeles Regional Reentry Partnership
          National Association of Social Workers - California Chapter
          National Council of La Raza
          Rural Counties Representatives of California
          San Francisco Sheriff
          Taxpayers for Improving Public Safety
          Urban Strategies Council
          Women's Foundation of California


           ARGUMENTS IN SUPPORT  :    According to the author's office, this  
          bill requires 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% recidivism reduction for female inmates who  
          underwent substance abuse treatment and a 29% reduction for male  
          inmates who underwent such treatment.
          
          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 a facility outside  
          the jail. 


           ASSEMBLY FLOOR  :  56-19, 5/29/13

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          AYES:  Achadjian, Alejo, Ammiano, Atkins, Bloom, Blumenfield,  
            Bocanegra, Bonilla, Bonta, Bradford, Brown, Buchanan, Ian  
            Calderon, Campos, Chau, Chesbro, Cooley, Daly, Dickinson,  
            Eggman, Fong, Fox, Frazier, Garcia, Gatto, Gomez, Gonzalez,  
            Gordon, Hall, Roger Hernández, Jones-Sawyer, Levine,  
            Lowenthal, Medina, Melendez, Mitchell, Mullin, Muratsuchi,  
            Nazarian, Nestande, Pan, Perea, V. Manuel Pérez, Quirk,  
            Quirk-Silva, Rendon, Skinner, Stone, Ting, Waldron, Weber,  
            Wieckowski, Wilk, Williams, Yamada, John A. Pérez
          NOES:  Allen, Bigelow, Chávez, Conway, Dahle, Donnelly, Beth  
            Gaines, Grove, Hagman, Harkey, Jones, Logue, Maienschein,  
            Mansoor, Morrell, Olsen, Patterson, Salas, Wagner
          NO VOTE RECORDED:  Gorell, Gray, Holden, Linder, Vacancy


          JL:MW:nl  9/3/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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