BILL ANALYSIS                                                                                                                                                                                                    Ó

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          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  

          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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          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  

           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  

           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  

          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  

           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  

           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  


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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  

             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  

           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  

          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  


          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

          None on file.
          Analysis Prepared by  :    Marjorie Swartz / HEALTH / (916)