BILL NUMBER: AB 2077 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MARCH 18, 2016
INTRODUCED BY Assembly Members Burke and Bonilla
FEBRUARY 17, 2016
An act to amend Section 14005.37 of, and to add Section 15927
to, the Welfare and Institutions Code, relating to public
health.
LEGISLATIVE COUNSEL'S DIGEST
AB 2077, as amended, Burke. Health Care Eligibility, Enrollment,
and Retention Act.
Existing law establishes various programs to provide health care
coverage to persons with limited financial resources, including the
Medi-Cal program and the state's children's health insurance program
(CHIP). Existing law establishes the California Health Benefit
Exchange (Exchange), pursuant to the federal Patient Protection and
Affordable Care Act, and specifies the duties and powers of the board
governing the Exchange relative to determining eligibility for
enrollment in the Exchange and arranging for coverage under qualified
health plans through the Exchange.
Existing law, the Health Care Reform Eligibility, Enrollment, and
Retention Planning Act, requires an individual to have the option to
apply for insurance affordability programs in person, by mail,
online, by telephone, or by other commonly available electronic
means. Existing law defines "insurance affordability programs" to
include the Medi-Cal program, CHIP, and a program that makes
available to qualified individuals coverage in a qualified health
benefit plan through the Exchange with advance payment of the premium
tax credit established under a specified provision of the Internal
Revenue Code. Code and a cost-sharing
reduction under a specified provision of federal law. During
the processing of an application, renewal, or a transition due to a
change in circumstances, existing law requires an entity making
eligibility determinations for an insurance affordability program to
ensure that an eligible applicant and recipient of those programs
that meets all program eligibility requirements and complies with all
necessary requirements for information moves between programs
without any breaks in coverage and without being required to provide
any forms, documents, or other information or undergo verification
that is duplicative or otherwise unnecessary.
This bill would declare the intent of the Legislature to
enact legislation that would establish procedures to ensure that
individuals move between Medi-Cal and the Exchange without any breaks
in coverage as required under the provision described above.
establish procedures to ensure that eligible
recipients of insurance affordability programs move between the
Medi-Cal program and other insurance affordability programs without
any breaks in coverage as required under the provision described
above. The bill would require, among other things, an individual's
case to be run through the California Healthcare Eligibility,
Enrollment, and Retention System (CalHEERs) if an individual enrolled
in a qualified health benefit plan through the Exchange reports a
change in circumstances or is reevaluated for eligibility, and there
is a change in circumstances affecting his or her eligibility for an
insurance affordability program. The bill would require the
individual's case file to be sent to his or her county of
residence within 3 business days if CalHEERs receives information
indicating that the individual is newly eligible for Medi-Cal. The
bill would prohibit the county from treating the receipt of a case
file under these circumstances as a new Medi-Cal application, and
would require those case files to be processed by the county
according to specified timelines. The bill would require the county
to issue to those individuals who are newly eligible for Medi-Cal a
notice that contains specified information, including instructions on
how to select a Medi-Cal managed care health plan. The bill would
establish different enrollment procedures to be followed for those
counties that provide Medi-Cal services under the two-pla
n model or the geographic managed care plan model, or a county
organized health system, as specified.
The bill would generally prohibit Medi-Cal benefits from being
terminated until at least 30 days after the county sends the notice
of action terminating Medi-Cal eligibility, and would require the
notice of action to inform the individual of the date by which he or
she must select and enroll in a qualified health benefit plan through
the Exchange, as specified.
By modifying the enrollment process under the Medi-Cal program,
thereby increasing the responsibilities of counties in the
administration of the Medi-Cal program, this bill would impose a
state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no
yes .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. It is the intent of the Legislature to enact
legislation that would Legislature, with the enactment
of this act, to establish procedures to ensure that
individuals move between Medi-Cal and the California Health Benefit
Exchange without any breaks in coverage as required under subdivision
(h) of Section 15926 of the Welfare and Institutions Code.
SEC. 2. Section 14005.37 of the Welfare
and Institutions Code is amended to read:
14005.37. (a) Except as provided in Section 14005.39, a county
shall perform redeterminations of eligibility for Medi-Cal
beneficiaries every 12 months and shall promptly redetermine
eligibility whenever the county receives information about changes in
a beneficiary's circumstances that may affect eligibility for
Medi-Cal benefits. The procedures for redetermining Medi-Cal
eligibility described in this section shall apply to all Medi-Cal
beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not
result in a redetermination under this section unless the reason for
the loss of eligibility is one that would result in the need for a
redetermination for a person whose eligibility for Medi-Cal under
Section 14005.30 was determined without a concurrent determination of
eligibility for cash aid under the CalWORKs program.
(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.
(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section and a beneficiary's Medi-Cal eligibility
shall not be terminated under this section until the county makes a
specific determination based on facts clearly demonstrating that the
beneficiary is no longer eligible for Medi-Cal benefits under any
basis and due process rights guaranteed under this division have been
met. For the purposes of this subdivision, for a beneficiary who is
subject to the use of MAGI-based financial methods, the determination
of whether the beneficiary is eligible for Medi-Cal benefits under
any basis shall include, but is not limited to, a determination of
eligibility for Medi-Cal benefits on a basis that is exempt from the
use of MAGI-based financial methods only if either of the following
occurs:
(A)
(1) The county assesses the beneficiary as being
potentially eligible under a program that is exempt from the use of
MAGI-based financial methods, including, but not limited to, on the
basis of age, blindness, disability, or the need for long-term care
services and supports.
(B)
(2) The beneficiary requests that the county determine
whether he or she is eligible for Medi-Cal benefits on a basis that
is exempt from the use of MAGI-based financial methods.
(e) (1) For purposes of acquiring information necessary to conduct
the eligibility redeterminations described in this section, a county
shall gather information available to the county that is relevant to
the beneficiary's Medi-Cal eligibility prior to contacting the
beneficiary. Sources for these efforts shall include information
contained in the beneficiary's file or other information, including
more recent information available to the county, including, but not
limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
beneficiary or of any of his or her immediate family members, which
are open, or were closed within the last 90 days, information
accessed through any databases accessed under Sections 435.948,
435.949, and 435.956 of Title 42 of the Code of Federal Regulations,
and wherever feasible, other sources of relevant information
reasonably available to the county or to the county via the
department.
(2) In the case of an annual redetermination, if, based upon
information obtained pursuant to paragraph (1), the county is able to
make a determination of continued eligibility, the county shall
notify the beneficiary of both of the following:
(A) The eligibility determination and the information it is based
on.
(B) That the beneficiary is required to inform the county via the
Internet, by telephone, by mail, in person, or through other commonly
available electronic means, in counties where such electronic
communication is available, if any information contained in the
notice is inaccurate but that the beneficiary is not required to sign
and return the notice if all information provided on the notice is
accurate.
(3) The county shall make all reasonable efforts not to send
multiple notices during the same time period about eligibility. The
notice of eligibility renewal shall contain other related information
such as if the beneficiary is in a new Medi-Cal program.
(4) In the case of a redetermination due to a change in
circumstances, if a county determines that the change in
circumstances does not affect the beneficiary's eligibility status,
the county shall not send the beneficiary a notice unless required to
do so by federal law.
(f) (1) In the case of an annual eligibility redetermination, if
the county is unable to determine continued eligibility based on the
information obtained pursuant to paragraph (1) of subdivision (e),
the beneficiary shall be so informed and shall be provided with an
annual renewal form, at least 60 days before the beneficiary's annual
redetermination date, that is prepopulated with information that the
county has obtained and that identifies any additional information
needed by the county to determine eligibility. The form shall include
all of the following:
(A) The requirement that he or she provide any necessary
information to the county within 60 days of the date that the form is
sent to the beneficiary.
(B) That the beneficiary may respond to the county via the
Internet, by mail, by telephone, in person, or through other commonly
available electronic means if those means are available in that
county.
(C) That if the beneficiary chooses to return the form to the
county in person or via mail, the beneficiary shall sign the form in
order for it to be considered complete.
(D) The telephone number to call in order to obtain more
information.
(2) The county shall attempt to contact the beneficiary via the
Internet, by telephone, or through other commonly available
electronic means, if those means are available in that county, during
the 60-day period after the prepopulated form is mailed to the
beneficiary to collect the necessary information if the beneficiary
has not responded to the request for additional information or has
provided an incomplete response.
(3) If the beneficiary has not provided any response to the
written request for information sent pursuant to paragraph (1) within
60 days from the date the form is sent, the county shall terminate
his or her eligibility for Medi-Cal benefits following the provision
of timely notice.
(4) If the beneficiary responds to the written request for
information during the 60-day period pursuant to paragraph (1) but
the information provided is not complete, the county shall follow the
procedures set forth in paragraph (3) of subdivision (g) to work
with the beneficiary to complete the information.
(5) (A) The form required by this subdivision shall be developed
by the department in consultation with the counties and
representatives of eligibility workers and consumers.
(B) For beneficiaries whose eligibility is not determined using
MAGI-based financial methods, the county may use existing renewal
forms until the state develops prepopulated renewal forms to provide
to beneficiaries. The department shall develop prepopulated renewal
forms for use with beneficiaries whose eligibility is not determined
using MAGI-based financial methods by January 1, 2015.
(g) (1) In the case of a redetermination due to change in
circumstances, if a county cannot obtain sufficient information to
redetermine eligibility pursuant to subdivision (e), the county shall
send to the beneficiary a form that is prepopulated with the
information that the county has obtained and that states the
information needed to renew eligibility. The county shall only
request information related to the change in circumstances. The
county shall not request information or documentation that has been
previously provided by the beneficiary, that is not absolutely
necessary to complete the eligibility determination, or that is not
subject to change. The county shall only request information for
nonapplicants necessary to make an eligibility determination or for a
purpose directly related to the administration of the state Medicaid
plan. The form shall advise the individual to provide any necessary
information to the county via the Internet, by telephone, by mail, in
person, or through other commonly available electronic means and, if
the individual will provide the form by mail or in person, to sign
the form. The form shall include a telephone number to call in order
to obtain more information. The form shall be developed by the
department in consultation with the counties, representatives of
consumers, and eligibility workers. A Medi-Cal beneficiary shall have
30 days from the date the form is mailed pursuant to this
subdivision to respond. Except as provided in paragraph (2), failure
to respond prior to the end of this 30-day period shall not impact
his or her Medi-Cal eligibility.
(2) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in this
subdivision marked as undeliverable shall result in an immediate
notice of action terminating Medi-Cal eligibility.
(3) During the 30-day period after the date of mailing of a form
to the Medi-Cal beneficiary pursuant to this subdivision, the county
shall attempt to contact the beneficiary by telephone, in writing, or
other commonly available electronic means, in counties where such
electronic communication is available, to request the necessary
information if the beneficiary has not responded to the request for
additional information or has provided an incomplete response. If the
beneficiary does not supply the necessary information to the county
within the 30-day limit, a 10-day notice of termination of Medi-Cal
eligibility shall be sent.
(h) Beneficiaries shall be required to report any change in
circumstances that may affect their eligibility within 10 calendar
days following the date the change occurred.
(i) If within 90 days of termination of a Medi-Cal beneficiary's
eligibility or a change in eligibility status pursuant to this
section, the beneficiary submits to the county a signed and completed
form or otherwise provides the needed information to the county,
eligibility shall be redetermined by the county and if the
beneficiary is found eligible, or the beneficiary's eligibility
status has not changed, whichever applies, the termination shall be
rescinded as though the form were submitted in a timely manner.
(j) If the information available to the county pursuant to the
redetermination procedures of this section does not indicate a basis
of eligibility, Medi-Cal benefits may be terminated so long as due
process requirements have otherwise been met.
(k) The department shall, with the counties and representatives of
consumers, including those with disabilities, and Medi-Cal
eligibility workers, develop a timeframe for redetermination of
Medi-Cal eligibility based upon disability, including ex parte
review, the redetermination forms described in subdivisions (f) and
(g), timeframes for responding to county or state requests for
additional information, and the forms and procedures to be used. The
forms and procedures shall be as consumer-friendly as possible for
people with disabilities. The timeframe shall provide a reasonable
and adequate opportunity for the Medi-Cal beneficiary to obtain and
submit medical records and other information needed to establish
eligibility for Medi-Cal based upon disability.
(l) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary's vision has
improved beyond the applicable definition of blindness contained in
the plan.
(m) The county shall consider disability as continuing until the
review team determines that a beneficiary's disability no longer
meets the applicable definition of disability contained in the plan.
(n) In the case of a redetermination due to a change in
circumstances, if a county determines that the beneficiary remains
eligible for Medi-Cal benefits, the county shall begin a new 12-month
eligibility period.
(o) (1) For individuals determined
ineligible for Medi-Cal by a county following the redetermination
procedures set forth in this section, the county shall determine
eligibility for other insurance affordability programs and if the
individual is found to be eligible, the county shall, as appropriate,
transfer the individual's electronic account to other insurance
affordability programs via a secure electronic interface.
(2) If the individual is eligible to enroll in a qualified health
plan through the California Health Benefit Exchange established
pursuant to Title 22 (commencing with Section 100500) of the
Government Code under any insurance affordability program, Medi-Cal
benefits shall not be terminated until at least 30 days after the
county sends the notice of action terminating Medi-Cal eligibility.
The notice of action shall inform the individual of the date by which
he or she must select and enroll in a qualified health plan through
the Exchange to avoid being uninsured. If the individual has
effectuated his or her enrollment in a qualified health plan through
the Exchange before the termination date specified in the notice,
Medi-Cal eligibility shall be terminated as of the date of enrollment
in the qualified health plan.
(p) Any renewal form or notice shall be accessible to persons who
are limited-English proficient and persons with disabilities
consistent with all federal and state requirements.
(q) The requirements to provide information in subdivisions (e)
and (g), and to report changes in circumstances in subdivision (h),
may be provided through any of the modes of submission allowed in
Section 435.907(a) of Title 42 of the Code of Federal Regulations,
including an Internet Web site identified by the department,
telephone, mail, in person, and other commonly available electronic
means as authorized by the department.
(r) Forms required to be signed by a beneficiary pursuant to this
section shall be signed under penalty of perjury. Electronic
signatures, telephonic signatures, and handwritten signatures
transmitted by electronic transmission shall be accepted.
(s) For purposes of this section, "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 federal Patient Protection and Affordable Care Act
(Public Law 111-148), as amended by the federal Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any
subsequent amendments.
(t) When contacting a beneficiary under paragraphs (2) and (4) of
subdivision (f), and paragraph (3) of subdivision (g), a county shall
first attempt to use the method of contact identified by the
beneficiary as the preferred method of contact, if a method has been
identified.
(u) The department shall seek federal approval to extend the
annual redetermination date under this section for a three-month
period for those Medi-Cal beneficiaries whose annual redeterminations
are scheduled to occur between January 1, 2014, and March 31, 2014.
(v) 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. 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.
(w) 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.
(x) This section shall become operative on January 1, 2014.
SEC. 3. Section 15927 is added to the
Welfare and Institutions Code , immediately
following Section 15926 , to read:
15927. (a) If an individual enrolled in a qualified health plan
through the California Health Benefit Exchange established under
Title 22 (commencing with Section 100500) of the Government Code
reports a change in circumstances, goes through the renewal process,
or is reevaluated for eligibility and there is a change affecting his
or her eligibility for any insurance affordability program, the
individual's case shall be run through the California Healthcare
Eligibility, Enrollment, and Retention System (CalHEERS) developed
under Section 15926. If CalHEERS receives information indicating that
an individual who has been enrolled in a qualified health plan
through the Exchange is newly eligible for Medi-Cal, the individual's
case file shall be sent to his or her county of residence within
three business days.
(b) (1) If the county of residence receives a case file regarding
an individual described in subdivision (a) who is newly eligible for
Medi-Cal, the county shall not treat this as a new Medi-Cal
application.
(A) Case files received by the county prior to the 15th day of the
month shall be processed for final Medi-Cal eligibility by the
county by the end of that month.
(B) Case files received by the county after the 15th day of the
month shall be processed for final Medi-Cal eligibility by the 15th
day of the following month.
(2) For individuals described in subdivision (a) who are newly
eligible for Medi-Cal, the county shall issue a notice at least 15
days before the individual's enrollment in a qualified health plan
through the Exchange ends that advises the individual of all of the
following information:
(A) He or she will be enrolled into Medi-Cal.
(B) Instructions on how to select a Medi-Cal managed care health
plan.
(C) His or her right to appeal an action related to the individual'
s eligibility for or enrollment in an insurance affordability program
pursuant to Section 100506.1 of the Government Code.
(D) Instructions on how to request continued enrollment in a
qualified health benefit plan pending the outcome of his or her
appeal of an action related to the individual's eligibility for or
enrollment in an insurance affordability program.
(3) If information is needed by the county to verify income, the
county shall follow the procedures set forth in subdivisions (f) and
(g) of Section 14005.37 to obtain that information.
(c) An individual described in subdivision (a) who is newly
eligible for Medi-Cal shall be enrolled in the Medi-Cal program
according to the following procedures:
(1) (A) In a county that provides Medi-Cal services under the
two-plan model or the geographic managed care plan model pursuant to
Article 2.7 (commencing with Section 14087.3), Article 2.81
(commencing with Section 14087.96), and Article 2.91 (commencing with
Section 14089), the individual shall be enrolled in a Medi-Cal
managed care plan according to either of the following:
(i) If the qualified health plan the individual was enrolled in
through the Exchange is an available Medi-Cal managed care plan in
his or her county and that plan has the same or substantially similar
provider network, the individual shall be assigned to that plan.
(ii) The individual shall be assigned to a plan using the usual
Medi-Cal managed care default algorithm.
(B) The 15-day notice issued to the individual newly eligible for
Medi-Cal shall advise him or her of all of the following information:
(i) The Medi-Cal managed care plan to which he or she will be
assigned if the individual does not take any action.
(ii) The individual may choose any available Medi-Cal managed care
plan.
(iii) A description of the Medi-Cal managed care plans available
in his or her county.
(iv) Instructions on how the individual may change Medi-Cal
managed care plans.
(2) In a county that provides Medi-Cal services under a county
organized health system pursuant to Article 2.8 (commencing with
Section 14087.5), the individual shall be enrolled into the county
organized health system plan on the first date of Medi-Cal coverage
and shall be sent the provider directory for the managed care plan.
SEC. 4. 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.