BILL ANALYSIS                                                                                                                                                                                                    Ó






                             SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:       AB 1233
          AUTHOR:        Chesbro
          AMENDED:       June 11, 2013
          HEARING DATE:  June 26, 2013
          CONSULTANT:    Bain

           SUBJECT  :  Medi-Cal: Administrative Claiming process.
           
          SUMMARY :  Permits American Indian tribes, tribal organizations,  
          or subgroups of a Native American Indian tribe or tribal  
          organization participating in the Medi-Cal administrative  
          claiming process to claim as a Medi-Cal Administrative Activity,  
          facilitating Medi-Cal applications using the California  
          Healthcare Eligibility, Enrollment, and Retention System.

          Existing law:
          1.Establishes the Medi-Cal program, administered by the  
            Department of Health Care Services (DHCS), under which health  
            care services are provided to qualified, low-income persons. 

          2.Permits DHCS to contract with participating local governmental  
            agency (LGA) or local educational consortium (LEC) to assist  
            with the performance of administrative activities necessary  
            for the proper and efficient administration of the Medi-Cal  
            program. This process is known as the Medi-Cal Administrative  
            Activities (MAA).

          3.Defines "participating local governmental agency" as a county,  
            chartered city, Native American Indian tribe, tribal  
            organization, or subgroup of a Native American Indian tribe or  
            tribal organization, under contract with DHCS.

          4.Requires, as a condition for participation in the MAA process,  
            each participating LGA or LEC, for the purpose of claiming  
            federal Medicaid reimbursement, to enter into a contract with  
            DHCS and to certify to DHCS the total amount the LGA or LEC  
            expended on the allowable administrative activities.
               
          This bill: 
          1.Permits American Indian tribes, tribal organizations, or  
            subgroups of a Native American Indian tribe or tribal  
            organization participating in the MAA process to claim, as a  
            Medi-Cal Administrative Activity, facilitating Medi-Cal  
                                                         Continued---



          AB 1233 | Page 2




            applications using California Healthcare Eligibility,  
            Enrollment, and Retention System (CalHEERS).

          2.Takes effect immediately as an urgency statute.

           FISCAL EFFECT  :  According to the Assembly Appropriations  
          Committee analysis of the previous version of this bill, likely  
          minor costs to DHCS and The California Health Benefit Exchange  
          (Covered California) because there appear to be numerous funding  
          sources for tribes and tribal organizations to facilitate  
          Medi-Cal enrollment without General Fund involvement. 

           PRIOR VOTES  :  
          Assembly Health:    19- 0
          Assembly Appropriations:17- 0
          Assembly Floor:     77- 0
           COMMENTS  :  
           1.Author's statement.  According to the author, this bill seeks  
            to clarify that the activities conducted to assist Native  
            Americans in Medi-Cal applications through CalHEERS are  
            included within MAA.  Native Americans suffer from significant  
            health disparities. Specifically, they are more likely to die  
            from alcoholism (650 percent), diabetes (380 percent),  
            accidents (240 percent) and pneumonia/influenza (140 percent)  
            than other Americans. Native Americans are more likely than  
            non-Hispanic Caucasians to be uninsured and problematic gaps  
            exist in Native American access to health care and rates of  
            service utilization, especially for low-income Native  
            Americans. In addition to health disparities many Native  
            Americans live in very rural areas where there is limited  
            access to the Internet and at times phones, making the  
            application process, even with CalHEERS particularly  
            challenging. 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 percent federal financial  
            participation (FFP) for providing Medi-Cal covered services to  
            American Indians eligible for Medi-Cal.  
          
          2.MAA. MAA is a federal reimbursement program for the costs of  
            "administrative activities" that directly support efforts to  
            identify and enroll individuals in the Medi-Cal program or  
            to assist those already enrolled in Medi-Cal access  
            services. The overarching policy for MAA is that allowable  
            administrative costs must be directly related to the  




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            Medi-Cal State Plan or waiver service, if administering a  
            Medicaid waiver, and is "found necessary for the proper and  
            efficient administration of the Medi-Cal State Plan."  
            Participating entities put up the state match for the  
            program and pay an annual participation fee to DHCS.  
            Examples of reimbursable administrative activities include: 

             §    Medi-Cal outreach; 
             §    Facilitating Medi-Cal application; 
             §    Medi-Cal related referral; 
             §    Medi-Cal related program planning and policy  
               development; 
             §    Providing transportation to Medi-Cal services; and,
             §    General administrative activities. 

            DHCS' California Tribal Medi-Cal Administrative Activities  
            Implementation Plan from December 2008 is designed to be  
            used by the state's federally recognized tribes and tribal  
            organizations that participate in the Tribal MAA program.  
            The purpose of the Tribal MAA program is to: 

             §    Form a partnership between DHCS and participating  
               federally recognized Tribes and Tribal Organizations; 

             §    Share in the responsibility for promoting access to  
               Medi-Cal health care for Native American Indians/Alaskan  
               Natives (AI/AN); and, 

             §    Reimburse Tribes and Tribal Organizations for performing  
               administrative activities allowed by Tribal MAA. 

            Per the Tribal MAA plan and conversations with DHCS staff,  
            facilitating a Medi-Cal application is currently reimbursable  
            through MAA. This bill would codify this provision and would  
            explicitly state that using CalHEERS (which did not exist in  
            December 2008 when the Tribal MAA plan was finished) to  
            facilitate enrollment is reimbursable through MAA.
          1.CalHEERS. Covered California was established in 2010 by AB  
            1602 (Pérez), Chapter 655, Statutes of 2010, and SB 900  
            (Alquist), Chapter 659, Statutes of 2010. Individuals with  
            incomes up to 400 percent of the FPL are eligible for advance  
            premium tax credits, and those up to 250 percent of the 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  




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            programs. 

          Covered California and DHCS are the joint program sponsors of  
            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.  

          2.Prior legislation. SB 308 (Figueroa), Chapter 253, Statutes of  
            2003, included Native American Indian tribes, tribal  
            organizations, and subgroups of tribes or tribal organizations  
            as participating LGA for purposes of contracting with DHCS for  
            MAAs.
                 
          3.Support.  This bill is sponsored by the California Rural  
            Indian Health Board (CRIHB) and supported by California  
            Pan-Ethnic Health Network, California Primary Care  
            Association, and multiple tribes and tribal organizations to  
            enable tribal health care clinics and other tribal government  
            entities to facilitate the enrollment of Native Americans who  
            qualify for Medi-Cal into the program at no cost to the state  
            using CalHEERS.  California Pan-Ethnic Health Network

          4.Amendment. DHCS indicates that "facilitating the Medi-Cal  
            application" as codifying existing authority, but that the  
            language in this bill (facilitating Medi-Cal applications  
            using the CalHEERS system) is more restrictive than CMS  
            guidance that allows claiming for facilitating Medi-Cal  
            applications without reference to any particular means of  
            applying. An amendment is needed to clarify that MAA claiming  
            for facilitating Medi-Cal applications is not limited to using  
            CalHEERS.

           SUPPORT AND OPPOSITION  :
          Support:  California Rural Indian Health Board (sponsor)
                    California Pan-Ethnic Health Network
                    California Primary Care Association
                    California Valley Miwok Tribe
                    Chapa-De Indian Health Program
                    Elk Valley Rancheria, California
                    Karuk Tribe




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                    Manchester Band of Pomo Indians
                    Pala Band of Mission Indians
                    Resighini Rancheria
                    Tuolomne Me-Wuk Indian Health Center, Inc.
                    51 Individuals

          Oppose:   None received.



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