BILL ANALYSIS Ó
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THIRD READING
Bill No: SB 1X1
Author: Hernandez (D) and Steinberg (D)
Amended: As introduced
Vote: 21
SENATE HEALTH COMMITTEE : 6-1, 2/27/13
AYES: Hernandez, Beall, DeSaulnier, Monning, Pavley, Wolk
NOES: Anderson
NO VOTE RECORDED: Nielsen, Vacancy
SENATE APPROPRIATIONS COMMITTEE : 4-1, 3/4/13
AYES: De León, Hill, Lara, Steinberg
NOES: Walters
NO VOTE RECORDED: Gaines, Padilla
SUBJECT : Medi-Cal: eligibility
SOURCE : Author
DIGEST : This bill implements the expansion of federal
Medicaid coverage in California (Medicaid is known as Medi-Cal
in California) to low-income adults with incomes between 0 and
138% of the federal poverty level (FPL), establishes the
Medi-Cal benefit package for this expansion population, and
requires the existing Medi-Cal program to cover the essential
health benefits (EHB) contained in the Patient Protection and
Affordable Care Act (ACA). This bill implements a number of the
Medicaid ACA provisions to simplify the eligibility, enrollment
and renewal processes for Medi-Cal.
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ANALYSIS : This analysis is broken down by each major policy
area affected by this bill, describes existing federal law and
state law, the proposed change to state law, gives background on
existing law (if necessary), and provides the rationale for the
proposed changes.
Medi-Cal Expansion to Low-Income Adults
Under existing federal law, prior to the enactment of the ACA,
adults were generally not eligible for Medi-Cal coverage unless
they met categorical eligibility requirements, such as being
low-income and having minor children living at home, having a
disability, being over the age of 65, or being pregnant.
Currently, Medicaid requires financial need and a categorical
relationship (family with children, aged, persons with
disability). For example, adults who are not disabled, pregnant
or who do not have minor children are not categorically eligible
for Medi-Cal. The 2014 Medicaid expansion's largest enrollment
impact will be from the expansion to non-disabled childless
adults with incomes at or below 138% of the FPL (for a single
adult, 138% of the FPL is $1,321 per month or $15,856 per year
in 2013).
Counties draw down federal Medicaid matching funds to cover
low-income adults under California's "Bridge to Reform" Section
1115 Medicaid waiver as a transition to implementation of the
ACA Medicaid expansion through the Low Income Health Program
(LIHP). Over 500,000 individuals are covered under the LIHPs,
but not all counties have LIHPs (three counties have elected not
to implement a LIHP [Fresno, Merced and San Luis Obispo]). The
benefits in the LIHPs are more limited than in Medi-Cal, and
eligibility varies county by county. For example, eligibility
for San Francisco's LIHP is 25% of the FPL and Santa Clara is
75% of the FPL. Coverage under the LIHPs ends December 31,
2013. Statute establishing the LIHP requires the state, on and
after January 1, 2014, to implement comprehensive health care
reform for the populations targeted by the LIHP in compliance
with the federal ACA and subsequent amendments.
Under the ACA, starting January 1, 2014, Medi-Cal will expand
coverage to most adults who are at or below 138% of the FPL.
This coverage expansion applies to non-elderly, non-pregnant
adults under the age of 65. The Supreme Court ruling in June
2012 effectively allowed states to opt-out of the expansion by
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prohibiting the federal government from withholding federal
Medicaid funds for a state's entire Medicaid program if the
state failed to implement the expansion.
This bill:
1.Implements the Medicaid expansion in California.
2.Requires that individuals who qualify for the Medicaid
expansion who are currently enrolled in a LIHP be transitioned
to the Medi-Cal program in accordance with the transition plan
as approved by the federal Centers for Medicare and Medicaid
Services.
3.Requires LIHP enrollees be:
Notified which Medi-Cal health plan or plans contain
his/her existing medical home provider.
Notified that he/she can select a health plan that
contains his/her existing medical home provider.
Provided the opportunity to choose a different health
plan if there is more than one plan available in the county
where he/she resides.
Informed that if he/she does not affirmatively choose a
plan or there is only one plan in the county where he/she
resides, he/she shall be enrolled into the Medi-Cal managed
care plan that contains his/her LIHP medical home provider,
if the medical home provider contracts with a Medi-Cal
managed care plan.
In order to ensure that no persons lose health care coverage in
the course of the transition, notices of the January 1, 2014,
change must be sent to LIHP enrollees upon their LIHP
redetermination in 2013 and again at least 90 days prior to the
transition.
Medi-Cal benefits for the current population and expansion
population
Under existing federal law (since 2006), state Medicaid programs
have had the option to provide certain groups of enrollees with
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an alternative benefit package known as "benchmark" or
"benchmark-equivalent" coverage. The four benchmarks are:
1.The Standard Blue Cross/Blue Shield Preferred Provider Option
offered through the Federal Employees Health Benefit program;
2.State employee coverage that is offered and generally
available to state employees;
3.The commercial HMO with the largest insured commercial,
non-Medicaid enrollment in the state; and
4.Secretary-approved coverage, which can include the Medicaid
state plan benefit package offered in that state.
"Benchmark-equivalent" means that the benefits include certain
specified services, and the overall benefits are at least
actuarially equivalent to one of the statutorily specified
benchmark coverage packages. California has not implemented
this federal option. The ACA requires states to select a
benefit package for the Medi-Cal expansion population using
"benchmark" or "benchmark-equivalent" coverage.
The ACA requires any Medicaid benchmark benefit package to
additionally provide coverage for the EHB. The 10 EHB are
ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, including behavioral health
treatment, prescription drugs, rehabilitative and habilitative
services and devices, laboratory services, preventive and
wellness services and chronic disease management, and pediatric
services, including oral and vision care. The federal Centers
for Medicare and Medicaid Services indicates a state is not
required to select the same EHB benchmark reference plan it
selects for the individual and small group market (California
designated the Kaiser Small Group product as the state's EHB
benchmark plan in legislation last session), and it could have
more than one EHB benchmark reference plan for Medicaid.
Under the ACA, the Medicaid benefits provided to the expansion
population of adults must be consistent with the federal law
benchmark authority. If the EHB benchmark reference plan
selected for Medicaid were to lack coverage within one or more
of the ten required categories of benefits, it would need to be
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supplemented to ensure that it provides coverage in each of the
10 EHB categories. This would be in addition to any other
requirements for benchmark or benchmark-equivalent plans,
including federal mental parity (known as the Mental Health
Parity and Addition Equity Act) compliance.
This bill:
1.Requires the Department of Health Care Services (DHCS) to seek
federal approval to establish a benchmark benefit package that
includes the same benefits, services, and coverage that are
provided to all other full-scope Medi-Cal enrollees. In
addition, these benefits would be supplemented by any
benefits, services, and coverage included in the EHB package
adopted by the state and approved by the federal Secretary of
the Department of Health and Human Services.
2.Requires the existing Medi-Cal benefit package for the
non-expansion population to include any benefits, services,
and coverage not otherwise described in existing law that are
included in the approved EHB package.
Medi-Cal coverage for former foster youth until age 26
Federal regulations require states to provide Medicaid to
children for whom adoption assistance or foster care maintenance
payments are made. In addition, California has adopted the
federal option that allows states to provide Medicaid coverage
for former foster children between the ages of 18 and 21. The
state does not require an income, asset test or share-of-cost
for former foster youth. In 2010, there were slightly more than
7,000 former foster youth ages 18 through 20 enrolled in
Medi-Cal.
The ACA requires states cover former foster care children who:
Are under 26 years of age;
Are not eligible or enrolled under existing Medicaid mandatory
eligibility groups (or who are described in any of the
existing Medicaid mandatory eligibility groups but have income
that exceeds the upper income eligibility limit);
Were in foster care under the responsibility of the state at
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18 years of age (or such higher age as the state has elected);
and
Were enrolled in the Medicaid state plan or under a waiver
while in foster care.
The ACA also allows states to make "presumptive eligibility"
determinations for these individuals. Medicaid services
rendered to individuals in this new mandatory eligibility group
will be matched at the state's regular federal funds matching
rate, which in California is usually 50% federal funds and 50%
state funds.
This provision takes effect January 1, 2014, and mirrors a
similar provision in the ACA that allows dependents to stay on
their parents' private insurance coverage until age 26.
This bill:
1.Requires, to the extent federal financial participation is
available, DHCS to extend Medi-Cal benefits to a foster care
youth until age 26. A foster care youth is deemed eligible
for the benefits, and would be enrolled to receive these
benefits until his/her 26th birthday without any interruption
in coverage and without requiring a new application so long as
he/she was in foster care on his/her 18th birthday. These
changes are required by the ACA. This bill does not implement
the presumptive eligibility option.
2.Requires DHCS to identify and track all former independent
foster care youth who lost Medi-Cal coverage as a result of
turning age 21 in the 2013 calendar year. Requires DHCS to
develop and implement a simplified redetermination form for
these youth. A former foster youth qualifying for the
benefits is required to fill out and return this form only if
information previously reported to DHCS is no longer accurate,
and failure to return the form alone would not constitute a
basis for termination of Medi-Cal. If the form is returned as
undeliverable and the county is otherwise unable to establish
contact, the former foster youth remains eligible for
fee-for-service Medi-Cal until such time as contact is
reestablished or ineligibility is established, to the extent
federal financial participation is available. These changes
would take effect January 1, 2014.
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The requirement in this bill that DHCS track independent foster
care adolescent who lost Medi-Cal coverage as a result of
turning age 21 in the 2013 calendar year is because these
individuals will lose Medi-Cal coverage upon the date of their
21st birthday, only to be eligible again effective January 1,
2014 under the ACA. The provisions regarding the return of
undelivered forms ensure that former foster youth are not
disenrolled because they have moved and their mail is returned
as undeliverable. Former foster youth retain their right to
Medi-Cal coverage if they move within the state, obtain a job
and have an increase in income or obtain health insurance (in
which case Medi-Cal coverage would be the secondary payor), so
removing them from coverage to which they are entitled does not
make sense. This provision also ensures these individuals
retain access to health care services and decrease the amount of
"churning," which occurs when a beneficiary loses coverage and
must reapply for coverage. If the redetermination form is
returned as undeliverable and the county is unable to establish
contact with the individual, this bill shifts the former foster
youth's Medi-Cal coverage to fee-for-service (if he/she is in
Medi-Cal managed care) until contact is re-established or the
person is found ineligible so the state is not making monthly
capitation payments to Medi-Cal managed care plans for
individuals who have moved out of state or are deceased.
Implementation of ACA option for attestation of
application-related information
Existing state law required DHCS, by July 1, 2007, to implement
a process that allows applicants and beneficiaries of certain
Medi-Cal programs to self-certify the amount and nature of
assets and income without the need to submit documentation.
This process is required to apply to applicants and
beneficiaries in the 1931(b) program, the FPL programs for
infants, children and pregnant women, the Medically-Indigent and
Medically-Needy Programs for children and families, and other
similar programs designated by DHCS. This process was to be
implemented in two phases. However, these provisions have not
been implemented.
Federal regulations implementing the ACA allow the agency
determining eligibility (counties in California) to accept
attestation of information needed to determine the eligibility
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of an individual for Medicaid (either self-attestation or
attestation by an adult who is in the applicant's household)
without requiring further information (including documentation).
Self-attestation is not permitted for citizenship status and
immigration. Federal regulations require the agency to accept
self-attestation for pregnancy unless the state has information
that is not reasonably compatible with the attestation. The
county is authorized to verify state residency, date of birth,
and household size and composition.
To determine financial eligibility, federal regulations require
the county to request specified information from other agencies
in the state, other states, and federal programs to the extent
such information is useful in verifying the financial
eligibility of an individual. In addition, federal ACA
regulations require the Secretary of the Department of Health
and Human Services to establish an electronic service through
which states can verify information with or obtain information
from federal agencies and other data sources (referred to as the
"federal data hub"). Counties must promptly evaluate
information received or obtained to determine whether such
information may affect the eligibility of an individual or the
benefits to which he/she is entitled. If information provided
by an individual is reasonably compatible with information
obtained by the county, it must determine or renew eligibility
based on that information. The federal Centers for Medicare and
Medicaid Services guidance indicates that, if a state accepts
self-attestation of income, it must conduct post-enrollment
verification with the electronic data sources it determines
useful.
Existing state law authorizes state health subsidy programs to
accept self-attestation with respect to all information needed
to determine eligibility, to the extent permitted by law state
and federal law.
This bill requires state health subsidy programs (Medi-Cal,
coverage through Covered California and the Basic Health
Program, if enacted), to accept an individual's attestation,
without further documentation, for age, date of birth, family
size, household income, state residency, pregnancy, and any
other applicable eligibility criteria for which attestation is
permitted by federal law.
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The purpose of this provision is to implement the ACA option, to
reduce program administrative costs, and to move the state
toward electronic verification and away from the existing
burdensome paper-based application process. The preamble of
federal regulations indicates the purpose of the proposed
federal changes was to make verification processes more
efficient, modern, and coordinated by relying on trusted
third-party electronic data sources and shifting certain
verification responsibilities to the federal government, rather
than using paperwork submitted by Medi-Cal applicants and
beneficiaries.
Prohibition on asset test for modified adjusted gross income
(MAGI) individuals, required five percent income disregard, and
equivalent income standard
Existing state law requires each Medi-Cal applicant who is not a
recipient of aid under the California Work Opportunity and
Responsibility to Kids Act (CalWORKS) or Supplemental Security
Income/State Supplementary Payment to file an affirmation
setting forth such facts about his/her annual income and other
resources and qualifications for eligibility, as may be required
by DHCS.
Prior to the ACA, federal rules allowed income and asset
eligibility standards to vary across states, and different
standards to apply to different groups within states. For
example, children and pregnant women in California are eligible
for Medi-Cal without an asset test, while families under the
1931(b) coverage category have an asset test. Assets include
cash, savings, stocks, bonds, mutual funds, property, and life
insurance policies with a face value of less than $1,500.
Certain property is exempt, including a home, clothing, and the
first $4,650 value of a car. Property limits vary with family
size. For a family of two persons, the property limit is
$3,000.
Effective January 1, 2014, the ACA requires states to change the
way they calculate income for purposes of determining Medi-Cal
eligibility. Under the ACA, state income disregards and asset
or resource tests would no longer apply when calculating income
eligibility (except for specified groups, such as seniors and
individuals eligible for Medicaid on a basis that does not
require determination of income by the Medicaid state agency).
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In addition, the ACA prohibits the use of an asset or resource
test, except for:
Individuals eligible for Medicaid on a basis that does not
require a determination of income by the Medicaid state agency
(for example, foster care children, or individuals receiving
SSI);
Individuals who have attained age 65;
Individuals who qualify for Medicaid on the basis of being
blind or disabled regardless of whether the individual is
eligible for SSI;
Medically needy individuals;
Individuals dually eligible for Medicare and Medicaid; and
Individuals whose eligibility is being determined for purposes
of receiving nursing facility services, a level of care in any
institution equivalent to a nursing facility, home or
community-based services furnished under a Medicaid waiver or
state plan amendment.
Instead, the income eligibility for an individual or a family
would be measured based on MAGI. MAGI is defined as the
Internal Revenue Code's Adjusted Gross Income, which allows a
number of income deductions, including trade and business
deductions, losses from the sale of property, and alimony
payments. MAGI is increased by tax-exempt interest and income
earned by U.S. citizens or residents living abroad.
This bill:
1.Conforms state law to the ACA by prohibiting the use of an
asset or resource test for individuals whose financial
eligibility for Medi-Cal is determined based on MAGI.
2.Implements the ACA requirement that a 5% income disregard
applies to individuals whose income eligibility is determined
based on MAGI.
3.Requires DHCS, effective January 1, 2014, to implement an
equivalent income level for each eligibility group whose
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income level will be converted to MAGI. The equivalent income
level shall not be less than the dollar amount of all income
exemptions, exclusions, deductions, and disregards in effect
on March 23, 2010, plus the existing income level expressed as
a percent of the federal poverty level for each eligibility
group so as to ensure that the use of MAGI income methodology
does not result in populations, who would have been eligible
for either the Medi-Cal Program or the Healthy Families
Program, losing coverage. The state is awaiting further
guidance from the federal government on implementation of the
equivalent income level.
Changes to Pregnancy-Related Coverage in California
Access for Infants and Mothers Program
State law establishes the Access for Infants and Mothers (AIM)
Program, which provides prenatal care, labor and delivery and
coverage for pregnant women with family income between 200% and
300% of FPL, and for children less than two years of age who
were born under AIM. AIM coverage continues for 60 days
postpartum. If the 60th day falls in the middle of the month,
coverage terminates as of that date.
Federal regulations for Exchanges (Covered California) require
individuals enrolling between the first and the 15th of a month
to have coverage the first day of the following month. For
individuals enrolling between the 16th and the last day of the
month, the Exchange must ensure a coverage effective date on the
first day of the second following month.
This bill requires, at a minimum, AIM coverage to be provided to
pregnant women during pregnancy, and until the end of the month
in which the 60th day thereafter occurs. This change becomes
effective January 1, 2014.
The purpose of this change is so that coverage does not end in
the middle of the month, to avoid a gap in coverage between when
AIM coverage ends and coverage through the Exchange begins, and
to conform to the existing Medi-Cal requirement to provide
coverage until the end of the month in which the 60th day
occurs.
Full scope coverage for pregnant women in Medi-Cal
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State law requires Medi-Cal to cover pregnant women without a
share of cost with incomes below 200% of the FPL. However, the
type of coverage a woman receives (full scope Medi-Cal coverage
versus Medi-Cal coverage for pregnancy-only services) depends
upon her income, immigration status, assets, and whether she
meets other criteria (a pregnant woman can only receive full
scope coverage if she has "linkage" to Medi-Cal because she has
a "deprived" child in the home, is in her third trimester, or is
disabled or blind). For example, a low-income pregnant woman in
her first or second trimester with income below 100% of the FPL
does not qualify for full-scope Medi-Cal unless she is otherwise
linked to Medi-Cal (such as being on CalWORKS or disabled) until
she reaches her third trimester.
If a low-income pregnant woman is not eligible for full-scope
benefits, she is eligible for pregnancy-only services without a
share of cost if her income is at or below 200% of the FPL.
There is no asset test for pregnancy only coverage.
Pregnancy-only coverage covers prenatal care, labor and
delivery, and care through the end of the month in which the
60th post-partum day occurs.
Draft federal regulations released in January 2013 revise the
Medicaid exemption for pregnancy-related services so that all
services provided to pregnant women must be considered
pregnancy-related unless specifically identified in the state
plan as not pregnancy-related. In addition, the most recent
proposed Internal Revenue Service regulations that define
minimum essential coverage for purposes of meeting the
requirement that individual maintain such coverage (known as the
"individual mandate") states that pregnancy-related services
under Medicaid do not provide minimum essential coverage.
This bill:
1.Requires that pregnant women enrolled in Medi-Cal be provided
with all medically necessary services, and not just
pregnancy-only coverage, unless federal approval is granted to
provide fewer benefits during pregnancy.
2.Defines "pregnancy-related services" to mean, at a minimum,
all services required under the Medi-Cal program unless
federal approval is granted to provide fewer benefits during
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pregnancy. This requirement would take effect January 1,
2014.
The purpose of providing full scope coverage to pregnant women
is to help prevent premature delivery and low birth weight
infants, and to promote women's overall health, well-being, and
financial security and that of their families.
Repeal of semi-annual status reports
Existing state law requires adult Medi-Cal beneficiaries to file
a semi-annual status report in order to remain eligible for
Medi-Cal. Existing state law also requires information about
the semi-annual status report to be included in a notice used by
counties for Medi-Cal beneficiaries.
Regulations implementing the Medicaid ACA changes require
individuals' whose income is determined using MAGI to be renewed
once every 12 months but not more frequently than once every 12
months, thus prohibiting the semi-annual status report
requirement.
This bill conforms state law to the federal regulation by
repealing the semi-annual status report requirement.
Authorized representative to assist in application and renewal
process
Regulations implementing the ACA Medicaid changes require
agencies to allow individual(s) of the applicant or
beneficiary's choice to assist in the application process or
during a renewal of eligibility.
DHCS indicates it does not have statute or regulation that
defines authorized representatives.
This bill:
1.Requires a person who wishes to apply for a state health
subsidy program to be allowed to file an application on
his/her own behalf or on behalf of his/her family. The
individual also has the rights to be accompanied, assisted,
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and represented in the application and renewal process by an
individual or organization of his/her choosing. If the
individual for any reason is unable to apply or renew on
his/her own behalf, any of the following persons may file the
application for the applicant:
The individual's guardian, conservator, or executor;
A public agency representative; or
The individual's legal counsel, relative, friend, or
other spokesperson of his/her choice.
1.Gives a person, who wishes to challenge a decision concerning
his/her eligibility for or receipt of benefits from a state
health subsidy program, the right to represent himself/herself
or use legal counsel, a relative, a friend, or other
spokesperson of his/her choice.
The purpose of this provision of the bill is to meet the ACA
requirement, and to address an issue raised during the Medi-Cal
managed care stakeholder workgroup process regarding individuals
who are authorized representatives in the federal Social
Security System are not recognized as authorized representatives
by the state Medi-Cal computer system (known as MEDS).
Repeal of deprivation requirement
Under existing state law, the Medi-Cal 1931(b) program covers
children up through age 18 (and up to age 19 if they are
expected to graduate) and parents and caretaker relatives who
are "deprived" of full parental support. Deprivation means at
least one parent in the family must be absent, deceased or
disabled, or the principal wage earner must be unemployed or
underemployed.
The ACA allows states to eliminate the deprivation requirement.
This bill adopts the ACA option to repeal the deprivation
requirement.
The purpose of eliminating the deprivation requirement is there
is no longer a need for an administratively burdensome and
outdated welfare-based rule when individuals are subject to an
individual mandate and are eligible for coverage.
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Requirements prior to terminating Medi-Cal coverage
Existing state law establishes requirements for counties prior
to terminating eligibility for Medi-Cal under legislation known
as SB 87 (Escutia), Chapter 1088, Statutes of 2000. Under SB
87, counties must make "every reasonable effort" to gather
information available to the county that is relevant to the
beneficiary's Medi-Cal eligibility prior to contacting the
beneficiary. This includes Medi-Cal, CalWORKS, and CalFresh
case files of the beneficiary or any of his/her immediate family
members.
Federal regulations require the county to make a redetermination
of eligibility without requiring information from the individual
if able to do so based on reliable information contained in the
individual's account, or other more current information
available to the county. If the county is able to renew
eligibility based on such information, the county must notify
the individual of the eligibility determination, basis, and that
the individual must inform the county, through any of the modes
permitted for submission of applications (by telephone, in
person, mail, or through other commonly available electronic
means) if any of the information contained in such notice is
inaccurate. The individual is not required to sign and return
such notice if all information is accurate. If the county
cannot renew eligibility, the county must provide the individual
with a renewal form containing specified information.
This bill:
1.Eliminates the provision that limits the requirement that
counties "make every reasonable effort" to gather information,
thereby requiring counties to gather the information.
2.Requires counties to check federal and state databases to
verify financial and non-financial information.
3.Requires the county, if it is able to renew eligibility based
on information in the databases, to notify the individual of
the eligibility determination and basis, and that the
individual is required to inform the county if any information
contained in the notice is inaccurate. Under this bill, the
individual is not required to sign and return the notice if
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all information provided on the notice is accurate so as to
conform to federal regulations. Requires counties to make all
reasonable efforts not to send multiple notices during the
same time period about eligibility, and the notice of
eligibility renewal must contain other related information,
such as if the individual is in a new Medi-Cal program.
Under existing state law, if a county cannot obtain information
necessary to redetermine eligibility, counties have to attempt
to reach the beneficiary by telephone. This bill also requires
the county to attempt to reach the beneficiary through other
commonly available electronic means (for example, email or text)
in counties where such electronic means are available.
Under existing state law, if a county's efforts to obtain the
information necessary to redetermine eligibility have failed,
the county is required to send to the beneficiary a form which
highlights the information needed to complete the eligibility
determination. This bill repeals this requirement and instead
requires the county to send a form containing information
available to the county needed to renew eligibility, and
requires the form to advise the individual to provide any
necessary information to the county via internet, telephone,
mail, in person or through other commonly available electronic
means, and to sign the renewal form. This bill prohibits a
county from requesting information from non-applicants necessary
to make an eligibility determination.
Under existing state law, if a beneficiary submits an incomplete
form, counties must attempt to contact the beneficiary by
telephone.
This bill requires counties to attempt to contact the
beneficiary in writing and other commonly available electronic
means in counties where such electronic communication is
available.
Federal regulations implementing the Medicaid ACA-related
changes extend this 30-day timeframe. These regulations
require, for individuals whose income is determined based on
MAGI, annual eligibility redeterminations to be reconsidered if
an individual whose eligibility has been terminated for failure
to submit the renewal form or necessary information submits the
required information within 90 days, or a longer period elected
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by the state, without requiring a new application.
Under existing state law, if a Medi-Cal beneficiary is
terminated from coverage, but that former beneficiary submits a
completed form within 30 days of termination, the county is
required to determine eligibility as though the form was
submitted in a timely manner. If the beneficiary is found
eligible, existing law requires the termination to be rescinded.
This bill:
1.Conforms state law to the federal regulation by codifying the
90-day federal requirement, but does not extend it beyond 90
days.
2.Requires the county, if it has enough information available to
it to renew eligibility with respect to all eligibility
criteria, to begin a new 12-month eligibility period.
3.Requires individuals determined ineligible for Medi-Cal, to
determine eligibility for other state health subsidy programs,
and comply with specified procedures in existing law.
4.Requires any renewal form or notice to accessible to persons
who are limited English proficient and persons with
disabilities consistent with all federal and state
requirements.
Blindness and disability
Federal regulations allow counties determining eligibility to
consider blindness as continuing until the reviewing physician
determines that a beneficiary's vision has improved beyond the
definition of blindness contained in the state's Medicaid State
Plan. In addition, the Medicaid ACA-related changes allow the
county to consider disability as continuing until the review
team determines that a beneficiary's disability no longer meets
the definition of disability contained in the plan.
This bill adopts the two federal options outlined above. DHCS
indicates this provision adopts its current policy.
Redetermination of Medi-Cal eligibility
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Existing state law requires Medi-Cal redetermination to be filed
annually. Existing law permits redetermination to be required
at other times in accordance with general standards established
by DHCS.
Federal regulations implementing the Medicaid ACA changes
prohibit an individual whose income is determined using the MAGI
methodology to be renewed once every 12 months but not more
frequently than once every 12 months, thus prohibiting the
semi-annual status report requirement.
This bill eliminates the semi-annual status report requirement
to conform to federal requirements.
Implementation of Income Option
Federal regulations implementing the ACA require, for applicants
and new enrollees, financial eligibility to be based on current
monthly household income and family size. For current
beneficiaries, individuals who have been determined financially
eligible for Medicaid using the MAGI-based methods, a state may
elect to base financial eligibility either on current monthly
household income and family size or income based on projected
annual household income and family size for the remainder of the
current calendar year.
This bill:
1.Requires DHCS to adopt procedures to take into account
projected future changes in income and family size, for
individuals whose Medi-Cal income eligibility is determined
using MAGI-based methods, in order to grant or maintain
eligibility for those individuals who may be ineligible or
become ineligible if only the current monthly income and
family size are considered.
2.Requires, for current beneficiaries, DHCS to base financial
eligibility on projected annual household income for the
remainder of the current calendar year if the current monthly
income renders the beneficiary ineligible due to fluctuating
income. For applicants, DHCS is required to base an initial
determination of eligibility on the projected annual household
income and family size for the upcoming year if considering
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the current monthly income and family size in isolation
renders an applicant ineligible.
3.Requires DHCS to implement a reasonable method to account for
a reasonably predictable decrease in income and increase in
family size, as evidenced by a history of predictable
fluctuations in income or other clear indicia of a future
decrease in income and increase in family size.
4.Prohibits DHCS from assuming potential future increases in
income or decreases in family size to make an applicant or
beneficiary ineligible in the current month.
The MC 210 application for Medi-Cal instructs individuals to
list how much income they receive. The MC 210 instructs
individuals, who know that their family's income will fluctuate
in the next few months, to explain this on a separate sheet of
paper. The provision in allowing the use of projected annual
income this bill provides individuals the option to still enroll
in Medi-Cal by using their annual income if they have knowledge
their annual income is likely to be lower than their current
income in the month they apply for Medi-Cal.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
According to the Senate Appropriations Committee:
1.The Mandatory Expansion. By simplifying the process for
determining eligibility for Medi-Cal and enrolling program
participants, the bill will increase enrollment in the
program. The Legislative Analyst's Office projects that the
total costs due to increased enrollment of people already
eligible for the program will be about $620 million in 2014-15
($290 million General Fund at traditional cost sharing) rising
to about $1.1 billion in 2020-21 ($460 million General Fund).
Note that these costs will occur due to changes mandated by
federal law.
2.The Optional Expansion. By expanding Medi-Cal eligibility to
all childless adults under 65 years of age with household
income below 138% of the federal poverty level, the bill
substantially increases the eligible population, increasing
program costs. Under the Affordable Care Act federal
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financial participation will be substantially higher than
current practice, starting at 100% and declining to 90% by
2020 and thereafter.
State Medi-Cal health care costs. The Legislative
Analyst's Office projects that, under reasonable
assumptions, about 1.8 million additional people will be
eligible for Medi-Cal under the bill and that about 65% of
eligible persons will enroll in the program. In 2014-15,
total projected costs for medical services under the
optional expansion are projected to be about $3.5 billion
per year, entirely funded by the federal government. In
2020-21, the total costs for medical services under the
optional expansion are projected to be $6.0 billion per
year, including about $605 million per year in General Fund
costs (based on the ultimate 90% federal matching rate for
the optional expansion population).
State Medi-Cal administrative costs. In addition to the
direct costs to provide medical services to the expansion
population, there will be administrative costs to make
eligibility determinations and enroll beneficiaries in
Medi-Cal. Due to the changes to eligibility and enrollment
processes under the bill, per capita administrative costs
associated with the expansion population may be lower than
current per capita administrative costs. Administrative
costs are subject to the standard 50% federal matching
rate. By 2020-21, state General Fund administrative costs
are likely to be in the lows tens of millions per year.
State savings in other health care programs and in
corrections. The Legislative Analyst's Office also
indicates that the state will see substantial savings in
other state health-subsidy programs, such as the
Genetically Handicapped Persons Program, the Breast and
Cervical Cancer Treatment Program, and other programs. As
Medi-Cal eligibility increases, some participants in these
state programs will be eligible for full scope health
benefits from Medi-Cal and may no longer need services from
these specialized programs. There is a good deal of
uncertainty about the impact of the Medi-Cal expansion on
these programs, but the Legislative Analyst's Office
indicates that state savings could be in the low hundreds
of millions per year. In addition, the state could
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experience General Fund savings up to $60 million per year
due to the shift of certain outpatient medical costs for
inmates to Medi-Cal under the expansion.
County health care savings. Under current law, county
governments are responsible for providing certain health
care services to medically indigent adults who do not
qualify for other public health care programs. Under the
proposed expansion of Medi-Cal, a portion of that
population would transition from county responsibility to
the Medi-Cal program. While there is a great deal of
uncertainty regarding how many people would transition from
county-provided health care coverage to Medi-Cal and the
cost savings to the counties, the Legislative Analyst's
Office indicates that the counties are likely to realize
cost savings in the range of $800 million to $1.2 billion
per year. It is important to note that under SB X1 1, all
county savings would be retained by the counties and would
not be shared with the state.
1.Policies that will impact enrollment and costs. In addition
to the general uncertainty in projecting future Medi-Cal
enrollment levels and health care costs, there are certain
policy issues addressed by the bill that are likely to have
impacts on enrollment levels or per capita costs. The fiscal
impacts of these policy choices are not fully known at this
time. Key policy choices made in the bill include:
The benefit package provided to the expansion
population. Federal law provides some flexibility to the
state to design a benefit package for the expansion
population (although the benefit package must provide the
essential health benefits required under the Affordable
Care Act).
This bill directs the Department of Health Care Services to
seek federal approval to provide the same benefit package
to the expansion population as is provided under the
current Medi-Cal population as well as providing coverage
required under the essential health benefit package. In
addition, the bill requires the existing Medi-Cal
population to also receive the same essential health
benefit benchmark coverage. In general, the existing
Medi-Cal benefit package is broader than the essential
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health benefit benchmark plan the state has selected (the
Kaiser Small Group plan), particularly in coverage of
long-term services and supports. However, the Kaiser plan
provides some additional benefits such as some acupuncture
services and more generous substance abuse benefits.
The fiscal projections above assume that the expansion
population gets the existing Medi-Cal benefit package.
There may be additional costs, for both the existing
Medi-Cal eligible population and the expansion population,
by requiring both populations to receive benefits
equivalent to the Kaiser benchmark plan.
Self-attestation by applicants. Federal law and
regulations allow states to accept self-attestation by
applicants of certain information, such as age, date of
birth, household income, and state residency (not
immigration status). This bill requires the Department to
accept self-attestation of this information. By allowing
applicants to self-attest (rather than requiring them to
provide documentation) this provision simplifies the
application process and is likely to increase enrollment.
Full scope pregnancy-related coverage. Under current
state law, pregnant women with incomes up to 200% of the
federal poverty level are eligible for Medi-Cal. Some of
these beneficiaries are eligible for full-scope benefits
during pregnancy, while other beneficiaries are only
entitled to pregnancy-related benefits, depending on a
variety of eligibility factors. Draft federal regulations
indicate that Medicaid programs must provide full scope
benefits to pregnant women, unless the federal government
specifically authorizes states to limit such benefits.
This bill requires that all pregnant women enrolled in
Medi-Cal (up to 200% of the federal poverty level) be
provided with full scope benefits, unless approval is
granted by the federal government to provide lesser
benefits. (The author indicates that the intent of the bill
is to require full-scope benefits to be provided to all
pregnant women enrolled in Medi-Cal.)
Elimination of the existing deprivation requirement.
Under current state law, the Medi-Cal program covers
children and caretaker relatives who are "deprived" of full
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parental support (i.e. one parent is absent, deceased,
disabled, unemployed or underemployed). Federal law allows
states to eliminate this requirement and this bill does so.
It is not clear whether eliminating this requirement would
actually increase the number of eligible individuals for
the program.
Projection of annual income. Federal guidance to date
indicates that projected annual income (rather than an
applicant's current monthly income) can be used to
determine income eligibility. The bill requires the
Department to allow applicants to use projected annual
income to determine income eligibility. The counties (who
currently perform eligibility determinations) have
indicated that they already allow some projection of income
when making eligibility determinations, so it is not clear
whether this would actually increase overall enrollment in
Medi-Cal.
SUPPORT : (Verified 3/6/13)
100% Campaign
Alliance for Boys and Men of Color
Alliance of California Autism Organizations
American Cancer Society Cancer Action Network
American Federation of State, County, and Municipal Employees
American Heart Association
California Academy of Family Physicians
California Association of Public Hospitals and Health Systems
California Coverage and Health Initiatives
California Department of Insurance
California Health Advocates
California Hospital Association
California Immigrant Policy Center
California Labor Federation
California Mental Health Directors Association
California Nurses Association
California Opioid Maintenance Providers
California Pan-Ethnic Health Network
California Primary Care Association
California School Employees Association, AFL-CIO
California School Health Centers Association
California State Association of Counties
Californians for Patient Care
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Children Now
Children's Defense Fund California
Congress of California Seniors
Consumers Union
County Welfare Directors Association of California
Epilepsy California
Health Access California
Laborers' Local 777 and 792
Latino Health Alliance
Los Angeles Area Chamber of Commerce
Los Angeles County Board of Supervisors
March of Dimes Foundation - California Chapter
National Association of Social Workers - California chapter
National Health Law Program
PICO California
Planned Parenthood
San Mateo County Central Labor Council
Santa Clara County
Service Employees International Union
The Children's Partnership
The Greenlining Institute
Transgender Law Center
United Ways of California
Urban Counties Caucus
Western Center on Law and Poverty
JJA:nl 3/4/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
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