BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 720| |Office of Senate Floor Analyses | | |1020 N Street, Suite 524 | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: AB 720 Author: Skinner (D), et al. Amended: 9/6/13 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. Deletes the age restriction CONTINUED AB 720 Page 2 relating to Medi-Cal benefits provided to inmates of the public institution. Senate Floor Amendments of 9/6/13 (1) incorporate technical changes suggested by the Department of Health Care Services (DHCS) concerning the process for Medi-Cal eligibility of acute inpatient treatment; (2) clarify that inmate status alone will not preclude a county human services agency from processing an inmate's Medi-Cal application; and (3) include a specific statutory reference in the provisions concerning suspension of Medi-Cal eligibility for jail inmates. 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 CONTINUED AB 720 Page 3 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, streamlined form that may be used to apply for all state health subsidy programs, as defined, within the state. This bill: 1.Expresses intent of the Legislature in enacting the provisions of this bill, among other things, to ensure that county human services agencies recognize the following: A. That federal law generally does not authorize FFP for Medi-Cal when a person is an inmate of a public institution, as defined in federal law, unless the inmate is admitted as an inpatient to a non-correctional health care facility; B. FFP is available after an inmate is released from a county jail, and C. The fact that an applicant is currently an inmate does not, in and of itself, preclude the county human services agency from processing the application submitted to it by, or on behalf of, that inmate. 1.Allows the board of supervisors in each county, in consultation with the county sheriff, to designate an entity or entities 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 CONTINUED AB 720 Page 4 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.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 his/her detention unless required by federal law, he/she becomes otherwise ineligible, or the inmate's suspension of benefits has ended, pursuant to existing law. 6.Notwithstanding any other state law, and only to the extent federal law allows and FFP is available, the designated entity is authorized to act on behalf of a county jail inmate for the purpose of applying for, or determinations of, Medi-Cal eligibility for acute inpatient hospital services authorized, pursuant to existing law. Prohibits a designated entity, as defined, from determining or redetermining Medi-Cal eligibility, unless the entity is the county human services agency. 7.Prohibits the fact that an applicant is an inmate from, in and of itself, precluding a county human services agency from processing an application for the Medi-Cal program submitted to it by, or on behalf of, that inmate. 8. 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 CONTINUED AB 720 Page 5 Covered California. 1. Permits DHCS to implement this bill by means of all-county letters or similar instructions, without taking regulatory 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 FFP is jeopardized by this bill and implement the provisions of this bill only if, and to the extent that, FFP 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 CONTINUED AB 720 Page 6 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. 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 CONTINUED AB 720 Page 7 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. 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 9/9/13) 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 CONTINUED AB 720 Page 8 Greenlining Institute Housing California Legal Services for Prisoners with Children 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. CONTINUED AB 720 Page 9 ASSEMBLY FLOOR : 56-19, 5/29/13 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 9/9/13 Senate Floor Analyses SUPPORT/OPPOSITION: SEE ABOVE **** END **** CONTINUED