Senate Bill No. 28

Introduced by Senators Hernandez and Steinberg

December 3, 2012

An act to amend Section 12698.30 of the Insurance Code, and to amend Sections 14005.31, 14005.32, 14132, and 15926 of, to amend and repeal Sections 14008.85, 14011.16, and 14011.17 of, to amend, repeal, and add Sections 14005.18, 14005.28, 14005.30, 14005.37, and 14012 of, to add Sections 14005.60, 14005.62, 14005.63, 14005.64, 14132.02, and 15926.2 to, the Welfare and Institutions Code, relating to health.

LEGISLATIVE COUNSEL’S DIGEST

SB 28, as introduced, Hernandez. Medi-Cal: eligibility.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

This bill would, commencing January 1, 2014, implement various provisions of the federal Patient Protection and Affordable Care Act (Affordable Care Act), as amended, by, among other things, modifying provisions relating to determining eligibility for certain groups. The bill would, in this regard, extend Medi-Cal eligibility to specified adults and would require that income eligibility be determined based on modified adjusted gross income (MAGI), as prescribed. The bill would prohibit the use of an asset or resources test for individuals whose financial eligibility for Medi-Cal is determined based on the application of MAGI. The bill would also add, commencing January 1, 2014, benefits, services, and coverage included in the essential health benefits package, as adopted by the state and approved by the United States Secretary of Health and Human Services, to the schedule of Medi-Cal benefits.

Because counties are required to make Medi-Cal eligibility determinations and this bill would expand Medi-Cal eligibility, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

The Legislature finds and declares all of the
following:

(a) The United States is the only industrialized country in the
world without a universal health insurance system.

(b) (1) In 2006, the United States Census reported that 46
million Americans did not have health insurance.

(2) In California in 2009, according to the UCLA Center for
Health Policy Research’s “The State of Health Insurance in
California: Findings from the 2009 California Health Interview
Survey,” 7.1 million Californians were uninsured in 2009,
amounting to 21.1 percent of nonelderly Californians who had no
health insurance coverage for all or some of 2009, up nearly 2
percentage points from 2007.

(c) On March 23, 2010, President Obama signed the Patient
Protection and Affordable Care Act (Public Law 111-148), which
was amended by the Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152), and together are referred to as
the Affordable Care Act of 2010 (Affordable Care Act).

(d) The Affordable Care Act is the culmination of decades of
movement toward health reform, and is the most fundamental
legislative transformation of the United States health care system
in 40 years.

(e) As a result of the enactment of the Affordable Care Act,
according to estimates by the UCLA Center for Health Policy
Research and the UC Berkeley Labor Center, using the California
Simulation of Insurance Markets, in 2019, after the Affordable
Care Act is fully implemented:

(1) Between 89 and 92 percent of Californians under 65 years
of age will have health coverage.

(2) Between 1.2 and 1.6 million individuals will be newly
enrolled in Medi-Cal.

(f) It is the intent of the Legislature to ensure full implementation
of the Affordable Care Act, including the Medi-Cal expansion for
individuals with incomes below 133 percent of the federal poverty
level, so that millions of uninsured Californians can receive health
care coverage.

SEC. 2.  

Section 12698.30 of the Insurance Code is amended
to read:

12698.30.  

(a)  begin delete At end delete begin insert (1) end insert begin insert   end insert begin insert Subject to paragraph (2), at end insert a minimum,
coverage shall be provided to subscribers during one pregnancy,
and for 60 days thereafter, and to children less than two years of
age who were born of a pregnancy covered under this program to
a woman enrolled in the program before July 1, 2004.

begin insert

(2) Commencing January 1, 2014, at a minimum, coverage shall
be provided to subscribers during one pregnancy, and until the
end of the month in which the 60th day thereafter occurs, and to
children less than two years of age who were born of a pregnancy
covered under this program to a woman enrolled in the program
before July 1, 2004.

end insert

(b) Coverage provided pursuant to this part shall include, at a
minimum, those services required to be provided by health care
service plans approved by the begin insert United States end insert Secretary of Health
and Human Services as a federally qualified health care service
plan pursuant to Section 417.101 of Title 42 of the Code of Federal
Regulations.

(c) Coverage shall include health education services related to
tobacco use.

(d) Medically necessary prescription drugs shall be a required
benefit in the coverage provided under this part.

SEC. 3.  

Section 14005.18 of the Welfare and Institutions Code
is amended to read:

14005.18.  

begin insert (a) end insert begin insert   end insert A woman is eligible, to the extent required by
federal law, as though she were pregnant, for all pregnancy-related
and postpartum services for a 60-day period beginning on the last
day of pregnancy.

For purposes of this section, “postpartum services” means those
services provided after childbirth, child delivery, or miscarriage.

begin insert

(b) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 4.  

Section 14005.18 is added to the Welfare and
Institutions Code, to read:

14005.18.  

(a) To help prevent premature delivery and low
birthweights, the leading causes of infant and maternal morbidity
and mortality, and to promote women’s overall health, well-being,
and financial security and that of their families, it is imperative
that pregnant women enrolled in Medi-Cal be provided with all
medically necessary services. Therefore, a woman is eligible, to
the extent required by federal law, as though she were pregnant,
for all pregnancy-related and postpartum services for a 60-day
period beginning on the last day of pregnancy and continuing until
the end of the month in which the 60th day of postpartum occurs.

(b) For purposes of this section, the following definitions shall
apply:

(1) “Pregnancy-related services” means, at a minimum, all
services required under the state plan unless federal approval is
granted after January 1, 2014, pursuant to the procedure under the
Preamble to the Final Rule at page 17149 of volume 77 of the
Federal Register (March 23, 2012) to provide fewer benefits during
pregnancy.

(2) “Postpartum services” means those services provided after
child birth, child delivery, or miscarriage.

(c) This section shall become operative January 1, 2014.

SEC. 5.  

Section 14005.28 of the Welfare and Institutions Code
is amended to read:

14005.28.  

(a) To the extent federal financial participation is
available pursuant to an approved state plan amendment, the
department shall exercise its option under Section
begin delete 1902(a)(10)(A)(XV) end delete begin insert 1902(a)(10)(A)(ii)(XVII) end insert of the federal Social
Security Act (42 U.S.C. Sec. begin delete 1396a(a)(10)(A)(XV)) end delete
begin insert 1396a(a)(10)(A)(ii)(XVII)) end insert to extend Medi-Cal benefits to
independent foster care adolescents, as defined in Section
begin delete 1905(v)(1) end delete begin insert 1905(w)(1) end insert of the federal Social Security Act (42 U.S.C.
Sec. begin delete 1396d(v)(1)) end delete begin insert 1396(w)(1)) end insert .

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
and if the state plan amendment described in subdivision (a) is
approved by the federal Health Care Financing Administration,
the department may implement subdivision (a) without taking any
regulatory action and by means of all-county letters or similar
instructions. Thereafter, the department shall adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code.

(c) The department shall implement subdivision (a) on October
1, 2000, but only if, and to the extent that, the department has
obtained all necessary federal approvals.

begin insert

(d) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 6.  

Section 14005.28 is added to the Welfare and
Institutions Code, to read:

14005.28.  

(a) Commencing January 1, 2014, and to the extent
federal financial participation is available pursuant to an approved
state plan amendment, the department shall implement Section
1902(a)(10)(A)(i)(IX) of the federal Social Security Act (42 U.S.C.
Sec. 1396a(a)(10)(A)(i)(IX)) to extend Medi-Cal benefits to a
foster care adolescent, until his or her 26th birthday.

(1) A foster care adolescent who is in foster care on his or her
18th birthday shall be deemed eligible for the benefits extended
pursuant to this section and shall be enrolled to receive these
benefits until his or her 26th birthday without any interruption in
coverage and without requiring a new application.

(2) The department shall develop and implement a simplified
redetermination form for this program. A recipient qualifying for
the benefits extended pursuant to this section shall fill out and
return this form only if information previously reported to the
department is no longer accurate. Failure to return the form alone
will not constitute a basis for termination of Medi-Cal. If the form
is returned as undeliverable and the county is otherwise unable to
establish contact, the recipient shall remain eligible for
fee-for-service Medi-Cal until such time as contact is reestablished
or ineligibility is established, and to the extent federal financial
participation is available. The department may terminate eligibility
if it determines that the recipient is no longer eligible only after
ineligibility is established and all due process requirements are
met in accordance with state and federal law.

(3) This section shall be implemented to the extent that federal
financial participation is available, and any necessary federal
approvals are obtained.

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
and if the state plan amendment described in subdivision (a) is
approved by the federal Centers for Medicare and Medicaid
Services, the department may implement this section without taking
any regulatory action and by means of all-county letters or similar
instructions. Thereafter, the department shall adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code.

(c) This section shall become operative January 1, 2014.

SEC. 7.  

Section 14005.30 of the Welfare and Institutions Code
is amended to read:

14005.30.  

(a) (1) To the extent that federal financial
participation is available, Medi-Cal benefits under this chapter
shall be provided to individuals eligible for services under Section
1396u-1 of Title 42 of the United States Code, including any
options under Section 1396u-1(b)(2)(C) made available to and
exercised by the state.

(2) The department shall exercise its option under Section
1396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
less restrictive income and resource eligibility standards and
methodologies to the extent necessary to allow all recipients of
benefits under Chapter 2 (commencing with Section 11200) to be
eligible for Medi-Cal under paragraph (1).

(3) To the extent federal financial participation is available, the
department shall exercise its option under Section 1396u-1(b)(2)(C)
of Title 42 of the United States Code authorizing the state to
disregard all changes in income or assets of a beneficiary until the
next annual redetermination under Section 14012. The department
shall implement this paragraph only if, and to the extent begin delete that end delete begin insert that, end insert
the State Child Health Insurance Program waiver described in
Section 12693.755 of the Insurance Code extending Healthy
Families Program eligibility to parents and certain other adults is
approved and implemented.

(b) To the extent that federal financial participation is available,
the department shall exercise its option under Section
1396u-1(b)(2)(C) of Title 42 of the United States Code as necessary
to expand eligibility for Medi-Cal under subdivision (a) by
establishing the amount of countable resources individuals or
families are allowed to retain at the same amount medically needy
individuals and families are allowed to retain, except that a family
of one shall be allowed to retain countable resources in the amount
of three thousand dollars ($3,000).

(c) To the extent federal financial participation is available, the
department shall, commencing March 1, 2000, adopt an income
disregard for applicants equal to the difference between the income
standard under the program adopted pursuant to Section 1931(b)
of the federal Social Security Act (42 U.S.C. Sec. 1396u-1) and
the amount equal to 100 percent of the federal poverty level
applicable to the size of the family. A recipient shall be entitled
to the same disregard, but only to the extent it is more beneficial
than, and is substituted for, the earned income disregard available
to recipients.

(d) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec.
401 and following) arising from cost-of-living adjustments shall
be disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the
federal poverty level requires the department to modify the income
disregard pursuant to subdivision (c) and in which new income
limits for the program established by this section are adopted by
the department.

(e) Subdivision (b) shall be applied retroactively to January 1,
1998.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall implement, without taking regulatory action,
subdivisions (a) and (b) of this section by means of an all county
letter or similar instruction. Thereafter, the department shall adopt
regulations in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code.

begin insert

(g) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 8.  

Section 14005.30 is added to the Welfare and
Institutions Code, to read:

14005.30.  

(a) (1) To the extent that federal financial
participation is available, Medi-Cal benefits under this chapter
shall be provided to individuals eligible for services under Section
1396u-1 of Title 42 of the United States Code, known as the
Section 1931(b) program, including any options under Section
1396u-1(b)(2)(C) made available to and exercised by the state.

(2) The department shall exercise its option under Section
1396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
less restrictive income and resource eligibility standards and
methodologies to the extent necessary to allow all recipients of
benefits under Chapter 2 (commencing with Section 11200) to be
eligible for Medi-Cal under paragraph (1).

(b) Commencing January 1, 2014, pursuant to Section
1396a(e)(14)(C) of Title 42 of the United States Code, there shall
be no assets test and no deprivation test for any individual under
this section.

(c) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec.
401 et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the
federal poverty level requires the department to modify the income
disregard pursuant to subdivision (c) and in which new income
limits for the program established by this section are adopted by
the department.

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall implement, without taking regulatory action,
this section by means of an all-county letter or similar instruction.
Thereafter, the department shall adopt regulations in accordance
with the requirements of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
Beginning six months after the effective date of this section, the
department shall provide a status report to the Legislature on a
semiannual basis until regulations have been adopted.

(e) This section shall become operative January 1, 2014.

SEC. 9.  

Section 14005.31 of the Welfare and Institutions Code
is amended to read:

14005.31.  

(a) (1) Subject to paragraph (2), for any person
whose eligibility for benefits under Section 14005.30 has been
determined with a concurrent determination of eligibility for cash
aid under Chapter 2 (commencing with Section 11200), loss of
eligibility or termination of cash aid under Chapter 2 (commencing
with Section 11200) shall not result in a loss of eligibility or
termination of benefits under Section 14005.30 absent the existence
of a factor that would result in loss of eligibility for benefits under
Section 14005.30 for a person whose eligibility under Section
14005.30 was determined without a concurrent determination of
eligibility for benefits under Chapter 2 (commencing with Section
11200).

(2) Notwithstanding paragraph (1), a person whose eligibility
would otherwise be terminated pursuant to that paragraph shall
not have his or her eligibility terminated until the transfer
procedures set forth in Section 14005.32 or the redetermination
procedures set forth in Section 14005.37 and all due process
requirements have been met.

(b) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice
to be used by the counties, to inform Medi-Cal beneficiaries whose
eligibility for cash aid under Chapter 2 (commencing with Section
11200) has ended, but whose eligibility for benefits under Section
14005.30 continues pursuant to subdivision (a), that their benefits
will continue. To the extent feasible, the notice shall be sent out
at the same time as the notice of discontinuation of cash aid, and
shall include all of the following:

(1) A statement that Medi-Cal benefits will continue even though
cash aid under the CalWORKs program has been terminated.

(2) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.

(3)  begin insert (A) end insert begin insert   end insert A statement that the Medi-Cal beneficiary does not
need to fill out monthly status reports in order to remain eligible
for Medi-Cal, but begin delete shall end delete begin insert may end insert be required to submit a semiannual
status report and annual reaffirmation forms. The notice shall
remind individuals whose cash aid ended under the CalWORKs
program as a result of not submitting a status report that he or she
should review his or her circumstances to determine if changes
have occurred that should be reported to the Medi-Cal eligibility
worker.

begin insert

(B) Commencing January 1, 2014, the semiannual status report
requirement shall not be included in the statement described in
subparagraph (A).

end insert

(4) A statement describing the responsibility of the Medi-Cal
beneficiary to report to the county, within 10 days, significant
changes that may affect eligibility.

(5) A telephone number to call for more information.

(6) A statement that the Medi-Cal beneficiary’s eligibility
worker will not change, or, if the case has been reassigned, the
new worker’s name, address, and telephone number, and the hours
during which the county’s eligibility workers can be contacted.

(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act begin delete (Title 42 end delete begin insert (42 end insert U.S.C.
Sec. 1396 begin delete and following) end delete begin insert et seq.) end insert is available.

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall, without taking any regulatory action,
implement this section by means of all county letters or similar
instructions. Thereafter, the department shall adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code. Comprehensive implementing instructions
shall be issued to the counties no later than March 1, 2001.

SEC. 10.  

Section 14005.32 of the Welfare and Institutions
Code is amended to read:

14005.32.  

(a) (1) If the county has evidence clearly
demonstrating that a beneficiary is not eligible for benefits under
this chapter pursuant to Section 14005.30, but is eligible for
benefits under this chapter pursuant to other provisions of law, the
county shall transfer the individual to the corresponding Medi-Cal
program. Eligibility under Section 14005.30 shall continue until
the transfer is complete.

(2) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice
to be used by the counties, to inform beneficiaries that their
Medi-Cal benefits have been transferred pursuant to paragraph (1)
and to inform them about the program to which they have been
transferred. To the extent feasible, the notice shall be issued with
the notice of discontinuance from cash aid, and shall include all
of the following:

(A) A statement that Medi-Cal benefits will continue under
another program, even though aid under Chapter 2 (commencing
with Section 11200) has been terminated.

(B) The name of the program under which benefits will continue,
and an explanation of that program.

(C) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.

(D)  begin insert (i) end insert begin insert   end insert A statement that the Medi-Cal beneficiary does not need
to fill out monthly status reports in order to remain eligible for
Medi-Cal, but begin delete shall end delete begin insert may end insert be required to submit a semiannual status
report and annual reaffirmation forms. In addition, if the person
or persons to whom the notice is directed has been found eligible
for transitional Medi-Cal as described in Section 14005.8 begin delete , end delete
begin delete 14005.81, end delete or 14005.85, the statement shall explain the reporting
requirements and duration of benefits under those programs, and
shall further explain that, at the end of the duration of these
benefits, a redetermination, as provided for in Section 14005.37
shall be conducted to determine whether benefits are available
under any other provision of law.

begin insert

(ii) Commencing January 1, 2014, the semiannual status report
requirement shall not be included in the statement described in
clause (i).

end insert

(E) A statement describing the beneficiary’s responsibility to
report to the county, within 10 days, significant changes that may
affect eligibility or share of cost.

(F) A telephone number to call for more information.

(G) A statement that the beneficiary’s eligibility worker will
not change, or, if the case has been reassigned, the new worker’s
name, address, and telephone number, and the hours during which
the county’s Medi-Cal eligibility workers can be contacted.

(b) No later than September 1, 2001, the department shall submit
a federal waiver application seeking authority to eliminate the
reporting requirements imposed by transitional medicaid under
Section 1925 of the federal Social Security Act (Title 42 U.S.C.
Sec. 1396r-6).

(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act begin delete (Title 42 end delete begin insert (42 end insert U.S.C.
Sec. 1396 begin delete and following) end delete begin insert et seq.) end insert is available.

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall, without taking any regulatory action,
implement this section by means of all county letters or similar
instructions. Thereafter, the department shall adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code. Comprehensive implementing instructions
shall be issued to the counties no later than March 1, 2001.

SEC. 11.  

Section 14005.37 of the Welfare and Institutions
Code is amended to read:

14005.37.  

(a) Except as provided in Section 14005.39,
whenever a county receives information about changes in a
beneficiary’s circumstances that may affect eligibility for Medi-Cal
benefits, the county shall promptly redetermine eligibility. The
procedures for redetermining Medi-Cal eligibility described in this
section shall apply to all Medi-Cal beneficiaries.

(b)  Loss of eligibility for cash aid under that program shall not
result in a redetermination under this section unless the reason for
the loss of eligibility is one that would result in the need for a
redetermination for a person whose eligibility for Medi-Cal under
Section 14005.30 was determined without a concurrent
determination of eligibility for cash aid under the CalWORKs
program.

(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.

(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section. A Medi-Cal beneficiary’s eligibility shall
not be terminated under this section until the county makes a
specific determination based on facts clearly demonstrating that
the beneficiary is no longer eligible for Medi-Cal under any basis
and due process rights guaranteed under this division have been
met.

(e) For purposes of acquiring information necessary to conduct
the eligibility determinations described in subdivisions (a) to (d),
inclusive, a county shall make every reasonable effort to gather
information available to the county that is relevant to the
beneficiary’s Medi-Cal eligibility prior to contacting the
beneficiary. Sources for these efforts shall include, but are not
limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
beneficiary or of any of his or her immediate family members,
which are open or were closed within the last 45 days, and
wherever feasible, other sources of relevant information reasonably
available to the counties.

(f) If a county cannot obtain information necessary to
redetermine eligibility pursuant to subdivision (e), the county shall
attempt to reach the beneficiary by telephone in order to obtain
this information, either directly or in collaboration with
community-based organizations so long as confidentiality is
protected.

(g) If a county’s efforts pursuant to subdivisions (e) and (f) to
obtain the information necessary to redetermine eligibility have
failed, the county shall send to the beneficiary a form, which shall
highlight the information needed to complete the eligibility
determination. The county shall not request information or
documentation that has been previously provided by the
beneficiary, that is not absolutely necessary to complete the
eligibility determination, or that is not subject to change. The form
shall be accompanied by a simple, clear, consumer-friendly cover
letter, which shall explain why the form is necessary, the fact that
it is not necessary to be receiving CalWORKs benefits to be
receiving Medi-Cal benefits, the fact that receipt of Medi-Cal
benefits does not count toward any time limits imposed by the
CalWORKs program, the various bases for Medi-Cal eligibility,
including disability, and the fact that even persons who are
employed can receive Medi-Cal benefits. The cover letter shall
include a telephone number to call in order to obtain more
information. The form and the cover letter shall be developed by
the department in consultation with the counties and representatives
of consumers, managed care plans, and Medi-Cal providers. A
Medi-Cal beneficiary shall have no less than 20 days from the date
the form is mailed pursuant to this subdivision to respond. Except
as provided in subdivision (h), failure to respond prior to the end
of this 20-day period shall not impact his or her Medi-Cal
eligibility.

(h) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in subdivision
(g) marked as undeliverable shall result in an immediate notice of
action terminating Medi-Cal eligibility.

(i) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary
does not submit the completed form to the county, the county shall
send the beneficiary a written notice of action stating that his or
her eligibility shall be terminated 10 days from the date of the
notice and the reasons for that determination, unless the beneficiary
submits a completed form prior to the end of the 10-day period.

(j) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
submits an incomplete form, the county shall attempt to contact
the beneficiary by telephone and in writing to request the necessary
information. If the beneficiary does not supply the necessary
information to the county within 10 days from the date the county
contacts the beneficiary in regard to the incomplete form, a 10-day
notice of termination of Medi-Cal eligibility shall be sent.

(k) If, within 30 days of termination of a Medi-Cal beneficiary’s
eligibility pursuant to subdivision (h), (i), or (j), the beneficiary
submits to the county a completed form, eligibility shall be
determined as though the form was submitted in a timely manner
and if a beneficiary is found eligible, the termination under
subdivision (h), begin delete (I), end delete begin insert (i) end insert , or (j) shall be rescinded.

(l) If the information reasonably available to the county pursuant
to the redetermination procedures of subdivisions (d), (e), (g), and
(m) does not indicate a basis of eligibility, Medi-Cal benefits may
be terminated so long as due process requirements have otherwise
been met.

(m) The department shall, with the counties and representatives
of consumers, including those with disabilities, and Medi-Cal
providers, develop a timeframe for redetermination of Medi-Cal
eligibility based upon disability, including ex parte review, the
redetermination form described in subdivision (g), timeframes for
responding to county or state requests for additional information,
and the forms and procedures to be used. The forms and procedures
shall be as consumer-friendly as possible for people with
disabilities. The timeframe shall provide a reasonable and adequate
opportunity for the Medi-Cal beneficiary to obtain and submit
medical records and other information needed to establish
eligibility for Medi-Cal based upon disability.

(n) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act begin delete (Title 42 end delete begin insert (42 end insert U.S.C.
Sec. 1396 begin delete and following) end delete begin insert et seq.) end insert is available.

(o) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall, without taking any regulatory action,
implement this section by means of all county letters or similar
instructions. Thereafter, the department shall adopt regulations in
accordance with the requirements of Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code. Comprehensive implementing instructions
shall be issued to the counties no later than March 1, 2001.

begin insert

(p) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 12.  

Section 14005.37 is added to the Welfare and
Institutions Code, to read:

14005.37.  

(a) Except as provided in Section 14005.39,
whenever a county receives information about changes in a
beneficiary’s circumstances that may affect eligibility for Medi-Cal
benefits, the county shall promptly redetermine eligibility. The
procedures for redetermining Medi-Cal eligibility described in this
section shall apply to all Medi-Cal beneficiaries.

(b)  Loss of eligibility for cash aid under that program shall not
result in a redetermination under this section unless the reason for
the loss of eligibility is one that would result in the need for a
redetermination for a person whose eligibility for Medi-Cal under
Section 14005.30 was determined without a concurrent
determination of eligibility for cash aid under the CalWORKs
program.

(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.

(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section. A Medi-Cal beneficiary’s eligibility shall
not be terminated under this section until the county makes a
specific determination based on facts clearly demonstrating that
the beneficiary is no longer eligible for Medi-Cal under any basis
and due process rights guaranteed under this division have been
met.

(e) (1) For purposes of acquiring information necessary to
conduct the eligibility determinations described in subdivisions
(a) to (d), inclusive, a county shall gather information available to
the county that is relevant to the beneficiary’s Medi-Cal eligibility
prior to contacting the beneficiary. Sources for these efforts shall
include, but are not limited to, Medi-Cal, CalWORKs, and
CalFresh case files of the beneficiary or of any of his or her
immediate family members, which are open or were closed within
the last 45 days, information accessed through any databases
accessed by the agency under Sections 435.948, 435.949, and
435.956 of Title 42 of the Code of Federal Regulations, and
wherever feasible, other sources of relevant information reasonably
available to the counties.

(2) If the county is able to renew eligibility based on such
information, the county shall notify the individual of both of the
following:

(A) The eligibility determination and basis.

(B) That the individual is required to inform the county via the
Internet, by telephone, by mail, in person, or through other
commonly available electronic means, in counties where such
electronic communication is available, if any information contained
in the notice is inaccurate but that the individual is not required to
sign and return the notice if all information provided on the notice
is accurate.

(3) The county shall make all reasonable efforts not to send
multiple notices during the same time period about eligibility. The
notice of eligibility renewal shall contain other related information
such as if the individual is in a new Medi-Cal program.

(f) If a county cannot obtain information necessary to
redetermine eligibility pursuant to subdivision (e), the county shall
attempt to reach the beneficiary by telephone and other commonly
available electronic means, in counties where such electronic
communication is available, in order to obtain this information,
either directly or in collaboration with community-based
organizations so long as confidentiality is protected.

(g) If a county’s efforts pursuant to subdivisions (e) and (f) to
obtain the information necessary to redetermine eligibility have
failed, the county shall send to the beneficiary a form containing
information available to the county needed to renew eligibility.
The county shall not request information or documentation that
has been previously provided by the beneficiary, that is not
absolutely necessary to complete the eligibility determination, or
that is not subject to change. The county shall not request
information for nonapplicants necessary to make an eligibility
determination. The form shall be accompanied by a simple, clear,
consumer-friendly cover letter, that shall explain why the form is
necessary, the fact that it is not necessary to be receiving
CalWORKs benefits to be receiving Medi-Cal benefits, the fact
that receipt of Medi-Cal benefits does not count toward any time
limits imposed by the CalWORKs program, the various bases for
Medi-Cal eligibility, including disability, and the fact that even
persons who are employed can receive Medi-Cal benefits. The
form shall advise the individual to provide any necessary
information to the county via the Internet, by telephone, by mail,
in person, or through other commonly available electronic means
and to sign the renewal form. The cover letter shall include a
telephone number to call in order to obtain more information. The
form and the cover letter shall be developed by the department in
consultation with the counties and representatives of consumers,
managed care plans, and Medi-Cal providers. A Medi-Cal
beneficiary shall have no less than 20 days from the date the form
is mailed pursuant to this subdivision to respond. Except as
provided in subdivision (h), failure to respond prior to the end of
this 20-day period shall not impact his or her Medi-Cal eligibility.

(h) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in subdivision
(g) marked as undeliverable shall result in an immediate notice of
action terminating Medi-Cal eligibility.

(i) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary
does not submit the completed form to the county, the county shall
send the beneficiary a written notice of action stating that his or
her eligibility shall be terminated 10 days from the date of the
notice and the reasons for that determination, unless the beneficiary
submits a completed form prior to the end of the 10-day period.

(j) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
submits an incomplete form, the county shall attempt to contact
the beneficiary by telephone, in writing, and other commonly
available electronic means, in counties where such electronic
communication is available, to request the necessary information.
If the beneficiary does not supply the necessary information to the
county within 10 days from the date the county contacts the
beneficiary in regard to the incomplete form, a 10-day notice of
termination of Medi-Cal eligibility shall be sent.

(k) (1) Subject to paragraph (2), if within 30 days of termination
of a Medi-Cal beneficiary’s eligibility pursuant to subdivision (h),
(i), or (j), the beneficiary submits to the county a completed form,
eligibility shall be determined as though the form was submitted
in a timely manner and if a beneficiary is found eligible, the
termination under subdivision (h), (i), or (j) shall be rescinded.

(2) Commencing January 1, 2014, if within 90 days of
termination of a Medi-Cal beneficiary’s eligibility pursuant to
subdivision (h), (i), or (j), the beneficiary submits to the county a
completed form, eligibility shall be determined as though the form
was submitted in a timely manner and if a beneficiary is found
eligible, the termination under subdivision (h), (i), or (j) shall be
rescinded.

(l) If the information available to the county pursuant to the
redetermination procedures of subdivisions (d), (e), (g), and (m)
does not indicate a basis of eligibility, Medi-Cal benefits may be
terminated so long as due process requirements have otherwise
been met.

(m) The department shall, with the counties and representatives
of consumers, including those with disabilities, and Medi-Cal
providers, develop a timeframe for redetermination of Medi-Cal
eligibility based upon disability, including ex parte review, the
redetermination form described in subdivision (g), timeframes for
responding to county or state requests for additional information,
and the forms and procedures to be used. The forms and procedures
shall be as consumer-friendly as possible for people with
disabilities. The timeframe shall provide a reasonable and adequate
opportunity for the Medi-Cal beneficiary to obtain and submit
medical records and other information needed to establish
eligibility for Medi-Cal based upon disability.

(n) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary’s vision has
improved beyond the definition of blindness contained in the plan.

(o) The county shall consider disability as continuing until the
review team determines that a beneficiary’s disability no longer
meets the definition of disability contained in the plan.

(p) If a county has enough information available to it to renew
eligibility with respect to all eligibility criteria, the county shall
begin a new 12-month eligibility period.

(q)  For individuals determined ineligible for Medi-Cal, the
county shall determine eligibility for other state health subsidy
programs and comply with the procedures in Section 15926.

(r) Any renewal form or notice shall be accessible to persons
who are limited English proficient and persons with disabilities
consistent with all federal and state requirements.

(s) This section shall become operative January 1, 2014.

SEC. 13.  

Section 14005.60 is added to the Welfare and
Institutions Code, to read:

14005.60.  

(a) Commencing January 1, 2014, the department
shall provide eligibility for Medi-Cal benefits for any person who
meets the eligibility requirements of Section
1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security
Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)).

(b) Persons who qualify under subdivision (a) and are currently
enrolled in a Low Income Health Program (LIHP) under
California’s Bridge to Reform Section 1115(a) Medicaid
Demonstration shall be transitioned to the Medi-Cal program under
this section in accordance with the transition plan as approved by
the federal Centers for Medicare and Medicaid Services. With
respect to plan enrollment, a LIHP enrollee shall be all of the
following:

(1) Notified which Medi-Cal health plan or plans contain his or
her existing medical home provider.

(2) Notified that he or she can select a health plan that contains
his or her existing medical home provider.

(3) Provided the opportunity to choose a different health plan
if there is more than one plan available in the county where he or
she resides.

(4) Informed that if he or she does not affirmatively choose a
plan or there is only one plan in the county where he or she resides,
he or she shall be enrolled into the Medi-Cal managed care plan
that contains his or her LIHP medical home provider.

(c) In order to ensure that no persons lose health care coverage
in the course of the transition, the department shall require that
notices of the January 1, 2014, change be sent to LIHP enrollees
upon their LIHP redetermination in 2013 and again at least 90 days
prior to the transition. Pursuant to Section 1902(k)(1) and Section
1937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
1396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
shall seek approval from the United States Secretary of Health and
Human Services to establish a benchmark benefit package that
includes the same benefits, services, and coverage that are provided
to all other full-scope Medi-Cal enrollees, supplemented by any
benefits, services, and coverage included in the essential health
benefits package adopted by the state and approved by the United
States Secretary of Health and Human Services under Section
18022 of Title 42 of the United States Code.

SEC. 14.  

Section 14005.62 is added to the Welfare and
Institutions Code, to read:

14005.62.  

Commencing January 1, 2014, the department shall
accept an individual’s attestation of information and verify
information pursuant to Section 15926.2.

SEC. 15.  

Section 14005.63 is added to the Welfare and
Institutions Code, to read:

14005.63.  

(a) Commencing January 1, 2014, a person who
wishes to apply for a state health subsidy program, as defined in
subdivision (a) of Section 15926, shall be allowed to file an
application on his or her own behalf or on behalf of his or her
family. The individual also has the right to be accompanied,
assisted, and represented in the application and renewal process
by an individual or organization of his or her own choice. If the
individual for any reason is unable to apply or renew on his or her
own behalf, any of the following persons may file the application
for the applicant:

(1) The individual’s guardian, conservator, or executor.

(2) A public agency representative.

(3) The individual’s legal counsel, relative, friend, or other
spokesperson of his or her choice.

(b) A person who wishes to challenge a decision concerning his
or her eligibility for or receipt of benefits from a state health
subsidy program has the right to represent himself or herself or
use legal counsel, a relative, a friend, or other spokesperson of his
or her choice.

SEC. 16.  

Section 14005.64 is added to the Welfare and
Institutions Code, to read:

14005.64.  

(a) This section implements Section 1902(e)(14)(C)
of the federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(C))
and Section 435.603(g) of Title 42 of the Code of Federal
Regulations, which prohibits the use of an assets test for individuals
whose income eligibility is determined based on modified adjusted
gross income (MAGI), and Section 2002 of the federal Patient
Protection and Affordable Care Act (Affordable Care Act) (42
U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of Title 42
of the Code of Federal Regulations, which requires a 5-percent
income disregard for individuals whose income eligibility is
determined based on MAGI.

(b) In the case of individuals whose financial eligibility for
Medi-Cal is determined based on the application of MAGI pursuant
to Section 435.603 of Title 42 of the Code of Federal Regulations,
the eligibility determination shall not include any assets or
resources test.

(c) The department shall implement the 5-percent income
disregard for individuals whose income eligibility is determined
based on MAGI in Section 2002 of the Affordable Care Act (42
U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of the Title
42 of the Code of Federal Regulations.

(d) The department shall adopt an equivalent income level for
each eligibility group whose income level will be converted to
MAGI. The equivalent income level shall not be less than the dollar
amount of all income exemptions, exclusions, deductions, and
disregards in effect on March 23, 2010, plus the existing income
level expressed as a percent of the federal poverty level for each
eligibility group so as to ensure that the use of MAGI income
methodology does not result in populations who would have been
eligible under this chapter and Part 6.3 (commencing with Section
12695) of Division 2 of the Insurance Code losing coverage.

(e) This section shall become operative on January 1, 2014.

SEC. 17.  

Section 14008.85 of the Welfare and Institutions
Code is amended to read:

14008.85.  

(a) To the extent federal financial participation is
available, a parent who is the principal wage earner shall be
considered an unemployed parent for purposes of establishing
eligibility based upon deprivation of a child where any of the
following applies:

(1) The parent works less than 100 hours per month as
determined pursuant to the rules of the Aid to Families with
Dependent Children program as it existed on July 16, 1996,
including the rule allowing a temporary excess of hours due to
intermittent work.

(2) The total net nonexempt earned income for the family is not
more than 100 percent of the federal poverty level as most recently
calculated by the federal government. The department may adopt
additional deductions to be taken from a family’s income.

(3) The parent is considered unemployed under the terms of an
existing federal waiver of the 100-hour rule for recipients under
the program established by Section 1931(b) of the federal Social
Security Act (42 U.S.C. Sec. 1396u-1).

(b) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall implement this section by means of an all
county letter or similar instruction without taking regulatory action.
Thereafter, the department shall adopt regulations in accordance
with the requirements of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.

begin delete

(c) This section shall become operative March 1, 2000.

end delete begin insert

(c) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 18.  

Section 14011.16 of the Welfare and Institutions
Code is amended to read:

14011.16.  

(a) Commencing August 1, 2003, the department
shall implement a requirement for beneficiaries to file semiannual
status reports as part of the department’s procedures to ensure that
beneficiaries make timely and accurate reports of any change in
circumstance that may affect their eligibility. The department shall
develop a simplified form to be used for this purpose. The
department shall explore the feasibility of using a form that allows
a beneficiary who has not had any changes to so indicate by
checking a box and signing and returning the form.

(b) Beneficiaries who have been granted continuous eligibility
under Section 14005.25 shall not be required to submit semiannual
status reports. To the extent federal financial participation is
available, all children under 19 years of age shall be exempt from
the requirement to submit semiannual status reports.

(c) For any period of time that the continuous eligibility period
described in paragraph (1) of subdivision (a) of Section 14005.25
is reduced to six months, subdivision (b) shall become inoperative,
and all children under 19 years of age shall be required to file
semiannual status reports.

(d) Beneficiaries whose eligibility is based on a determination
of disability or on their status as aged or blind shall be exempt
from the semiannual status report requirement described in
subdivision (a). The department may exempt other groups from
the semiannual status report requirement as necessary for simplicity
of administration.

(e) When a beneficiary has completed, signed, and filed a
semiannual status report that indicated a change in circumstance,
eligibility shall be redetermined.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department shall implement this section by means of all-county
letters or similar instructions without taking regulatory action.
Thereafter, the department shall adopt regulations in accordance
with the requirements of Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.

(g) This section shall be implemented only if and to the extent
federal financial participation is available.

begin insert

(h) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 19.  

Section 14011.17 of the Welfare and Institutions
Code is amended to read:

14011.17.  

The following persons shall be exempt from the
semiannual reporting requirements described in Section 14011.16:

(a) Pregnant women whose eligibility is based on pregnancy.

(b) Beneficiaries receiving Medi-Cal through Aid for Adoption
of Children Program.

(c) Beneficiaries who have a public guardian.

(d) Medically indigent children who are not living with a parent
or relative and who have a public agency assuming their financial
responsibility.

(e) Individuals receiving minor consent services.

(f) Beneficiaries in the Breast and Cervical Cancer Treatment
Program.

(g) Beneficiaries who are CalWORKs recipients and custodial
parents whose children are CalWORKs recipients.

begin insert

(h) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 20.  

Section 14012 of the Welfare and Institutions Code
is amended to read:

14012.  

begin insert (a) end insert begin insert   end insert Reaffirmation shall be filed annually and may be
required at other times in accordance with general standards
established by the department.

begin insert

(b) This section shall remain in effect only until January 1, 2014,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2014, deletes or extends that date.

end insert

SEC. 21.  

Section 14012 is added to the Welfare and Institutions
Code, to read:

14012.  

(a) This section implements Section 435.916(a)(1) of
Title 42 of the Code of Federal Regulations, which applies to the
eligibility of Medi-Cal beneficiaries whose financial eligibility is
determined using modified adjusted gross income (MAGI) based
income.

(b) To the extent required by federal law or regulations, the
eligibility of Medi-Cal beneficiaries whose financial eligibility is
determined using a MAGI-based income shall be renewed once
every 12 months, and no more frequently than every 12 months.

(c) This section shall become operative on January 1, 2014.

SEC. 22.  

Section 14132 of the Welfare and Institutions Code
is amended to read:

14132.  

The following is the schedule of benefits under this
chapter:

(a) Outpatient services are covered as follows:

Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer
or healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by
federal participation under an approved plan, subject to utilization
controls.

(b) (1) Inpatient hospital services, including, but not limited
to, physician and podiatric services, physical therapy and
occupational therapy, are covered subject to utilization controls.

(2) For Medi-Cal fee-for-service beneficiaries, emergency
services and care that are necessary for the treatment of an
emergency medical condition and medical care directly related to
the emergency medical condition. This paragraph shall not be
construed to change the obligation of Medi-Cal managed care
plans to provide emergency services and care. For the purposes of
this paragraph, “emergency services and care” and “emergency
medical condition” shall have the same meanings as those terms
are defined in Section 1317.1 of the Health and Safety Code.

(c) Nursing facility services, subacute care services, and services
provided by any category of intermediate care facility for the
developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.

(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.

(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.

(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall
conform to the guidance issued by the federal Centers of Medicare
and Medicaid Services but shall not conflict with state statutes on
the characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety
Code. The department shall provide providers and beneficiaries
with as much flexibility in implementing these rules as allowed
by the federal government. The department shall notify and consult
with appropriate stakeholders in implementing, interpreting, or
making specific this paragraph.

(B) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may take the actions specified in subparagraph (A)
by means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.

(4) (A) (i) For the purposes of this paragraph, nonlegend has
the same meaning as defined in subdivision (a) of Section
14105.45.

(ii) Nonlegend acetaminophen-containing products, with the
exception of children’s acetaminophen-containing products,
selected by the department are not covered benefits.

(iii) Nonlegend cough and cold products selected by the
department are not covered benefits. This clause shall be
implemented on the first day of the first calendar month following
90 days after the effective date of the act that added this clause,
or on the first day of the first calendar month following 60 days
after the date the department secures all necessary federal approvals
to implement this section, whichever is later.

(iv) Beneficiaries under the Early and Periodic Screening,
Diagnosis, and Treatment Program shall be exempt from clauses
(ii) and (iii).

(B) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may take the actions specified in subparagraph (A)
by means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.

(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and
equipment required for dialysis, are covered, subject to utilization
controls.

(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.

(g) Blood and blood derivatives are covered.

(h) (1) Emergency and essential diagnostic and restorative
dental services, except for orthodontic, fixed bridgework, and
partial dentures that are not necessary for balance of a complete
artificial denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary
to prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary’s control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical
conditions that preclude the use of removable dental prostheses,
and for orthodontic services in cleft palate deformities administered
by the department’s California Children Services Program.

(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:

(A) Periodontal treatment is not a benefit.

(B) Endodontic therapy is not a benefit except for vital
pulpotomy.

(C) Laboratory processed crowns are not a benefit.

(D) Removable prosthetics shall be a benefit only for patients
as a requirement for employment.

(E) The director may, by regulation, provide for the provision
of fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.

(F) Notwithstanding the conditions specified in subparagraphs
(A) to (E), inclusive, the department may approve services for
persons with special medical disorders subject to utilization review.

(3) Paragraph (2) shall become inoperative July 1, 1995.

(i) Medical transportation is covered, subject to utilization
controls.

(j) Home health care services are covered, subject to utilization
controls.

(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances
beyond the beneficiary’s control. Frame styles for eyeglasses
replaced pursuant to this subdivision shall not change more than
once every two years, unless the department so directs.

Orthopedic and conventional shoes are covered when provided
by a prosthetic and orthotic supplier on the prescription of a
physician and when at least one of the shoes will be attached to a
prosthesis or brace, subject to utilization controls. Modification
of stock conventional or orthopedic shoes when medically
indicated, is covered subject to utilization controls. When there is
a clearly established medical need that cannot be satisfied by the
modification of stock conventional or orthopedic shoes,
custom-made orthopedic shoes are covered, subject to utilization
controls.

Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.

(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances
beyond the beneficiary’s control.

(m) Durable medical equipment and medical supplies are
covered, subject to utilization controls. The utilization controls
shall allow the replacement of durable medical equipment and
medical supplies when necessary because of loss or destruction
due to circumstances beyond the beneficiary’s control. The
utilization controls shall allow authorization of durable medical
equipment needed to assist a disabled beneficiary in caring for a
child for whom the disabled beneficiary is a parent, stepparent,
foster parent, or legal guardian, subject to the availability of federal
financial participation. The department shall adopt emergency
regulations to define and establish criteria for assistive durable
medical equipment in accordance with the rulemaking provisions
of the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code).

(n) Family planning services are covered, subject to utilization
controls.

(o) Inpatient intensive rehabilitation hospital services, including
respiratory rehabilitation services, in a general acute care hospital
are covered, subject to utilization controls, when either of the
following criteria are met:

(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.

(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient’s present functional level as
long as possible.

(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).

(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request,
adult day health care is covered for a maximum of three days per
week.

(3) As provided in accordance with paragraph (4), adult day
health care is covered for a maximum of five days per week.

(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2)
shall become inoperative and paragraph (3) shall become operative.

(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.

(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and
1770 of the Business and Professions Code may be covered as
long as they are within the scope of Denti-Cal benefits and they
are necessary services provided by a registered dental hygienist
in alternative practice.

(r) (1) Paramedic services performed by a city, county, or
special district, or pursuant to a contract with a city, county, or
special district, and pursuant to a program established under Article
3 (commencing with Section 1480) of Chapter 2.5 of Division 2
of the Health and Safety Code by a paramedic certified pursuant
to that article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.

(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming
a Medi-Cal provider.

(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.

(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time
in an acute care hospital at a cost higher than in-home medical
care services. The director shall have the authority under this
section to contract with organizations qualified to provide in-home
medical care services to those persons. These services may be
provided to patients placed in shared or congregate living
arrangements, if a home setting is not medically appropriate or
available to the beneficiary. As used in this section, “in-home
medical care service” includes utility bills directly attributable to
continuous, 24-hour operation of life-sustaining medical equipment,
to the extent that federal financial participation is available.

As used in this subdivision, in-home medical care services,
include, but are not limited to:

(1) Level of care and cost of care evaluations.

(2) Expenses, directly attributable to home care activities, for
materials.

(3) Physician fees for home visits.

(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.

(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.

(6) Medically related personal services.

(7) Home nursing education.

(8) Emergency maintenance repair.

(9) Home health agency personnel benefits which permit
coverage of care during periods when regular personnel are on
vacation or using sick leave.

(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.

(11) Emergency and nonemergency medical transportation.

(12) Medical supplies.

(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.

(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.

(15) Special drugs and medications.

(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency
rate.

(17) Therapy services.

(18) Household appliances and household utensil costs directly
attributable to home care activities.

(19) Modification of medical equipment for home use.

(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.

(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.

Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.

(t) Home- and community-based services approved by the
United States Department of Health and Human Services may be
covered to the extent that federal financial participation is available
for those services under waivers granted in accordance with Section
1396n of Title 42 of the United States Code. The director may
seek waivers for any or all home- and community-based services
approvable under Section 1396n of Title 42 of the United States
Code. Coverage for those services shall be limited by the terms,
conditions, and duration of the federal waivers.

(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section
14134.5 and meeting the standards developed by the department
pursuant to Section 14134.5, subject to utilization controls.

The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for
which waivers are not required shall be implemented
notwithstanding any inability to obtain federal waivers for the
other provisions. No provision of this subdivision shall be
implemented unless matching funds from Subchapter XIX
(commencing with Section 1396) of Chapter 7 of Title 42 of the
United States Code are available.

(v) Early and periodic screening, diagnosis, and treatment for
any individual under 21 years of age is covered, consistent with
the requirements of Subchapter XIX (commencing with Section
1396) of Chapter 7 of Title 42 of the United States Code.

(w) Hospice service which is Medicare-certified hospice service
is covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs
are incurred.

(x) When a claim for treatment provided to a beneficiary
includes both services which are authorized and reimbursable
under this chapter, and services which are not reimbursable under
this chapter, that portion of the claim for the treatment and services
authorized and reimbursable under this chapter shall be payable.

(y) Home- and community-based services approved by the
United States Department of Health and Human Services for
beneficiaries with a diagnosis of AIDS or ARC, who require
intermediate care or a higher level of care.

Services provided pursuant to a waiver obtained from the
Secretary of the United States Department of Health and Human
Services pursuant to this subdivision, and which are not otherwise
included in the Medi-Cal schedule of benefits, shall be available
only to the extent that federal financial participation for these
services is available in accordance with the waiver, and subject to
the terms, conditions, and duration of the waiver. These services
shall be provided to individual beneficiaries in accordance with
the client’s needs as identified in the plan of care, and subject to
medical necessity and applicable utilization control.

The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.

(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).

(aa) (1) There is hereby established in the department, a
program to provide comprehensive clinical family planning
services to any person who has a family income at or below 200
percent of the federal poverty level, as revised annually, and who
is eligible to receive these services pursuant to the waiver identified
in paragraph (2). This program shall be known as the Family
Planning, Access, Care, and Treatment (Family PACT) Program.

(2) The department shall seek a waiver in accordance with
Section 1315 of Title 42 of the United States Code, or a state plan
amendment adopted in accordance with Section
begin delete 1396a(a)(10)(A)(ii)(XXI)(ii)(2) end delete begin insert 1396a(a)(10)(A)(ii)(XXI) end insert of Title
42 of the United States Code, which was added to Section 1396a
of Title 42 of the United States Code by Section 2303(a)(2) of the
federal Patient Protection and Affordable Care Act (PPACA)
(Public Law 111-148), for a program to provide comprehensive
clinical family planning services as described in paragraph (8).
Under the waiver, the program shall be operated only in accordance
with the waiver and the statutes and regulations in paragraph (4)
and subject to the terms, conditions, and duration of the waiver.
Under the state plan amendment, which shall replace the waiver
and shall be known as the Family PACT successor state plan
amendment, the program shall be operated only in accordance with
this subdivision and the statutes and regulations in paragraph (4).
The state shall use the standards and processes imposed by the
state on January 1, 2007, including the application of an eligibility
discount factor to the extent required by the federal Centers for
Medicare and Medicaid Services, for purposes of determining
eligibility as permitted under Section
begin delete 1396a(a)(10)(A)(ii)(XXI)(ii)(2) end delete begin insert 1396a(a)(10)(A)(ii)(XXI) end insert of Title
42 of the United States Code. To the extent that federal financial
participation is available, the program shall continue to conduct
education, outreach, enrollment, service delivery, and evaluation
services as specified under the waiver. The services shall be
provided under the program only if the waiver and, when
applicable, the successor state plan amendment are approved by
the federal Centers for Medicare and Medicaid Services and only
to the extent that federal financial participation is available for the
services. Nothing in this section shall prohibit the department from
seeking the Family PACT successor state plan amendment during
the operation of the waiver.

(3) Solely for the purposes of the waiver or Family PACT
successor state plan amendment and notwithstanding any other
provision of law, the collection and use of an individual’s social
security number shall be necessary only to the extent required by
federal law.

(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005,
and 24013, and any regulations adopted under these statutes shall
apply to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only
Family Planning Program shall apply to the program provided for
under this subdivision.

(5) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, without taking regulatory action,
the provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section
by means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement
this section and the approved waiver in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of the act adding this
subdivision, the department shall provide a status report to the
Legislature on a semiannual basis until regulations have been
adopted.

(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described
in paragraph (2) or the Family PACT successor state plan
amendment is no longer cost effective, this subdivision shall
become inoperative on the first day of the first month following
the issuance of a 30-day notification of that determination in
writing by the Department of Finance to the chairperson in each
house that considers appropriations, the chairpersons of the
committees, and the appropriate subcommittees in each house that
considers the State Budget, and the Chairperson of the Joint
Legislative Budget Committee.

(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either
if they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.

(8) For purposes of this subdivision, “comprehensive clinical
family planning services” means the process of establishing
objectives for the number and spacing of children, and selecting
the means by which those objectives may be achieved. These
means include a broad range of acceptable and effective methods
and services to limit or enhance fertility, including contraceptive
methods, federal Food and Drug Administration approved
contraceptive drugs, devices, and supplies, natural family planning,
abstinence methods, and basic, limited fertility management.
Comprehensive clinical family planning services include, but are
not limited to, preconception counseling, maternal and fetal health
counseling, general reproductive health care, including diagnosis
and treatment of infections and conditions, including cancer, that
threaten reproductive capability, medical family planning treatment
and procedures, including supplies and followup, and
informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive
clinical family planning services shall be subject to utilization
control and include all of the following:

(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and
supplies, and followup, consultation, and referral services, as
indicated, which may require treatment authorization requests.

(B) All United States Department of Agriculture, federal Food
and Drug Administration approved contraceptive drugs, devices,
and supplies that are in keeping with current standards of practice
and from which the individual may choose.

(C) Culturally and linguistically appropriate health education
and counseling services, including informed consent, that include
all of the following:

(i) Psychosocial and medical aspects of contraception.

(ii) Sexuality.

(iii) Fertility.

(iv) Pregnancy.

(v) Parenthood.

(vi) Infertility.

(vii) Reproductive health care.

(viii) Preconception and nutrition counseling.

(ix) Prevention and treatment of sexually transmitted infection.

(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and
supplies.

(xi) Possible contraceptive consequences and followup.

(xii) Interpersonal communication and negotiation of
relationships to assist individuals and couples in effective
contraceptive method use and planning families.

(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.

(E) A complete physical examination on initial and subsequent
periodic visits.

(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.

(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.

(ab) (1) Purchase of prescribed enteral nutrition products is
covered, subject to the Medi-Cal list of enteral nutrition products
and utilization controls.

(2) Purchase of enteral nutrition products is limited to those
products to be administered through a feeding tube, including, but
not limited to, a gastric, nasogastric, or jejunostomy tube.
Beneficiaries under the Early and Periodic Screening, Diagnosis,
and Treatment Program shall be exempt from this paragraph.

(3) Notwithstanding paragraph (2), the department may deem
an enteral nutrition product, not administered through a feeding
tube, including, but not limited to, a gastric, nasogastric, or
jejunostomy tube, a benefit for patients with diagnoses, including,
but not limited to, malabsorption and inborn errors of metabolism,
if the product has been shown to be neither investigational nor
experimental when used as part of a therapeutic regimen to prevent
serious disability or death.

(4) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement the amendments to this subdivision
made by the act that added this paragraph by means of all-county
letters, provider bulletins, or similar instructions, without taking
regulatory action.

(5) The amendments made to this subdivision by the act that
added this paragraph shall be implemented June 1, 2011, or on the
first day of the first calendar month following 60 days after the
date the department secures all necessary federal approvals to
implement this section, whichever is later.

(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.

begin insert

(ad) Commencing January 1, 2014, any benefits, services, and
coverage not otherwise described in this section that are included
in the essential health benefits package adopted by the state and
approved by the United States Secretary of Health and Human
Services under Section 18022 of Title 42 of the United States Code.

end insert

SEC. 23.  

Section 14132.02 is added to the Welfare and
Institutions Code, to read:

14132.02.  

(a) Pursuant to Sections 1902(k)(1) and
1937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
1396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
shall seek approval from the United States Secretary of Health and
Human Services to establish a benchmark benefit package that
includes the same benefits, services, and coverage as is provided
to all other full-scope Medi-Cal enrollees, supplemented by any
benefits, services, and coverage included in the essential health
benefits package adopted by the state and approved by the secretary
under Section 18022 of Title 42 of the United States Code.

(b) This section shall become operative January 1, 2014.

SEC. 24.  

Section 15926 of the Welfare and Institutions Code
is amended to read:

15926.  

(a) The following definitions apply for purposes of
this part:

(1) “Accessible” means in compliance with Section 11135 of
the Government Code, Section 1557 of the PPACA, and regulations
or guidance adopted pursuant to these statutes.

(2) “Limited-English-proficient” means not speaking English
as one’s primary language and having a limited ability to read,
speak, write, or understand English.

(3) “State health subsidy programs” means the programs
described in Section 1413(e) of the PPACA.

(b) An individual shall have the option to apply for state health
subsidy programs in person, by mail, online, by telephone, or by
other commonly available electronic means.

(c) (1) A single, accessible, standardized paper, electronic, and
telephone application for state health subsidy programs shall be
developed by the department in consultation with MRMIB and
the board governing the Exchange as part of the stakeholder process
described in subdivision (b) of Section 15925. The application
shall be used by all entities authorized to make an eligibility
determination for any of the state health subsidy programs and by
their agents.

(2) The application shall be tested and operational by the date
as required by the federal Secretary of Health and Human Services.

(3) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:

(A) The form shall include simple, user-friendly language and
instructions.

(B) The form may not ask for information related to a
nonapplicant that is not necessary to determine eligibility in the
applicant’s particular circumstances.

(C) The form may require only information necessary to support
the eligibility and enrollment processes for state health subsidy
programs.

(D) The form may be used for, but shall not be limited to,
screening.

(E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through a state health subsidy program for the infant’s birth, for
the purpose of automatically enrolling the infant into the applicable
program without the family having to complete the application
process for the infant.

(F) The form may include questions that are voluntary for
applicants to answer regarding demographic data categories,
including race, ethnicity, primary language, disability status, and
other categories recognized by the federal Secretary of Health and
Human Services under Section 4302 of the PPACA.

(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for state
health subsidy programs or other health programs that differs from
the application form described in subdivision (c), and related
enrollment procedures.

(e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of
the applicant in accordance with the state and federal rules
governing state health subsidy programs.

(f) (1) If the eligibility, enrollment, and retention system has
the ability to prepopulate an application form for insurance
affordability programs with personal information from available
electronic databases, an applicant shall be given the option, with
his or her informed consent, to have the application form
prepopulated. Before a prepopulated renewal form or, if available,
prepopulated application is submitted to the entity authorized to
make eligibility determinations, the individual shall be given the
opportunity to provide additional eligibility information and to
correct any information retrieved from a database.

(2) All state health subsidy programs begin delete may end delete begin insert shall end insert accept
self-attestation, instead of requiring an individual to produce a
document, begin delete with respect to all information end delete begin insert end insert begin insert for age, date of birth, end insert
begin insert family size, household income, state residence, pregnancy, and end insert
begin insert any other applicable end insert begin insert criteria end insert needed to determine the eligibility
of an applicant or recipient, to the extent permitted by state and
federal law.

(3) An applicant or recipient shall have his or her information
electronically verified in the manner required by the PPACA and
implementing federal regulations and guidance.

(4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.

(5) The eligibility of an applicant shall not be delayed or denied
for any state health subsidy program unless the applicant is given
a reasonable opportunity, of at least the kind provided for under
the Medi-Cal program pursuant to Section 14007.5 and paragraph
(7) of subdivision (e) of Section 14011.2, to resolve discrepancies
concerning any information provided by a verifying entity.

(6) To the extent federal financial participation is available, an
applicant shall be provided benefits in accordance with the rules
of the state health subsidy program, as implemented in federal
regulations and guidance, for which he or she otherwise qualifies
until a determination is made that he or she is not eligible and all
applicable notices have been provided. Nothing in this section
shall be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.

(g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for a state health subsidy program in person, over the
telephone, and online, and in a manner that is accessible to
individuals with disabilities and those who are limited English
proficient.

(h) (1) During the processing of an application, renewal, or a
transition due to a change in circumstances, an entity making
eligibility determinations for a state health subsidy program shall
ensure that an eligible applicant and recipient of state health
subsidy programs that meets all program eligibility requirements
and complies with all necessary requests for information moves
between programs without any breaks in coverage and without
being required to provide any forms, documents, or other
information or undergo verification that is duplicative or otherwise
unnecessary. The individual shall be informed about how to obtain
information about the status of his or her application, renewal, or
transfer to another program at any time, and the information shall
be promptly provided when requested.

(2) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross
Income (MAGI) household income but who may be eligible on
the basis of being 65 years of age or older, or on the basis of
blindness or disability, shall be forwarded to the Medi-Cal program
for an eligibility determination. During the period this application
or case is processed for a non-MAGI Medi-Cal eligibility
determination, if the applicant or recipient is otherwise eligible
for a state health subsidy program, he or she shall be determined
eligible for that program.

(3) Renewal procedures shall include all available methods for
reporting renewal information, including, but not limited to,
face-to-face, telephone, and online renewal.

(4) An applicant who is not eligible for a state health subsidy
program for a reason other than income eligibility, or for any reason
in the case of applicants and recipients residing in a county that
offers a health coverage program for individuals with income above
the maximum allowed for the Exchange premium tax credits, shall
be referred to the county health coverage program in his or her
county of residence.

(i) Notwithstanding subdivisions (e), (f), and (j), before an online
applicant who appears to be eligible for the Exchange with a
premium tax credit or reduction in cost sharing, or both, may be
enrolled in the Exchange, both of the following shall occur:

(1) The applicant shall be informed of the overpayment penalties
under the federal Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011
(Public Law 112-9), if the individual’s annual family income
increases by a specified amount or more, calculated on the basis
of the individual’s current family size and current income, and that
penalties are avoided by prompt reporting of income increases
throughout the year.

(2) The applicant shall be informed of the penalty for failure to
have minimum essential health coverage.

(j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among state health subsidy programs using the least
restrictive rules and requirements permitted by federal and state
law. This process shall include the consideration of methodologies
for determining income levels, assets, rules for household size,
citizenship and immigration status, and self-attestation and
verification requirements.

(k) (1) Forms and notices developed pursuant to this section
shall be accessible and standardized, as appropriate, and shall
comply with federal and state laws, regulations, and guidance
prohibiting discrimination.

(2) Forms and notices developed pursuant to this section shall
be developed using plain language and shall be provided in a
manner that affords meaningful access to limited-English-proficient
individuals, in accordance with applicable state and federal law,
and at a minimum, provided in the same threshold languages as
required for Medi-Cal managed care plans.

(l) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall establish a process
for receiving and acting on stakeholder suggestions regarding the
functionality of the eligibility systems supporting the Exchange,
including the activities of all entities providing eligibility screening
to ensure the correct eligibility rules and requirements are being
used. This process shall include consumers and their advocates,
be conducted no less than quarterly, and include the recording,
review, and analysis of potential defects or enhancements of the
eligibility systems. The process shall also include regular updates
on the work to analyze, prioritize, and implement corrections to
confirmed defects and proposed enhancements, and to monitor
screening.

(m) In designing and implementing the eligibility, enrollment,
and retention system, the department, MRMIB, and the Exchange
board shall ensure that all privacy and confidentiality rights under
the PPACA and other federal and state laws are incorporated and
followed, including responses to security breaches.

(n) Except as otherwise specified, this section shall be operative
on and after January 1, 2014.

SEC. 25.  

Section 15926.2 is added to the Welfare and
Institutions Code, to read:

15926.2.  

In accordance with paragraph (2) of subdivision (f)
of Section 15926 and Sections 435.945(a) and 435.956 of Title 42
of the Code of Federal Regulations, state health subsidy programs
shall accept an individual’s attestation, without further
documentation from the individual, for age, date of birth, family
size, household income, state residence, pregnancy, and any other
applicable eligibility criteria for which attestation is permitted by
federal law.

SEC. 26.  

If the Commission on State Mandates determines
that this act contains costs mandated by the state, reimbursement
to local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division
4 of Title 2 of the Government Code.