BILL ANALYSIS Ó
AB 1233
Page 1
Date of Hearing: April 16, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1233 (Chesbro) - As Introduced: February 22, 2013
SUBJECT : Medi-Cal: Administrative Claiming process.
SUMMARY : Authorizes federally-recognized American Indian tribes
and tribal organizations to use the California Healthcare
Eligibility, Enrollment, and Retention System (CalHEERS)
software to submit applications for Medi-Cal coverage and enroll
applicants in the Medi-Cal program as part of the Medi-Cal
Administrative Activities (MAA) claiming process.
EXISTING LAW :
1)Establishes, under state and federal law, the Medicaid program
(Medi-Cal in California) as a joint federal and state program
offering a variety of health and long-term services to
low-income women and children, low-income residents of
long-term care facilities, seniors, and people with
disabilities.
2)Establishes the MAA claiming process, which authorizes the
Department of Health Care Services (DHCS) to contract with a
local government agency (LGA), including a Native American
Indian tribe, a tribal organization, or subgroup of a Native
American Indian tribe or tribal organization under contract
with DHCS, or a local educational consortium (LEC) to assist
with the performance of MAAs.
3)Requires LGAs and LECs to cover the entire nonfederal share of
costs for performing Administrative Claiming process
activities and requires participating LGAs and LECs to pay a
participation fee to DHCS to cover the costs of administering
the Medi-Cal Administrative Claiming (MAC) process.
4)Requires, effective January 1, 2014, under federal law, an
individual to have the option to apply for state subsidy
programs, which includes the state Medicaid program, the state
Children's Health Insurance Program (CHIP), enrollment in a
qualified health plan through a state exchange and a Basic
Health Plan (BHP), if there is one, by either in person, mail,
online, telephone, or other commonly available electronic
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means.
5)Requires under state and federal law, effective January 1,
2014, the development of a single, accessible standardized
application for the state subsidy programs to be used by all
eligibility entities and establishes a process for developing
and testing the application.
6)Creates the California Health Benefits Exchange referred to as
Covered California, as an independent state entity governed by
a five-member board, to be a marketplace for Californians to
purchase affordable, quality health care coverage, claim
available tax credits and cost-sharing subsidies and one way
to meet the personal responsibility requirements of the
federal Affordable Care Act (ACA).
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author this bill is
needed to ensure American Indians who are eligible for
Medi-Cal and other services can receive the care they need.
This bill is also needed to strengthen the tribal health care
delivery system by providing the tribal entities access to the
100% federal financial participation (FFP) for providing
Medi-Cal covered services to American Indians eligible for
Medi-Cal. In addition, the author states that this bill is
needed to clarify that tribal entities can access CalHEERS to
submit applications for Medi-Cal coverage. The author cites
an April 2012 report, "Preserving Integrity in California's
Healthcare Eligibility, Enrollment and Retention System:
Policy Recommendations" by the Consumers Union and Center for
Democracy and Technology recommendation that "Assisters,
navigators, brokers and agents should access CalHEERS through
a unique login, rather than using the login of the individual
whom they are assisting." The author argues that as part of
operating the MAA programs and serving as assisters and other
navigational agents in the operation of CalHEERS, tribal
entities need access to this system to submit applications for
Medi-Cal coverage. Without passage of this bill, tribal
entities will not be specifically identified as having access
to CalHEERS and this could create barriers to patient care.
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The author also points out that currently, local governmental
agencies, including Federally-recognized tribes and tribal
organizations, and local educational consortiums are able to
participate in the MAA process in order to receive federal
financial participation for Medi-Cal administrative
activities. The author further states that as LGAs are able
to enroll Californians who are eligible for Medi-Cal into the
program, yet when the related authorizing provision was
developed, tribes and tribal organizations were overlooked and
left out of the provision. This was surprising, the author
asserts, especially since there was and continues to be no
cost to the State for tribal entities that provide MAA to
American Indians who are eligible for Medi-Cal services. In
addition, the tribal entities pay the State an administration
fee. This program is known as the Tribal MAA Program. The
author explains that the federal government has developed a
number of policies to promote the use of Medicaid by tribal
entities. As a result the federal government and the
tribal/federal partnership will each pay 50% of the costs
associated with tribal entities that enroll American Indians
who qualify for Medi-Cal into the program. The tribal/federal
partnership funds are derived from the federal government
through Indian Self Determination Act health care delivery
contracts.
2)BACKGROUND . According to data from 2005-07, supplied by the
author from the Indian Health Services (IHS), an agency of the
United States Department of Health and Human Services, Native
Americans suffer from significant health disparities,
including lower life expectancy, high rates of diabetes,
cardiovascular disease, pneumonia, mental health issues,
influenza, and injuries. They are more likely to die from
alcoholism (552% higher), diabetes (182% higher),
unintentional injuries (138% higher), and suicide (74% higher)
than other Americans. As a result of these substantial health
problems, the life expectancy for Native Americans is 74 years
of age, approximately four years less than the rest of the US
population. Diseases of the heart, malignant neoplasm,
unintentional injuries, and diabetes mellitus are the leading
causes of deaths. Native Americans have much lower rates of
employer coverage and higher rates of public coverage,
according to a January 2004 article in the American Journal of
Public Health, "Health Service Access, Use, and Insurance
Coverage Among American Indians/Alaska Natives and Whites:
What Role Does the Indian Health Service Play?" Stephen
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Zuckerman, PhD, Jennifer Haley, MA, Yvette Roubideaux, MD,
MPH, and Marsha Lillie-Blanton, DrPH. According to this
article 49% reported employer or other coverage, 16% reported
IHS coverage only and an additional 19% were uninsured. The
2004 article reported problematic gaps in Native American
access to health care and rates of service utilization,
especially for low-income Native Americans.
The 2010 US Census reports that a) there is a total population
of 689,320 Native Americans in California; b) the median
income of Native American households ($44,620) in the State is
substantially less than many other Californians; c) 22% of
Native Americans in California have an income below poverty
level; and, d) 26.7% of Native American children ages 0-17
live in poverty in the region.
According to the author, there are 30 Tribal Health Programs
(THPs) in California that provide diagnostic, treatment,
health maintenance and other services across 37 mostly rural
counties. All of the THPs provide federal IHS and 18 of them
also participate in the Tribal MAA Program. A number of the
THPs serve as the only health care safety net providers in
their regions.
3)ACA . The ACA increases access to health insurance beginning
in 2014 through a coordinated system of "insurance
affordability programs," including Medicaid, CHIP, Advance
Premium Tax Credits (APTCs) for coverage provided through new
Health Benefit Exchanges (Exchanges), and optional
state-established BHPS. It also provides for coordinated,
streamlined enrollment processes for these programs.
Beginning in 2014, the ACA expands Medicaid eligibility to a
new "adult group" and collapses most existing eligibility
categories into three broad groups: parents, pregnant women,
and children under age 19. The "adult group" includes all
non-pregnant individuals ages 19 to 65 with household incomes
at or below 133% of the federal poverty level (FPL). (The law
includes a five percentage point of FPL disregard making the
effective limit 138% FPL). The Supreme Court ruling, National
Federation of Independent Business v. Sebelius 132 S. Ct. 2566
(2012), on the ACA maintains the adult Medicaid expansion, but
limits the Secretary's authority to enforce it as mandatory on
the states, effectively making implementation of the expansion
a state choice. As required by the ACA Medicaid financial
eligibility for most groups will be based on modified adjusted
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gross income (MAGI), as defined in the Internal Revenue Code.
The rule generally adopts MAGI household income counting
methods, eliminating various income disregards currently used
by states. The Centers for Medicare and Medicaid Services
(CMS) guidelines also generally aligns "family size" in the
current Medicaid rules with the MAGI definition of "household"
and provides household composition rules for individuals, such
as non-tax filers, who are not addressed by MAGI methods.
Certain groups are exempt from use of MAGI; their financial
eligibility will continue to be determined using existing
Medicaid rules.
The Medicaid eligibility determination process will begin with a
MAGI screen. If an individual is not found eligible for a
MAGI group, the state must collect necessary information and
determine eligibility under all other Medicaid eligibility
categories (i.e., MAGI-exempt groups, such as disability) and
potential eligibility for APTC in an Exchange. Each state
will be required to establish timeliness and performance
standards for determining eligibility subject to an outer
limit timeliness standard of 45 days for non-disability based
eligibility determinations and 90 days for disability-based
determinations. States are also required, to the maximum
extent possible, to rely on electronic data matches with
trusted third party sources to verify information provided by
applicants.
State Medicaid agencies are to enter into one or more agreements
with an Exchange and other insurance affordability programs to
coordinate eligibility determinations and enrollment. The
state Medicaid agency must ensure that any individual who is
determined ineligible for Medicaid is screened for potential
eligibility for benefits available through an Exchange and
promptly transfer the electronic account of individuals
screened as potentially eligible to the Exchange. States also
have the option to enter into an agreement with an Exchange to
make final determinations of eligibility for tax credits for
Exchange coverage. With regard to Exchange determinations of
Medicaid eligibility, states can enter into agreements to
either have the Exchange make final Medicaid eligibility
determinations or have the Exchange make assessments of
potential Medicaid eligibility and transfer accounts to the
Medicaid agency for final determination.
States must provide information on Medicaid eligibility
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requirements, covered services, and applicant/beneficiary
rights and responsibilities via a website as well as orally
and in writing. The information must be provided in "plain
language" and be accessible to people with disabilities and
people with limited English proficiency at no cost to the
individual.
4)CalHEERS . The California Health Benefit Exchange was
established in 2010 by AB 1602 (Pérez), Chapter 655, Statutes
of 2010, and SB 900 (Alquist), Chapter 659, Statutes of 2010.
Through the Exchange, now called Covered California, people
with incomes up to 400% FPL are eligible for APTCs and those
up to 250% FPL are also eligible for cost sharing reductions.
The ACA requires states to have a single streamlined
application for Exchange subsidies, their Medicaid programs
and their CHIP programs. Covered California and DHCS are
joint program sponsors of the CalHEERS which is the
Information Technology system running both the online
application for the Exchange, Medi-Cal, and Access for Infants
and Mothers and also the phone service center functions.
CalHEERS is scheduled to take live applications October 1, 2013
for the new coverage to begin on January 1, 2014. CalHEERS is
a Web-based portal designed to be the single streamlined
resource for Californians to find out what health program they
are eligible for and to make buying health insurance as easy
as possible. This state of-the-art system will allow
Californians to compare health plans to make the purchase that
best meets their individual or small business needs and
receive federal subsidies if eligible. CalHEERS Program
Design Goals call for: a) A "No Wrong Door" service system
that provides consistent consumer experiences for all entry
points; b) Culturally and linguistically appropriate oral and
written communications which also ensure access for persons
with disabilities; c) Seamless and timely transition between
health programs; and, d) Minimizing the burden of establishing
and maintaining eligibility. Accenture, LLP was awarded a
contract for over $325 million for the development of
CalHEERS.
5)ASSISTERS PROGRAM . Covered California is in the process of
establishing an Assister's Program that will include assister
enrollment entities (AEE) and individual entities. AEEs are
entities and organizations eligible to be trained and
registered to provide in-person assistance to consumers and
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help them apply for Covered California programs, particularly
entities that have access to Covered California's targeted
population. Individual assisters are individuals who are
employed, trained, certified, and linked to AEEs to provide
in-person assistance to consumers and help them apply for
Covered California programs and are individuals who can
provide assistance in culturally and linguistic appropriate
manners to consumers. According to a recent stakeholder
webinar conducted by Covered California on the assisters
program (March 14, 2013 Stakeholder Webinar), preliminary
notification of an entity's intent to participate in the
Assisters Program was solicited through submission of an
Assister Interest Form which was released initially in late
January (via the Outreach and Education Grant Application).
The Webinar material specifically lists American Indian tribe
or tribal organizations and IHS Facilities as proposed
entities eligible to be compensated AEEs. The proposed
compensation for AEEs is $58.00 per new enrollment into
Covered California, including a person who was a MAGI-eligible
Medi-Cal enrollee but upon redetermination qualifies for
Covered California and when a currently enrolled person adds a
new dependent. Compensation for annual renewal is $25.00.
The funding source for the initial application is the federal
funding from the Level II Establishment Federal Grant and
renewals will be funded as operating costs from
self-sustainability funds.
MAA. The MAA Program offers a way for LGAs and LECs to obtain
federal reimbursement for the cost of certain administrative
activities necessary for the proper and efficient
administration of the Medi-Cal program. MAA activities
include: a) Medi-Cal outreach; b) facilitating the Medi-Cal
application; c) Non-emergency & non-medical transportation of
Medi-Cal eligible individuals to Medi-Cal covered services; d)
contracting for Medi-Cal services; e) program planning and
policy development; f) MAA coordination and claims
administration; g) coordination and claims administration;
h)training, and, i) general administration. An LGA is defined
as a county or chartered city. The LGA and LEC must have a
signed contract with DHCS to claim federal reimbursement and
an approved claiming plan. The claiming plan is the basis for
determining the allowable costs and activities for which
federal reimbursement may be claimed by a particular LGA or
LEC.
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SB 308 (Figueroa), Chapter 253, Statutes of 2003, adds Native
American Indian tribes, tribal organizations, and tribal
subgroups as participants in the MAA program. SB 308 allows
Native American Indian tribes, tribal organizations, and
subgroups of tribes or tribal Organizations within the
definition of an LGA to contract for MAAs. The Tribal MAA
program was created to address a number of concerns. These
include improving the relatively low rate of American Indian
enrollment in Medi-Cal and assisting American Indian enrollees
in accessing Medi-Cal services, thereby helping to address
Indian health disparities by linking American Indian people
with Medi-Cal in the face of compelling health needs and
inadequate IHS funding. At that time California had 107
federally recognized tribes and about 12 tribal organizations.
Only federally recognized tribes and eligible tribal
Organizations may claim MAA. The Tribal MAA program was
implemented pursuant to the provisions contained in the Tribal
MAA Implementation Plan in December of 2008 developed in
consultation with the California Rural Indian Health Board
(CRIHB). The Plan provides that a designated Tribal MAA
Contractor is authorized to submit the claims as certified
public expenditures (CPEs) and is responsible for the
preparation of the Tribal MAA Invoice and all backup and
supporting documentation kept in the audit file. The Plan
also describes the CMS approved time-study methodology that
tribes and eligible tribal Organizations must use to document
their MAA costs. Many tribes and tribal organizations were
already providing these activities, but not being reimbursed
for them. DHCS, in concert with the federal government and
the participating tribes and tribal organizations, created a
strategy by which tribes and tribal organizations can claim
administrative costs, not otherwise reimbursed, for providing
services that are directly related to the .Medi-Cal program.
Tribes and tribal organizations are in a unique position to
participate in this program. Due to federal IHS policy,
tribes must provide information about the Medi-Cal program,
and assist those enrolled in Medi-Cal in gaining access to
services and benefits. Through MAA, the related
administrative costs can be reimbursed at a 50% match rate.
Federally recognized tribes and eligible tribal organizations
contracting with DHCS for MAA, referred to as Tribal MAA
contractors in this plan, and may enter into contracts with
organizations performing MAA with preference given to Native
American Indian tribes or tribal organizations in support of
the contractor claiming administrative reimbursement.
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6)LOW INCOME HEALTH PROGRAM (LIHP) . In 2005, the State of
California sought a five year federal waiver as a Medicaid
demonstration project under the authority of Section 1115(a)
of the Social Security Act. Under the 2005 waiver, $180
million in federal funds were allotted to the county-based
Health Care Coverage Initiatives (HCCI) to provide coverage to
more than 130,000 medically-indigent adults who are not
eligible for other public programs. Using a competitive
process, California selected 10 counties in waiver years
three, four, and five (September 1, 2007-August 31, 2010) to
provide coverage to this population through an organized
system of care. The participating counties-Alameda, Contra
Costa, Kern, Los Angeles, Orange, San Diego, San Francisco,
San Mateo, Santa Clara, and Ventura-used local expenditures,
referred to as CPEs, to draw down the available federal funds.
In November 2010, California received federal approval for a
new five year Waiver, entitled "A Bridge to Reform." A key
component of this waiver is the establishment of the LIHPs as
a transition to implementation of the ACA. The Special Terms
and Conditions (STCs) that accompanied the Bridge to Reform
Demonstration Waiver approval by CMS treat this county-based
coverage as a Medicaid Coverage Expansion and a bridge to the
more significant coverage that is effective in 2014. Under
this federal waiver and implementing state legislation,
counties draw down federal Medicaid matching funds to cover
low-income adults. This Demonstration builds on the 10 county
HCCIs from the 2005 waiver by offering participation to all
counties in the state to cover as many as 500,000 low-income
uninsured individuals. All but five counties have established
or are in the process of establishing a LIHP. The STCs also
require the development of a transition plan so that this
population can be seamlessly converted to a MAGI Medicaid
expansion population in January 2014.
On April 5, 2013, CMS announce that it approved California's
amendment to their section 1115(a) demonstration, entitled
California Bridge to Reform Demonstration. As discussed at
the CMS meeting with tribes on February 4, 2013 this amendment
allows for supplemental payments to tribal health facilities
to recognize the burden of uncompensated care costs faced by
IHS and tribal facilities in California. The state officially
submitted the amendment request to CMS on March 1, 2013
following two consultations held on February 15 and 22, 2013
to discuss the uncompensated care payments to IHS and 638
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facilities in greater detail. These payments approved through
this amendment will support the facilities' ability to
continue to provide primary care services so that they will be
an available delivery system option in 2014 and beyond. The
amendment will:
a) Provide supplemental payments to Medicaid-participating
IHS and tribal facilities operating in 37 out of 58
California counties;
b) The supplemental payments will recognize the burden of
uncompensated primary care provided by IHS and tribal
facilities to uninsured individuals with incomes up to 133%
of the FPL who are not enrolled in a county-based LIHP;
c) The supplemental payments will also recognize the burden
of uncompensated care in the form of services that were
eliminated from the Medicaid state plan in 2009 that are
furnished to these uninsured individuals or Medi-Cal
beneficiaries;
d) The supplemental payments will reflect the costs of
qualifying uncompensated encounters based on the published
IHS encounter rate. The CRIHB will operate as a billing
agent for participating facilities; and,
e) IHS eligible individuals receiving care at these
facilities would continue to receive other services, such
as acute care hospital and specialty care services, as they
do now through the IHS contract health service referral
system.
7)INDIAN SOVEREIGNTY . The US Constitution recognizes Indian
sovereignty by classing Indian treaties among the "supreme law
of the land," and establishes Indian affairs as a unique area
of federal concern. Early U.S. Supreme Court cases held that
since the US chose to relegate tribes to a dependent status in
terms of tribal dealings with other nations, the federal
government, then, also assumed a "Trust" responsibility toward
the tribes and their members, commonly known as a "Federal
Trust Responsibility." This trust responsibility requires
that medical services be provided to federally recognized
Indian tribes, and that the federal government, not the state,
has that responsibility. In keeping with the obligation to
carry out the federal trust responsibility in accordance with
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the government-to-government relationship set forth under
federal Indian law, CMS policy requires it to consult with
Indian tribes around all issues that may impact the tribe.
8)SUPPORT . Tribes and tribal organizations, such as the
Manchester Band of Pomo Indians, the California Valley Miwok
Tribe, the Cloverdale Rancheria of Pomo Indians, the Pala Band
of Mission Indians, the Karuk Tribe, the Resighini Rancheria,
the Bear River Band of Rohnerville Rancheria, the Smith River
Rancheria, the Big Pine Paiute Tribe of the Owens Valley,
Feather River Tribal Health, Inc., Mooretown Rancheria,
Susanville Indian Rancheria, Torres Martinez Desert Cahuilla
Indians, and others such as the Fort Bidwell Indian Community
Council, Chapa-De Indian Health Program, Inc., state in
support that this bill will enable tribal health care clinics
and other tribal government entities to enroll Native
Americans who qualify for Medi-Cal into the program at no cost
to the State. According to these supporters, this bill would
also allow tribal government entities to use CalHEERS to
submit applications for Medi-Cal coverage. These supporters
point out that state oversight of this enrollment process
would be provided by DHCS Tribal Medi-Cal MAA program.
According to the supporters, the Tribal MAA program has been
in operation since 2009 and administers outreach and referral,
facilitating Medi-Cal applications, arranging, accompanying,
and providing non-emergency/non-medical transportation and
program planning and policy development services. The
supporters point out that the program offers a way for tribal
governmental entities, similar to the MAA program designed for
local governmental agencies and local educational consortia,
to obtain federal reimbursement for the cost of MAA activities
necessary for the proper and efficient administration of the
Medi-Cal program. According to the supporters, there are
currently 18 tribal health clinics throughout California
participating in the Tribal MAA Program.
9)PRIOR LEGISLATION .
a) AB 2780 (Gallegos), Chapter 310. Statutes of 1998,
allowed local enforcement agencies to claim MAA either
through their LEC or through LGAs.
b) AB 2377, (Committee on Ways and Means), Chapter 147,
Statutes of 1994 authorized the State to implement the MAA
claiming process.
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10)POLICY COMMENTS . The intent of this bill is unclear. As
stated above, American Indian tribe or tribal organizations
and IHS Facilities are proposed, by Covered California to be
eligible as entities compensated as AEEs by Covered California
through CalHEERS. Furthermore, on April 5, 2013, Covered
California announced a notice of intent to award a contract to
the California Rural Indian Health Board, Inc. for a Tribal
Community Mobilizations Program. The purpose is to engage in
consultation with the tribes and receive technical assistance
on a number of issues, including the application and
enrollment process, and to achieve maximization of
participation of eligible American Indians. To advance any of
these purposes, this bill is only needed if the author
believes that further codification or mandates are required.
With regard to Medi-Cal, if the purpose of this bill by use of
the terminology "enroll" is to allow American Indian tribes,
tribal organizations, or IHS Facilities staff to make Medi-Cal
eligibility determinations, it raises a number of policy and
practical questions. Federal and state laws require Medi-Cal
eligibility determinations to be made by individuals who are
employed under merit system principles by State or local
governments, including local health departments. Although
tribes and tribal organizations are recognized as LGAs and use
CPEs to draw down the federal match for the purposes of MAA,
they have not been granted the authority to make eligibility
determinations, neither for Medi-Cal nor in the LIHP program.
In fact the recent waiver amendment is structured as
supplemental payments to recognize the burden of uncompensated
care costs and to support the overall IHS and tribal health
care delivery system. Qualifying uncompensated encounters
will be primary care encounters furnished to uninsured
individuals with incomes up to 133% FPL who are not enrolled
in a California county LIHP and for uncompensated costs of
furnishing services that had been covered under Medi-Cal as of
January 1, 2009 to such uninsured individuals and to Medi-Cal
beneficiaries.
If this bill is intended to allow tribal staff to determine
eligibility then it should be more explicit. Furthermore
there would be other issues that would need to be addressed.
The primary problem is that time spent on establishing
eligibility is not reimbursable under MAA, as provided by this
bill and a different reimbursement system would need to be
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established. In addition, the staff making these
determinations would need to be connected to one of the
existing eligibility systems and properly trained. In
addition notice of action and appeal processes would have to
be developed. On the other hand, if the intent is to allow
MAA reimbursement for assisting with Medi-Cal applications
through the new CalHEERS process, the bill should be so
clarified.
REGISTERED SUPPORT / OPPOSITION :
Support
Bear River Band of Rohnerville Rancheria
Big Pine Paiute Tribe of the Owens Valley
California Association of Tribal Governments
California Valley Miwok Tribe
Chapa-De Indian Health Program, Inc.
Cloverdale Rancheria of Pomo Indians
Consolidated Tribal Health Project, Inc.
Elk Valley Rancheria, California
Feather River Tribal Health, Inc.
Fort Bidwell Indian Community Council,
Karuk Tribe
Manchester Band of Pomo Indians,
Mooretown Rancheria
Pala Band of Mission Indians
Resighini Rancheria
Smith River Rancheria
Susanville Indian Rancheria
Toiyabe Indian Health Project, Inc.
Torres Martinez Desert Cahuilla Indians
Numerous individuals
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097