BILL ANALYSIS                                                                                                                                                                                                    

                                                                  AB 1233
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          Date of Hearing:   May 15, 2013

                                  Mike Gatto, Chair

                   AB 1233 (Chesbro) - As Amended:  April 23, 2013 

          Policy Committee:                              HealthVote:19-0

          Urgency:     No                   State Mandated Local Program:  
          No     Reimbursable:              No


          This bill authorizes a participating Native American Indian  
          tribe or tribal organization, as specified, to facilitate  
          Medi-Cal eligibility determinations using the California  
          Healthcare Eligibility, Enrollment, and Retention System  
          (CalHEERS) as a Medi-Cal Administrative Activities-specific  

           FISCAL EFFECT  

          Likely minor costs to the Department of Health Care Services  
          (DHCS) and Covered California because there appear to be  
          numerous funding sources for tribes and tribal organizations to  
          facilitate Medi-Cal enrollment without GF involvement.  

           1)Rationale  .  This bill is intended to ensure American Indians  
            who are eligible for Medi-Cal and other services receive the  
            care they need.  This bill is also needed to strengthen the  
            tribal health care delivery system by providing tribal  
            entities access to the 100% federal financial participation  
            (FFP) where available for providing Medi-Cal covered services  
            to American Indians eligible for Medi-Cal.  In addition, this  
            bill seeks to clarify tribal entities can access CalHEERS to  
            submit applications for Medi-Cal coverage.  

            According to federal data, Native Americans suffer from  
            significant health disparities, including lower life  
            expectancy, high rates of diabetes, cardiovascular disease,  
            pneumonia, mental health issues, influenza, and injuries. This  
            bill is supported by numerous tribes and tribal organizations.


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           2)Federal health reform  .  Pursuant to the federal Affordable  
            Care Act (ACA), California established a health benefit  
            exchange to serve as a large purchasing pool for health  
            coverage.  Rebranded as Covered California, the exchange will  
            begin enrollment in October 2013 for coverage starting January  
            1, 2014.  Medi-Cal is being expanded to adults, and existing  
            categories for parents, pregnant women, and children are being  
            collapsed to enable coordinated, streamlined eligibility and  
            enrollment processes.  Medi-Cal eligibility will be based on  
            modified adjusted gross income (MAGI).  People with incomes  
            above the eligibility level (generally 138% of the federal  
            poverty level (FPL)) will be eligible for tax credits and  
            subsidies when they buy coverage.  The ACA requires states to  
            have a single streamlined application that includes subsidies,  
            Medi-Cal, and other related programs.  

            CalHEERS, jointly sponsored by Covered California and DHCS),  
            is a web-based portal designed to be the single streamlined  
            resource for Californians to learn about health care options  
            and 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.  

           3)Assisters Program and tribes  .  Covered California is  
            establishing an Assisters Program that will compensate various  
            entities trained and registered to provide in-person  
            assistance to consumers and help them apply for Covered  
            California programs.  According to a recent stakeholder  
            webinar conducted by Covered California, American Indian tribe  
            or tribal organizations and Indian Health Service (HIS)  
            Facilities are identified as proposed assister entities.  

            According to the author, local governmental agencies (LGAs),  
            including federally-recognized tribes and tribal  
            organizations, and local educational consortia, 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 while LGAs are  
            able to enroll Californians who are eligible for Medi-Cal,  
            related authorization overlooked tribes and tribal  
            organizations.  The author asserts this was surprising because  
            there was and continues to be no cost to the state for tribal  


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            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 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  

           4)Previous legislation  .  SB 308 (Figueroa), Chapter 253,  
            Statutes of 2003, added Native American Indian tribes, tribal  
            organizations, and tribal subgroups as participants in the MAA  
            program. 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).  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  


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          Analysis Prepared by:    Debra Roth / APPR. / (916) 319-2081