BILL NUMBER: SBX1 1 ENROLLED
BILL TEXT
PASSED THE SENATE JUNE 15, 2013
PASSED THE ASSEMBLY JUNE 15, 2013
AMENDED IN ASSEMBLY JUNE 14, 2013
AMENDED IN ASSEMBLY JUNE 4, 2013
INTRODUCED BY Senators Hernandez and Steinberg
(Coauthors: Senators Calderon, Correa, De León, Hueso, and Lara)
(Coauthors: Assembly Members Alejo, Blumenfield, Campos, Eggman,
Garcia, Gomez, Roger Hernández, V. Manuel Pérez, and Quirk-Silva)
JANUARY 28, 2013
An act to amend Sections 11026, 14005.39, and 14132 of, to amend
and repeal Section 14008.85 of, to amend, repeal, and add
Sections14005.28, 14005.31, 14005.32, 14007.1, and 14007.6 of, to add
Sections 14000.7,14005.63, 14005.65, 14005.66, 14005.67, 14005.68,
14007.15, 14011.66, 14014.5,14057, 14102, 14103, 14132.02, and
14132.03 to, and to add Article 5.9 (commencing with Section 14189)
to Chapter 7 of Part 3 of Division 9 of, the Welfare and Institutions
Code, relating to health.
LEGISLATIVE COUNSEL'S DIGEST
SB 1, 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 former foster children. The bill would also add, commencing
January 1, 2014, mental health services and substance use disorder
services 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, as
specified. The bill would require the department to seek approval
from the United States Secretary of Health and Human Services to
provide, effective January 1, 2014, specified individuals with an
alternative benefit package, which would provide the same schedule of
benefits provided to full-scope Medi-Cal beneficiaries qualifying
under the modified adjusted gross income (MAGI) income standard,
except as specified. The bill would provide that the implementation
of the optional expansion of Medi-Cal benefits to adults who meet
specified eligibility requirements shall be contingent on the federal
medical assistance percentage (FMAP) payable to the state under the
Affordable Care Act not being reduced to specified percentages, as
specified.
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.
This bill would require that a person who wishes to apply for an
insurance affordability program, as defined, be allowed to file an
application on his or her own behalf or on behalf of his or her
family and would authorize a person to be accompanied, assisted, and
represented in the application and renewal process by an individual
or organization of his or her choice. This bill would also require
the department, to the extent required by federal law, to provide
assistance to any applicant or beneficiary who requests help with the
application or redetermination. The bill would require the
department to file a state plan amendment to exercise a federal
option to allow beneficiaries to use projected annual household
income and to allow applicants and beneficiaries to use reasonably
predictable annual income, as specified.
This bill would require the department to seek any federal waivers
necessary to use eligibility information of certain individuals who
have been determined eligible for the CalFresh program to determine
their eligibility for Medi-Cal and to automatically enroll parents
who apply for Medi-Cal who have one or more children who are eligible
based on determined income level at or below a specified standard.
The bill would authorize the department to seek any federal waivers
or state plan amendments necessary to use the eligibility information
of individuals determined eligible for other state-only funded
health care programs and county general assistance programs to
determine an applicant's Medi-Cal eligibility to the extent that
there is no General Fund impact.
This bill would require the department to provide Medi-Cal
benefits during the presumptive eligibility period to individuals who
have been determined eligible on the basis of preliminary
information by a qualified hospital, as specified.
Existing law requires the department to adopt regulations for use
by the county in determining whether an applicant is a resident of
the state and of the county, subject to the requirements of federal
law. Existing law requires that the regulations require that state
residency be established only if certain requirements are met,
including the requirement that the applicant makes specified
declarations under penalty of perjury.
This bill would revise those provisions to, among other things,
further prescribe the circumstances under which state residency may
be established and to require the department to electronically verify
an individual's state residency using certain sources and would set
forth how an individual may establish state residency if the
department is unable to electronically verify his or her state
residency. The bill would, for purposes of establishing state
residency, authorize an individual to make various declarations under
penalty of perjury, and would authorize other individuals, such as
parents or legal guardians, to make various declarations under
penalty of perjury regarding the individual's state residency if the
individual is incapable of indicating intent. By expanding the crime
of perjury, the bill would impose a state-mandated local program.
This bill would provide that any individual who is 21 years of age
or older, does not have minor children eligible for Medi-Cal
benefits, would be eligible for Medi-Cal benefits but for a specified
five-year eligibility limitation, and who is enrolled in and covered
through the California Health Benefit Exchange with an advanced
premium tax credit shall be eligible for specified Medi-Cal benefits
and insurance premium costs and cost-sharing charges paid by the
department, as specified.
Under existing law, one of the ways by which Medi-Cal services are
provided is pursuant to contracts with various types of managed care
plans.
This bill would require Medi-Cal managed care plans to provide
mental health benefits covered by the state plan, as prescribed.
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 with regard to certain mandates no
reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that,
if the Commission on State Mandates determines that the bill contains
costs so mandated by the state, reimbursement for those costs shall
be made pursuant to the statutory provisions noted above.
This bill would become operative only if AB 1 of the First
Extraordinary Session is enacted and takes effect.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) The United States is the only industrialized country in the
world without a universal health insurance system.
(b) (1) In 2006, the United States Census reported that 46 million
Americans did not have health insurance.
(2) In California in 2009, according to the UCLA Center for Health
Policy Research's "The State of Health Insurance in California:
Findings from the 2009 California Health Interview Survey," 7.1
million Californians were uninsured in 2009, amounting to 21.1
percent of nonelderly Californians who had no health insurance
coverage for all or some of 2009, up nearly 2 percentage points from
2007.
(c) On March 23, 2010, President Obama signed the Patient
Protection and Affordable Care Act (Public Law 111-148), which was
amended by the Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and together are referred to as the Affordable
Care Act of 2010 (Affordable Care Act).
(d) The Affordable Care Act is the culmination of decades of
movement toward health reform, and is the most fundamental
legislative transformation of the United States health care system in
40 years.
(e) As a result of the enactment of the Affordable Care Act,
according to estimates by the UCLA Center for Health Policy Research
and the UC Berkeley Labor Center, using the California Simulation of
Insurance Markets, in 2019, after the Affordable Care Act is fully
implemented:
(1) Between 89 and 92 percent of Californians under 65 years of
age will have health coverage.
(2) Between 1.2 and 1.6 million individuals will be newly enrolled
in Medi-Cal.
(f) It is the intent of the Legislature to ensure full
implementation of the Affordable Care Act, including the Medi-Cal
expansion for individuals with incomes below 133 percent of the
federal poverty level, so that millions of uninsured Californians can
receive health care coverage.
SEC. 2. Section 11026 of the Welfare and Institutions Code is
amended to read:
11026. (a) Notwithstanding any other provision of law, the State
Department of Social Services and the State Department of Health Care
Services shall annually inform the Franchise Tax Board of the names
and social security numbers of all applicants or recipients of public
social services or public assistance programs. The Franchise Tax
Board, upon receipt of that information, shall furnish to the
departments the information required by Section 19555 of the Revenue
and Taxation Code.
(b) This section shall be implemented only to the extent it is
funded in the annual Budget Act.
SEC. 3. Section 14000.7 is added to the Welfare and Institutions
Code, to read:
14000.7. (a) The department shall provide assistance to any
applicant or beneficiary that requests help with the application or
redetermination process to the extent required by federal law.
(b) The assistance provided under subdivision (a) shall be
available to the individual in person, over the telephone, and
online, and in a manner that is accessible to individuals with
disabilities and those who have limited English proficiency.
(c) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(e) This section shall become operative on January 1, 2014.
SEC. 4. Section 14005.28 of the Welfare and Institutions Code is
amended to read:
14005.28. (a) To the extent federal financial participation is
available pursuant to an approved state plan amendment, the
department shall exercise its option under Section 1902(a)(10)(A)(ii)
(XVII) of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)
(10)(A)(ii)(XVII)) to extend Medi-Cal benefits to independent foster
care adolescents, as defined in Section 1905(w)(1) of the federal
Social Security Act (42 U.S.C. Sec. 1396d(w)(1)).
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and if the
state plan amendment described in subdivision (a) is approved by the
federal Health Care Financing Administration, the department may
implement subdivision (a) without taking any regulatory action and by
means of all-county letters or similar instructions. Thereafter, the
department shall adopt regulations in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.
(c) The department shall implement subdivision (a) on October 1,
2000, but only if, and to the extent that, the department has
obtained all necessary federal approvals.
(d) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 5. Section 14005.28 is added to the Welfare and Institutions
Code, to read:
14005.28. (a) To the extent federal financial participation is
available pursuant to an approved state plan amendment, the
department shall implement Section 1902(a)(10)(A)(i)(IX) of the
federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(IX))
to provide Medi-Cal benefits to an individual who is in foster care
on his or her 18th birthday until his or her 26th birthday. In
addition, the department shall implement the federal option to
provide Medi-Cal benefits to individuals who were in foster care and
enrolled in Medicaid in any state.
(1) A foster care adolescent who is in foster care in this state
on his or her 18th birthday shall be enrolled to receive benefits
under this section without any interruption in coverage and without
requiring a new application.
(2) The department shall develop procedures to identify and enroll
individuals who meet the criteria for Medi-Cal eligibility in this
subdivision, including, but not limited to, former foster care
adolescents who were in foster care on their 18th birthday and who
lost Medi-Cal coverage as a result of attaining 21 years of age. The
department shall work with counties to identify and conduct outreach
to former foster care adolescents who lost Medi-Cal coverage during
the 2013 calendar year as a result of attaining 21 years of age, to
ensure they are aware of the ability to reenroll under the coverage
provided pursuant to this section.
(3) (A) The department shall develop and implement a simplified
redetermination form for this program. A beneficiary qualifying for
the benefits extended pursuant to this section shall fill out and
return this form only if information known to the department is no
longer accurate or is materially incomplete.
(B) The department shall seek federal approval to institute a
renewal process that allows a beneficiary receiving benefits under
this section to remain on Medi-Cal after a redetermination form is
returned as undeliverable and the county is otherwise unable to
establish contact. If federal approval is granted, the recipient
shall remain eligible for services under the Medi-Cal fee-for-service
program until the time contact is reestablished or ineligibility is
established, and to the extent federal financial participation is
available.
(C) The department shall terminate eligibility only after it
determines that the recipient is no longer eligible and all due
process requirements are met in accordance with state and federal
law.
(b) This section shall be implemented only if and to the extent
that federal financial participation is available.
(c) This section shall become operative January 1, 2014.
SEC. 6. Section 14005.31 of the Welfare and Institutions Code is
amended to read:
14005.31. (a) (1) Subject to paragraph (2), for any person whose
eligibility for benefits under Section 14005.30 has been determined
with a concurrent determination of eligibility for cash aid under
Chapter 2 (commencing with Section 11200), loss of eligibility or
termination of cash aid under Chapter 2 (commencing with Section
11200) shall not result in a loss of eligibility or termination of
benefits under Section 14005.30 absent the existence of a factor that
would result in loss of eligibility for benefits under Section
14005.30 for a person whose eligibility under Section 14005.30 was
determined without a concurrent determination of eligibility for
benefits under Chapter 2 (commencing with Section 11200).
(2) Notwithstanding paragraph (1), a person whose eligibility
would otherwise be terminated pursuant to that paragraph shall not
have his or her eligibility terminated until the transfer procedures
set forth in Section 14005.32 or the redetermination procedures set
forth in Section 14005.37 and all due process requirements have been
met.
(b) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform Medi-Cal beneficiaries whose
eligibility for cash aid under Chapter 2 (commencing with Section
11200) has ended, but whose eligibility for benefits under Section
14005.30 continues pursuant to subdivision (a), that their benefits
will continue. To the extent feasible, the notice shall be sent out
at the same time as the notice of discontinuation of cash aid, and
shall include all of the following:
(1) A statement that Medi-Cal benefits will continue even though
cash aid under the CalWORKs program has been terminated.
(2) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(3) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but shall be required to submit a semiannual status report
and annual reaffirmation forms. The notice shall remind individuals
whose cash aid ended under the CalWORKs program as a result of not
submitting a status report that he or she should review his or her
circumstances to determine if changes have occurred that should be
reported to the Medi-Cal eligibility worker.
(4) A statement describing the responsibility of the Medi-Cal
beneficiary to report to the county, within 10 days, significant
changes that may affect eligibility.
(5) A telephone number to call for more information.
(6) A statement that the Medi-Cal beneficiary's eligibility worker
will not change, or, if the case has been reassigned, the new worker'
s name, address, and telephone number, and the hours during which the
county's eligibility workers can be contacted.
(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall, without taking any regulatory action, implement
this section by means of all-county letters or similar instructions.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Comprehensive
implementing instructions shall be issued to the counties no later
than March 1, 2001.
(e) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 7. Section 14005.31 is added to the Welfare and Institutions
Code, to read:
14005.31. (a) (1) Subject to paragraph (2), for any person whose
eligibility for benefits under Section 14005.30 has been determined
with a concurrent determination of eligibility for cash aid under
Chapter 2 (commencing with Section 11200), loss of eligibility or
termination of cash aid under Chapter 2 (commencing with Section
11200) shall not result in a loss of eligibility or termination of
benefits under Section 14005.30 absent the existence of a factor that
would result in loss of eligibility for benefits under Section
14005.30 for a person whose eligibility under Section 14005.30 was
determined without a concurrent determination of eligibility for
benefits under Chapter 2 (commencing with Section 11200).
(2) Notwithstanding paragraph (1), a person whose eligibility
would otherwise be terminated pursuant to that paragraph shall not
have his or her eligibility terminated until the transfer procedures
set forth in Section 14005.32 or the redetermination procedures set
forth in Section 14005.37 and all due process requirements have been
met.
(b) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties to inform Medi-Cal beneficiaries whose
eligibility for cash aid under Chapter 2 (commencing with Section
11200) has ended, but whose eligibility for benefits under Section
14005.30 continues pursuant to subdivision (a), that their benefits
will continue. To the extent feasible, the notice shall be sent out
at the same time as the notice of discontinuation of cash aid, and
shall include all of the following:
(1) A statement that Medi-Cal benefits will continue even though
cash aid under the CalWORKs program has been terminated.
(2) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(3) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but may be required to submit annual reaffirmation forms.
The notice shall remind individuals whose cash aid ended under the
CalWORKs program as a result of not submitting a status report that
he or she should review his or her circumstances to determine if
changes have occurred that should be reported to the Medi-Cal
eligibility worker.
(4) A statement describing the responsibility of the Medi-Cal
beneficiary to report to the county, within 10 days, significant
changes that may affect eligibility.
(5) A telephone number to call for more information.
(6) A statement that the Medi-Cal beneficiary's eligibility worker
will not change, or, if the case has been reassigned, the new worker'
s name, address, and telephone number, and the hours during which the
county's eligibility workers can be contacted.
(c) This section shall be implemented only to the extent that
federal financial participation under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning six
months after the effective date of this section, and notwithstanding
Section 10231.5 of the Government Code, the department shall provide
a status report to the Legislature on a semiannual basis until
regulations have been adopted.
(e) This section shall become operative on January 1, 2014.
SEC. 8. Section 14005.32 of the Welfare and Institutions Code is
amended to read:
14005.32. (a) (1) If the county has evidence clearly
demonstrating that a beneficiary is not eligible for benefits under
this chapter pursuant to Section 14005.30, but is eligible for
benefits under this chapter pursuant to other provisions of law, the
county shall transfer the individual to the corresponding Medi-Cal
program. Eligibility under Section 14005.30 shall continue until the
transfer is complete.
(2) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform beneficiaries that their Medi-Cal
benefits have been transferred pursuant to paragraph (1) and to
inform them about the program to which they have been transferred. To
the extent feasible, the notice shall be issued with the notice of
discontinuance from cash aid, and shall include all of the following:
(A) A statement that Medi-Cal benefits will continue under another
program, even though aid under Chapter 2 (commencing with Section
11200) has been terminated.
(B) The name of the program under which benefits will continue,
and an explanation of that program.
(C) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(D) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but shall be required to submit a semiannual status report
and annual reaffirmation forms. In addition, if the person or persons
to whom the notice is directed has been found eligible for
transitional Medi-Cal as described in Section 14005.8 or 14005.85,
the statement shall explain the reporting requirements and duration
of benefits under those programs, and shall further explain that, at
the end of the duration of these benefits, a redetermination, as
provided for in Section 14005.37 shall be conducted to determine
whether benefits are available under any other provision of law.
(E) A statement describing the beneficiary's responsibility to
report to the county, within 10 days, significant changes that may
affect eligibility or share of cost.
(F) A telephone number to call for more information.
(G) A statement that the beneficiary's eligibility worker will not
change, or, if the case has been reassigned, the new worker's name,
address, and telephone number, and the hours during which the county'
s Medi-Cal eligibility workers can be contacted.
(b) No later than September 1, 2001, the department shall submit a
federal waiver application seeking authority to eliminate the
reporting requirements imposed by transitional Medicaid under Section
1925 of the federal Social Security Act (Title 42 U.S.C. Sec.
1396r-6).
(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall, without taking any regulatory action, implement
this section by means of all-county letters or similar instructions.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Comprehensive
implementing instructions shall be issued to the counties no later
than March 1, 2001.
(e) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 9. Section 14005.32 is added to the Welfare and Institutions
Code, to read:
14005.32. (a) (1) If the county has evidence clearly
demonstrating that a beneficiary is not eligible for benefits under
this chapter pursuant to Section 14005.30, but is eligible for
benefits under this chapter pursuant to other provisions of law, the
county shall transfer the individual to the corresponding Medi-Cal
program in conformity with and subject to the requirements of Section
14005.37. Eligibility under Section 14005.30 shall continue until
the transfer is complete.
(2) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties to inform beneficiaries that their Medi-Cal
benefits have been transferred pursuant to paragraph (1) and to
inform them about the program to which they have been transferred. To
the extent feasible, the notice shall be issued with the notice of
discontinuance from cash aid, and shall include all of the following:
(A) A statement that Medi-Cal benefits will continue under another
program, even though aid under Chapter 2 (commencing with Section
11200) has been terminated.
(B) The name of the program under which benefits will continue and
an explanation of that program.
(C) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(D) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but may be required to submit annual reaffirmation forms.
In addition, if the person or persons to whom the notice is directed
has been found eligible for transitional Medi-Cal as described in
Section 14005.8 or 14005.85, the statement shall explain the
reporting requirements and duration of benefits under those programs
and shall further explain that, at the end of the duration of these
benefits, a redetermination, as provided in Section 14005.37, shall
be conducted to determine whether benefits are available under any
other law.
(E) A statement describing the beneficiary's responsibility to
report to the county, within 10 days, significant changes that may
affect eligibility or share of cost.
(F) A telephone number to call for more information.
(G) A statement that the beneficiary's eligibility worker will not
change, or, if the case has been reassigned, the new worker's name,
address, and telephone number, and the hours during which the county'
s Medi-Cal eligibility workers can be contacted.
(c) This section shall be implemented only to the extent that
federal financial participation under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning six
months after the effective date of this section, and notwithstanding
Section 10231.5 of the Government Code, the department shall provide
a status report to the Legislature on a semiannual basis until
regulations have been adopted.
(e) This section shall become operative on January 1, 2014.
SEC. 10. Section 14005.39 of the Welfare and Institutions Code is
amended to read:
14005.39. (a) If a county has facts clearly demonstrating that a
Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an event,
such as death or change of state residency, Medi-Cal benefits shall
be terminated without a redetermination under Section 14005.37.
(b) Whenever Medi-Cal eligibility is terminated without a
redetermination, as provided in subdivision (a), the Medi-Cal
eligibility worker shall record that fact or event causing the
eligibility termination in the beneficiary's file, along with a
certification that a full redetermination could not result in a
finding of Medi-Cal eligibility. Following this certification, a
notice of action specifying the basis for termination of Medi-Cal
eligibility shall be sent to the beneficiary.
(c) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et. seq.) is available and
necessary federal approvals have been obtained.
SEC. 11. Section 14005.63 is added to the Welfare and Institutions
Code, to read:
14005.63. (a) A person who wishes to apply for an insurance
affordability program shall be allowed to file an application on his
or her own behalf or on behalf of his or her family. Subject to the
requirements of Section 14014.5, an individual also may be
accompanied, assisted, and represented in the application and renewal
process by an individual or organization of his or her own choice.
If the individual, for any reason, is unable to apply or renew on his
or her own behalf, any of the following persons may assist in the
application process or during a renewal of eligibility:
(1) The individual's guardian, conservator, a person authorized to
make health care decisions on behalf of the individual pursuant to
an advance health care directive, or executor or administrator of the
individual's estate.
(2) A public agency representative.
(3) The individual's legal counsel, relative, friend, or other
spokesperson of his or her choice.
(b) A person who wishes to challenge a decision concerning his or
her eligibility for or receipt of benefits from an insurance
affordability program has the right to represent himself or herself
or use legal counsel, a relative, a friend, or other spokesperson of
his or her choice subject to the requirements of Section 14014.5.
(c) To the
extent otherwise required by Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department shall adopt emergency regulations implementing this
section no later than July 1, 2015. The department may thereafter
readopt the emergency regulations pursuant to that chapter. The
adoption and readoption, by the department, of regulations
implementing this section shall be deemed to be an emergency and
necessary to avoid serious harm to the public peace, health, safety,
or general welfare for purposes of Sections 11346.1 and 11349.6 of
the Government Code, and the department is hereby exempted from the
requirement that it describe facts showing the need for immediate
action and from review by the Office of Administrative Law.
(d) This section shall be implemented on October 1, 2013, or when
all necessary federal approvals have been obtained, whichever is
later, and only if and to the extent that federal financial
participation is available.
SEC. 12. Section 14005.65 is added to the Welfare and Institutions
Code, to read:
14005.65. (a) The department shall file a state plan amendment to
exercise the federal option under subdivision (h) of Section 435.603
of Title 42 of the Code of Federal Regulations to allow
beneficiaries to use projected annual household income and to allow
applicants and beneficiaries to use reasonably predictable annual
income as set forth in this section when determining their
eligibility for Medi-Cal benefits.
(b) (1) Beneficiaries shall be allowed to use projected annual
household income to establish eligibility for Medi-Cal benefits for
the remainder of the calendar year in which that projected income is
used to determine eligibility if the current monthly income would
render the beneficiary ineligible due to an increase in income.
(2) If projected annual household income has been used by the
beneficiary, the department shall redetermine the beneficiary's
Medi-Cal benefits at the end of the calendar year.
(c) (1) Applicants and beneficiaries shall be allowed to use
reasonably predictable annual income to establish eligibility for
Medi-Cal benefits.
(2) Before being allowed to use reasonably predictable annual
income pursuant to establishing eligibility for Medi-Cal benefits,
the applicant or beneficiary shall provide the department with
adequate evidence of the predicted change, including, but not limited
to, a signed contract for employment, clear proof of a history of
predictable fluctuations in income, or other clear indicia of such
future changes in income.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(e) This section shall become operative on January 1, 2014.
SEC. 13. Section 14005.66 is added to the Welfare and Institutions
Code, to read:
14005.66. The department shall seek any federal waivers necessary
to use the eligibility information of individuals who have been
determined eligible for the CalFresh program under Chapter 10
(commencing with Section 18900) of Part 6, and who are under 65 years
of age and are not disabled, to determine their Medi-Cal
eligibility.
SEC. 14. Section 14005.67 is added to the Welfare and Institutions
Code, to read:
14005.67. The department shall seek any federal waivers necessary
to automatically enroll parents in the Medi-Cal program who apply
for Medi-Cal benefits and have one or more children who are eligible
for Medi-Cal benefits based upon a determined income level that is at
or below the applicable income standard for eligibility under
Section 14005.60.
SEC. 15. Section 14005.68 is added to the Welfare and Institutions
Code, to read:
14005.68. The department may seek any federal waivers or state
plan amendments necessary to use the eligibility information of
individuals determined eligible for other state-only funded health
care programs and county general assistance programs to determine an
applicant's Medi-Cal eligibility to the extent that there is no
General Fund impact.
SEC. 16. Section 14007.1 of the Welfare and Institutions Code is
amended to read:
14007.1. (a) The department shall adopt regulations for use by
the county welfare department in determining whether an applicant is
a resident of this state and of the county subject to the
requirements of federal law. The regulations shall require that state
residency is not established unless the applicant does both of the
following:
(1) The applicant produces one of the following:
(A) A recent California rent or mortgage receipt or utility bill
in the applicant's name.
(B) A current California motor vehicle driver's license or
California Identification Card issued by the Department of Motor
Vehicles in the applicant's name.
(C) A current California motor vehicle registration in the
applicant's name.
(D) A document showing that the applicant is employed in this
state.
(E) A document showing that the applicant has registered with a
public or private employment service in this state.
(F) Evidence that the applicant has enrolled his or her children
in a school in this state.
(G) Evidence that the applicant is receiving public assistance in
this state.
(H) Evidence of registration to vote in this state.
(2) The applicant declares, under penalty of perjury, that all of
the following apply:
(A) The applicant does not own or lease a principal residence
outside this state.
(B) The applicant is not receiving public assistance outside this
state. As used in this subdivision, "public assistance" does not
include unemployment insurance benefits.
(b) A denial of a determination of residency may be appealed in
the same manner as any other denial of eligibility. The
administrative law judge shall receive any proof of residency offered
by the applicant and may inquire into any facts relevant to the
question of residency. A determination of residency shall not be
granted unless a preponderance of the credible evidence supports the
applicant's intent to remain indefinitely in this state.
(c) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 17. Section 14007.1 is added to the Welfare and Institutions
Code, to read:
14007.1. (a) The department shall electronically verify an
individual's state residency using information from the federal
Supplemental Nutrition Assistance Program, the CalWORKs program, the
California Health Benefit Exchange, the Franchise Tax Board, the
Department of Motor Vehicles, the Employment Development Department,
or the electronic service established in accordance with Section
435.949 of Title 42 of the Code of Federal Regulations, and other
available sources. If the department is unable to electronically
verify an individual's state residency using these electronic data
sources, an individual shall verify state residency as set forth in
this section.
(b) If the individual is 21 years of age or older, is capable of
indicating intent, and is not residing in an institution, state
residency is established when the individual provides one of the
following:
(1) A recent California rent or mortgage receipt or utility bill
in the individual's name.
(2) A current California motor vehicle driver's license or
California Identification Card issued by the Department of Motor
Vehicles in the individual's name.
(3) A current California motor vehicle registration in the
individual's name.
(4) A document showing that the individual is employed in this
state or is seeking employment in the state.
(5) A document showing that the individual has registered with a
public or private employment service in this state.
(6) Evidence that the individual has enrolled his or her children
in a school in this state.
(7) Evidence that the individual is receiving public assistance in
this state. For purposes of this paragraph, "public assistance"
shall not include unemployment insurance benefits.
(8) Evidence of registration to vote in this state.
(9) A declaration by the individual under penalty of perjury that
he or she intends to reside in this state and does not have a fixed
address and cannot provide any of the documents identified in
paragraphs (1) to (8), inclusive.
(10) A declaration by the individual under penalty of perjury that
he or she has entered the state with a job commitment or is seeking
employment in the state and cannot provide any of the documents
identified in paragraphs (1) to (8), inclusive.
(c) If the individual is 21 years of age or older, is incapable of
indicating intent, and is not residing in an institution, state
residency is established when the parent, legal guardian of the
individual, or any other person with knowledge declares, under
penalty of perjury, that the individual is residing in this state.
(d) If the individual is 21 years of age or older, is residing in
an institution, and became incapable of indicating intent before
reaching 21 years of age, state residency is established by any of
the following:
(1) When the parent applying for Medi-Cal on the individual's
behalf (A) declares under penalty of perjury that the individual's
parents reside in separate states and (B) establishes that he or she
(the parent) is a resident of this state in accordance with the
requirements of this section.
(2) When the legal guardian applying for Medi-Cal on the
individual's behalf (A) declares under penalty of perjury that
parental rights have been terminated and (B) establishes that he or
she (the legal guardian) is a resident of this state in accordance
with the requirements of this section.
(3) When the parent or parents applying for Medi-Cal on the
individual's behalf establishes in accordance with the requirements
of this section that he, she, or they (the parent or parents), were a
resident of this state at the time the individual was placed in the
institution.
(4) When the legal guardian applying for Medi-Cal on the
individual's behalf (A) declares under penalty of perjury that
parental rights have been terminated and (B) establishes in
accordance with the requirements of this section that he or she (the
legal guardian) was a resident of this state at the time the
individual was placed in the institution.
(5) When the parent, or parents, applying for Medi-Cal on the
individual's behalf (A) provides a document from the institution that
demonstrates that the individual is institutionalized in this state
and (B) establishes in accordance with the requirements of this
section that he, she, or they (the parent or parents), are a resident
of this state.
(6) When the legal guardian applying for Medi-Cal on the
individual's behalf (A) provides a document from the institution that
demonstrates that the individual is institutionalized in this state,
(B) declares under penalty of perjury that parental rights have been
terminated, and (C) establishes in accordance with the requirements
of this section that he or she (the legal guardian) is a resident of
this state.
(7) When the individual or party applying for Medi-Cal on the
individual's behalf (A) provides a document from the institution that
demonstrates that the individual is institutionalized in this state,
(B) declares under penalty of perjury that the individual has been
abandoned by his or her parents and does not have a legal guardian,
and (C) establishes that he or she (the individual or party applying
for Medi-Cal on the individual's behalf) is a resident of this state
in accordance with the requirements of this section.
(e) Except when another state has placed the individual in the
institution, if the individual is 21 years of age or older, is
residing in an institution, and became incapable of indicating intent
on or after reaching 21 years of age, state residency is established
when the person filing the application on the individual's behalf
provides a document from the institution that demonstrates that the
individual is institutionalized in this state.
(f) If the individual is 21 years of age or older, is capable of
indicating intent, and is residing in an institution, state residency
is established when the individual (1) provides a document from the
institution that demonstrates that the individual is
institutionalized in this state, and (2) declares under penalty of
perjury that he or she intends to reside in this state.
(g) If the individual is under 21 years of age, is married or
emancipated from his or her parents, is capable of indicating intent,
and is not residing in an institution, state residency is
established in accordance with subdivision (b).
(h) If the individual is under 21 years of age, is not living in
an institution, and is not described in subdivision (g), state
residency is established by any of the following:
(1) When the individual resides with his or her parent or parents
and the parent or parents establish that he, she, or they (the parent
or parents), as the case may be, are a resident of this state in
accordance with the requirements of subdivision (b).
(2) When the individual resides with a caretaker relative and the
caretaker relative establishes that he, she, or they (the caretaker
relative or caretaker relatives), are a resident of this state in
accordance with the requirements of subdivision (b).
(3) When the person with whom the individual is residing is not
the individual's parent or caretaker relative and he or she (A)
declares under penalty of perjury that the individual is residing
with him or her, and (B) establishes that he or she (the person with
whom the individual is residing) is a resident of this state in
accordance with the requirements of subdivision (b).
(4) When the individual does not reside with his or her parents or
with a caretaker relative and he or she declares under penalty of
perjury that he or she is living in this state.
(i) If the individual is under 21 years of age, is
institutionalized, and is not married or emancipated, state residency
is established in accordance with paragraph (3), (4), (5), (6), or
(7) of subdivision (d).
(j) A denial of a determination of residency may be appealed in
the same manner as any other denial of eligibility. The
administrative law judge shall receive any proof of residency offered
by the individual and may inquire into any facts relevant to the
question of residency. A determination of residency shall not be
granted unless a preponderance of the credible evidence supports that
the individual is a resident of this state under Section 14007.15.
(k) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(l) For purposes of this section, the definitions in subdivision
(i) of Section 14007.15 shall apply.
(m) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(n) This section shall become operative on January 1, 2014.
SEC. 18. Section 14007.15 is added to the Welfare and Institutions
Code, immediately following Section 14007.1, to read:
14007.15. (a) Except as provided in subdivision (f), an
individual is a resident of this state if he or she is 21 years of
age or older, is not residing in an institution, is living in the
state, and any of the following apply:
(1) The individual intends to reside in this state, including
individuals who do not have a fixed address.
(2) The individual has entered this state with a job commitment or
is seeking employment in this state, regardless of whether he or she
is currently employed.
(3) The individual is incapable of indicating intent.
(b) Except as provided in subdivision (f), an individual that is
21 years of age or older, is residing in an institution, and became
incapable of indicating intent before reaching 21 years of age is a
resident of this state if any of the following apply:
(1) The individual's parents reside in separate states and the
parent applying for Medi-Cal on the individual's behalf is a resident
of this state under this section.
(2) The parental rights have been terminated and a legal guardian
has been appointed for the individual and the legal guardian applying
for Medi-Cal on the individual's behalf is a resident of this state
under this section.
(3) The individual's parent or parents, or legal guardian if
parental rights have been terminated, was a resident of this state
under this section at the time the individual was placed in the
institution.
(4) The individual is institutionalized in this state and the
parent or parents, or legal guardian if parental rights have been
terminated, applying for Medi-Cal on the individual's behalf is a
resident of this state under this section.
(5) The individual is institutionalized in this state, has been
abandoned by his or her parent or parents, does not have a legal
guardian, and the individual or party that filed the Medi-Cal
application on the individual's behalf is a resident of this state
under this section.
(c) Except as provided in subdivision (f) and except where another
state has placed the individual in the institution, an individual is
a resident of this state if he or she is 21 years of age or older,
is institutionalized in this state, and became incapable of
indicating intent on or after reaching 21 years of age.
(d) Except as provided in subdivision (f), an individual is a
resident of this state if he or she is 21 years of age or older, is
institutionalized in this state, and intends to reside in this state.
(e) Except as provided in subdivision (f), an individual that is
under 21 years of age is a resident of this state if one of the
following apply:
(1) The individual is not residing in an institution, is capable
of indicating intent, is married or is emancipated from his or her
parents, is living in this state, and one of the following apply:
(A) The individual intends to reside in this state, which includes
an individual who does not have a fixed address.
(B) The individual has entered this state with a job commitment or
is seeking employment in this state, regardless of whether he or she
is currently employed.
(2) The individual is not described in paragraph (1) and is not
living in an institution, and any of the following apply:
(A) The individual resides in this state, including without a
fixed address.
(B) The individual resides with his or her parent or parents or a
caretaker relative who is a resident of this state under this
section.
(3) The individual is institutionalized, is not married or
emancipated, and any of the following apply:
(A) The individual's parent or parents, or legal guardian if
parental rights have been terminated, was a resident of this state
under this section at the time of placement in the institution.
(B) The individual is institutionalized in this state and his or
her parent or parents, or legal guardian if parental rights have been
terminated, who files the application on the individual's behalf is
a resident of this state under this section.
(C) The individual is institutionalized in this state, has been
abandoned by his or her parents, does not have a legal guardian, and
the individual or party that files the application on the individual'
s behalf is a resident of this state under this section.
(f) An individual who is receiving a state supplementary payment
(SSP) is a resident of the state paying the SSP.
(g) An individual who lives in this state and is receiving foster
care or adoption assistance under Title IV-E of the federal Social
Security Act is a resident of this state.
(h) (1) If this state or an agent of this state arranges for an
individual to be placed in an institution located in another state,
the individual is a resident of this state.
(2) The following actions do not constitute a placement by this
state:
(A) Providing basic information to the individual about another
state's Medicaid program and information about the availability of
health care services and facilities in another state.
(B) Assisting an individual to locate an institution in another
state when the individual is capable of indicating intent and
independently decides to move to the other state.
(3) When a competent individual leaves the facility in which he or
she was placed by this state, that individual's state of residence
is the state where the individual is physically located.
(4) If this state initiates a placement in another state because
it lacks an appropriate facility to provide services to the
individual, the individual is a resident of this state.
(i) For the purposes of this section and Section 14007.1, the
following definitions apply:
(1) "Incapable of indicating intent" means when an individual is
considered to be any of the following:
(A) Determined to have an I.Q. of 49 or less or to have a mental
age of 7 years or younger based upon tests administered by a properly
licensed mental health or developmental disabilities professional.
(B) Found to be incapable of indicating intent based on medical
documentation provided by a physician, psychologist, or other person
licensed by the state in the field of mental health or developmental
disabilities.
(C) Been judicially determined to be legally incompetent.
(2) "Institution" shall have the same meaning as that term is
defined in Section 435.1010 of Title 42 of the Code of Federal
Regulations. For the purposes of determining residency under
subdivision (h), the term also includes licensed foster care homes
providing food, shelter, and supportive services to one or more
persons unrelated to the proprietor.
(j) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(k) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(l) This section shall become operative on January 1, 2014.
SEC. 19. Section 14007.6 of the Welfare and Institutions Code is
amended to read:
14007.6. (a) A recipient who maintains a residence outside of
this state for a period of at least two months shall not be eligible
for services under this chapter where the county has made inquiry of
the recipient pursuant to Section 11100, and where the recipient has
not responded to this inquiry by clearly showing that he or she has
(1) not established residence elsewhere; and (2) been prevented by
illness or other good cause from returning to this state.
(b) If a recipient whose services are terminated pursuant to
subdivision (a) reapplies for services, services shall be restored
provided all other eligibility criteria are met if this individual
can prove both of the following:
(1) His or her permanent residence is in this state.
(2) That residence has not been established in any other state
which can be considered to be of a permanent nature.
(c) This section shall remain in effect only until January 1,
2014, and as of that date is repealed unless a later enacted statute,
that is enacted before January 1, 2014, deletes or extends that
date.
SEC. 20. Section 14007.6 is added to the Welfare and Institutions
Code, to read:
14007.6. (a) A recipient who maintains a residence outside of
this state for a period of at least two months shall not be eligible
for services under this chapter where the county has made inquiry of
the recipient pursuant to Section 11100, and where the recipient has
not responded to this inquiry by clearly showing that he or she has
(1) not established residence elsewhere; or (2) been prevented by
illness or other good cause from returning to this state.
(b) If a recipient whose services are terminated pursuant to
subdivision (a) reapplies for services, services shall be restored
provided all other eligibility criteria are met and the individual is
considered a resident pursuant to Section 14007.15.
(c) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(e) This section shall become operative on January 1, 2014.
SEC. 21. Section 14008.85 of the Welfare and Institutions Code is
amended to read:
14008.85. (a) To the
extent federal financial participation is available, a parent who is
the principal wage earner shall be considered an unemployed parent
for purposes of establishing eligibility based upon deprivation of a
child where any of the following applies:
(1) The parent works less than 100 hours per month as determined
pursuant to the rules of the Aid to Families with Dependent Children
program as it existed on July 16, 1996, including the rule allowing a
temporary excess of hours due to intermittent work.
(2) The total net nonexempt earned income for the family is not
more than 100 percent of the federal poverty level as most recently
calculated by the federal government. The department may adopt
additional deductions to be taken from a family's income.
(3) The parent is considered unemployed under the terms of an
existing federal waiver of the 100-hour rule for recipients under the
program established by Section 1931(b) of the federal Social
Security Act (42 U.S.C. Sec. 1396u-1).
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of an all-county
letter or similar instruction without taking regulatory action.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code.
(c) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 22. Section 14011.66 is added to the Welfare and Institutions
Code, to read:
14011.66. (a) Effective January 1, 2014, the department shall
provide Medi-Cal benefits during a presumptive eligibility period to
individuals who have been determined eligible on the basis of
preliminary information by a qualified hospital in accordance with
Section 1396a(a)(47)(B) of Title 42 of the United States Code and as
set forth in this section.
(b) A hospital may only make presumptive eligibility
determinations under this section if it complies with all of
following:
(1) It is a participating provider under the state plan or under a
federal waiver under Section 1315 of Title 42 of the United States
Code.
(2) It has notified the department in writing that it has elected
to be a qualified entity for the purpose of making presumptive
eligibility determinations.
(3) It agrees to make presumptive eligibility determinations
consistent with all applicable policies and procedures.
(4) It has not been disqualified to make presumptive eligibility
determinations by the department.
(c) Qualified hospitals may only make presumptive eligibility
determinations based upon income for children, pregnant women,
parents and other caretaker relatives, and other adults, whose income
is calculated using the applicable MAGI-based income standard.
(d) The department shall establish a process for determining
whether a hospital should be disqualified from being able to make
presumptive eligibility determinations under this section.
(e) For purposes of this section, "MAGI-based income" means income
calculated using the financial methodologies described in Section
1396a(e)(14) of Title 42 of the United States Code, as added by the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) and any subsequent
amendments.
(f) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 23. Section 14014.5 is added to the Welfare and Institutions
Code, to read:
14014.5. (a) It is the intent of the Legislature to protect
individual privacy and the integrity of Medi-Cal and other insurance
affordability programs by restricting the disclosure of personal
identifying information to prevent identity theft, abuse, or fraud in
situations where an insurance affordability program applicant or
beneficiary appoints an authorized representative to assist him or
her in obtaining health care benefits.
(b) The department, in consultation with the California Health
Benefit Exchange, shall implement policies and prescribe forms,
notices, and other safeguards to ensure the privacy and protection of
the rights of applicants who appoint an authorized representative
consistent with the provisions of Section 1902 of the federal Social
Security Act (42 U.S.C. Sec. 1396a) and Section 435.908 of Title 42
of the Code of Federal Regulations.
(c) All insurance affordability programs shall obtain completed
authorization forms pursuant to subdivision (b) prior to making the
final determination concerning the eligibility or renewal to which
the authorization applies.
(d) An authorization pursuant to this section shall do both of the
following:
(1) Specify what authority the applicant or beneficiary is
granting to the authorized representative and what notices, if any,
should be sent to the authorized representative in addition to the
applicant or beneficiary.
(2) Be effective until the applicant or beneficiary cancels or
modifies the authorization or appoints a new authorized
representative, or the authorized representative informs the agency
that he or she is no longer acting in that capacity or there is a
change in the legal authority on which the authority was based. The
notice shall conform to all federal requirements.
(e) An authorization pursuant to this section may be canceled or
modified at any time for any reason by the insurance affordability
program applicant or beneficiary by submitting notice of cancellation
or modification to the appropriate insurance affordability program
in accordance with policies and forms developed pursuant to
subdivision (b).
(f) The agency shall accept electronic, including telephonically
recorded, signatures, and handwritten signatures transmitted by
facsimile or other electronic transmission.
(g) For purposes of this section all of the following definitions
shall apply:
(1) "Authorized representative" means:
(A) (i) Any individual appointed in writing, on a form designated
by the department, by a competent person that is an applicant for or
beneficiary of any insurance affordability program, to act in place
or on behalf of the applicant or beneficiary for purposes related to
the insurance affordability program, including, but not limited to,
accompanying, assisting, or representing the applicant in the
application process or the beneficiary in the redetermination of
eligibility process, as specified by the applicant or beneficiary.
(ii) Legal documentation of authority to act on behalf of the
applicant or beneficiary under state law, including, but not limited
to, a court order establishing legal guardianship or a valid power of
attorney to make health care decisions, shall serve in place of a
written appointment by the applicant or beneficiary.
(2) "Competent" means being able to act on one's own behalf in
business and personal matters.
(h) An authorized representative of an applicant or beneficiary of
an insurance affordability program who also is employed by or is a
contractor for any type of health care provider or facility shall
fully disclose in writing to the applicant or beneficiary that the
authorized representative is employed by or contracting with such a
provider or facility and of any potential conflicts of interest.
(i) All notices regarding the insurance affordability program,
including, but not limited to, those related to the application,
redetermination, or actions taken by the agency, shall be sent to the
applicant or beneficiary, and to the authorized representative if
authorized by the applicant or beneficiary.
(j) (1) If an applicant or beneficiary is not competent and has
not appointed an appropriately authorized representative pursuant to
this section or that appointment is no longer effective, any of the
individuals identified in subparagraphs (A) to (C), inclusive, may be
recognized by the hearing officer as the authorized representative
to represent the applicant or beneficiary at the state hearing
regarding a notice of action if, at the hearing, he or she
demonstrates that the applicant or beneficiary is not competent and
that lack of competency is the reason that he or she has not been
authorized by the applicant or beneficiary to act as the applicant's
or beneficiary's authorized representative. The individuals that may
be recognized are:
(A) A relative of the applicant or beneficiary or a person
appointed by the relative.
(B) A person with knowledge of the applicant's or beneficiary's
circumstances that completed and signed the statement of facts on the
applicant's or beneficiary's behalf.
(C) An applicant's or beneficiary's legal counsel or advocate
working under the supervision of an attorney.
(2) If an applicant or beneficiary is not competent and has not
appointed an appropriately authorized representative pursuant to this
section or that appointment is no longer effective, the hearing
officer may allow an individual with knowledge about the applicant's
or beneficiary's circumstances to represent the applicant or
beneficiary at the hearing if (A) the hearing officer determines that
the representation is in the applicant or beneficiary's best
interests and (B) there is not a person who qualifies under paragraph
(1) that is available to represent the applicant or beneficiary.
(k) (1) A provider or staff member or volunteer of an organization
who intends to serve as an authorized representative shall comply
with, and shall provide, a signed written agreement that he or she
will adhere to all federal and state requirements governing his or
her appointment as an authorized representative, including, but not
limited to, those relating to confidentiality of information,
prohibitions against reassignment of provider claims, and conflicts
of interest. The department shall work with counties and consumer
advocates to develop a standard agreement form that may be used for
this purpose.
(2) The standard agreement form developed pursuant to paragraph
(1) shall include a notification regarding the requirements of this
subdivision and a statement that by signing the agreement, the
individual named as an authorized representative agrees to abide by
those requirements.
(l) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(m) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(n) This section shall be implemented on October 1, 2013, or when
all necessary federal approvals have been obtained, whichever is
later.
SEC. 24. Section 14057 is added to the Welfare and Institutions
Code, to read:
14057. (a) For the purposes of this chapter, "insurance
affordability program" means a program that is one of the following:
(1) The state's Medi-Cal program under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(2) The state's children's health insurance program (CHIP) under
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa
et seq.).
(3) A program that makes available to qualified applicants
coverage in a qualified health plan through the California Health
Benefit Exchange, established pursuant to Title 22 (commencing with
Section 100500) of the Government Code, with advance payment of the
premium tax credit established under Section 36B of the Internal
Revenue Code.
(4) A program that makes available coverage in a qualified health
plan through the California Health Benefit Exchange, established
pursuant to Title 22 (commencing with Section 100500) of the
Government Code, with cost-sharing reductions established under
Section 1402 of the federal Patient Protection and Affordable Care
Act (Public Law 111-148), and any subsequent amendments to that act.
(b) This section shall become operative on October 1, 2013.
SEC. 25. Section 14102 is added to the Welfare and Institutions
Code, to read:
14102. (a) Notwithstanding any other provision of law and except
as otherwise provided in this section, any individual who is 21 years
of age or older, who does not have minor children eligible for
Medi-Cal benefits and would be eligible for Medi-Cal benefits
pursuant to Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII))
but for the five-year eligibility limitation under Section 1613 of
Title 8 of the United States Code, and who is enrolled in coverage
through the Exchange with an advanced premium tax credit shall be
eligible for the following:
(1) Those Medi-Cal benefits for which he or she would have been
eligible but for the five-year eligibility limitation only to the
extent that they are not available through his or her individual
health plan.
(2) The department shall pay on behalf of the beneficiary:
(A) The beneficiary's insurance premium costs for an individual
health plan, minus the beneficiary's premium tax credit authorized by
Section 36B of Title 26 of the United States Code and its
implementing regulations.
(B) The beneficiary's cost-sharing charges so that the individual
has the same cost-sharing charges as he or she would have in the
Medi-Cal program.
(b) (1) If an individual is eligible for benefits under
subdivision (a) and he or she is otherwise eligible for state-only
funded full-scope benefits, but (A) he or she is barred from
enrolling in an Exchange qualified health plan because he or she is
outside of an available enrollment period for coverage or (B) the
Exchange and the department do not have the operational capability to
implement the benefits under subdivision (a), he or she shall remain
eligible for those state-only funded benefits subject to paragraph
(2).
(2) On the first date that an individual referenced in paragraph
(1) is eligible for and can enroll in coverage under a qualified
health plan offered through the Exchange, he or she shall be
ineligible for the state-only funded full-scope benefits referenced
in paragraph (1) unless the Exchange and the department do not have
the operational capability to implement the benefits under
subdivision (a).
(c) The department shall inform and assist individuals eligible
under this section on enrolling in coverage through the Exchange with
the premium assistance, cost sharing, and benefits described in
subdivision (a), including, but not limited to, developing processes
to coordinate with the county entities that administer eligibility
for coverage in Medi-Cal and the Exchange.
(d) For purposes of this section, the following definitions shall
apply:
(1) "Cost-sharing charges" means any expenditure required by or on
behalf of an enrollee by his or her individual health plan with
respect to essential health benefits and includes deductibles,
coinsurance, copayments, or similar charges, but excludes premiums,
and spending for noncovered services.
(2) "Exchange" means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.
(e) Benefits for services under this section shall be provided
with state-only funds only if federal financial participation is not
available for those services. The department shall maximize federal
financial participation in implementing this section to the extent
allowable.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted.
Thereafter, the department shall adopt regulations in accordance with
the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning six
months after the effective date of this section, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(g) This section shall become operative on January 1, 2014.
SEC. 26. Section 14103 is added to the Welfare and Institutions
Code, to read:
14103. (a) The implementation of the optional expansion of
Medi-Cal benefits to adults who meet the eligibility requirements of
Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), shall be
contingent upon the following:
(1) If the federal medical assistance percentage payable to the
state under the ACA for the optional expansion of Medi-Cal benefits
to adults is reduced below 90 percent, that reduction shall be
addressed in a timely manner through the annual state budget or
legislative process. Upon receiving notification of any reduction in
federal assistance pursuant to this paragraph, the Director of
Finance shall immediately notify the Chairpersons of the Senate and
Assembly Health Committees and the Chairperson of the Joint
Legislative Budget Committee.
(2) If, prior to January 1, 2018, the federal medical assistance
percentage payable to the state under the ACA for the optional
expansion of Medi-Cal benefits to adults is reduced to 70 percent or
less, the implementation of any provision in this chapter authorizing
the optional expansion of Medi-Cal benefits to adults shall cease 12
months after the effective date of the federal law or other action
reducing the federal medical assistance percentage.
(b) For purposes of this section, "ACA" means the federal Patient
Protection and Affordable Care Act (Public Law 111-148) as originally
enacted and as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) and any subsequent
amendments.
SEC. 27. Section 14132 of the Welfare and Institutions Code is
amended to read:
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) (1) Inpatient hospital services, including, but not limited
to, physician and podiatric services, physical therapy and
occupational therapy, are covered subject to utilization controls.
(2) For Medi-Cal fee-for-service beneficiaries, emergency services
and care that are necessary for the treatment of an emergency
medical condition and medical care directly related to the emergency
medical condition. This paragraph shall not be construed to change
the obligation of Medi-Cal managed care plans to provide emergency
services and care. For the purposes of this paragraph, "emergency
services and care" and "emergency medical condition" shall have the
same meanings as those terms are defined in Section 1317.1 of the
Health and Safety Code.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers for Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) (i) For the purposes of this paragraph, nonlegend has the
same meaning as defined in subdivision (a) of Section 14105.45.
(ii) Nonlegend acetaminophen-containing products, with the
exception of children's acetaminophen-containing products, selected
by the department are not covered benefits.
(iii) Nonlegend cough and cold products selected by the department
are not covered benefits. This clause shall be implemented on the
first day of the first calendar month following 90 days after the
effective date of the act that added this clause, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(iv) Beneficiaries under the Early and Periodic Screening,
Diagnosis, and Treatment Program shall be exempt from clauses (ii)
and (iii).
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once
every two years, unless the
department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services are covered to the
extent that federal financial participation is available for those
services under the state plan or waivers granted in accordance with
Section 1315 or 1396n of Title 42 of the United States Code. The
director may seek waivers for any or all home- and community-based
services approvable under Section 1315 or 1396n of Title 42 of the
United States Code. Coverage for those services shall be limited by
the terms, conditions, and duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title
42 of the United States Code, which was added to Section 1396a of
Title 42 of the United States Code by Section 2303(a)(2) of the
federal Patient Protection and Affordable Care Act (PPACA) (Public
Law 111-148), for a program to provide comprehensive clinical family
planning services as described in paragraph (8). Under the waiver,
the program shall be operated only in accordance with the waiver and
the statutes and regulations in paragraph (4) and subject to the
terms, conditions, and duration of the waiver. Under the state plan
amendment, which shall replace the waiver and shall be known as the
Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section 1396a
(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the
extent that federal financial participation is available, the program
shall continue to conduct education, outreach, enrollment, service
delivery, and evaluation services as specified under the waiver. The
services shall be provided under the program only if the waiver and,
when applicable, the successor state plan amendment are approved by
the federal Centers for Medicare and Medicaid Services and only to
the extent that federal financial participation is available for the
services. Nothing in this section shall prohibit the department from
seeking the Family PACT successor state plan amendment during the
operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other provision of law,
the collection and use of an individual's social security number
shall be necessary only to the extent required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division
3 of Title 2 of the Government Code. Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) (1) Purchase of prescribed enteral nutrition products is
covered, subject to the Medi-Cal list of enteral nutrition products
and utilization controls.
(2) Purchase of enteral nutrition products is limited to those
products to be administered through a feeding tube, including, but
not limited to, a gastric, nasogastric, or jejunostomy tube.
Beneficiaries under the Early and Periodic Screening, Diagnosis, and
Treatment Program shall be exempt from this paragraph.
(3) Notwithstanding paragraph (2), the department may deem an
enteral nutrition product, not administered through a feeding tube,
including, but not limited to, a gastric, nasogastric, or jejunostomy
tube, a benefit for patients with diagnoses, including, but not
limited to, malabsorption and inborn errors of metabolism, if the
product has been shown to be neither investigational nor experimental
when used as part of a therapeutic regimen to prevent serious
disability or death.
(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the amendments to this subdivision made by
the act that added this paragraph by means of all-county letters,
provider bulletins, or similar instructions, without taking
regulatory action.
(5) The amendments made to this subdivision by the act that added
this paragraph shall be implemented June 1, 2011, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
SEC. 28. Section 14132.02 is added to the Welfare and Institutions
Code, to read:
14132.02. (a) The department shall seek approval from the United
States Secretary of Health and Human Services to provide individuals
made eligible pursuant to Section 14005.60 with the alternative
benefit package option authorized by Section 1396u-7(b)(1)(D) of
Title 42 of the United States Code. Effective January 1, 2014, the
alternative benefit package shall provide the same schedule of
benefits provided to full-scope Medi-Cal beneficiaries qualifying
under the modified adjusted gross income standard pursuant to Section
1396a(e)(14) of Title 42 of the United States Code, except coverage
of long-term services and supports shall be excluded unless otherwise
required by Section 1396u-7(a)(2) of Title 42 of the United States
Code or made available pursuant to subdivision (b). The alternative
benefit package shall also include any benefits otherwise required by
Section 1396u-7 of Title 42 of the United States Code and any
regulations or guidance issued pursuant to that section.
(b) Notwithstanding Section 14005.64, and only to the extent
federal approval is obtained, the department shall provide coverage
for long-term services and supports to only those individuals who
meet the asset requirements imposed under the Medi-Cal program for
receipt of such services.
(c) For purposes of this section, long-term services and supports
include nursing facility services, a level of care in any institution
equivalent to nursing facility services, home- and community-based
services furnished under the state plan or a waiver under Section
1315 or 1396n of Title 42 of the United States Code, home health
services as described in Section 1396d(a)(7) of Title 42 of the
United States Code, and personal care services described in Section
1396d(a)(24) of Title 42 of the United States Code.
(d) The department may seek approval of any necessary state plan
amendments or waivers to implement this section.
(e) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 29. Section 14132.03 is added to the Welfare and Institutions
Code, to read:
14132.03. (a) The following shall be covered Medi-Cal benefits
effective January 1, 2014:
(1) Mental health services included in the essential health
benefits package adopted by the state pursuant to Section 1367.005 of
the Health and Safety Code and Section 10112.27 of the Insurance
Code and approved by the United States Secretary of Health and Human
Services under Section 18022 of Title 42 of the United States Code.
To the extent behavioral health treatment services are considered
mental health services pursuant to the essential health benefits
package, these services shall only be provided to individuals who
receive services through federally approved waivers or state plan
amendments pursuant to the Lanterman Developmental Disability
Services Act, at Division 4.5 (commencing with Section 4500).
(2) Substance use disorder services included in the essential
health benefits package adopted by the state pursuant to Section
1367.005 of the Health and Safety Code and Section 10112.27 of the
Insurance Code and approved by the United States Secretary of Health
and Human Services under Section 18022 of Title 42 of the United
States Code.
(b) The department may seek approval of any necessary state plan
amendments to implement this section.
(c) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 30. Article 5.9 (commencing with Section 14189) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 5.9. Medi-Cal Managed Care Plan Mental Health Benefits
14189. Medi-Cal managed care plans shall provide mental health
benefits covered in the state plan excluding those benefits provided
by county mental health plans under the Specialty Mental Health
Services Waiver. The department may require the managed care plans to
cover mental health pharmacy benefits to the extent provided in the
contracts between the department and the Medi-Cal managed care plans.
SEC. 31. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution for
certain costs that may be incurred by a local agency or school
district because, in that regard, this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
However, if the
Commission on State Mandates determines that this act contains other
costs mandated by the state, reimbursement to local agencies and
school districts for those costs shall be made pursuant to Part 7
(commencing with Section 17500) of Division 4 of Title 2 of the
Government Code.
SEC. 32. This act shall become operative only if Assembly Bill 1
of the 2013-14 First Extraordinary Session is enacted and takes
effect.