California Legislature—2013–14 First Extraordinary Session

Senate BillNo. 1


Introduced by Senators Hernandez and Steinberg

January 28, 2013


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, 14007.1, 14007.6, and 14012 of, and to add Sections 14005.60, 14005.62, 14005.63, 14005.64, 14005.65, and 14132.02 to, the Welfare and Institutions Code, relating to health.

LEGISLATIVE COUNSEL’S DIGEST

SB 1, 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:

P2    1

SECTION 1.  

The Legislature finds and declares all of the
2following:

3(a) The United States is the only industrialized country in the
4world without a universal health insurance system.

5(b) (1) In 2006, the United States Census reported that 46
6million Americans did not have health insurance.

7(2) In California in 2009, according to the UCLA Center for
8Health Policy Research’s “The State of Health Insurance in
9California: Findings from the 2009 California Health Interview
10Survey,” 7.1 million Californians were uninsured in 2009,
11amounting to 21.1 percent of nonelderly Californians who had no
12health insurance coverage for all or some of 2009, up nearly 2
13percentage points from 2007.

14(c) On March 23, 2010, President Obama signed the Patient
15Protection and Affordable Care Act (Public Law 111-148), which
16was amended by the Health Care and Education Reconciliation
17Act of 2010 (Public Law 111-152), and together are referred to as
18the Affordable Care Act of 2010 (Affordable Care Act).

19(d) The Affordable Care Act is the culmination of decades of
20movement toward health reform, and is the most fundamental
P3    1legislative transformation of the United States health care system
2in 40 years.

3(e) As a result of the enactment of the Affordable Care Act,
4according to estimates by the UCLA Center for Health Policy
5Research and the UC Berkeley Labor Center, using the California
6Simulation of Insurance Markets, in 2019, after the Affordable
7Care Act is fully implemented:

8(1) Between 89 and 92 percent of Californians under 65 years
9of age will have health coverage.

10(2) Between 1.2 and 1.6 million individuals will be newly
11enrolled in Medi-Cal.

12(f) It is the intent of the Legislature to ensure full implementation
13of the Affordable Care Act, including the Medi-Cal expansion for
14individuals with incomes below 133 percent of the federal poverty
15level, so that millions of uninsured Californians can receive health
16care coverage.

17

SEC. 2.  

Section 12698.30 of the Insurance Code is amended
18to read:

19

12698.30.  

(a) begin deleteAt end deletebegin insert(1)end insertbegin insertend insertbegin insertSubject to paragraph (2), at end inserta minimum,
20coverage shall be provided to subscribers during one pregnancy,
21and for 60 days thereafter, and to children less than two years of
22age who were born of a pregnancy covered under this program to
23a woman enrolled in the program before July 1, 2004.

begin insert

24(2) Commencing January 1, 2014, at a minimum, coverage shall
25be provided to subscribers during one pregnancy, and until the
26end of the month in which the 60th day thereafter occurs, and to
27children less than two years of age who were born of a pregnancy
28covered under this program to a woman enrolled in the program
29before July 1, 2004.

end insert

30(b) Coverage provided pursuant to this part shall include, at a
31minimum, those services required to be provided by health care
32service plans approved by thebegin insert United Statesend insert Secretary of Health
33and Human Services as a federally qualified health care service
34plan pursuant to Section 417.101 of Title 42 of the Code of Federal
35Regulations.

36(c) Coverage shall include health education services related to
37tobacco use.

38(d) Medically necessary prescription drugs shall be a required
39benefit in the coverage provided under this part.

P4    1

SEC. 3.  

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

3

14005.18.  

begin insert(a)end insertbegin insertend insertA woman is eligible, to the extent required by
4federal law, as though she were pregnant, for all pregnancy-related
5and postpartum services for a 60-day period beginning on the last
6day of pregnancy.

7For purposes of this section, “postpartum services” means those
8services provided after childbirth, child delivery, or miscarriage.

begin insert

9(b) This section shall remain in effect only until January 1, 2014,
10and as of that date is repealed, unless a later enacted statute, that
11is enacted before January 1, 2014, deletes or extends that date.

end insert
12

SEC. 4.  

Section 14005.18 is added to the Welfare and
13Institutions Code
, to read:

14

14005.18.  

(a) To help prevent premature delivery and low
15birthweights, the leading causes of infant and maternal morbidity
16and mortality, and to promote women’s overall health, well-being,
17and financial security and that of their families, it is imperative
18that pregnant women enrolled in Medi-Cal be provided with all
19medically necessary services. Therefore, a woman is eligible, to
20the extent required by federal law, as though she were pregnant,
21for all pregnancy-related and postpartum services for a 60-day
22period beginning on the last day of pregnancy and continuing until
23the end of the month in which the 60th day of postpartum occurs.

24(b) For purposes of this section, the following definitions shall
25apply:

26(1) “Pregnancy-related services” means, at a minimum, all
27services required under the state plan unless federal approval is
28granted after January 1, 2014, pursuant to the procedure under the
29Preamble to the Final Rule at page 17149 of volume 77 of the
30Federal Register (March 23, 2012) to provide fewer benefits during
31pregnancy.

32(2) “Postpartum services” means those services provided after
33child birth, child delivery, or miscarriage.

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

35

SEC. 5.  

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

37

14005.28.  

(a) To the extent federal financial participation is
38available pursuant to an approved state plan amendment, the
39department shall exercise its option under Section
40begin delete 1902(a)(10)(A)(XV)end deletebegin insert 1902(a)(10)(A)(ii)(XVII)end insert of the federal Social
P5    1Security Act (42 U.S.C. Sec.begin delete 1396a(a)(10)(A)(XV))end delete
2begin insert 1396a(a)(10)(A)(ii)(XVII))end insert to extend Medi-Cal benefits to
3independent foster care adolescents, as defined in Section
4begin delete 1905(v)(1)end deletebegin insert 1905(w)(1)end insert of the federal Social Security Act (42 U.S.C.
5Sec.begin delete 1396d(v)(1))end deletebegin insert 1396d(w)(1))end insert.

6(b) Notwithstanding Chapter 3.5 (commencing with Section
711340) of Part 1 of Division 3 of Title 2 of the Government Code,
8and if the state plan amendment described in subdivision (a) is
9approved by the federal Health Care Financing Administration,
10the department may implement subdivision (a) without taking any
11regulatory action and by means of all-county letters or similar
12instructions. Thereafter, the department shall adopt regulations in
13accordance with the requirements of Chapter 3.5 (commencing
14with Section 11340) of Part 1 of Division 3 of Title 2 of the
15Government Code.

16(c) The department shall implement subdivision (a) on October
171, 2000, but only if, and to the extent that, the department has
18obtained all necessary federal approvals.

begin insert

19(d) The department shall identify and track all former
20independent foster care adolescents who, on or after January 1,
212013, lost Medi-Cal coverage as a result of attaining 21 years of
22age.

end insert
begin insert

23(e) This section shall remain in effect only until January 1, 2014,
24and as of that date is repealed, unless a later enacted statute, that
25is enacted before January 1, 2014, deletes or extends that date.

end insert
26

SEC. 6.  

Section 14005.28 is added to the Welfare and
27Institutions Code
, to read:

28

14005.28.  

(a) Commencing January 1, 2014, and to the extent
29federal financial participation is available pursuant to an approved
30state plan amendment, the department shall implement Section
311902(a)(10)(A)(i)(IX) of the federal Social Security Act (42 U.S.C.
32Sec. 1396a(a)(10)(A)(i)(IX)) to provide Medi-Cal benefits to a
33former foster care adolescent until his or her 26th birthday.

34(1) A foster care adolescent who was in foster care on his or
35her 18th birthday shall be deemed eligible for the benefits provided
36pursuant to this section and shall be enrolled to receive these
37benefits until his or her 26th birthday without any interruption in
38coverage and without requiring a new application.

39(2) The department shall develop procedures to identify
40individuals who meet the criteria in paragraph (1), including, but
P6    1not limited to, former foster care adolescents who lost Medi-Cal
2coverage as a result of attaining 21 years of age, and reenroll them
3in Medi-Cal.

4(3) The department shall develop and implement a simplified
5redetermination form for this program. A recipient qualifying for
6the benefits extended pursuant to this section shall fill out and
7return this form only if information previously reported to the
8department is no longer accurate. Failure to return the form alone
9will not constitute a basis for termination of Medi-Cal. If the form
10is returned as undeliverable and the county is otherwise unable to
11establish contact, the recipient shall remain eligible for
12fee-for-service Medi-Cal until such time as contact is reestablished
13or ineligibility is established, and to the extent federal financial
14participation is available. The department may terminate eligibility
15if it determines that the recipient is no longer eligible only after
16ineligibility is established and all due process requirements are
17met in accordance with state and federal law.

18(4) This section shall be implemented to the extent that federal
19financial participation is available, and any necessary federal
20approvals are obtained.

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

22

SEC. 7.  

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

24

14005.30.  

(a) (1) To the extent that federal financial
25participation is available, Medi-Cal benefits under this chapter
26shall be provided to individuals eligible for services under Section
271396u-1 of Title 42 of the United States Code, including any
28options under Section 1396u-1(b)(2)(C) made available to and
29exercised by the state.

30(2) The department shall exercise its option under Section
311396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
32less restrictive income and resource eligibility standards and
33methodologies to the extent necessary to allow all recipients of
34benefits under Chapter 2 (commencing with Section 11200) to be
35eligible for Medi-Cal under paragraph (1).

36(3) To the extent federal financial participation is available, the
37 department shall exercise its option under Section 1396u-1(b)(2)(C)
38of Title 42 of the United States Code authorizing the state to
39disregard all changes in income or assets of a beneficiary until the
40next annual redetermination under Section 14012. The department
P7    1shall implement this paragraph only if, and to the extent that the
2State Child Health Insurance Program waiver described in Section
312693.755 of the Insurance Code extending Healthy Families
4Program eligibility to parents and certain other adults is approved
5and implemented.

6(b) To the extent that federal financial participation is available,
7the department shall exercise its option under Section
81396u-1(b)(2)(C) of Title 42 of the United States Code as necessary
9to expand eligibility for Medi-Cal under subdivision (a) by
10establishing the amount of countable resources individuals or
11families are allowed to retain at the same amount medically needy
12individuals and families are allowed to retain, except that a family
13of one shall be allowed to retain countable resources in the amount
14of three thousand dollars ($3,000).

15(c) To the extent federal financial participation is available, the
16department shall, commencing March 1, 2000, adopt an income
17disregard for applicants equal to the difference between the income
18standard under the program adopted pursuant to Section 1931(b)
19of the federal Social Security Act (42 U.S.C. Sec. 1396u-1) and
20the amount equal to 100 percent of the federal poverty level
21applicable to the size of the family. A recipient shall be entitled
22to the same disregard, but only to the extent it is more beneficial
23than, and is substituted for, the earned income disregard available
24to recipients.

25(d) For purposes of calculating income under this section during
26any calendar year, increases in social security benefit payments
27under Title II of the federal Social Security Act (42 U.S.C. Sec.
28401 and following) arising from cost-of-living adjustments shall
29be disregarded commencing in the month that these social security
30benefit payments are increased by the cost-of-living adjustment
31through the month before the month in which a change in the
32federal poverty level requires the department to modify the income
33disregard pursuant to subdivision (c) and in which new income
34limits for the program established by this section are adopted by
35the department.

36(e) Subdivision (b) shall be applied retroactively to January 1,
371998.

38(f) Notwithstanding Chapter 3.5 (commencing with Section
3911340) of Part 1 of Division 3 of Title 2 of the Government Code,
40the department shall implement, without taking regulatory action,
P8    1subdivisions (a) and (b) of this section by means of an all county
2letter or similar instruction. Thereafter, the department shall adopt
3regulations in accordance with the requirements of Chapter 3.5
4(commencing with Section 11340) of Part 1 of Division 3 of Title
52 of the Government Code.

begin insert

6(g) This section shall remain in effect only until January 1, 2014,
7and as of that date is repealed, unless a later enacted statute, that
8is enacted before January 1, 2014, deletes or extends that date.

end insert
9

SEC. 8.  

Section 14005.30 is added to the Welfare and
10Institutions Code
, to read:

11

14005.30.  

(a) (1) To the extent that federal financial
12participation is available, Medi-Cal benefits under this chapter
13shall be provided to individuals eligible for services under Section
141396u-1 of Title 42 of the United States Code, known as the
15Section 1931(b) program, including any options under Section
161396u-1(b)(2)(C) made available to and exercised by the state.

17(2) The department shall exercise its option under Section
181396u-1(b)(2)(C) of Title 42 of the United States Code to adopt
19less restrictive income and resource eligibility standards and
20methodologies to the extent necessary to allow all recipients of
21benefits under Chapter 2 (commencing with Section 11200) to be
22eligible for Medi-Cal under paragraph (1).

23(b) Commencing January 1, 2014, pursuant to Section
241396a(e)(14)(C) of Title 42 of the United States Code, there shall
25be no assets test and no deprivation test for any individual under
26this section.

27(c) For purposes of calculating income under this section during
28any calendar year, increases in social security benefit payments
29under Title II of the federal Social Security Act (42 U.S.C. Sec.
30401 et seq.) arising from cost-of-living adjustments shall be
31disregarded commencing in the month that these social security
32benefit payments are increased by the cost-of-living adjustment
33through the month before the month in which a change in the
34federal poverty level requires the department to modify the income
35disregard pursuant to subdivision (c) and in which new income
36limits for the program established by this section are adopted by
37the department.

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

39

SEC. 9.  

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

P9    1

14005.31.  

(a) (1) Subject to paragraph (2), for any person
2whose eligibility for benefits under Section 14005.30 has been
3determined with a concurrent determination of eligibility for cash
4aid under Chapter 2 (commencing with Section 11200), loss of
5eligibility or termination of cash aid under Chapter 2 (commencing
6with Section 11200) shall not result in a loss of eligibility or
7termination of benefits under Section 14005.30 absent the existence
8of a factor that would result in loss of eligibility for benefits under
9Section 14005.30 for a person whose eligibility under Section
1014005.30 was determined without a concurrent determination of
11eligibility for benefits under Chapter 2 (commencing with Section
1211200).

13(2) Notwithstanding paragraph (1), a person whose eligibility
14would otherwise be terminated pursuant to that paragraph shall
15not have his or her eligibility terminated until the transfer
16procedures set forth in Section 14005.32 or the redetermination
17procedures set forth in Section 14005.37 and all due process
18requirements have been met.

19(b) The department, in consultation with the counties and
20representatives of consumers, managed care plans, and Medi-Cal
21providers, shall prepare a simple, clear, consumer-friendly notice
22to be used by the counties, to inform Medi-Cal beneficiaries whose
23eligibility for cash aid under Chapter 2 (commencing with Section
2411200) has ended, but whose eligibility for benefits under Section
2514005.30 continues pursuant to subdivision (a), that their benefits
26will continue. To the extent feasible, the notice shall be sent out
27at the same time as the notice of discontinuation of cash aid, and
28shall include all of the following:

29(1) A statement that Medi-Cal benefits will continue even though
30cash aid under the CalWORKs program has been terminated.

31(2) A statement that continued receipt of Medi-Cal benefits will
32not be counted against any time limits in existence for receipt of
33cash aid under the CalWORKs program.

34(3) begin insert(A)end insertbegin insertend insert A statement that the Medi-Cal beneficiary does not
35need to fill out monthly status reports in order to remain eligible
36for Medi-Cal, butbegin delete shallend deletebegin insert mayend insert be required to submit a semiannual
37status report and annual reaffirmation forms. The notice shall
38remind individuals whose cash aid ended under the CalWORKs
39program as a result of not submitting a status report that he or she
40should review his or her circumstances to determine if changes
P10   1have occurred that should be reported to the Medi-Cal eligibility
2worker.

begin insert

3(B) Commencing January 1, 2014, the semiannual status report
4requirement shall not be included in the statement described in
5subparagraph (A).

end insert

6(4) A statement describing the responsibility of the Medi-Cal
7beneficiary to report to the county, within 10 days, significant
8changes that may affect eligibility.

9(5) A telephone number to call for more information.

10(6) A statement that the Medi-Cal beneficiary’s eligibility
11worker will not change, or, if the case has been reassigned, the
12new worker’s name, address, and telephone number, and the hours
13during which the county’s eligibility workers can be contacted.

14(c) This section shall be implemented on or before July 1, 2001,
15but only to the extent that federal financial participation under
16Title XIX of the federal Social Security Actbegin delete (Title 42end deletebegin insert (42end insert U.S.C.
17Sec. 1396begin delete and following)end deletebegin insert et seq.)end insert is available.

18(d) Notwithstanding Chapter 3.5 (commencing with Section
1911340) of Part 1 of Division 3 of Title 2 of the Government Code,
20the department shall, without taking any regulatory action,
21implement this section by means of all county letters or similar
22instructions. Thereafter, the department shall adopt regulations in
23accordance with the requirements of Chapter 3.5 (commencing
24with Section 11340) of Part 1 of Division 3 of Title 2 of the
25Government Code. Comprehensive implementing instructions
26shall be issued to the counties no later than March 1, 2001.

27

SEC. 10.  

Section 14005.32 of the Welfare and Institutions
28Code
is amended to read:

29

14005.32.  

(a) (1) If the county has evidence clearly
30demonstrating that a beneficiary is not eligible for benefits under
31this chapter pursuant to Section 14005.30, but is eligible for
32benefits under this chapter pursuant to other provisions of law, the
33county shall transfer the individual to the corresponding Medi-Cal
34program. Eligibility under Section 14005.30 shall continue until
35the transfer is complete.

36(2) The department, in consultation with the counties and
37representatives of consumers, managed care plans, and Medi-Cal
38providers, shall prepare a simple, clear, consumer-friendly notice
39to be used by the counties, to inform beneficiaries that their
40Medi-Cal benefits have been transferred pursuant to paragraph (1)
P11   1and to inform them about the program to which they have been
2transferred. To the extent feasible, the notice shall be issued with
3the notice of discontinuance from cash aid, and shall include all
4of the following:

5(A) A statement that Medi-Cal benefits will continue under
6another program, even though aid under Chapter 2 (commencing
7with Section 11200) has been terminated.

8(B) The name of the program under which benefits will continue,
9and an explanation of that program.

10(C) A statement that continued receipt of Medi-Cal benefits will
11not be counted against any time limits in existence for receipt of
12cash aid under the CalWORKs program.

13(D) begin insert(i)end insertbegin insertend insertA statement that the Medi-Cal beneficiary does not need
14to fill out monthly status reports in order to remain eligible for
15Medi-Cal, butbegin delete shallend deletebegin insert mayend insert be required to submit a semiannual status
16report and annual reaffirmation forms. In addition, if the person
17or persons to whom the notice is directed has been found eligible
18for transitional Medi-Cal as described in Section 14005.8begin delete, end delete
19begin delete14005.81,end delete or 14005.85, the statement shall explain the reporting
20requirements and duration of benefits under those programs, and
21shall further explain that, at the end of the duration of these
22benefits, a redetermination, as provided for in Section 14005.37
23shall be conducted to determine whether benefits are available
24under any other provision of law.

begin insert

25(ii) Commencing January 1, 2014, the semiannual status report
26requirement shall not be included in the statement described in
27clause (i).

end insert

28(E) A statement describing the beneficiary’s responsibility to
29report to the county, within 10 days, significant changes that may
30affect eligibility or share of cost.

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

32(G) A statement that the beneficiary’s eligibility worker will
33not change, or, if the case has been reassigned, the new worker’s
34name, address, and telephone number, and the hours during which
35the county’s Medi-Cal eligibility workers can be contacted.

36(b) No later than September 1, 2001, the department shall submit
37a federal waiver application seeking authority to eliminate the
38reporting requirements imposed by transitional medicaid under
39Section 1925 of the federal Social Security Act (Title 42 U.S.C.
40Sec. 1396r-6).

P12   1(c) This section shall be implemented on or before July 1, 2001,
2but only to the extent that federal financial participation under
3Title XIX of the federal Social Security Actbegin delete (Title 42end deletebegin insert (42end insert U.S.C.
4Sec. 1396begin delete and following)end deletebegin insert et seq.)end insert is available.

5(d) Notwithstanding Chapter 3.5 (commencing with Section
611340) of Part 1 of Division 3 of Title 2 of the Government Code,
7the department shall, without taking any regulatory action,
8implement this section by means of all county letters or similar
9instructions. Thereafter, the department shall adopt regulations in
10accordance with the requirements of Chapter 3.5 (commencing
11with Section 11340) of Part 1 of Division 3 of Title 2 of the
12Government Code. Comprehensive implementing instructions
13shall be issued to the counties no later than March 1, 2001.

14

SEC. 11.  

Section 14005.37 of the Welfare and Institutions
15Code
is amended to read:

16

14005.37.  

(a) Except as provided in Section 14005.39,
17whenever a county receives information about changes in a
18beneficiary’s circumstances that may affect eligibility for Medi-Cal
19benefits, the county shall promptly redetermine eligibility. The
20procedures for redetermining Medi-Cal eligibility described in this
21section shall apply to all Medi-Cal beneficiaries.

22(b)  Loss of eligibility for cash aid under that program shall not
23result in a redetermination under this section unless the reason for
24the loss of eligibility is one that would result in the need for a
25redetermination for a person whose eligibility for Medi-Cal under
26Section 14005.30 was determined without a concurrent
27determination of eligibility for cash aid under the CalWORKs
28program.

29(c) A loss of contact, as evidenced by the return of mail marked
30in such a way as to indicate that it could not be delivered to the
31intended recipient or that there was no forwarding address, shall
32require a prompt redetermination according to the procedures set
33forth in this section.

34(d) Except as otherwise provided in this section, Medi-Cal
35eligibility shall continue during the redetermination process
36described in this section. A Medi-Cal beneficiary’s eligibility shall
37not be terminated under this section until the county makes a
38specific determination based on facts clearly demonstrating that
39the beneficiary is no longer eligible for Medi-Cal under any basis
P13   1and due process rights guaranteed under this division have been
2met.

3(e) For purposes of acquiring information necessary to conduct
4the eligibility determinations described in subdivisions (a) to (d),
5inclusive, a county shall make every reasonable effort to gather
6information available to the county that is relevant to the
7beneficiary’s Medi-Cal eligibility prior to contacting the
8beneficiary. Sources for these efforts shall include, but are not
9limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
10beneficiary or of any of his or her immediate family members,
11which are open or were closed within the last 45 days, and
12wherever feasible, other sources of relevant information reasonably
13available to the counties.

14(f) If a county cannot obtain information necessary to
15redetermine eligibility pursuant to subdivision (e), the county shall
16attempt to reach the beneficiary by telephone in order to obtain
17this information, either directly or in collaboration with
18community-based organizations so long as confidentiality is
19protected.

20(g) If a county’s efforts pursuant to subdivisions (e) and (f) to
21obtain the information necessary to redetermine eligibility have
22failed, the county shall send to the beneficiary a form, which shall
23highlight the information needed to complete the eligibility
24determination. The county shall not request information or
25documentation that has been previously provided by the
26beneficiary, that is not absolutely necessary to complete the
27eligibility determination, or that is not subject to change. The form
28shall be accompanied by a simple, clear, consumer-friendly cover
29letter, which shall explain why the form is necessary, the fact that
30it is not necessary to be receiving CalWORKs benefits to be
31receiving Medi-Cal benefits, the fact that receipt of Medi-Cal
32benefits does not count toward any time limits imposed by the
33CalWORKs program, the various bases for Medi-Cal eligibility,
34including disability, and the fact that even persons who are
35employed can receive Medi-Cal benefits. The cover letter shall
36include a telephone number to call in order to obtain more
37information. The form and the cover letter shall be developed by
38the department in consultation with the counties and representatives
39of consumers, managed care plans, and Medi-Cal providers. A
40Medi-Cal beneficiary shall have no less than 20 days from the date
P14   1the form is mailed pursuant to this subdivision to respond. Except
2as provided in subdivision (h), failure to respond prior to the end
3of this 20-day period shall not impact his or her Medi-Cal
4eligibility.

5(h) If the purpose for a redetermination under this section is a
6loss of contact with the Medi-Cal beneficiary, as evidenced by the
7return of mail marked in such a way as to indicate that it could not
8be delivered to the intended recipient or that there was no
9forwarding address, a return of the form described in subdivision
10(g) marked as undeliverable shall result in an immediate notice of
11action terminating Medi-Cal eligibility.

12(i) If, within 20 days of the date of mailing of a form to the
13Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary
14does not submit the completed form to the county, the county shall
15send the beneficiary a written notice of action stating that his or
16her eligibility shall be terminated 10 days from the date of the
17notice and the reasons for that determination, unless the beneficiary
18submits a completed form prior to the end of the 10-day period.

19(j) If, within 20 days of the date of mailing of a form to the
20Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
21submits an incomplete form, the county shall attempt to contact
22the beneficiary by telephone and in writing to request the necessary
23information. If the beneficiary does not supply the necessary
24information to the county within 10 days from the date the county
25contacts the beneficiary in regard to the incomplete form, a 10-day
26notice of termination of Medi-Cal eligibility shall be sent.

27(k) If, within 30 days of termination of a Medi-Cal beneficiary’s
28eligibility pursuant to subdivision (h), (i), or (j), the beneficiary
29submits to the county a completed form, eligibility shall be
30determined as though the form was submitted in a timely manner
31and if a beneficiary is found eligible, the termination under
32subdivision (h),begin delete (I),end deletebegin insert(i)end insert, or (j) shall be rescinded.

33(l) If the information reasonably available to the county pursuant
34to the redetermination procedures of subdivisions (d), (e), (g), and
35(m) does not indicate a basis of eligibility, Medi-Cal benefits may
36be terminated so long as due process requirements have otherwise
37been met.

38(m) The department shall, with the counties and representatives
39of consumers, including those with disabilities, and Medi-Cal
40providers, develop a timeframe for redetermination of Medi-Cal
P15   1eligibility based upon disability, including ex parte review, the
2redetermination form described in subdivision (g), timeframes for
3responding to county or state requests for additional information,
4and the forms and procedures to be used. The forms and procedures
5shall be as consumer-friendly as possible for people with
6disabilities. The timeframe shall provide a reasonable and adequate
7opportunity for the Medi-Cal beneficiary to obtain and submit
8medical records and other information needed to establish
9eligibility for Medi-Cal based upon disability.

10(n) This section shall be implemented on or before July 1, 2001,
11but only to the extent that federal financial participation under
12Title XIX of the federal Social Security Actbegin delete (Title 42end deletebegin insert (42end insert U.S.C.
13Sec. 1396begin delete and following)end deletebegin insert et seq.)end insert is available.

14(o) Notwithstanding Chapter 3.5 (commencing with Section
1511340) of Part 1 of Division 3 of Title 2 of the Government Code,
16the department shall, without taking any regulatory action,
17implement this section by means of all county letters or similar
18instructions. Thereafter, the department shall adopt regulations in
19accordance with the requirements of Chapter 3.5 (commencing
20with Section 11340) of Part 1 of Division 3 of Title 2 of the
21Government Code. Comprehensive implementing instructions
22shall be issued to the counties no later than March 1, 2001.

begin insert

23(p) This section shall remain in effect only until January 1, 2014,
24and as of that date is repealed, unless a later enacted statute, that
25is enacted before January 1, 2014, deletes or extends that date.

end insert
26

SEC. 12.  

Section 14005.37 is added to the Welfare and
27Institutions Code
, to read:

28

14005.37.  

(a) Except as provided in Section 14005.39,
29whenever a county receives information about changes in a
30beneficiary’s circumstances that may affect eligibility for Medi-Cal
31benefits, the county shall promptly redetermine eligibility. The
32procedures for redetermining Medi-Cal eligibility described in this
33section shall apply to all Medi-Cal beneficiaries.

34(b)  Loss of eligibility for cash aid under that program shall not
35result in a redetermination under this section unless the reason for
36the loss of eligibility is one that would result in the need for a
37redetermination for a person whose eligibility for Medi-Cal under
38Section 14005.30 was determined without a concurrent
39determination of eligibility for cash aid under the CalWORKs
40program.

P16   1(c) A loss of contact, as evidenced by the return of mail marked
2in such a way as to indicate that it could not be delivered to the
3intended recipient or that there was no forwarding address, shall
4require a prompt redetermination according to the procedures set
5forth in this section.

6(d) Except as otherwise provided in this section, Medi-Cal
7eligibility shall continue during the redetermination process
8described in this section. A Medi-Cal beneficiary’s eligibility shall
9not be terminated under this section until the county makes a
10specific determination based on facts clearly demonstrating that
11the beneficiary is no longer eligible for Medi-Cal under any basis
12and due process rights guaranteed under this division have been
13met.

14(e) (1) For purposes of acquiring information necessary to
15conduct the eligibility determinations described in subdivisions
16(a) to (d), inclusive, a county shall gather information available to
17the county that is relevant to the beneficiary’s Medi-Cal eligibility
18prior to contacting the beneficiary. Sources for these efforts shall
19include, but are not limited to, Medi-Cal, CalWORKs, and
20CalFresh case files of the beneficiary or of any of his or her
21immediate family members, which are open or were closed within
22the last 45 days, information accessed through any databases
23accessed by the agency under Sections 435.948, 435.949, and
24435.956 of Title 42 of the Code of Federal Regulations, and
25wherever feasible, other sources of relevant information reasonably
26available to the counties.

27(2) If the county is able to renew eligibility based on such
28information, the county shall notify the individual of both of the
29following:

30(A) The eligibility determination and basis.

31(B) That the individual is required to inform the county via the
32Internet, by telephone, by mail, in person, or through other
33commonly available electronic means, in counties where such
34electronic communication is available, if any information contained
35in the notice is inaccurate but that the individual is not required to
36sign and return the notice if all information provided on the notice
37is accurate.

38(3) The county shall make all reasonable efforts not to send
39multiple notices during the same time period about eligibility. The
P17   1notice of eligibility renewal shall contain other related information
2such as if the individual is in a new Medi-Cal program.

3(f) If a county cannot obtain information necessary to
4redetermine eligibility pursuant to subdivision (e), the county shall
5attempt to reach the beneficiary by telephone and other commonly
6available electronic means, in counties where such electronic
7communication is available, in order to obtain this information,
8either directly or in collaboration with community-based
9organizations so long as confidentiality is protected.

10(g) If a county’s efforts pursuant to subdivisions (e) and (f) to
11obtain the information necessary to redetermine eligibility have
12failed, the county shall send to the beneficiary a form containing
13information available to the county needed to renew eligibility.
14The county shall not request information or documentation that
15has been previously provided by the beneficiary, that is not
16absolutely necessary to complete the eligibility determination, or
17that is not subject to change. The county shall not request
18information for nonapplicants necessary to make an eligibility
19determination. The form shall be accompanied by a simple, clear,
20consumer-friendly cover letter, that shall explain why the form is
21necessary, the fact that it is not necessary to be receiving
22CalWORKs benefits to be receiving Medi-Cal benefits, the fact
23that receipt of Medi-Cal benefits does not count toward any time
24limits imposed by the CalWORKs program, the various bases for
25Medi-Cal eligibility, including disability, and the fact that even
26persons who are employed can receive Medi-Cal benefits. The
27form shall advise the individual to provide any necessary
28information to the county via the Internet, by telephone, by mail,
29in person, or through other commonly available electronic means
30and to sign the renewal form. The cover letter shall include a
31telephone number to call in order to obtain more information. The
32form and the cover letter shall be developed by the department in
33consultation with the counties and representatives of consumers,
34managed care plans, and Medi-Cal providers. A Medi-Cal
35beneficiary shall have no less than 20 days from the date the form
36is mailed pursuant to this subdivision to respond. Except as
37provided in subdivision (h), failure to respond prior to the end of
38this 20-day period shall not impact his or her Medi-Cal eligibility.

39(h) If the purpose for a redetermination under this section is a
40loss of contact with the Medi-Cal beneficiary, as evidenced by the
P18   1return of mail marked in such a way as to indicate that it could not
2be delivered to the intended recipient or that there was no
3forwarding address, a return of the form described in subdivision
4(g) marked as undeliverable shall result in an immediate notice of
5action terminating Medi-Cal eligibility.

6(i) If, within 20 days of the date of mailing of a form to the
7Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary
8does not submit the completed form to the county, the county shall
9send the beneficiary a written notice of action stating that his or
10her eligibility shall be terminated 10 days from the date of the
11notice and the reasons for that determination, unless the beneficiary
12submits a completed form prior to the end of the 10-day period.

13(j) If, within 20 days of the date of mailing of a form to the
14Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
15submits an incomplete form, the county shall attempt to contact
16the beneficiary by telephone, in writing, and other commonly
17available electronic means, in counties where such electronic
18communication is available, to request the necessary information.
19If the beneficiary does not supply the necessary information to the
20county within 10 days from the date the county contacts the
21beneficiary in regard to the incomplete form, a 10-day notice of
22termination of Medi-Cal eligibility shall be sent.

23(k) (1) Until January 1, 2014, if within 30 days of termination
24of a Medi-Cal beneficiary’s eligibility pursuant to subdivision (h),
25(i), or (j), the beneficiary submits to the county a completed form,
26eligibility shall be determined as though the form was submitted
27in a timely manner and if a beneficiary is found eligible, the
28termination under subdivision (h), (i), or (j) shall be rescinded.

29(2) Commencing January 1, 2014, if within 90 days of
30termination of a Medi-Cal beneficiary’s eligibility pursuant to
31subdivision (h), (i), or (j), the beneficiary submits to the county a
32completed form, eligibility shall be determined as though the form
33was submitted in a timely manner and if a beneficiary is found
34eligible, the termination under subdivision (h), (i), or (j) shall be
35rescinded.

36(l) If the information available to the county pursuant to the
37redetermination procedures of subdivisions (d), (e), (g), and (m)
38does not indicate a basis of eligibility, Medi-Cal benefits may be
39terminated so long as due process requirements have otherwise
40been met.

P19   1(m) The department shall, with the counties and representatives
2of consumers, including those with disabilities, and Medi-Cal
3providers, develop a timeframe for redetermination of Medi-Cal
4eligibility based upon disability, including ex parte review, the
5redetermination form described in subdivision (g), timeframes for
6responding to county or state requests for additional information,
7and the forms and procedures to be used. The forms and procedures
8shall be as consumer-friendly as possible for people with
9disabilities. The timeframe shall provide a reasonable and adequate
10opportunity for the Medi-Cal beneficiary to obtain and submit
11medical records and other information needed to establish
12eligibility for Medi-Cal based upon disability.

13(n) The county shall consider blindness as continuing until the
14reviewing physician determines that a beneficiary’s vision has
15improved beyond the definition of blindness contained in the plan.

16(o) The county shall consider disability as continuing until the
17review team determines that a beneficiary’s disability no longer
18meets the definition of disability contained in the plan.

19(p) If a county has enough information available to it to renew
20eligibility with respect to all eligibility criteria, the county shall
21begin a new 12-month eligibility period.

22(q)  For individuals determined ineligible for Medi-Cal, the
23county shall determine eligibility for other state health subsidy
24programs and comply with the procedures in Section 15926.

25(r) Any renewal form or notice shall be accessible to persons
26who are limited English proficient and persons with disabilities
27consistent with all federal and state requirements.

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

29

SEC. 13.  

Section 14005.60 is added to the Welfare and
30Institutions Code
, to read:

31

14005.60.  

(a) Commencing January 1, 2014, the department
32shall provide eligibility for Medi-Cal benefits for any person who
33meets the eligibility requirements of Section
341902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security
35Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)).

36(b) Persons who qualify under subdivision (a) and are currently
37enrolled in a Low Income Health Program (LIHP) under
38California’s Bridge to Reform Section 1115(a) Medicaid
39Demonstration shall be transitioned to the Medi-Cal program under
40this section in accordance with the transition plan as approved by
P20   1the federal Centers for Medicare and Medicaid Services. With
2respect to plan enrollment, a LIHP enrollee shall be all of the
3following:

4(1) Notified which Medi-Cal health plan or plans contain his or
5 her existing medical home provider.

6(2) Notified that he or she can select a health plan that contains
7his or her existing medical home provider.

8(3) Provided the opportunity to choose a different health plan
9if there is more than one plan available in the county where he or
10she resides.

11(4) Informed that if he or she does not affirmatively choose a
12plan or there is only one plan in the county where he or she resides,
13he or she shall be enrolled into the Medi-Cal managed care plan
14that contains his or her LIHP medical home provider, if the medical
15home provider contracts with a Medi-Cal managed care plan.

16(c) In order to ensure that no persons lose health care coverage
17in the course of the transition, the department shall require that
18notices of the January 1, 2014, change be sent to LIHP enrollees
19upon their LIHP redetermination in 2013 and again at least 90 days
20prior to the transition. Pursuant to Section 1902(k)(1) and Section
211937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
221396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
23shall seek approval from the United States Secretary of Health and
24Human Services to establish a benchmark benefit package that
25includes the same benefits, services, and coverage that are provided
26to all other full-scope Medi-Cal enrollees, supplemented by any
27benefits, services, and coverage included in the essential health
28benefits package adopted by the state and approved by the United
29States Secretary of Health and Human Services under Section
3018022 of Title 42 of the United States Code.

31

SEC. 14.  

Section 14005.62 is added to the Welfare and
32Institutions Code
, to read:

33

14005.62.  

Commencing January 1, 2014, the department shall
34accept an individual’s attestation of information and verify
35information pursuant to Section 15926.2.

36

SEC. 15.  

Section 14005.63 is added to the Welfare and
37Institutions Code
, to read:

38

14005.63.  

(a) Commencing January 1, 2014, a person who
39wishes to apply for a state health subsidy program, as defined in
40subdivision (a) of Section 15926, shall be allowed to file an
P21   1application on his or her own behalf or on behalf of his or her
2family. The individual also has the right to be accompanied,
3assisted, and represented in the application and renewal process
4by an individual or organization of his or her own choice. If the
5individual for any reason is unable to apply or renew on his or her
6own behalf, any of the following persons may file the application
7for the applicant:

8(1) The individual’s guardian, conservator, or executor.

9(2) A public agency representative.

10(3) The individual’s legal counsel, relative, friend, or other
11spokesperson of his or her choice.

12(b) A person who wishes to challenge a decision concerning his
13or her eligibility for or receipt of benefits from a state health
14subsidy program has the right to represent himself or herself or
15use legal counsel, a relative, a friend, or other spokesperson of his
16or her choice.

17

SEC. 16.  

Section 14005.64 is added to the Welfare and
18Institutions Code
, to read:

19

14005.64.  

(a) This section implements Section 1902(e)(14)(C)
20of the federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(C))
21and Section 435.603(g) of Title 42 of the Code of Federal
22Regulations, which prohibits the use of an assets test for individuals
23whose income eligibility is determined based on modified adjusted
24gross income (MAGI), and Section 2002 of the federal Patient
25Protection and Affordable Care Act (Affordable Care Act) (42
26U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of Title 42
27of the Code of Federal Regulations, which requires a 5-percent
28income disregard for individuals whose income eligibility is
29determined based on MAGI.

30(b) In the case of individuals whose financial eligibility for
31Medi-Cal is determined based on the application of MAGI pursuant
32to Section 435.603 of Title 42 of the Code of Federal Regulations,
33the eligibility determination shall not include any assets or
34resources test.

35(c) The department shall implement the 5-percent income
36disregard for individuals whose income eligibility is determined
37based on MAGI in Section 2002 of the Affordable Care Act (42
38U.S.C. Sec. 1396a(e)(14)(I)) and Section 435.603(d) of Title 42
39of the Code of Federal Regulations.

P22   1(d) The department shall adopt an equivalent income level for
2each eligibility group whose income level will be converted to
3MAGI. The equivalent income level shall not be less than the dollar
4amount of all income exemptions, exclusions, deductions, and
5disregards in effect on March 23, 2010, plus the existing income
6level expressed as a percent of the federal poverty level for each
7eligibility group so as to ensure that the use of MAGI income
8methodology does not result in populations who would have been
9eligible under this chapter and Part 6.3 (commencing with Section
1012695) of Division 2 of the Insurance Code losing coverage.

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

12

SEC. 17.  

Section 14005.65 is added to the Welfare and
13Institutions Code
, to read:

14

14005.65.  

In accordance with the state’s options under Section
15435.603(h) of Title 42 of the Code of Federal Regulations, the
16department shall adopt procedures to take into account projected
17future changes in income and family size, for individuals whose
18Medi-Cal income eligibility is determined using MAGI-based
19methods, in order to grant or maintain eligibility for those
20individuals who may be ineligible or become ineligible if only the
21current monthly income and family size are considered.

22(a) For current beneficiaries whose eligibility has already been
23approved, the department shall base financial eligibility on
24projected annual household income for the remainder of the current
25calendar year if the current monthly income would render the
26beneficiary ineligible due to fluctuating income.

27(b) For applicants, the department shall, in determining the
28current monthly household income and family size, base an initial
29determination of eligibility on the projected annual household
30income and family size for the upcoming year if considering the
31current monthly income and family size in isolation would render
32an applicant ineligible.

33(c) In the procedures adopted pursuant to this section, the
34department shall implement a reasonable method to account for a
35reasonably predictable decrease in income and increase in family
36size, as evidenced by a history of predictable fluctuations in income
37or other clear indicia of a future decrease in income and increase
38in family size. The department shall not assume potential future
39increases in income or decreases in family size to make an applicant
40or beneficiary ineligible in the current month.

P23   1(d) This section shall become operative on January 1, 2014.

2

SEC. 18.  

Section 14007.1 of the Welfare and Institutions Code
3 is amended to read:

4

14007.1.  

(a) The department shall adopt regulations for use
5by the county welfare department in determining whether an
6applicant is a resident of this state and of the county subject to the
7requirements of federal law. The regulations shall require that state
8residency is not established unless the applicant does both of the
9following.

10(1) The applicant produces one of the following:

11(A) A recent California rent or mortgage receipt or utility bill
12in the applicant’s name.

13(B) A current California motor vehicle driver’s license or
14California Identification Card issued by the California Department
15of Motor Vehicles in the applicant’s name.

16(C) A current California motor vehicle registration in the
17applicant’s name.

18(D) A document showing that the applicant is employed in this
19state.

20(E) A document showing that the applicant has registered with
21a public or private employment service in this state.

22(F) Evidence that the applicant has enrolled his or her children
23in a school in this state.

24(G) Evidence that the applicant is receiving public assistance
25in this state.

26(H) Evidence of registration to vote in this state.

27(2) The applicant declares, under penalty of perjury, that all of
28the following apply:

29(A) The applicant does not own or lease a principal residence
30outside this state.

31(B) The applicant is not receiving public assistance outside this
32state. As used in this subdivision, “public assistance” does not
33include unemployment insurance benefits.

34(b) A denial of a determination of residency may be appealed
35in the same manner as any other denial of eligibility. The
36Administrative Law Judge shall receive any proof of residency
37offered by the applicant and may inquire into any facts relevant
38to the question of residency. A determination of residency shall
39not be granted unless a preponderance of the credible evidence
40supports the applicant’s intent to remain indefinitely in this state.

begin insert

P24   1(c) This section shall remain in effect only until January 1, 2014,
2and as of that date is repealed, unless a later enacted statute, that
3is enacted before January 1, 2014, deletes or extends that date.

end insert
4

SEC. 19.  

Section 14007.1 is added to the Welfare and
5Institutions Code
, to read:

6

14007.1.  

(a) An individual 21 years of age or older shall be
7considered a resident of this state for the purposes of determining
8his or her eligibility for Medi-Cal benefits if he or she attests that
9he or she lives in this state and that he or she either intends to reside
10in this state or has entered this state with a job commitment or to
11seek employment. The individual shall not be required to have a
12fixed address or to be currently employed to be considered a
13resident of this state.

14(b) (1) An individual under 21 years of age shall be considered
15a resident of this state for the purposes of determining his or her
16eligibility for Medi-Cal benefits if he or she satisfies the
17requirements of subdivision (a), is capable of indicating intent,
18and is emancipated from his or her parent or parents or is married.

19(2) An individual under 21 years of age who does not satisfy
20the requirements of paragraph (1), and who is not living in an
21institution, not eligible for Medi-Cal based on his or her receipt
22of assistance under Title IV-E of the federal Social Security Act,
23and not receiving a state supplementary payment, as defined in
24Section 435.403(f) of Title 42 of the Code of Federal Regulations,
25shall be considered a resident of this state for the purposes of
26determining his or her eligibility for Medi-Cal benefits if he or she
27lives in this state, whether or not he or she has a fixed address, or
28his or her parent or parents, or other caretaker, with whom he or
29she resides satisfies the requirements of subdivision (a).

30(c) The state of residency for an individual who is incapable of
31stating intent or who is living in an institution shall be determined
32 in accordance with Section 435.403 of Title 42 of the Code of
33Federal Regulations.

34(d) A denial of a determination of residency may be appealed
35in the same manner as any other denial of eligibility. The
36administrative law judge shall receive any proof of residency
37offered by the individual and may inquire into any facts relevant
38to the question of residency. A determination of residency shall
39be granted if a preponderance of the credible evidence supports a
P25   1finding that the individual meets the requirements of either
2subdivision (a) or (b).

3(e) This section shall be interpreted in a manner consistent with
4federal law.

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

6

SEC. 20.  

Section 14007.6 of the Welfare and Institutions Code
7 is amended to read:

8

14007.6.  

(a) A recipient who maintains a residence outside of
9this state for a period of at least two months shall not be eligible
10for services under this chapter where the county has made inquiry
11of the recipient pursuant to Section 11100, and where the recipient
12has not responded to this inquiry by clearly showing that he or she
13has (1) not established residence elsewhere; and (2) been prevented
14by illness or other good cause from returning to this state.

15(b) If a recipient whose services are terminated pursuant to
16subdivision (a) reapplies for services, services shall be restored
17provided all other eligibility criteria are met if this individual can
18prove both of the following:

19(1) His or her permanent residence is in this state.

20(2) That residence has not been established in any other state
21which can be considered to be of a permanent nature.

begin insert

22(c) This section shall remain in effect only until January 1, 2014,
23and as of that date is repealed unless a later enacted statute, that
24is enacted before January 1, 2014, deletes or extends that date.

end insert
25

SEC. 21.  

Section 14007.6 is added to the Welfare and
26Institutions Code
, to read:

27

14007.6.  

(a) A recipient who maintains a residence outside of
28this state for a period of at least two months shall not be eligible
29for services under this chapter where the county has made inquiry
30of the recipient pursuant to Section 11100, and where the recipient
31has not responded to this inquiry by clearly showing that he or she
32has (1) not established residence elsewhere; or (2) been prevented
33by illness or other good cause from returning to this state.

34(b) If a recipient whose services are terminated pursuant to
35subdivision (a) reapplies for services, services shall be restored
36provided all other eligibility criteria are met if this individual can
37prove both of the following:

38(1) His or her residence is in this state.

39(2) That residence has not been established in any other state
40which can be considered to be of a permanent nature.

P26   1(c) This section shall become operative on January 1, 2014.

2

SEC. 22.  

Section 14008.85 of the Welfare and Institutions
3Code
is amended to read:

4

14008.85.  

(a) To the extent federal financial participation is
5available, a parent who is the principal wage earner shall be
6considered an unemployed parent for purposes of establishing
7eligibility based upon deprivation of a child where any of the
8following applies:

9(1) The parent works less than 100 hours per month as
10determined pursuant to the rules of the Aid to Families with
11Dependent Children program as it existed on July 16, 1996,
12including the rule allowing a temporary excess of hours due to
13intermittent work.

14(2) The total net nonexempt earned income for the family is not
15more than 100 percent of the federal poverty level as most recently
16calculated by the federal government. The department may adopt
17additional deductions to be taken from a family’s income.

18(3) The parent is considered unemployed under the terms of an
19existing federal waiver of the 100-hour rule for recipients under
20the program established by Section 1931(b) of the federal Social
21Security Act (42 U.S.C. Sec. 1396u-1).

22(b) Notwithstanding Chapter 3.5 (commencing with Section
2311340) of Part 1 of Division 3 of Title 2 of the Government Code,
24the department shall implement this section by means of an all
25county letter or similar instruction without taking regulatory action.
26Thereafter, the department shall adopt regulations in accordance
27with the requirements of Chapter 3.5 (commencing with Section
2811340) of Part 1 of Division 3 of Title 2 of the Government Code.

begin delete

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

end delete
begin insert

30(c) This section shall remain in effect only until January 1, 2014,
31and as of that date is repealed, unless a later enacted statute, that
32is enacted before January 1, 2014, deletes or extends that date.

end insert
33

SEC. 23.  

Section 14011.16 of the Welfare and Institutions
34Code
is amended to read:

35

14011.16.  

(a) Commencing August 1, 2003, the department
36shall implement a requirement for beneficiaries to file semiannual
37status reports as part of the department’s procedures to ensure that
38beneficiaries make timely and accurate reports of any change in
39circumstance that may affect their eligibility. The department shall
40develop a simplified form to be used for this purpose. The
P27   1department shall explore the feasibility of using a form that allows
2a beneficiary who has not had any changes to so indicate by
3checking a box and signing and returning the form.

4(b) Beneficiaries who have been granted continuous eligibility
5under Section 14005.25 shall not be required to submit semiannual
6status reports. To the extent federal financial participation is
7available, all children under 19 years of age shall be exempt from
8the requirement to submit semiannual status reports.

9(c) For any period of time that the continuous eligibility period
10described in paragraph (1) of subdivision (a) of Section 14005.25
11is reduced to six months, subdivision (b) shall become inoperative,
12and all children under 19 years of age shall be required to file
13semiannual status reports.

14(d) Beneficiaries whose eligibility is based on a determination
15of disability or on their status as aged or blind shall be exempt
16from the semiannual status report requirement described in
17subdivision (a). The department may exempt other groups from
18the semiannual status report requirement as necessary for simplicity
19of administration.

20(e) When a beneficiary has completed, signed, and filed a
21semiannual status report that indicated a change in circumstance,
22eligibility shall be redetermined.

23(f) Notwithstanding Chapter 3.5 (commencing with Section
2411340) of Part 1 of Division 3 of Title 2 of the Government Code,
25the department shall implement this section by means of all-county
26letters or similar instructions without taking regulatory action.
27Thereafter, the department shall adopt regulations in accordance
28with the requirements of Chapter 3.5 (commencing with Section
2911340) of Part 1 of Division 3 of Title 2 of the Government Code.

30(g) This section shall be implemented only if and to the extent
31federal financial participation is available.

begin insert

32(h) This section shall remain in effect only until January 1, 2014,
33and as of that date is repealed, unless a later enacted statute, that
34is enacted before January 1, 2014, deletes or extends that date.

end insert
35

SEC. 24.  

Section 14011.17 of the Welfare and Institutions
36Code
is amended to read:

37

14011.17.  

The following persons shall be exempt from the
38semiannual reporting requirements described in Section 14011.16:

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

P28   1(b) Beneficiaries receiving Medi-Cal through Aid for Adoption
2of Children Program.

3(c) Beneficiaries who have a public guardian.

4(d) Medically indigent children who are not living with a parent
5or relative and who have a public agency assuming their financial
6responsibility.

7(e) Individuals receiving minor consent services.

8(f) Beneficiaries in the Breast and Cervical Cancer Treatment
9Program.

10(g) Beneficiaries who are CalWORKs recipients and custodial
11parents whose children are CalWORKs recipients.

begin insert

12(h) This section shall remain in effect only until January 1, 2014,
13and as of that date is repealed, unless a later enacted statute, that
14is enacted before January 1, 2014, deletes or extends that date.

end insert
15

SEC. 25.  

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

17

14012.  

begin insert(a)end insertbegin insertend insert Reaffirmation shall be filed annually and may be
18required at other times in accordance with general standards
19established by the department.

begin insert

20(b) This section shall remain in effect only until January 1, 2014,
21and as of that date is repealed, unless a later enacted statute, that
22is enacted before January 1, 2014, deletes or extends that date.

end insert
23

SEC. 26.  

Section 14012 is added to the Welfare and Institutions
24Code
, to read:

25

14012.  

(a) This section implements Section 435.916(a)(1) of
26Title 42 of the Code of Federal Regulations, which applies to the
27eligibility of Medi-Cal beneficiaries whose financial eligibility is
28determined using modified adjusted gross income (MAGI) based
29income.

30(b) To the extent required by federal law or regulations, the
31eligibility of Medi-Cal beneficiaries whose financial eligibility is
32determined using a MAGI-based income shall be renewed once
33every 12 months, and no more frequently than every 12 months.

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

35

SEC. 27.  

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

37

14132.  

The following is the schedule of benefits under this
38chapter:

39(a) Outpatient services are covered as follows:

P29   1Physician, hospital or clinic outpatient, surgical center,
2respiratory care, optometric, chiropractic, psychology, podiatric,
3occupational therapy, physical therapy, speech therapy, audiology,
4acupuncture to the extent federal matching funds are provided for
5acupuncture, and services of persons rendering treatment by prayer
6or healing by spiritual means in the practice of any church or
7religious denomination insofar as these can be encompassed by
8federal participation under an approved plan, subject to utilization
9controls.

10(b) (1) Inpatient hospital services, including, but not limited
11to, physician and podiatric services, physical therapy and
12occupational therapy, are covered subject to utilization controls.

13(2) For Medi-Cal fee-for-service beneficiaries, emergency
14services and care that are necessary for the treatment of an
15emergency medical condition and medical care directly related to
16the emergency medical condition. This paragraph shall not be
17construed to change the obligation of Medi-Cal managed care
18plans to provide emergency services and care. For the purposes of
19this paragraph, “emergency services and care” and “emergency
20medical condition” shall have the same meanings as those terms
21are defined in Section 1317.1 of the Health and Safety Code.

22(c) Nursing facility services, subacute care services, and services
23provided by any category of intermediate care facility for the
24developmentally disabled, including podiatry, physician, nurse
25practitioner services, and prescribed drugs, as described in
26subdivision (d), are covered subject to utilization controls.
27Respiratory care, physical therapy, occupational therapy, speech
28therapy, and audiology services for patients in nursing facilities
29and any category of intermediate care facility for the
30developmentally disabled are covered subject to utilization controls.

31(d) (1) Purchase of prescribed drugs is covered subject to the
32Medi-Cal List of Contract Drugs and utilization controls.

33(2) Purchase of drugs used to treat erectile dysfunction or any
34off-label uses of those drugs are covered only to the extent that
35federal financial participation is available.

36(3) (A) To the extent required by federal law, the purchase of
37outpatient prescribed drugs, for which the prescription is executed
38by a prescriber in written, nonelectronic form on or after April 1,
392008, is covered only when executed on a tamper resistant
40prescription form. The implementation of this paragraph shall
P30   1conform to the guidance issued by the federal Centers of Medicare
2and Medicaid Services but shall not conflict with state statutes on
3the characteristics of tamper resistant prescriptions for controlled
4substances, including Section 11162.1 of the Health and Safety
5Code. The department shall provide providers and beneficiaries
6with as much flexibility in implementing these rules as allowed
7by the federal government. The department shall notify and consult
8with appropriate stakeholders in implementing, interpreting, or
9making specific this paragraph.

10(B) Notwithstanding Chapter 3.5 (commencing with Section
1111340) of Part 1 of Division 3 of Title 2 of the Government Code,
12the department may take the actions specified in subparagraph (A)
13by means of a provider bulletin or notice, policy letter, or other
14similar instructions without taking regulatory action.

15(4) (A) (i) For the purposes of this paragraph, nonlegend has
16the same meaning as defined in subdivision (a) of Section
1714105.45.

18(ii) Nonlegend acetaminophen-containing products, with the
19exception of children’s acetaminophen-containing products,
20selected by the department are not covered benefits.

21(iii) Nonlegend cough and cold products selected by the
22department are not covered benefits. This clause shall be
23implemented on the first day of the first calendar month following
2490 days after the effective date of the act that added this clause,
25or on the first day of the first calendar month following 60 days
26after the date the department secures all necessary federal approvals
27to implement this section, whichever is later.

28(iv) Beneficiaries under the Early and Periodic Screening,
29Diagnosis, and Treatment Program shall be exempt from clauses
30(ii) and (iii).

31(B) Notwithstanding Chapter 3.5 (commencing with Section
3211340) of Part 1 of Division 3 of Title 2 of the Government Code,
33the department may take the actions specified in subparagraph (A)
34by means of a provider bulletin or notice, policy letter, or other
35similar instruction without taking regulatory action.

36(e) Outpatient dialysis services and home hemodialysis services,
37including physician services, medical supplies, drugs and
38equipment required for dialysis, are covered, subject to utilization
39controls.

P31   1(f) Anesthesiologist services when provided as part of an
2outpatient medical procedure, nurse anesthetist services when
3rendered in an inpatient or outpatient setting under conditions set
4forth by the director, outpatient laboratory services, and X-ray
5services are covered, subject to utilization controls. Nothing in
6this subdivision shall be construed to require prior authorization
7for anesthesiologist services provided as part of an outpatient
8medical procedure or for portable X-ray services in a nursing
9facility or any category of intermediate care facility for the
10developmentally disabled.

11(g) Blood and blood derivatives are covered.

12(h) (1) Emergency and essential diagnostic and restorative
13dental services, except for orthodontic, fixed bridgework, and
14partial dentures that are not necessary for balance of a complete
15artificial denture, are covered, subject to utilization controls. The
16utilization controls shall allow emergency and essential diagnostic
17and restorative dental services and prostheses that are necessary
18to prevent a significant disability or to replace previously furnished
19prostheses which are lost or destroyed due to circumstances beyond
20the beneficiary’s control. Notwithstanding the foregoing, the
21director may by regulation provide for certain fixed artificial
22dentures necessary for obtaining employment or for medical
23conditions that preclude the use of removable dental prostheses,
24and for orthodontic services in cleft palate deformities administered
25by the department’s California Children Services Program.

26(2) For persons 21 years of age or older, the services specified
27in paragraph (1) shall be provided subject to the following
28conditions:

29(A) Periodontal treatment is not a benefit.

30(B) Endodontic therapy is not a benefit except for vital
31pulpotomy.

32(C) Laboratory processed crowns are not a benefit.

33(D) Removable prosthetics shall be a benefit only for patients
34as a requirement for employment.

35(E) The director may, by regulation, provide for the provision
36of fixed artificial dentures that are necessary for medical conditions
37that preclude the use of removable dental prostheses.

38(F) Notwithstanding the conditions specified in subparagraphs
39(A) to (E), inclusive, the department may approve services for
40persons with special medical disorders subject to utilization review.

P32   1(3) Paragraph (2) shall become inoperative July 1, 1995.

2(i) Medical transportation is covered, subject to utilization
3controls.

4(j) Home health care services are covered, subject to utilization
5controls.

6(k) Prosthetic and orthotic devices and eyeglasses are covered,
7subject to utilization controls. Utilization controls shall allow
8replacement of prosthetic and orthotic devices and eyeglasses
9necessary because of loss or destruction due to circumstances
10beyond the beneficiary’s control. Frame styles for eyeglasses
11replaced pursuant to this subdivision shall not change more than
12once every two years, unless the department so directs.

13Orthopedic and conventional shoes are covered when provided
14by a prosthetic and orthotic supplier on the prescription of a
15physician and when at least one of the shoes will be attached to a
16prosthesis or brace, subject to utilization controls. Modification
17of stock conventional or orthopedic shoes when medically
18indicated, is covered subject to utilization controls. When there is
19a clearly established medical need that cannot be satisfied by the
20modification of stock conventional or orthopedic shoes,
21custom-made orthopedic shoes are covered, subject to utilization
22controls.

23Therapeutic shoes and inserts are covered when provided to
24beneficiaries with a diagnosis of diabetes, subject to utilization
25controls, to the extent that federal financial participation is
26available.

27(l) Hearing aids are covered, subject to utilization controls.
28Utilization controls shall allow replacement of hearing aids
29necessary because of loss or destruction due to circumstances
30beyond the beneficiary’s control.

31(m) Durable medical equipment and medical supplies are
32covered, subject to utilization controls. The utilization controls
33shall allow the replacement of durable medical equipment and
34medical supplies when necessary because of loss or destruction
35due to circumstances beyond the beneficiary’s control. The
36utilization controls shall allow authorization of durable medical
37equipment needed to assist a disabled beneficiary in caring for a
38child for whom the disabled beneficiary is a parent, stepparent,
39foster parent, or legal guardian, subject to the availability of federal
40financial participation. The department shall adopt emergency
P33   1regulations to define and establish criteria for assistive durable
2medical equipment in accordance with the rulemaking provisions
3of the Administrative Procedure Act (Chapter 3.5 (commencing
4with Section 11340) of Part 1 of Division 3 of Title 2 of the
5Government Code).

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

8(o) Inpatient intensive rehabilitation hospital services, including
9respiratory rehabilitation services, in a general acute care hospital
10are covered, subject to utilization controls, when either of the
11following criteria are met:

12(1) A patient with a permanent disability or severe impairment
13requires an inpatient intensive rehabilitation hospital program as
14described in Section 14064 to develop function beyond the limited
15amount that would occur in the normal course of recovery.

16(2) A patient with a chronic or progressive disease requires an
17inpatient intensive rehabilitation hospital program as described in
18Section 14064 to maintain the patient’s present functional level as
19long as possible.

20(p) (1) Adult day health care is covered in accordance with
21Chapter 8.7 (commencing with Section 14520).

22(2) Commencing 30 days after the effective date of the act that
23added this paragraph, and notwithstanding the number of days
24previously approved through a treatment authorization request,
25adult day health care is covered for a maximum of three days per
26week.

27(3) As provided in accordance with paragraph (4), adult day
28health care is covered for a maximum of five days per week.

29(4) As of the date that the director makes the declaration
30described in subdivision (g) of Section 14525.1, paragraph (2)
31shall become inoperative and paragraph (3) shall become operative.

32(q) (1) Application of fluoride, or other appropriate fluoride
33treatment as defined by the department, other prophylaxis treatment
34for children 17 years of age and under, are covered.

35(2) All dental hygiene services provided by a registered dental
36hygienist in alternative practice pursuant to Sections 1768 and
371770 of the Business and Professions Code may be covered as
38long as they are within the scope of Denti-Cal benefits and they
39are necessary services provided by a registered dental hygienist
40in alternative practice.

P34   1(r) (1) Paramedic services performed by a city, county, or
2special district, or pursuant to a contract with a city, county, or
3special district, and pursuant to a program established under Article
43 (commencing with Section 1480) of Chapter 2.5 of Division 2
5of the Health and Safety Code by a paramedic certified pursuant
6to that article, and consisting of defibrillation and those services
7specified in subdivision (3) of Section 1482 of the article.

8(2) All providers enrolled under this subdivision shall satisfy
9all applicable statutory and regulatory requirements for becoming
10a Medi-Cal provider.

11(3) This subdivision shall be implemented only to the extent
12funding is available under Section 14106.6.

13(s) In-home medical care services are covered when medically
14appropriate and subject to utilization controls, for beneficiaries
15who would otherwise require care for an extended period of time
16in an acute care hospital at a cost higher than in-home medical
17care services. The director shall have the authority under this
18section to contract with organizations qualified to provide in-home
19medical care services to those persons. These services may be
20provided to patients placed in shared or congregate living
21arrangements, if a home setting is not medically appropriate or
22available to the beneficiary. As used in this section, “in-home
23medical care service” includes utility bills directly attributable to
24continuous, 24-hour operation of life-sustaining medical equipment,
25to the extent that federal financial participation is available.

26As used in this subdivision, in-home medical care services,
27include, but are not limited to:

28(1) Level of care and cost of care evaluations.

29(2) Expenses, directly attributable to home care activities, for
30materials.

31(3) Physician fees for home visits.

32(4) Expenses directly attributable to home care activities for
33shelter and modification to shelter.

34(5) Expenses directly attributable to additional costs of special
35diets, including tube feeding.

36(6) Medically related personal services.

37(7) Home nursing education.

38(8) Emergency maintenance repair.

P35   1(9) Home health agency personnel benefits which permit
2coverage of care during periods when regular personnel are on
3vacation or using sick leave.

4(10) All services needed to maintain antiseptic conditions at
5stoma or shunt sites on the body.

6(11) Emergency and nonemergency medical transportation.

7(12) Medical supplies.

8(13) Medical equipment, including, but not limited to, scales,
9gurneys, and equipment racks suitable for paralyzed patients.

10(14) Utility use directly attributable to the requirements of home
11care activities which are in addition to normal utility use.

12(15) Special drugs and medications.

13(16) Home health agency supervision of visiting staff which is
14medically necessary, but not included in the home health agency
15rate.

16(17) Therapy services.

17(18) Household appliances and household utensil costs directly
18attributable to home care activities.

19(19) Modification of medical equipment for home use.

20(20) Training and orientation for use of life-support systems,
21including, but not limited to, support of respiratory functions.

22(21) Respiratory care practitioner services as defined in Sections
233702 and 3703 of the Business and Professions Code, subject to
24prescription by a physician and surgeon.

25Beneficiaries receiving in-home medical care services are entitled
26to the full range of services within the Medi-Cal scope of benefits
27as defined by this section, subject to medical necessity and
28applicable utilization control. Services provided pursuant to this
29subdivision, which are not otherwise included in the Medi-Cal
30schedule of benefits, shall be available only to the extent that
31federal financial participation for these services is available in
32accordance with a home- and community-based services waiver.

33(t) Home- and community-based services approved by the
34United States Department of Health and Human Services may be
35covered to the extent that federal financial participation is available
36for those services under waivers granted in accordance with Section
371396n of Title 42 of the United States Code. The director may
38seek waivers for any or all home- and community-based services
39approvable under Section 1396n of Title 42 of the United States
P36   1Code. Coverage for those services shall be limited by the terms,
2conditions, and duration of the federal waivers.

3(u) Comprehensive perinatal services, as provided through an
4agreement with a health care provider designated in Section
514134.5 and meeting the standards developed by the department
6pursuant to Section 14134.5, subject to utilization controls.

7The department shall seek any federal waivers necessary to
8implement the provisions of this subdivision. The provisions for
9which appropriate federal waivers cannot be obtained shall not be
10implemented. Provisions for which waivers are obtained or for
11which waivers are not required shall be implemented
12notwithstanding any inability to obtain federal waivers for the
13other provisions. No provision of this subdivision shall be
14implemented unless matching funds from Subchapter XIX
15(commencing with Section 1396) of Chapter 7 of Title 42 of the
16United States Code are available.

17(v) Early and periodic screening, diagnosis, and treatment for
18any individual under 21 years of age is covered, consistent with
19the requirements of Subchapter XIX (commencing with Section
201396) of Chapter 7 of Title 42 of the United States Code.

21(w) Hospice service which is Medicare-certified hospice service
22is covered, subject to utilization controls. Coverage shall be
23available only to the extent that no additional net program costs
24are incurred.

25(x) When a claim for treatment provided to a beneficiary
26includes both services which are authorized and reimbursable
27under this chapter, and services which are not reimbursable under
28this chapter, that portion of the claim for the treatment and services
29authorized and reimbursable under this chapter shall be payable.

30(y) Home- and community-based services approved by the
31United States Department of Health and Human Services for
32beneficiaries with a diagnosis of AIDS or ARC, who require
33intermediate care or a higher level of care.

34Services provided pursuant to a waiver obtained from the
35Secretary of the United States Department of Health and Human
36Services pursuant to this subdivision, and which are not otherwise
37included in the Medi-Cal schedule of benefits, shall be available
38only to the extent that federal financial participation for these
39services is available in accordance with the waiver, and subject to
40the terms, conditions, and duration of the waiver. These services
P37   1shall be provided to individual beneficiaries in accordance with
2the client’s needs as identified in the plan of care, and subject to
3medical necessity and applicable utilization control.

4The director may under this section contract with organizations
5qualified to provide, directly or by subcontract, services provided
6for in this subdivision to eligible beneficiaries. Contracts or
7agreements entered into pursuant to this division shall not be
8subject to the Public Contract Code.

9(z) Respiratory care when provided in organized health care
10systems as defined in Section 3701 of the Business and Professions
11Code, and as an in-home medical service as outlined in subdivision
12(s).

13(aa) (1) There is hereby established in the department, a
14program to provide comprehensive clinical family planning
15services to any person who has a family income at or below 200
16percent of the federal poverty level, as revised annually, and who
17is eligible to receive these services pursuant to the waiver identified
18in paragraph (2). This program shall be known as the Family
19Planning, Access, Care, and Treatment (Family PACT) Program.

20(2) The department shall seek a waiver in accordance with
21Section 1315 of Title 42 of the United States Code, or a state plan
22amendment adopted in accordance with Section
23begin delete 1396a(a)(10)(A)(ii)(XXI)(ii)(2)end deletebegin insert 1396a(a)(10)(A)(ii)(XXI)end insert of Title
2442 of the United States Code, which was added to Section 1396a
25of Title 42 of the United States Code by Section 2303(a)(2) of the
26federal Patient Protection and Affordable Care Act (PPACA)
27(Public Law 111-148), for a program to provide comprehensive
28clinical family planning services as described in paragraph (8).
29Under the waiver, the program shall be operated only in accordance
30with the waiver and the statutes and regulations in paragraph (4)
31and subject to the terms, conditions, and duration of the waiver.
32Under the state plan amendment, which shall replace the waiver
33and shall be known as the Family PACT successor state plan
34amendment, the program shall be operated only in accordance with
35this subdivision and the statutes and regulations in paragraph (4).
36The state shall use the standards and processes imposed by the
37state on January 1, 2007, including the application of an eligibility
38discount factor to the extent required by the federal Centers for
39Medicare and Medicaid Services, for purposes of determining
40eligibility as permitted under Section
P38   1begin delete 1396a(a)(10)(A)(ii)(XXI)(ii)(2)end deletebegin insert 1396a(a)(10)(A)(ii)(XXI)end insert of Title
242 of the United States Code. To the extent that federal financial
3participation is available, the program shall continue to conduct
4education, outreach, enrollment, service delivery, and evaluation
5services as specified under the waiver. The services shall be
6provided under the program only if the waiver and, when
7applicable, the successor state plan amendment are approved by
8the federal Centers for Medicare and Medicaid Services and only
9to the extent that federal financial participation is available for the
10services. Nothing in this section shall prohibit the department from
11seeking the Family PACT successor state plan amendment during
12the operation of the waiver.

13(3) Solely for the purposes of the waiver or Family PACT
14successor state plan amendment and notwithstanding any other
15provision of law, the collection and use of an individual’s social
16security number shall be necessary only to the extent required by
17federal law.

18(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005,
19and 24013, and any regulations adopted under these statutes shall
20apply to the program provided for under this subdivision. No other
21provision of law under the Medi-Cal program or the State-Only
22Family Planning Program shall apply to the program provided for
23under this subdivision.

24(5) Notwithstanding Chapter 3.5 (commencing with Section
2511340) of Part 1 of Division 3 of Title 2 of the Government Code,
26the department may implement, without taking regulatory action,
27the provisions of the waiver after its approval by the federal Health
28Care Financing Administration and the provisions of this section
29by means of an all-county letter or similar instruction to providers.
30Thereafter, the department shall adopt regulations to implement
31this section and the approved waiver in accordance with the
32requirements of Chapter 3.5 (commencing with Section 11340) of
33Part 1 of Division 3 of Title 2 of the Government Code. Beginning
34six months after the effective date of the act adding this
35subdivision, the department shall provide a status report to the
36Legislature on a semiannual basis until regulations have been
37adopted.

38(6) In the event that the Department of Finance determines that
39the program operated under the authority of the waiver described
40in paragraph (2) or the Family PACT successor state plan
P39   1amendment is no longer cost effective, this subdivision shall
2become inoperative on the first day of the first month following
3the issuance of a 30-day notification of that determination in
4writing by the Department of Finance to the chairperson in each
5house that considers appropriations, the chairpersons of the
6committees, and the appropriate subcommittees in each house that
7considers the State Budget, and the Chairperson of the Joint
8Legislative Budget Committee.

9(7) If this subdivision ceases to be operative, all persons who
10have received or are eligible to receive comprehensive clinical
11family planning services pursuant to the waiver described in
12paragraph (2) shall receive family planning services under the
13Medi-Cal program pursuant to subdivision (n) if they are otherwise
14eligible for Medi-Cal with no share of cost, or shall receive
15comprehensive clinical family planning services under the program
16established in Division 24 (commencing with Section 24000) either
17if they are eligible for Medi-Cal with a share of cost or if they are
18otherwise eligible under Section 24003.

19(8) For purposes of this subdivision, “comprehensive clinical
20family planning services” means the process of establishing
21objectives for the number and spacing of children, and selecting
22the means by which those objectives may be achieved. These
23means include a broad range of acceptable and effective methods
24and services to limit or enhance fertility, including contraceptive
25methods, federal Food and Drug Administration approved
26contraceptive drugs, devices, and supplies, natural family planning,
27abstinence methods, and basic, limited fertility management.
28Comprehensive clinical family planning services include, but are
29not limited to, preconception counseling, maternal and fetal health
30counseling, general reproductive health care, including diagnosis
31and treatment of infections and conditions, including cancer, that
32threaten reproductive capability, medical family planning treatment
33and procedures, including supplies and followup, and
34 informational, counseling, and educational services.
35Comprehensive clinical family planning services shall not include
36abortion, pregnancy testing solely for the purposes of referral for
37abortion or services ancillary to abortions, or pregnancy care that
38is not incident to the diagnosis of pregnancy. Comprehensive
39clinical family planning services shall be subject to utilization
40control and include all of the following:

P40   1(A) Family planning related services and male and female
2sterilization. Family planning services for men and women shall
3include emergency services and services for complications directly
4related to the contraceptive method, federal Food and Drug
5Administration approved contraceptive drugs, devices, and
6supplies, and followup, consultation, and referral services, as
7indicated, which may require treatment authorization requests.

8(B) All United States Department of Agriculture, federal Food
9and Drug Administration approved contraceptive drugs, devices,
10and supplies that are in keeping with current standards of practice
11and from which the individual may choose.

12(C) Culturally and linguistically appropriate health education
13and counseling services, including informed consent, that include
14all of the following:

15(i) Psychosocial and medical aspects of contraception.

16(ii) Sexuality.

17(iii) Fertility.

18(iv) Pregnancy.

19(v) Parenthood.

20(vi) Infertility.

21(vii) Reproductive health care.

22(viii) Preconception and nutrition counseling.

23(ix) Prevention and treatment of sexually transmitted infection.

24(x) Use of contraceptive methods, federal Food and Drug
25Administration approved contraceptive drugs, devices, and
26supplies.

27(xi) Possible contraceptive consequences and followup.

28(xii) Interpersonal communication and negotiation of
29relationships to assist individuals and couples in effective
30contraceptive method use and planning families.

31(D) A comprehensive health history, updated at the next periodic
32visit (between 11 and 24 months after initial examination) that
33includes a complete obstetrical history, gynecological history,
34contraceptive history, personal medical history, health risk factors,
35and family health history, including genetic or hereditary
36conditions.

37(E) A complete physical examination on initial and subsequent
38periodic visits.

P41   1(F) Services, drugs, devices, and supplies deemed by the federal
2Centers for Medicare and Medicaid Services to be appropriate for
3inclusion in the program.

4(9) In order to maximize the availability of federal financial
5participation under this subdivision, the director shall have the
6discretion to implement the Family PACT successor state plan
7amendment retroactively to July 1, 2010.

8(ab) (1) Purchase of prescribed enteral nutrition products is
9covered, subject to the Medi-Cal list of enteral nutrition products
10and utilization controls.

11(2) Purchase of enteral nutrition products is limited to those
12products to be administered through a feeding tube, including, but
13not limited to, a gastric, nasogastric, or jejunostomy tube.
14Beneficiaries under the Early and Periodic Screening, Diagnosis,
15and Treatment Program shall be exempt from this paragraph.

16(3) Notwithstanding paragraph (2), the department may deem
17an enteral nutrition product, not administered through a feeding
18tube, including, but not limited to, a gastric, nasogastric, or
19jejunostomy tube, a benefit for patients with diagnoses, including,
20but not limited to, malabsorption and inborn errors of metabolism,
21if the product has been shown to be neither investigational nor
22experimental when used as part of a therapeutic regimen to prevent
23serious disability or death.

24(4) Notwithstanding Chapter 3.5 (commencing with Section
2511340) of Part 1 of Division 3 of Title 2 of the Government Code,
26the department may implement the amendments to this subdivision
27made by the act that added this paragraph by means of all-county
28letters, provider bulletins, or similar instructions, without taking
29regulatory action.

30(5) The amendments made to this subdivision by the act that
31added this paragraph shall be implemented June 1, 2011, or on the
32first day of the first calendar month following 60 days after the
33date the department secures all necessary federal approvals to
34implement this section, whichever is later.

35(ac) Diabetic testing supplies are covered when provided by a
36pharmacy, subject to utilization controls.

begin insert

37(ad) Commencing January 1, 2014, any benefits, services, and
38coverage not otherwise described in this section that are included
39in the essential health benefits package adopted by the state and
P42   1approved by the United States Secretary of Health and Human
2Services under Section 18022 of Title 42 of the United States Code.

end insert
3

SEC. 28.  

Section 14132.02 is added to the Welfare and
4Institutions Code
, to read:

5

14132.02.  

(a) Pursuant to Sections 1902(k)(1) and
61937(b)(1)(D) of the federal Social Security Act (42 U.S.C. Sec.
71396a(k)(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department
8shall seek approval from the United States Secretary of Health and
9Human Services to establish a benchmark benefit package that
10includes the same benefits, services, and coverage as is provided
11to all other full-scope Medi-Cal enrollees, supplemented by any
12benefits, services, and coverage included in the essential health
13benefits package adopted by the state and approved by the secretary
14under Section 18022 of Title 42 of the United States Code.

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

16

SEC. 29.  

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

18

15926.  

(a) The following definitions apply for purposes of
19this part:

20(1) “Accessible” means in compliance with Section 11135 of
21the Government Code, Section 1557 of the PPACA, and regulations
22or guidance adopted pursuant to these statutes.

23(2) “Limited-English-proficient” means not speaking English
24as one’s primary language and having a limited ability to read,
25speak, write, or understand English.

26(3) “State health subsidy programs” means the programs
27described in Section 1413(e) of the PPACA.

28(b) An individual shall have the option to apply for state health
29 subsidy programs in person, by mail, online, by telephone, or by
30other commonly available electronic means.

31(c) (1) A single, accessible, standardized paper, electronic, and
32telephone application for state health subsidy programs shall be
33developed by the department in consultation with MRMIB and
34the board governing the Exchange as part of the stakeholder process
35described in subdivision (b) of Section 15925. The application
36shall be used by all entities authorized to make an eligibility
37determination for any of the state health subsidy programs and by
38their agents.

39(2) The application shall be tested and operational by the date
40as required by the federal Secretary of Health and Human Services.

P43   1(3) The application form shall, to the extent not inconsistent
2with federal statutes, regulations, and guidance, satisfy all of the
3following criteria:

4(A) The form shall include simple, user-friendly language and
5instructions.

6(B) The form may not ask for information related to a
7nonapplicant that is not necessary to determine eligibility in the
8applicant’s particular circumstances.

9(C) The form may require only information necessary to support
10the eligibility and enrollment processes for state health subsidy
11programs.

12(D) The form may be used for, but shall not be limited to,
13screening.

14(E) The form may ask, or be used otherwise to identify, if the
15mother of an infant applicant under one year of age had coverage
16through a state health subsidy program for the infant’s birth, for
17the purpose of automatically enrolling the infant into the applicable
18program without the family having to complete the application
19process for the infant.

20(F) The form may include questions that are voluntary for
21applicants to answer regarding demographic data categories,
22including race, ethnicity, primary language, disability status, and
23other categories recognized by the federal Secretary of Health and
24Human Services under Section 4302 of the PPACA.

25(d) Nothing in this section shall preclude the use of a
26provider-based application form or enrollment procedures for state
27health subsidy programs or other health programs that differs from
28the application form described in subdivision (c), and related
29enrollment procedures.

30(e) The entity making the eligibility determination shall grant
31eligibility immediately whenever possible and with the consent of
32the applicant in accordance with the state and federal rules
33governing state health subsidy programs.

34(f) (1) If the eligibility, enrollment, and retention system has
35the ability to prepopulate an application form for insurance
36affordability programs with personal information from available
37electronic databases, an applicant shall be given the option, with
38his or her informed consent, to have the application form
39prepopulated. Before a prepopulated renewal form or, if available,
40prepopulated application is submitted to the entity authorized to
P44   1make eligibility determinations, the individual shall be given the
2opportunity to provide additional eligibility information and to
3correct any information retrieved from a database.

4(2) All state health subsidy programsbegin delete mayend deletebegin insert shallend insert accept
5self-attestation, instead of requiring an individual to produce a
6document,begin delete with respect to all informationend deletebegin insert end insertbegin insertfor age, date of birth, end insert
7begin insertfamily size, household income, state residence, pregnancy, and end insert
8begin insertany other applicable end insertbegin insertcriteriaend insert needed to determine the eligibility
9of an applicant or recipient, to the extent permitted by state and
10federal law.

11(3) An applicant or recipient shall have his or her information
12electronically verified in the manner required by the PPACA and
13implementing federal regulations and guidance.

14(4) Before an eligibility determination is made, the individual
15shall be given the opportunity to provide additional eligibility
16information and to correct information.

17(5) The eligibility of an applicant shall not be delayed or denied
18for any state health subsidy program unless the applicant is given
19a reasonable opportunity, of at least the kind provided for under
20the Medi-Cal program pursuant to Section 14007.5 and paragraph
21(7) of subdivision (e) of Section 14011.2, to resolve discrepancies
22concerning any information provided by a verifying entity.

23(6) To the extent federal financial participation is available, an
24applicant shall be provided benefits in accordance with the rules
25of the state health subsidy program, as implemented in federal
26regulations and guidance, for which he or she otherwise qualifies
27until a determination is made that he or she is not eligible and all
28applicable notices have been provided. Nothing in this section
29shall be interpreted to grant presumptive eligibility if it is not
30otherwise required by state law, and, if so required, then only to
31the extent permitted by federal law.

32(g) The eligibility, enrollment, and retention system shall offer
33an applicant and recipient assistance with his or her application or
34renewal for a state health subsidy program in person, over the
35telephone, and online, and in a manner that is accessible to
36individuals with disabilities and those who are limited English
37proficient.

38(h) (1) During the processing of an application, renewal, or a
39transition due to a change in circumstances, an entity making
40eligibility determinations for a state health subsidy program shall
P45   1ensure that an eligible applicant and recipient of state health
2subsidy programs that meets all program eligibility requirements
3and complies with all necessary requests for information moves
4between programs without any breaks in coverage and without
5being required to provide any forms, documents, or other
6information or undergo verification that is duplicative or otherwise
7unnecessary. The individual shall be informed about how to obtain
8information about the status of his or her application, renewal, or
9transfer to another program at any time, and the information shall
10be promptly provided when requested.

11(2) The application or case of an individual screened as not
12eligible for Medi-Cal on the basis of Modified Adjusted Gross
13Income (MAGI) household income but who may be eligible on
14the basis of being 65 years of age or older, or on the basis of
15blindness or disability, shall be forwarded to the Medi-Cal program
16for an eligibility determination. During the period this application
17or case is processed for a non-MAGI Medi-Cal eligibility
18determination, if the applicant or recipient is otherwise eligible
19for a state health subsidy program, he or she shall be determined
20eligible for that program.

21(3) Renewal procedures shall include all available methods for
22reporting renewal information, including, but not limited to,
23face-to-face, telephone, and online renewal.

24(4) An applicant who is not eligible for a state health subsidy
25program for a reason other than income eligibility, or for any reason
26in the case of applicants and recipients residing in a county that
27offers a health coverage program for individuals with income above
28the maximum allowed for the Exchange premium tax credits, shall
29be referred to the county health coverage program in his or her
30county of residence.

31(i) Notwithstanding subdivisions (e), (f), and (j), before an online
32applicant who appears to be eligible for the Exchange with a
33premium tax credit or reduction in cost sharing, or both, may be
34enrolled in the Exchange, both of the following shall occur:

35(1) The applicant shall be informed of the overpayment penalties
36under the federal Comprehensive 1099 Taxpayer Protection and
37Repayment of Exchange Subsidy Overpayments Act of 2011
38(Public Law 112-9), if the individual’s annual family income
39increases by a specified amount or more, calculated on the basis
40of the individual’s current family size and current income, and that
P46   1penalties are avoided by prompt reporting of income increases
2throughout the year.

3(2) The applicant shall be informed of the penalty for failure to
4have minimum essential health coverage.

5(j) The department shall, in coordination with MRMIB and the
6Exchange board, streamline and coordinate all eligibility rules and
7requirements among state health subsidy programs using the least
8restrictive rules and requirements permitted by federal and state
9law. This process shall include the consideration of methodologies
10for determining income levels, assets, rules for household size,
11citizenship and immigration status, and self-attestation and
12verification requirements.

13(k) (1) Forms and notices developed pursuant to this section
14shall be accessible and standardized, as appropriate, and shall
15comply with federal and state laws, regulations, and guidance
16prohibiting discrimination.

17(2) Forms and notices developed pursuant to this section shall
18be developed using plain language and shall be provided in a
19manner that affords meaningful access to limited-English-proficient
20individuals, in accordance with applicable state and federal law,
21and at a minimum, provided in the same threshold languages as
22required for Medi-Cal managed care plans.

23(l) The department, the California Health and Human Services
24Agency, MRMIB, and the Exchange board shall establish a process
25for receiving and acting on stakeholder suggestions regarding the
26functionality of the eligibility systems supporting the Exchange,
27including the activities of all entities providing eligibility screening
28to ensure the correct eligibility rules and requirements are being
29used. This process shall include consumers and their advocates,
30be conducted no less than quarterly, and include the recording,
31review, and analysis of potential defects or enhancements of the
32eligibility systems. The process shall also include regular updates
33on the work to analyze, prioritize, and implement corrections to
34confirmed defects and proposed enhancements, and to monitor
35screening.

36(m) In designing and implementing the eligibility, enrollment,
37and retention system, the department, MRMIB, and the Exchange
38board shall ensure that all privacy and confidentiality rights under
39the PPACA and other federal and state laws are incorporated and
40followed, including responses to security breaches.

P47   1(n) Except as otherwise specified, this section shall be operative
2on and after January 1, 2014.

3

SEC. 30.  

If the Commission on State Mandates determines
4that this act contains costs mandated by the state, reimbursement
5to local agencies and school districts for those costs shall be made
6pursuant to Part 7 (commencing with Section 17500) of Division
74 of Title 2 of the Government Code.



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