BILL ANALYSIS Ó
AB 1124
Page 1
Date of Hearing: April 16, 2013
ASSEMBLY COMMITTEE ON VETERANS AFFAIRS
Al Muratsuchi, Chair
AB 1124 (Muratsuchi) - As Introduced: February 22, 2013
SUBJECT : Medi-Cal: Public Assistance Reporting Information
System
SUMMARY : Requires the Department of Health Care Services (DHCS)
to utilize the federal Public Assistance and Reporting
Information System (PARIS) to identify veterans and their
dependents or survivors who are enrolled in the Medi-Cal program
and assist them in obtaining federal veterans' health care
benefits statewide instead of as a two-year pilot program in
three counties. Specifically, this bill :
1)Requires DHCS to exchange information with PARIS and identify
veterans and their dependents or survivors who are receiving
Medi-Cal benefits.
2)Requires DHCS to refer identified Medi-Cal beneficiaries who
are receiving high-cost services, including long-term care
(LTC), to county veteran service officers (CVSOs) to obtain
information regarding, and assistance in obtaining, United
States Department of Veteran's Affairs (USDVA) benefits.
3)Requires DHCS to enter into an agreement with the California
Department of Veterans Affairs (CDVA) to perform CVSO outreach
services in connection with the pilot program and requires the
agreement to contain performance standards that would allow
DHCS to measure the effectiveness of the pilot program.
4)Requires DHCS to enter into any agreements that are required
by the federal government to utilize the PARIS system.
5)Requires DHCS to perform any information technology activities
that are necessary to utilize the PARIS system.
6)Authorizes DHCS to implement this bill by means of written
directives without taking further regulatory action and
provides for an expedited contracting process.
7)Repeals provisions relating to a two-year, three county pilot
project including the requirement to monitor and evaluate for
AB 1124
Page 2
outcome and savings.
8)Includes a blank appropriation from the General Fund (GF) to
CDVA to provide funding for CVSOs to identify veterans and
their dependents or survivors who are enrolled in the Medi-Cal
program and to assist them in obtaining federal veteran health
care benefits.
EXISTING LAW :
1)Establishes the federal Medicaid Program, Medi-Cal in
California, administered by DHCS, to provide comprehensive
health care services and LTC to pregnant women, children, and
people who are aged, blind, and disabled.
2)Establishes, under federal law and regulation the PARIS data
matching system to match public assistance recipients in
participating states against various state and federal public
assistance database.
3)Requires DHCS to implement by July 1, 2009 and to administer a
two-year, three-county pilot program to utilize the federal
PARIS to identify veterans and their dependents or survivors
who are enrolled in the Medi-Cal program and assist them in
obtaining federal veterans' health care benefits and
authorizes DHCS to implement the pilot project statewide if it
determines that the pilot is cost effective and continue
operation of PARIS indefinitely.
4)Establishes CDVA to aid and assist California veterans and
their families and to administer the California Veterans
Homes.
5)Establishes, under federal law, the USDVA, and within it, the
Veterans Health Administration (VA), which is responsible for
VA medical centers and outpatient clinics.
FISCAL EFFECT : Unknown at this time.
COMMENTS :
1)An analysis by the Legislative Analyst's Office (LAO) in 2007
that stated that implementing PARIS could save the state
millions of dollars annually in General Fund costs by shifting
eligible veterans enrolled in Medi-Cal who might be eligible
AB 1124
Page 3
for the USDVA health care system. According to the LAO
Report, 144,000 veterans and dependents on Medi-Cal coverage
could be eligible for comprehensive medical care and health
services through the USDVA health care system.
2)Under federal law, the Medicaid Program is intended to be the
payer of last resort, meaning that all other available sources
for a beneficiary's provision of care, such as private
insurance or other federal programs (such as the VA), must be
exhausted before Medi-Cal can provide services. Although
county welfare workers are supposed to screen for veterans
when processing Medi-Cal applications, a 2005 survey performed
by the US Census Bureau indicates that approximately 144,000
veterans in California received Medi-Cal benefits. The LAO
estimated the cost of such benefits totals approximately $500
million ($250 million General Fund). The LAO further assumed
that because approximately 90,000 of the 144,000 veterans
served in World War II, the Korean War, and the Vietnam War,
they likely fall into the aged and disabled category of
beneficiaries. The costs to treat the aged and disabled are
generally higher than costs to treat other groups of
beneficiaries, such as children. The LAO concluded that if
some portion of these veterans received medical services
through the VA, the state could potentially save many tens of
millions of dollars.
3)Participation in the VA health care system provides veterans
with access to a wide range of coordinated health care
services. Once enrolled in the VA healthcare system, veterans
may also have greater access to some medical benefits, such as
mental health counseling and treatment for alcohol and
substance abuse, than they would have under Medi-Cal. For
example, the VA does not place a cap on the cost of dental
services or limit the number of days a patient can be
hospitalized for inpatient stays on a yearly basis. Unlike
Medi-Cal, the VA system does not require that a beneficiary
pay down his or her assets until they become "medically needy"
before covering the costs of LTC. The VA also has no
requirement for repayment of LTC services as in the Medi-Cal
Program.
4)As part of the regular Medi-Cal eligibility screening process,
workers in county welfare offices are required to ask
applicants whether they have served in the armed forces and
have veteran's status. If a county eligibility worker
AB 1124
Page 4
determines that an applicant is a veteran, the eligibility
worker has the applicant fill out a form, which is then
forwarded to a County Veteran Service Officer (CVSO) where a
case worker will contact the VA to determine the benefits to
which the applicant is entitled. The referral process is
intended to ensure that all possible outside sources of income
are obtained and available to help reduce costs to the
Medi-Cal Program. Medi-Cal currently reimburses the CVSOs
approximately $800,000 annually for these activities.
5)In May 2008, in response to the LAO recommendation, DHCS
proposed a two-year pilot program to use PARIS match results
to identify veteran Medi-Cal beneficiaries receiving high-cost
services in three pilot counties and refer them to the CVSOs.
DHCS proposed to use criteria to identify Medi-Cal
beneficiaries who are receiving high-cost disability or LTC
services in excess of $2,000 per month or other appropriate
dollar threshold. According to DHCS, veterans with a
service-connected disability may be eligible for full USDVA
coverage and could elect to receive USDVA care in lieu of
Medi-Cal. DHCS determined that it would not be effective to
designate a high priority on referral of individuals that are
only eligible for increased USDVA income benefits. DHCS
proposed instead, to focus the pilot program on enrolling
high-cost LTC or disabled Medi-Cal beneficiaries in the fully
federally funded USDVA system of healthcare. DHCS proposed to
seek the highest yield from its investment in CVSO outreach
efforts through targeting of these high cost beneficiaries.
6)The PARIS-Veterans pilot project was implemented on July 1,
2009. DHCS entered into a memorandum of understanding with
the CDVA to operate the PARIS-Veterans pilot program.
7)During the two-year reporting period for the pilot, DHCS
identified 16,387 veterans who were also enrolled in Medi-Cal.
Of the positive data matches, DHCS focused on those
beneficiaries who may have had high Medi-Cal expenditures
(based on several criteria, including those with a
service-connected disability), those who could have veteran
benefits restored, and survivors who appeared eligible for the
Civilian Health and Medical Program of USDVA. This resulted in
3,933 referrals to CVSOs resulting in approximately 990
contacts, reaching 158 high-cost beneficiaries with both
Medi-Cal and USDVA health benefits coverage. Of the 158
beneficiaries, 117 came from San Bernardino, 24 from San
AB 1124
Page 5
Diego, 10 from Fresno, 5 from Sacramento, and 0 from the other
6 counties. Of the 158 individuals, 24 discontinued their
Medi-Cal coverage and chose to continue health coverage
through USDVA.
8)Based on the overall analysis of the pilot, DHCS' report
states it was able to accurately identify veterans who were
Medi-Cal beneficiaries and achieved modest success in
redirecting utilization to USDVA health benefits. The report
states this redirection resulted in $1.634 million in total
cost avoidance and savings for the Medi-Cal program over the
two years of the pilot program. DHCS incurred costs of
$150,000, for a net cost avoidance/savings of $1.484 million.
9)In its recommendations, DHCS states the state can continue its
current path in redirecting limited resources to maintain the
level of effort put forth in the pilot. The state can also
consider directing more resources for the pilot, or consider
additional or alternative measures to increase utilization of
USDVA benefits. By implementing one or more of the following
recommendations, DHCS could achieve additional Medi-Cal cost
reductions:
a) Direct more dedicated resources to DHCS, CDVA, and CVSOs
to act upon referrals . For the pilot, DHCS temporarily
redirected analytical staff to complete PARIS assignments
on an as-needed basis. Limitations on project management
were a constraint that did not allow for maximum success.
Follow-up on the 832 cases identified in the pilot as being
enrolled in Medi-Cal and also identified as a veteran would
likely identify additional individuals who may choose to
shift from Medi-Cal to USDVA benefits. Going forward,
dedicated staff resources for DHCS and CDVA to operate
PARIS statewide could be considered. DHCS' existing
workload does not permit redirection of staff to fully
support the functions necessary to operate PARIS to its
fullest potential with the same being true for CDVA. As the
lead agency for PARIS, DHCS indicates it could explore the
possibility of partnering with other assistance programs,
such as county General Relief.
b) Initiate direct contact between DHCS and beneficiaries .
DHCS could consider increasing its presence in the veteran
benefit enhancement efforts. For example, DHCS could post
information on its website to educate veterans enrolled in
Medi-Cal that they may qualify for USDVA health benefits.
The website would take the value proposition directly to
AB 1124
Page 6
veterans and explain that using USDVA health benefits may
give them more benefits, save them money, improve their
care, protect their family's assets, and free up state
Medi-Cal benefits for needy non-veterans. DHCS is already
developing efforts to add information to their website. In
another direct approach, DHCS could send letters to
veterans and surviving veteran dependents receiving
Medi-Cal explaining USDVA health benefits and how to
enroll.
c) Assist CVSOs to educate veteran Medi-Cal beneficiaries
of the advantages of USDVA health benefits over Medi-Cal .
This education could include providing additional
opportunities of conveying this information as part of
other contacts with local veterans as well as looking at
opportunities for CDVA and CVSOs to include information on
health care options as part of informational materials that
may be provided to veterans.
10) DHCS also reviewed best practices from other states in its
report. One state of note was Pennsylvania, which participated
in PARIS since its inception. Pennsylvania estimated
annualized cost avoidance/savings of approximately $27.8
million from a period covering nine quarters. Pennsylvania
worked 40,769 cases, resulting in reducing 4,448 cases from
its Medicaid program.
PREVIOUS LEGISLATION .
1)AB 1223 (Committee on Veterans Affairs) of 2011 would have
required the DHCS to utilize the federal PARIS to identify
veterans and their dependents or survivors who are enrolled in
the Medi-Cal program and assist them in obtaining federal
veterans' health care benefits statewide instead of as a
two-year pilot program in three counties. Governor Brown
vetoed AB 1223 stating that while he supported efforts to
inform veterans about the health care options that best meet
their needs, current law already requires screening of
Medi-Cal beneficiaries for veteran status and allows for
expansion of the PARIS data match project beyond the current
pilot counties. Rather than requiring the PARIS pilot project
to be implemented statewide, more effort should go into
understanding which health care benefits work best for
veterans, and how that outreach can be most effective before
expending additional resources statewide.
AB 1124
Page 7
2)AB 1568 (Committee on Veterans Affairs) of 2009 would have
made PARIS pilot project a permanent, statewide program. AB
1568 was amended into a different subject matter.
3)AB 3082 (Committee on Veterans Affairs) of 2008 would have
required any state or public assistance agency using PARIS to
identify veterans enrolled in the Medi-Cal Program for the
purpose of assisting them in obtaining federal health care
benefits. Required CDVA to develop a plan for handling
data-match information given to a CVSO. AB 3082 died on the
Senate Appropriations Suspense File.
4)AB 1183 required DHCS to establish a two-year pilot program
for the use of PARIS by July 1, 2009, and to report to the
Legislature the effectiveness of the program and included
authority for DHCS to make PARIS a permanent program if the
program was deemed effective.
REGISTERED SUPPORT / OPPOSITION :
Support
American Legion, Department of California
AMVETS- Department of California
California Association of County Veterans Service Officers
California State Commanders Veterans Council
VFW- Department of California
Vietnam Veterans of America- California State Council
Opposition
None at this time.
Analysis Prepared by : John Spangler / V. A. / (916) 319-3550