BILL NUMBER: SB 508 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY AUGUST 18, 2014
AMENDED IN ASSEMBLY JUNE 5, 2014
AMENDED IN SENATE JANUARY 9, 2014
INTRODUCED BY Senator Hernandez
FEBRUARY 21, 2013
An act to amend Sections 14005.20, 14005.26, 14005.27, 14005.28,
14005.30, 14005.64, 14051, 14148, and 14148.5 of, and to add Sections
14005.285, 14005.287, and 14005.288 to, the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 508, as amended, Hernandez. Medi-Cal: eligibility.
(1) 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. Existing law requires, with some
exceptions, a Medi-Cal applicant's or beneficiary's income and
resources be determined based on modified adjusted gross income
(MAGI), as specified. Existing law requires the department to
establish income eligibility thresholds for those eligibility groups
whose eligibility will be determined using MAGI-based financial
methods.
This bill would codify the income eligibility thresholds
established by the department and would make other related and
conforming changes.
(2) Existing law requires the department to implement specified
provisions of federal law 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, as specified.
This bill would instead require the department to implement those
provisions to provide Medi-Cal benefits to an individual until his or
her 26th birthday if he or she was in foster care on his or her 18th
birthday or such higher age at which the state's or tribe's
foster care assistance ends under federal law. The bill would, if
permitted under future federal regulations or guidance, require the
department to provide Medi-Cal benefits under these provisions to an
individual who left foster care before reaching the age at which the
state's or tribe's foster care assistance ends under federal law.
the state h as elected under federal law.
The bill would also require the department to exercise its
option under federal law to extend Medi-Cal benefits to independent
foster care adolescents, as specified.
This bill would require the department to exercise its option
under federal law to extend Medi-Cal benefits to individuals under 21
years of age placed in foster homes or private institutions and
individuals under 21 years of age for whom a specified adoption
agreement is in effect. The bill would require that all of the income
considered when determining an individual's eligibility under these
provisions be disregarded.
Because counties are required to make eligibility determinations
and this bill would expand Medi-Cal eligibility, the bill would
impose a state-mandated local program.
(3) Existing law, for purposes of determining eligibility,
defines, in part, a medically needy family person as a parent or
caretaker relative of a child who meets the deprivation requirements
of Aid to Families with Dependent Children.
This bill would delete the requirement that the parent or
caretaker relative meet the deprivation requirements.
(4) The California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14005.20 of the Welfare and Institutions Code
is amended to read:
14005.20. (a) The State Department of Health Care Services shall
adopt the option made available under Section 1902(a)(10)(A)(ii)(XII)
of Title XIX of the federal Social Security Act (42 U.S.C. Sec.
1396a(a)(10)(A)(ii)(XII)) to pay allowable tuberculosis related
services for persons infected with tuberculosis.
(b) (1) Except as provided in paragraph (2), the income and
resources of these persons may not exceed the maximum amount for a
disabled person as described in Section 1902(a)(10)(A)(i) of Title
XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)
(A)(i)).
(2) Effective January 1, 2014, the income and resources of
individuals eligible under this section may not exceed the maximum
amount for a disabled person as described in Section 1902(a)(10)(A)
(i) of Title XIX of the federal Social Security Act (42 U.S.C. Sec.
1396a(a)(10)(A)(i)), as determined, counted, and valued in accordance
with the requirements of Section 14005.64.
(c) The amendments made by the act that added this subdivision
shall be implemented only if and to the extent that federal financial
participation is available and any necessary federal approvals have
been obtained.
SEC. 2. Section 14005.26 of the Welfare and Institutions Code is
amended to read:
14005.26. (a) (1) Except as provided in subdivision (b), the
department shall exercise the option pursuant to Section 1902(a)(l0)
(A)(ii)(XIV) of the federal Social Security Act (42 U.S.C. Sec. 1396a
(a)(10)(A)(ii)(XIV)) to provide full-scope benefits with no share of
cost under this chapter and Chapter 8 (commencing with Section 14200)
to optional targeted low-income children pursuant to Section 1905(u)
(2)(B) of the federal Social Security Act (42 U.S.C. Sec. 1396d(u)(2)
(B)), with family incomes up to and including 200 percent of the
federal poverty level. The department shall seek federal approval of
a state plan amendment to implement this subdivision.
(2) (A) Pursuant to Section 1902(r)(2) of the federal Social
Security Act (42 U.S.C. Sec. 1396a(r)(2)), the department shall adopt
the option to use less restrictive income and resource methodologies
to exempt all resources and disregard income at or above 200 percent
and up to and including 250 percent of the federal poverty level for
the individuals described in paragraph (1). The department shall
seek federal approval of a state plan amendment to implement this
subdivision.
(B) This paragraph shall be inoperative on January 1, 2014.
(b) Effective January 1, 2014, the federal poverty level
percentage income eligibility threshold used pursuant to subdivision
(c) of Section 14005.64 to determine eligibility for medical
assistance under subdivision (a) shall equal 261 percent of the
federal poverty level.
(c) For purposes of carrying out the provisions of this section,
the department may adopt the option pursuant to Section 1902(e)(13)
of the federal Social Security Act (42 U.S.C. Sec. 1396a(e)(13)) to
rely upon findings of the Managed Risk Medical Insurance Board
(MRMIB) regarding one or more components of eligibility.
(d) (1) (A) Except as provided in subparagraph (B), the department
shall exercise the option pursuant to Section 1916A of the federal
Social Security Act (42 U.S.C. Sec. 1396o-1) to impose premiums for
individuals described in subdivision (a) whose family income has been
determined to be above 150 percent and up to and including 200
percent of the federal poverty level, after application of the income
disregard pursuant to paragraph (2) of subdivision (a). The
department shall not impose premiums under this subdivision for
individuals described in subdivision (a) whose family income has been
determined to be at or below 150 percent of the federal poverty
level, after application of the income disregard pursuant to
paragraph (2) of subdivision (a). The department shall obtain federal
approval for the implementation of this subdivision.
(B) Effective January 1, 2014, the department shall impose a
premium pursuant to subparagraph (A) for individuals whose family
income has been determined to be above 160 percent and up to and
including 261 percent of the federal poverty level, as determined,
counted, and valued in accordance with the requirements of Section
14005.64.
(2) (A) Monthly premiums imposed under this section shall equal
thirteen dollars ($13) per child with a maximum contribution of
thirty-nine dollars ($39) per family.
(B) Families that pay three months of required premiums in advance
shall receive the fourth consecutive month of coverage with no
premium required. For purposes of the discount provided by this
subparagraph, family contributions paid in the Healthy Families
Program for children transitioned to Medi-Cal pursuant to Section
14005.27 shall be credited as Medi-Cal premiums paid.
(C) Families that pay the required premium by an approved means of
electronic funds transfer, including credit card payment, shall
receive a 25-percent discount from the required premium. If the
department and the Managed Risk Medical Insurance Board determine
that it is feasible, the department shall treat an authorization for
electronic funds transfer or credit card payment to the Healthy
Families Program as an authorization for electronic funds transfer or
credit card payment to Medi-Cal.
(e) This section shall be implemented only to the extent that all
necessary federal approvals and waivers described in this section
have been obtained and the enhanced rate of federal financial
participation under Title XXI of the federal Social Security Act (42
U.S.C. Sec. 1397aa et seq.) is available for targeted low-income
children pursuant to that act.
(f) The department shall not enroll targeted low-income children
described in this section in the Medi-Cal program until all necessary
federal approvals and waivers have been obtained, and no sooner than
January 1, 2013.
(g) (1) (A) Except as provided in subparagraph (B), to the extent
the new budget methodology pursuant to paragraph (6) of subdivision
(a) of Section 14154 is not fully operational, for the purposes of
implementing this section, for individuals described in subdivision
(a) whose family income has been determined to be up to and including
150 percent of the federal poverty level, as determined pursuant to
paragraph (2) of subdivision (a), the department shall utilize the
budgeting methodology for this population as contained in the
November 2011 Medi-Cal Local Assistance Estimate for Medi-Cal county
administration costs for eligibility operations.
(B) Effective January 1, 2014, to the extent the new budget
methodology pursuant to paragraph (6) of subdivision (a) of Section
14154 is not fully operational, for purposes of implementing this
section for individuals whose family income has been determined to be
up to and including 160 percent of the federal poverty level, the
department shall utilize the budgeting methodology for this
population as contained in the November 2011 Medi-Cal Local
Assistance Estimate for Medi-Cal county administration costs for
eligibility operations.
(2) (A) Except as provided in subparagraph (B), for purposes of
implementing this section, the department shall include in the
Medi-Cal Local Assistance Estimate an amount for Medi-Cal eligibility
operations associated with the individuals whose family income is
determined to be above 150 percent and up to and including 200
percent of the federal poverty level, after application of the income
disregard pursuant to paragraph (2) of subdivision (a). In
developing an estimate for this activity, the department shall
consider the projected number of final eligibility determinations
each county will process and projected county costs. Within 60 days
of the passage of the annual Budget Act, the department shall notify
each county of their allocation for this activity based upon the
amount allotted in the annual Budget Act for this purpose.
(B) Effective January 1, 2014, for purposes of implementing this
section, the department shall include in the Medi-Cal Local
Assistance Estimate an amount for Medi-Cal eligibility operations
associated with the individuals whose family income is determined to
be above 160 percent and up to and including 261 percent of the
federal poverty level.
(h) When the new budget methodology pursuant to paragraph (6) of
subdivision (a) of Section 14154 is fully operational, the new budget
methodology shall be utilized to reimburse counties for eligibility
determinations made for individuals pursuant to this section.
(i) Eligibility determinations and annual redeterminations made
pursuant to this section shall be performed by county eligibility
workers.
(j) In conducting eligibility determinations for individuals
pursuant to this section and Section 14005.27, the following
reporting and performance standards shall apply to all counties:
(1) Counties shall report to the department, in a manner and for a
time period prescribed by the department, in consultation with the
County Welfare Directors Association, the number of applications
processed on a monthly basis, a breakout of the applications based on
income using the federal percentage of poverty levels, the final
disposition of each application, including information on the
approved Medi-Cal program, if applicable, and the average number of
days it took to make the final eligibility determination for
applications submitted directly to the county and from the single
point of entry (SPE).
(2) Notwithstanding any other law, the following performance
standards shall be applied to counties regarding eligibility
determinations for individuals eligible pursuant to this section:
(A) For children whose applications are received by the county
human services department from the SPE, the following standards shall
apply:
(i) Applications for children who are granted accelerated
enrollment by the SPE shall be processed according to the timeframes
specified in subdivision (d) of Section 14154.
(ii) Applications for children who are not granted accelerated
enrollment by the SPE due to the existence of an already active
Medi-Cal case shall be processed according to the timeframes
specified in subdivision (d) of Section 14154.
(iii) For applications for children who are not described in
clause (i) or (ii), 90 percent shall be processed within 10 working
days of being received, complete and without client errors.
(iv) If an application described in this section also contains
adults, and the adult applicants are required to submit additional
information beyond the information provided for the children, the
county shall process the eligibility for the child or children
without delay, consistent with this section while gathering the
necessary information to process eligibility for the adults.
(B) The department, in consultation with the County Welfare
Directors Association, shall develop reporting requirements for the
counties to provide regular data to the state regarding the
timeliness and outcomes of applications processed by the counties
that are received from the SPE.
(C) Performance thresholds and corrective action standards as set
forth in Section 14154 shall apply.
(D) For applications submitted directly to the county, these
applications shall be processed by the counties in accordance with
the performance standards established under subdivision (d) of
Section 14154.
(3) This subdivision shall be implemented no sooner than January
1, 2013.
(4) Twelve months after implementation of this section pursuant to
subdivision (f), the department shall provide enrollment information
regarding individuals determined eligible pursuant to subdivision
(a) to the fiscal and appropriate policy committees of the
Legislature.
(k) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, for
purposes of this transition, 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. It is the intent of the Legislature that the
department be allowed temporary authority as necessary to implement
program changes until completion of the regulatory process.
(2) 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, 2014. 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) To implement this section, the department may enter into and
continue contracts with the Healthy Families Program administrative
vendor, for the purposes of implementing and maintaining the
necessary systems and activities for providing health care coverage
to optional targeted low-income children in the Medi-Cal program for
purposes of accelerated enrollment application processing by single
point of entry, noneligibility-related case maintenance and premium
collection, maintenance of the Health-E-App Web portal, call center
staffing and operations, certified application assistant services,
and reporting capabilities. To further implement this section, the
department may also enter into a contract with the Health Care
Options Broker of the department for purposes of managed care
enrollment activities. The contracts entered into or amended under
this section may initially be completed on a noncompetitive bid basis
and are exempt from the Public Contract Code. Contracts thereafter
shall be entered into or amended on a competitive bid basis and shall
be subject to the Public Contract Code.
(m) (1) If at any time the director determines that this section
or any part of this section may jeopardize the state's ability to
receive federal financial participation under the federal Patient
Protection and Affordable Care Act (Public Law 111-148), or any
amendment or extension of that act, or any additional federal funds
that the director, in consultation with the Department of Finance,
determines would be advantageous to the state, the director shall
give notice to the fiscal and policy committees of the Legislature
and to the Department of Finance. After giving notice, this section
or any part of this section shall become inoperative on the date that
the director executes a declaration stating that the department has
determined, in consultation with the Department of Finance, that it
is necessary to cease to implement this section or a part or parts
thereof, in order to receive federal financial participation, any
increase in the federal medical assistance percentage available on or
after October 1, 2008, or any additional federal funds that the
director, in consultation with the Department of Finance, has
determined would be advantageous to the state.
(2) The director shall retain the declaration described in
paragraph (1), shall provide a copy of the declaration to the
Secretary of State, the Secretary of the Senate, the Chief Clerk of
the Assembly, and the Legislative Counsel, and shall post the
declaration on the department's Internet Web site.
(3) In the event that the director makes a determination under
paragraph (1) and this section ceases to be implemented, the children
shall be enrolled back into the Healthy Families Program.
SEC. 3. Section 14005.27 of the Welfare and Institutions Code is
amended to read:
14005.27. (a) Individuals enrolled in the Healthy Families
Program pursuant to Part 6.2 (commencing with Section 12693) of
Division 2 of the Insurance Code on June 27, 2012, and who are
determined eligible to receive benefits pursuant to subdivision (a)
of Section 14005.26, or, effective January 1, 2014, subdivision (b)
of Section 14005.26, shall be transitioned into Medi-Cal, pursuant to
this section.
(b) To the extent necessary and for the purposes of carrying out
the provisions of this section, in performing initial eligibility
determinations for children enrolled in the Healthy Families Program
pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of
the Insurance Code, the department shall adopt the option pursuant
to Section 1902(e)(13) of the federal Social Security Act (42 U.S.C.
Sec. 1396a(e)(13)) to allow the department or county human services
departments to rely upon findings made by the Managed Risk Medical
Insurance Board (MRMIB) regarding one or more components of
eligibility. The department shall seek federal approval of a state
plan amendment to implement this subdivision.
(c) To the extent necessary, the department shall seek federal
approval of a state plan amendment or a waiver to provide presumptive
eligibility for the optional targeted low-income category of
eligibility pursuant to Section 14005.26 for individuals
presumptively eligible for or enrolled in the Healthy Families
Program pursuant to Part 6.2 (commencing with Section 12693) of
Division 2 of the Insurance Code. The presumptive eligibility shall
be based upon the most recent information contained in the individual'
s Healthy Families Program file. The timeframe for the presumptive
eligibility shall begin no sooner than January 1, 2013, and shall
continue until a determination of Medi-Cal eligibility is made, which
determination shall be performed within one year of the individual's
Healthy Families Program annual review date.
(d) (1) The California Health and Human Services Agency, in
consultation with the Managed Risk Medical Insurance Board, the State
Department of Health Care Services, the Department of Managed Health
Care, and diverse stakeholders groups, shall provide the fiscal and
policy committees of the Legislature with a strategic plan for the
transition of the Healthy Families Program pursuant to this section
by no later than October 1, 2012. This strategic plan shall, at a
minimum, address all of the following:
(A) State, county, and local administrative components which
facilitate a successful subscriber transition such as communication
and outreach to subscribers and applicants, eligibility processing,
enrollment, communication, and linkage with health plan providers,
payments of applicable premiums, and overall systems operation
functions.
(B) Methods and processes for diverse stakeholder engagement
throughout the entire transition, including all phases of the
transition.
(C) State monitoring of managed care health plans' performance and
accountability for provision of services, and initial quality
indicators for children and adolescents transitioning to Medi-Cal.
(D) Health care and dental delivery system components such as
standards for informing and enrollment materials, network adequacy,
performance measures and metrics, fiscal solvency, and related
factors that ensure timely access to quality health and dental care
for children and adolescents transitioning to Medi-Cal.
(E) Inclusion of applicable operational steps, timelines, and key
milestones.
(F) A time certain for the transfer of the Healthy Families
Advisory Board, as described in Part 6.2 (commencing with Section
12693) of Division 2 of the Insurance Code, to the State Department
of Health Care Services.
(2) The intent of this strategic plan is to serve as an overall
guide for the development of each plan for each phase of this
transition, pursuant to paragraphs (1) to (8), inclusive, of
subdivision (e), to ensure clarity and consistency in approach and
subscriber continuity of care. This strategic plan may also be
updated by the California Health and Human Services Agency as
applicable and provided to the Legislature upon completion.
(e) (1) The department shall transition individuals from the
Healthy Families Program to the Medi-Cal program in four phases, as
follows:
(A) Phase 1. Individuals enrolled in a Healthy Families Program
health plan that is a Medi-Cal managed care health plan shall be
enrolled in the same plan no earlier than January 1, 2013, pursuant
to the requirements of this section and Section 14011.6, and to the
extent the individual is otherwise eligible under this chapter and
Chapter 8 (commencing with Section 14200).
(B) Phase 2. Individuals enrolled in a Healthy Families Program
managed care health plan that is a subcontractor of a Medi-Cal
managed health care plan, to the extent possible, shall be enrolled
into a Medi-Cal managed health care plan that includes the
individuals' current plan pursuant to the requirements of this
section and Section 14011.6, and to the extent the individuals are
otherwise eligible under this chapter and Chapter 8 (commencing with
Section 14200). The transition of individuals described in this
subparagraph shall begin no earlier than April 1, 2013.
(C) Phase 3. Individuals enrolled in a Healthy Families Program
plan that is not a Medi-Cal managed care plan and does not contract
or subcontract with a Medi-Cal managed care plan shall be enrolled in
a Medi-Cal managed care plan in that county. Enrollment shall
include consideration of the individuals' primary care providers
pursuant to the requirements of this section and Section 14011.6, and
to the extent the individuals are otherwise eligible under this
chapter and Chapter 8 (commencing with Section 14200). The transition
of individuals described in this subparagraph shall begin no earlier
than August 1, 2013.
(D) Phase 4.
(i) Individuals residing in a county that is not a Medi-Cal
managed care county shall be provided services under the Medi-Cal
fee-for-service delivery system, subject to clause (ii). The
transition of individuals described in this subparagraph shall begin
no earlier than September 1, 2013.
(ii) In the event the department creates a managed health care
system in the counties described in clause (i), individuals residing
in those counties shall be enrolled in managed health care plans
pursuant to this chapter and Chapter 8 (commencing with Section
14200).
(2) For the transition of individuals pursuant to subparagraphs
(A), (B), (C), and (D) of paragraph (1), implementation plans shall
be developed to ensure state and county systems readiness, health
plan network adequacy, and continuity of care with the goal of
ensuring there is no disruption of service and there is continued
access to coverage for all transitioning individuals. If an
individual is not retained with his or her current primary care
provider, the implementation plan shall require the managed care plan
to report to the department as to how continuity of care is being
provided. Transition of individuals described in subparagraphs (A),
(B), (C), and (D) of paragraph (1) shall not occur until 90 days
after the department has submitted an implementation plan to the
fiscal and policy committees of the Legislature. The implementation
plans shall include, but not be limited to, information on health and
dental plan network adequacy, continuity of care, eligibility and
enrollment requirements, consumer protections, and family
notifications.
(3) The following requirements shall be in place prior to
implementation of Phase 1, and shall be required for all phases of
the transition:
(A) Managed care plan performance measures shall be integrated and
coordinated with the Healthy Families Program performance standards
including, but not limited to, child-only Healthcare Effectiveness
Data and Information Set (HEDIS) measures, and measures indicative of
performance in serving children and adolescents. These performance
measures shall also be in compliance with all performance
requirements under the Knox-Keene Health Care Service Plan Act of
1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code) and existing Medi-Cal managed care
performance measurements and standards as set forth in this chapter
and Chapter 8 (commencing with Section 14200) of Title 22 of the
California Code of Regulations, and all-plan letters, including, but
not limited to, network adequacy and linguistic services, and shall
be met prior to the transition of individuals pursuant to Phase 1.
(B) Medi-Cal managed care health plans shall allow enrollees to
remain with their current primary care provider. If an individual
does not remain with the current primary care provider, the plan
shall report to the department as to how continuity of care is being
provided.
(4) (A) As individuals are transitioned pursuant to subparagraphs
(A), (B), (C), and (D) of paragraph (1), for individuals residing in
all counties except the Counties of Sacramento and Los Angeles, their
dental coverage shall transition to fee-for-service dental coverage
and may be provided by their current provider if the provider is a
Medi-Cal fee-for-service dental provider.
(B) For individuals residing in the County of Sacramento, their
dental coverage shall continue to be provided by their current dental
managed care plan if their plan is a Medi-Cal dental managed care
plan. If their plan is not a Medi-Cal dental managed care plan, they
shall select a Medi-Cal dental managed care plan. If they do not
choose a Medi-Cal dental managed care plan, they shall be assigned to
a plan with preference to a plan with which their current provider
is a contracted provider. Any children in the Healthy Families
Program transitioned into Medi-Cal dental managed care plans shall
also have access to the beneficiary dental exception process,
pursuant to Section 14089.09. Further, the Sacramento advisory
committee, established pursuant to Section 14089.08, shall be
consulted regarding the transition of children in the Healthy
Families Program into Medi-Cal dental managed care plans.
(C) (i) For individuals residing in the County of Los Angeles, for
purposes of continuity of care, their dental coverage shall continue
to be provided by their current dental managed care plan if that
plan is a Medi-Cal dental managed care plan. If their plan is not a
Medi-Cal dental managed care plan, they may select a Medi-Cal dental
managed care plan or choose to move into Medi-Cal fee-for-service
dental coverage.
(ii) It is the intent of the Legislature that children transitioning
to Medi-Cal under this section have a choice in dental coverage, as
provided under existing law.
(5) Dental health plan performance measures and benchmarks shall
be in accordance with Section 14459.6.
(6) Medi-Cal managed care health and dental plans shall report to
the department, as frequently as specified by the department,
specified information pertaining to transition implementation,
enrollees, and providers, including, but not limited to, grievances
related to access to care, continuity of care requests and outcomes,
and changes to provider networks, including provider enrollment and
disenrollment changes. The plans shall report this information by
county, and in the format requested by the department.
(7) The department may develop supplemental implementation plans
to separately account for the transition of individuals from the
Healthy Families Program to specific Medi-Cal delivery systems.
(8) The department shall consult with the Legislature and
stakeholders, including, but not limited to, consumers, families,
consumer advocates, counties, providers, and health and dental plans,
in the development of implementation plans described in paragraph
(3) for individuals who are transitioned to Medi-Cal in Phase 2,
Phase 3, and Phase 4, as described in subparagraphs (B), (C), and (D)
of paragraph (1).
(9) (A) The department shall consult and collaborate with the
Department of Managed Health Care in assessing Medi-Cal managed care
health plan network adequacy in accordance with the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) for purposes of
the developed transition plans pursuant to paragraph (2) for each of
the phases.
(B) For purposes of individuals transitioning in Phase 1, as
described in subparagraph (A) of paragraph (1), network adequacy
shall be assessed as described in this paragraph and findings from
this assessment shall be provided to the fiscal and appropriate
policy committees of the Legislature 60 days prior to the effective
date of implementing this transition.
(10) The department shall provide monthly status reports to the
fiscal and policy committees of the Legislature on the transition
commencing no later than February 15, 2013. This monthly status
transition report shall include, but not be limited to, information
on health plan grievances related to access to care, continuity of
care requests and outcomes, changes to provider networks, including
provider enrollment and disenrollment changes, and eligibility
performance standards pursuant to subdivision (n). A final
comprehensive report shall be provided within 90 days after
completion of the last phase of transition.
(f) (1) The department and MRMIB shall work collaboratively in the
development of notices for individuals transitioned pursuant to
paragraph (1) of subdivision (e).
(2) The state shall provide written notice to individuals enrolled
in the Healthy Families Program of their transition to the Medi-Cal
program at least 60 days prior to the transition of individuals in
Phase 1, as described in subparagraph (A) of paragraph (1) of
subdivision (e), and at least 90 days prior to transition of
individuals in Phases 2, 3, and 4, as described in subparagraphs (B),
(C), and (D) of paragraph (1) of subdivision (e).
(3) Notices developed pursuant to this subdivision shall ensure
individuals are informed regarding the transition, including, but not
limited to, how individuals' systems of care may change, when the
changes will occur, and whom they can contact for assistance when
choosing a Medi-Cal managed care plan, if applicable, including a
toll-free telephone number, and with problems they may encounter. The
department shall consult with stakeholders regarding notices
developed pursuant to this subdivision. These notices shall be
developed using plain language, and written translation of the
notices shall be available for those who are limited English
proficient or non-English speaking in all Medi-Cal threshold
languages.
(4) The department shall designate department liaisons responsible
for the coordination of the Healthy Families Program and may
establish a children's-focused section for this purpose and to
facilitate the provision of health care services for children
enrolled in Medi-Cal.
(5) The department shall provide a process for ongoing stakeholder
consultation and make information publicly available, including the
achievement of benchmarks, enrollment data, utilization data, and
quality measures.
(g) (1) In order to aid the transition of Healthy Families Program
enrollees, MRMIB, on the effective date of the act that added this
section and continuing through the completion of the transition of
Healthy Families Program enrollees to the Medi-Cal program, shall
begin requesting and collecting from health plans contracting with
MRMIB pursuant to Part 6.2 (commencing with Section 12693) of
Division 2 of the Insurance Code, information about each health plan'
s provider network, including, but not limited to, the primary care
and all specialty care providers assigned to individuals enrolled in
the health plan. MRMIB shall obtain this information in a manner that
coincides with the transition activities described in subdivision
(d), and shall provide all of the collected information to the
department within 60 days of the department's request for this
information to ensure timely transitions of Healthy Families Program
enrollees.
(2) The department shall analyze the existing Healthy Families
Program delivery system network and the Medi-Cal fee-for-service
provider networks, including, but not limited to, Medi-Cal dental
providers, to determine overlaps of the provider networks in each
county for which there are no Medi-Cal managed care plans or dental
managed care plans. To the extent there is a lack of existing
Medi-Cal fee-for-service providers available to serve the Healthy
Families Program enrollees, the department shall work with the
Healthy Families Program provider community to encourage
participation of those providers in the Medi-Cal program, and develop
a streamlined process to enroll them as Medi-Cal providers.
(3) (A) MRMIB, within 60 days of a request by the department,
shall provide the department any data, information, or record
concerning the Healthy Families Program as is necessary to implement
the transition of enrollment required pursuant to this section.
(B) Notwithstanding any other law, all of the following shall
apply:
(i) The term "data, information, or record" shall include, but is
not limited to, personal information as defined in Section 1798.3 of
the Civil Code.
(ii) Any data, information, or record shall be exempt from
disclosure under the California Public Records Act (Chapter 3.5
(commencing with Section 6250) of Division 7 of Title 1 of the
Government Code) and any other law, to the same extent that it was
exempt from disclosure or privileged prior to the provision of the
data, information, or record to the department.
(iii) The provision of any such data, information, or record to
the department shall not constitute a waiver of any evidentiary
privilege or exemption from disclosure.
(iv) The department shall keep all data, information, or records
provided by MRMIB confidential to the full extent permitted by law,
including, but not limited to, the California Public Records Act
(Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1
of the Government Code), and consistent with MRMIB's contractual
obligations to keep the data, information, or records confidential.
(h) This section shall be implemented only to the extent that all
necessary federal approvals and waivers have been obtained and the
enhanced rate of federal financial participation under Title XXI of
the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.) is
available for targeted low-income children pursuant to that act.
(i) (1) (A) Except as provided in subparagraph (B), the department
shall exercise the option pursuant to Section 1916A of the federal
Social Security Act (42 U.S.C. Sec. 1396o-1) to impose premiums for
individuals described in subdivision (a) of Section 14005.26 whose
family income has been determined to be above 150 percent and up to
and including 200 percent of the federal poverty level, after
application of the income disregard pursuant to paragraph (2) of
subdivision (a) of Section 14005.26. The department shall not impose
premiums under this subdivision for individuals described in
subdivision (a) of Section 14005.26 whose family income has been
determined to be at or below 150 percent of the federal poverty
level, after application of the income disregard pursuant to
paragraph (2) of subdivision (a) of Section 14005.26. The department
shall obtain federal approval for the implementation of this
subdivision.
(B) Effective January 1, 2014, the family income range for the
imposition of premiums pursuant to subparagraph (A) for individuals
described in subdivision (a) or (b) of Section 14005.26 shall be
above 160 percent and shall go up to and include 261 percent of the
federal poverty level as determined, counted, and valued in
accordance with the requirements of Section 14005.64. The department
shall not impose premiums for eligible individuals whose family
income has been determined to be at or below 160 percent of the
federal poverty level.
(2) All premiums imposed under this section shall equal the family
contributions described in paragraph (2) of subdivision (d) of
Section 12693.43 of the Insurance Code and shall be reduced in
conformity with subdivisions (e) and (f) of Section 12693.43 of the
Insurance Code.
(j) The department shall not enroll targeted low-income children
described in this section in the Medi-Cal program until all necessary
federal approvals and waivers have been obtained, or no sooner than
January 1, 2013.
(k) (1) (A) Except as provided in subparagraph (B), to the extent
the new budget methodology pursuant to paragraph (6) of subdivision
(a) of Section 14154 is not fully operational, for the purposes of
implementing this section, for individuals described in subdivision
(a) whose family income has been determined to be at or below 150
percent of the federal poverty level, after application of the
disregard pursuant to paragraph (2) of subdivision (a) of Section
14005.26, the department shall utilize the budgeting methodology for
this population as contained in the November 2011 Medi-Cal Local
Assistance Estimate for Medi-Cal county administration costs for
eligibility operations.
(B) Effective January 1, 2014, the federal poverty level
percentage used under subparagraph (A) for individuals described in
subdivision (a) shall equal 160 percent of the federal poverty level
as determined, counted, and valued in accordance with the
requirements of Section 14005.64.
(2) (A) Except as provided in subparagraph (B), for purposes of
implementing this section, the department shall include in the
Medi-Cal Local Assistance Estimate an amount for Medi-Cal eligibility
operations associated with the transfer of Healthy Families Program
enrollees eligible pursuant to subdivision (a) of Section 14005.26
and whose family income is determined to be above 150 percent and up
to and including 200 percent of the federal poverty level, after
application of the income disregard pursuant to paragraph (2) of
subdivision (a) of Section 14005.26. In developing an estimate for
this activity, the department shall consider the projected number of
final eligibility determinations each county will process and
projected county costs. Within 60 days of the passage of the annual
Budget Act, the department shall notify each county of their
allocation for this activity based upon the amount allotted in the
annual Budget Act for this purpose.
(B) Effective January 1, 2014, for purposes of implementing this
section, the department shall include in the Medi-Cal Local
Assistance Estimate an amount for Medi-Cal eligibility operations
associated with the transfer of Healthy Families Program enrollees
eligible pursuant to subdivision (a) or (b) of Section 14005.26 and
whose family income is determined to be above 160 percent and up to
and including 261 percent of the federal poverty level.
(l) When the new budget methodology pursuant to paragraph (6) of
subdivision (a) of Section 14154 is fully operational, the new budget
methodology shall be utilized to reimburse counties for eligibility
determinations made for individuals pursuant to this section.
(m) Except as provided in subdivision (b), eligibility
determinations and annual redeterminations made pursuant to this
section shall be performed by county eligibility workers.
(n) In conducting the eligibility determinations for individuals
pursuant to this section and Section 14005.26, the following
reporting and performance standards shall apply to all counties:
(1) Counties shall report to the department, in a manner and for a
time period determined by the department, in consultation with the
County Welfare Directors Association, the number of applications
processed on a monthly basis, a breakout of the applications based on
income using the federal percentage of poverty levels, the final
disposition of each application, including information on the
approved Medi-Cal program, if applicable, and the average number of
days it took to make the final eligibility determination for
applications submitted directly to the county and from the single
point of entry (SPE).
(2) Notwithstanding any other law, the following performance
standards shall be applied to counties for eligibility determinations
for individuals eligible pursuant to this section:
(A) For children whose applications are received by the county
human services department from the SPE, the following standards shall
apply:
(i) Applications for children who are granted accelerated
enrollment by the SPE shall be processed according to the timeframes
specified in subdivision (d) of Section 14154.
(ii) Applications for children who are not granted accelerated
enrollment by the SPE due to the existence of an already active
Medi-Cal case shall be processed according to the timeframes
specified in subdivision (d) of Section 14154.
(iii) For applications for children who are not described in
clause (i) or (ii), 90 percent shall be processed within 10 working
days of being received, complete and without client errors.
(iv) If an application described in this section also contains
adults, and the adult applicants are required to submit additional
information beyond the information provided for the children, the
county shall process the eligibility for the child or children
without delay, consistent with this section while gathering the
necessary information to process eligibility for the adults.
(B) The department, in consultation with the County Welfare
Directors Association, shall develop reporting requirements for the
counties to provide regular data to the state regarding the
timeliness and outcomes of applications processed by the counties
that are received from the SPE.
(C) Performance thresholds and corrective action standards as set
forth in Section 14154 shall apply.
(D) For applications received directly by the county, these
applications shall be processed by the counties in accordance with
the performance standards established under subdivision (d) of
Section 14154.
(3) This subdivision shall be implemented no sooner than January
1, 2013.
(4) Twelve months after implementation of this section pursuant to
subdivision (e), the department shall provide enrollment information
regarding individuals determined eligible pursuant to subdivision
(a) to the fiscal and appropriate policy committees of the
Legislature.
(o) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, for
purposes of this transition, 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. It is the intent of the Legislature that the
department be allowed temporary authority as necessary to implement
program changes until completion of the regulatory process.
(2) 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, 2014. 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.
(p) To implement this section, the department may enter into and
continue contracts with the Healthy Families Program administrative
vendor, for the purposes of implementing and maintaining the
necessary systems and activities for providing health care coverage
to optional targeted low-income children in the Medi-Cal program for
purposes of accelerated enrollment application processing by single
point of entry, noneligibility-related case maintenance and premium
collection, maintenance of the Health-E-App Web portal, call center
staffing and operations, certified application assistant services,
and reporting capabilities. To further implement this section, the
department may also enter into a contract with the Health Care
Options Broker of the department for purposes of managed care
enrollment activities. The contracts entered into or amended under
this section may initially be completed on a noncompetitive bid basis
and are exempt from the Public Contract Code. Contracts thereafter
shall be entered into or amended on a competitive bid basis and shall
be subject to the Public Contract Code.
(q) (1) If at any time the director determines that this section
or any part of this section may jeopardize the state's ability to
receive federal financial participation under the federal Patient
Protection and Affordable Care Act (Public Law 111-148), or any
amendment or extension of that act, or any additional federal funds
that the director, in consultation with the Department of Finance,
determines would be advantageous to the state, the director shall
give notice to the fiscal and policy committees of the Legislature
and to the Department of Finance. After giving notice, this section
or any part of this section shall become inoperative on the date that
the director executes a declaration stating that the department has
determined, in consultation with the Department of Finance, that it
is necessary to cease to implement this section or a part or parts
thereof in order to receive federal financial participation, any
increase in the federal medical assistance percentage available on or
after October 1, 2008, or any additional federal funds that the
director, in consultation with the Department of Finance, has
determined would be advantageous to the state.
(2) The director shall retain the declaration described in
paragraph (1), shall provide a copy of the declaration to the
Secretary of State, the Secretary of the Senate, the Chief Clerk of
the Assembly, and the Legislative Counsel, and shall post the
declaration on the department's Internet Web site.
(3) In the event that the director makes a determination under
paragraph (1) and this section ceases to be implemented, the children
shall be enrolled back into the Healthy Families Program.
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 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 until his or her 26th
birthday if he or she was in foster care on his or her 18th
birthday birthday, or such higher age
at which the state's or tribe's foster care assistance ends
the state has elected under Title IV-E of the federal
Social Security Act (42 U.S.C. Sec. 670 et seq.). 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 was in foster care in this state
on his or her 18th birthday, or such higher age at which the
state's or tribe's foster care assistance ends the
state has elected under Title IV-E of the federal Social
Security Act (42 U.S.C. Sec. 670 et seq.), 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) If future federal regulations or guidance permit Medi-Cal
benefits to be provided under 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 individuals who left foster care before reaching the age at which
the state's or tribe's foster care assistance ends under Title IV-E
of the federal Social Security Act (42 U.S.C. Sec. 670 et. seq.),
then the department shall implement this section in accordance with
those regulations or guidance.
(c)
( 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 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
any necessary regulations are adopted. The department shall adopt
regulations by July 1, 2017, 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, in compliance with Section
9795 of the Government Code, until regulations have been adopted.
(d)
( c) This section shall be implemented only
if and to the extent that federal financial participation is
available.
SEC. 5. Section 14005.285 is added to the Welfare and Institutions
Code, to read:
14005.285. (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, the
department may 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 any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(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. 6. Section 14005.287 is added to the Welfare and Institutions
Code, to read:
14005.287. (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)
(I) of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)
(A)(ii)(I)) to extend Medi-Cal benefits to individuals under 21 years
of age placed in foster homes or private institutions for whom a
public agency is assuming full or partial financial responsibility.
(b) Pursuant to Section 1902(r)(2)
of the federal Social Security Act (42 U.S.C. Sec. 1396a(r)(2)), all
of the income considered when determining an individual's
eligibility under this section shall be disregarded.
(c) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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.
(d) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 7. Section 14005.288 is added to the Welfare and Institutions
Code, to read:
14005.288. (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)
(VIII) of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)
(10)(A)(ii)(VIII)) to extend Medi-Cal benefits to individuals under
21 years of age for whom an adoption agreement, other than an
agreement under Title IV-E of the federal Social Security Act (42
U.S.C. Sec. 671 et seq.), between the state and the adoptive parent
or parents is in effect.
(b) Pursuant to Section 1902(r)(2) of the federal Social Security
Act (42 U.S.C. Sec. 1396a(r)(2)), all of the income considered when
determining an individual's eligibility under this section shall be
disregarded.
(c) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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.
(d) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 8. Section 14005.30 of the Welfare and Institutions Code is
amended to read:
14005.30. (a) Medi-Cal benefits under this chapter shall be
provided to individuals eligible for services under Section 1396u-1
of Title 42 of the United States Code with family incomes that do not
exceed 109 percent of the federal poverty level.
(b) (1) When determining eligibility under this section, an
applicant's or beneficiary's income and resources shall be
determined, counted, and valued in accordance with the requirements
of Section 1396a(e)(14) of Title 42 of the United States Code, as
added by the ACA.
(2) When determining eligibility under this section, an applicant'
s or beneficiary's assets shall not be considered and deprivation
shall not be a requirement for eligibility.
(c) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec. 401
et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the federal
poverty level requires the department to modify the income disregard
pursuant to subdivision (c) and in which new
income limits for the program established by this section are adopted
by the department.
(d) The MAGI-based income eligibility standard applied under this
section shall conform with the maintenance of effort requirements of
Sections 1396a(e)(14) and 1396a(gg) of Title 42 of the United States
Code, as added by the ACA.
(e) For purposes of this section, the following definitions shall
apply:
(1) "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.
(2) "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) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(g) 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. 9. Section 14005.64 of the Welfare and Institutions Code is
amended to read:
14005.64. (a) Effective January 1, 2014, and notwithstanding any
other law, when determining eligibility for Medi-Cal benefits, an
applicant's or beneficiary's income and resources shall be
determined, counted, and valued in accordance with the requirements
of Section 1902(e)(14) of the federal Social Security Act (42 U.S.C.
Sec. 1396a(e)(14)), as added by the ACA, which prohibits the use of
an assets or resources test for individuals whose income eligibility
is determined based on modified adjusted gross income.
(b) When determining the eligibility of applicants and
beneficiaries using the MAGI-based financial methods, the 5-percent
income disregard required under Section 1902(e)(14)(B)(I) of the
federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(B)(I)) shall
be applied.
(c) (1) The department shall establish income eligibility
thresholds for those Medi-Cal eligibility groups whose eligibility
will be determined using MAGI-based financial methods. The income
eligibility thresholds shall be developed using the financial
methodologies described in Section 1396a(e)(14) of Title 42 of the
United States Code and in conformity with Section 1396a(gg) of Title
42 of the United States Code as added by the ACA.
(2) In utilizing state data or the national standard methodology
with Survey of Income and Program Participation data to develop the
converted modified adjusted gross income standard for Medi-Cal
applicants and beneficiaries, the department shall ensure that the
financial methodology used for identifying the equivalent income
eligibility threshold preserves Medi-Cal eligibility for applicants
and beneficiaries to the extent required by federal law. The
department shall report to the Legislature on the expected changes in
income eligibility thresholds using the chosen methodology for
individuals whose income is determined on the basis of a converted
dollar amount or federal poverty level percentage. The department
shall convene stakeholders, including the Legislature, counties, and
consumer advocates regarding the results of the converted standards
and shall review with them the information used for the specific
calculations before adopting its final methodology for the equivalent
income eligibility threshold level.
(3) The income eligibility threshold levels required under this
subdivision shall be as follows for the identified coverage groups:
(A) For those pregnant women and infants eligible under Section
1396a(a)(10)(A)(i)(IV) of Title 42 of the United States Code, 208
percent of the federal poverty level.
(B) For those children one to five years of age, inclusive,
eligible under Section 1396a(a)(10)(A)(i)(VI) of Title 42 of the
United States Code, 142 percent of the federal poverty level.
(C) For those children 6 to 18 years of age, inclusive, eligible
under Section 1396a(a)(10)(A)(i)(VII) of Title 42 of the United
States Code, 133 percent of the federal poverty level.
(d) The department shall include individuals under 19 years of
age, or in the case of full-time students, under 21 years of age, in
the household for purposes of determining eligibility under Section
1396a(e)(14) of Title 42 of the United States Code, as added by the
ACA.
(e) For purposes of this section, the following definitions shall
apply:
(1) "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.
(2) "MAGI-based financial methods" means income calculated using
the financial methodologies described in Section 1396a(e)(14) of
Title 42 of the United States Code, and as added by the ACA.
(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, 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.
(g) 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. 10. Section 14051 of the Welfare and Institutions Code is
amended to read:
14051. (a) "Medically needy person" means any of the following:
(1) An aged, blind, or disabled person who meets the definition of
aged, blind, or disabled under the Supplemental Security Income
program and whose income and resources are insufficient to provide
for the costs of health care or coverage.
(2) A child in foster care for whom public agencies are assuming
financial responsibility, in whole or in part, or a person receiving
aid under Chapter 2.1 (commencing with Section 16115) of Part 4.
(3) A child who is eligible to receive Medi-Cal benefits pursuant
to interstate agreements for adoption assistance and related services
and benefits entered into under Chapter 2.6 (commencing with Section
16170) of Part 4, to the extent federal financial participation is
available.
(b) "Medically needy family person" means a parent or caretaker
relative of a child or a child under 21 years of age or a pregnant
woman of any age with a confirmed pregnancy, exclusive of those
persons specified in subdivision (a), whose income and resources are
insufficient to provide for the costs of health care or coverage.
SEC. 11. Section 14148 of the Welfare and Institutions Code is
amended to read:
14148. (a) (1) (A) Except as provided in subparagraph (B), the
department shall adopt the federal option provided under Section 4101
of the Omnibus Budget Reconciliation Act of 1987 (Public Law
100-203) to extend eligibility for medical assistance under Medicaid
to all pregnant women and infants with family incomes not in excess
of 185 percent of the federal poverty level.
(B) Effective January 1, 2014, the federal poverty level
percentage income eligibility threshold used pursuant to subdivision
(c) of Section 14005.64 to determine eligibility for medical
assistance under this section pursuant to subparagraph (A) shall
equal 208 percent of the federal poverty level.
(2) If a premium is imposed, the amount of the premium shall not
exceed 10 percent of the amount by which the family's income, less
actual child care costs, exceeds 150 percent of the federal poverty
level as provided in Section 1916(c) of the federal Social Security
Act (42 U.S.C. Sec. 1396o(c)) as determined, counted, and valued in
accordance with the requirements of Section 14005.64. The department
shall implement this section by emergency regulation.
(b) Upon order of the Department of Finance, the Controller shall
transfer funds from Item 4260-101-001 of the Budget Act of 1988 to
Item 4260-111-001 of the Budget Act of 1988 during the 1988-89 fiscal
year for the purpose of funding outreach efforts for perinatal
services.
(c) Notwithstanding subdivision (a), the state may limit
implementation of this section during the 1988-89 fiscal year, based
upon the availability of department funds. The department may use
maternal and child health funds to finance the increased costs of
implementing an expansion of Medi-Cal eligibility to women and
children with incomes of up to 185 percent of federal poverty levels
if both of the following conditions exist:
(1) The department has allocated for expenditure at least sixteen
million dollars ($16,000,000) in funds redirected from the Medi-Cal
program for that expansion.
(2) If, and to the extent, the department determines that
estimates of costs based on actual data indicate that the funds are
needed to cover costs.
(d) To assist Medi-Cal eligible pregnant women in receiving
prenatal care promptly, all pregnant women applying for Medi-Cal
shall be determined to have an immediate need. Counties, within
existing resources, shall expedite the eligibility determination
process for all pregnant women on the basis of their immediate needs.
Upon determination of eligibility, a Medi-Cal card shall be issued
immediately.
(e) The amendments made to subdivision (a) by Senate Bill 508
during the 2013-14 Regular Session shall be implemented only if and
to the extent that federal financial participation is available and
any necessary federal approvals have been obtained.
SEC. 12. Section 14148.5 of the Welfare and Institutions Code is
amended to read:
14148.5. (a) State funded perinatal services shall be provided
under the Medi-Cal program to pregnant women and state funded medical
services to infants up to one year of age in families with incomes
above 185 percent, but not more than 208 percent, of the federal
poverty level, in the same manner that these services are being
provided to the Medi-Cal population, including eligibility
requirements and integration of eligibility determinations and
payment of claims. When determining eligibility under this section,
an applicant's or beneficiary's income and resources shall be
determined, counted, and valued in accordance with the methodology
set forth in Section 14005.64.
(b) Services provided under this section shall not be subject to
any share-of-cost requirements.
(c) (1) The department, in implementing the Medi-Cal program and
public health programs, in coordination with the Managed Risk Medical
Insurance Board's Access for Infants and Mothers component, may
provide for outreach activities in order to enhance participation and
access to perinatal services. Funding received pursuant to the
federal provisions shall be used to expand perinatal outreach
activities. These outreach activities shall be implemented if funding
is provided for this purpose by an appropriation in the annual
Budget Act or other statute.
(2) Those outreach activities authorized by paragraph (1) shall be
targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or
uninsured pregnant women and infants. Outreach activities may
include, but not be limited to, all of the following:
(A) Education of the targeted women on the availability and
importance of early prenatal care and referral to Medi-Cal and other
programs.
(B) Information provided through toll-free telephone numbers.
(C) Recruitment and retention of perinatal providers.
(d) Notwithstanding any other law, contracts required to implement
the provisions of this section shall be exempt from the approval of
the Director of General Services and from the provisions of the
Public Contract Code.
SEC. 13. If the Commission on State Mandates determines that this
act contains costs mandated by the state, reimbursement to local
agencies and school districts for those costs shall be made pursuant
to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of
the Government Code.