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 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 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.
begin delete 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.end delete The bill would require begin delete the individual’s case fileend delete to be sent to his or her county of residence within 3 business days if begin delete CalHEERs receives information indicating thatend delete the individual is newly eligible for begin delete 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, andend delete would require those begin delete case filesend delete to be processed by the county according to specified timelines. begin delete 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.end delete The bill would establish different enrollment procedures to be followed for those counties that provide Medi-Cal services under the two-plan model or the geographic managed care plan model, or a county organized health system, as specified.
The bill would generally
begin delete prohibitend delete
Medi-Cal benefits from being terminated until at least begin delete 30end delete 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: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
It is the intent of the Legislature, with the
2enactment of this act, to establish procedures to ensure that
3individuals move between Medi-Cal and the California Health
4Benefit Exchange without any breaks in coverage as required under
5subdivision (h) of Section 15926 of the Welfare and Institutions
Section 14005.37 of the Welfare and Institutions Code
8 is amended to read:
(a) Except as provided in Section 14005.39, a county
10shall perform redeterminations of eligibility for Medi-Cal
11beneficiaries every 12 months and shall promptly redetermine
12eligibility whenever the county receives information about changes
13in a beneficiary’s circumstances that may affect eligibility for
14Medi-Cal benefits. The procedures for redetermining Medi-Cal
15eligibility described in this section shall apply to all Medi-Cal
P4 1(b) Loss of eligibility for cash aid under that program shall not
2result in a redetermination under this section unless the reason for
3the loss of eligibility is one that would result in the need for a
4redetermination for a person whose eligibility for Medi-Cal under
5Section 14005.30 was determined without a concurrent
6 determination of eligibility for cash aid under the CalWORKs
8(c) A loss of contact, as evidenced by the return of mail marked
9in such a way as to indicate that it could not be delivered to the
10intended recipient or that there was no forwarding address, shall
11require a prompt redetermination according to the procedures set
12forth in this section.
13(d) Except as otherwise provided in this section, Medi-Cal
14eligibility shall continue during the redetermination process
15described in this section and a beneficiary’s Medi-Cal eligibility
16shall not be terminated under this section until the county makes
17a specific determination based on facts clearly demonstrating that
18the beneficiary is no longer eligible for Medi-Cal benefits under
19any basis and due process rights guaranteed under this division
20have been met. For the purposes of this subdivision, for a
21beneficiary who is subject to the use of MAGI-based financial
22methods, the determination of whether the beneficiary is eligible
23for Medi-Cal benefits under any basis shall include, but is not
24limited to, a determination of eligibility for Medi-Cal benefits on
25a basis that is exempt from the use of MAGI-based financial
26methods only if either of the following occurs:
27(1) The county assesses the beneficiary as being potentially
28eligible under a program that is exempt from the use of
29MAGI-based financial methods, including, but not limited to, on
30the basis of age, blindness, disability, or the need for long-term
31care services and supports.
32(2) The beneficiary requests that the county determine
33he or she is eligible for Medi-Cal benefits on a basis that is exempt
34from the use of MAGI-based financial methods.
35(e) (1) For purposes of acquiring information necessary to
36conduct the eligibility redeterminations described in this section,
37a county shall gather information available to the county that is
38relevant to the beneficiary’s Medi-Cal eligibility prior to contacting
39the beneficiary. Sources for these efforts shall include information
40contained in the beneficiary’s file or other information, including
P5 1more recent information available to the county, including, but not
2limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
3beneficiary or of any of his or her immediate family members,
4which are open, or were closed within the last 90 days, information
5accessed through any databases accessed under Sections 435.948,
6435.949, and 435.956 of Title 42 of the Code of Federal
7Regulations, and wherever feasible, other sources of relevant
8information reasonably available to the county or to the county
9via the department.
10(2) In the case of an annual redetermination, if, based upon
11information obtained pursuant to paragraph (1), the county is able
12to make a determination of continued eligibility, the county shall
13notify the beneficiary of both of the following:
14(A) The eligibility determination and the information it is based
16(B) That the beneficiary is required to inform the county via the
17Internet, by telephone, by mail, in person, or through other
18commonly available electronic means, in counties where such
19electronic communication is available, if any information contained
20in the notice is inaccurate but that the beneficiary is not required
21to sign and return the notice if all information provided on the
22notice is accurate.
23(3) The county shall make all reasonable efforts not to send
24multiple notices during the same time period about eligibility. The
25notice of eligibility renewal shall contain other related information
26such as if the beneficiary is in a new Medi-Cal program.
27(4) In the case of a redetermination due to a change in
28circumstances, if a county determines that the change in
29circumstances does not affect the beneficiary’s eligibility status,
30the county shall not send the beneficiary a notice unless required
31to do so by federal law.
32(f) (1) In the case of an annual eligibility redetermination, if
33the county is unable to determine continued eligibility based on
34the information obtained pursuant to paragraph (1) of subdivision
35(e), the beneficiary shall be so informed and shall be provided with
36an annual renewal form, at least 60 days before the beneficiary’s
37annual redetermination date, that is prepopulated with information
38that the county has obtained and that identifies any additional
39information needed by the county to determine eligibility. The
40form shall include all of the following:
P6 1(A) The requirement that he or she provide any necessary
2information to the county within 60 days of the date that the form
3is sent to the beneficiary.
4(B) That the beneficiary may respond to
the county via the
5Internet, by mail, by telephone, in person, or through other
6commonly available electronic means if those means are available
7in that county.
8(C) That if the beneficiary chooses to return the form to the
9county in person or via mail, the beneficiary shall sign the form
10in order for it to be considered complete.
11(D) The telephone number to call in order to obtain more
13(2) The county shall attempt to contact the beneficiary via the
14Internet, by telephone, or through other commonly available
15electronic means, if those means are available in that county, during
16the 60-day period after the prepopulated form is mailed to the
17beneficiary to collect the necessary information if the beneficiary
18has not responded to the request for additional information or has
19provided an incomplete response.
20(3) If the beneficiary has not provided any response to the
21written request for information sent pursuant to paragraph (1)
22within 60 days from the date the form is sent, the county shall
23terminate his or her eligibility for Medi-Cal benefits following the
24provision of timely notice.
25(4) If the beneficiary responds to the written request for
26information during the 60-day period pursuant to paragraph (1)
27but the information provided is not complete, the county shall
28follow the procedures set forth in paragraph (3) of subdivision (g)
29to work with the beneficiary to complete the information.
30(5) (A) The form
required by this subdivision shall be developed
31by the department in consultation with the counties and
32representatives of eligibility workers and consumers.
33(B) For beneficiaries whose eligibility is not determined using
34MAGI-based financial methods, the county may use existing
35renewal forms until the state develops prepopulated renewal forms
36to provide to beneficiaries. The department shall develop
37prepopulated renewal forms for use with beneficiaries whose
38eligibility is not determined using MAGI-based financial methods
39by January 1, 2015.
P7 1(g) (1) In the case of a redetermination due to change in
2circumstances, if a county cannot obtain sufficient information to
3redetermine eligibility pursuant to subdivision (e), the county shall
4send to the beneficiary a form that is prepopulated with the
5information that the county has obtained and that states the
6information needed to renew eligibility. The county shall only
7request information related to the change in circumstances. The
8county shall not request information or documentation that has
9been previously provided by the beneficiary, that is not absolutely
10necessary to complete the eligibility determination, or that is not
11subject to change. The county shall only request information for
12nonapplicants necessary to make an eligibility determination or
13for a purpose directly related to the administration of the state
14Medicaid plan. The form shall advise the individual to provide
15any necessary information to the county via the Internet, by
16telephone, by mail, in person, or through other commonly available
17electronic means and, if the individual will provide the form by
18mail or in person, to sign the form. The form shall include a
19telephone number to call in order to obtain more information. The
20form shall be developed by the department in consultation with
21the counties, representatives of consumers, and eligibility workers.
22A Medi-Cal beneficiary shall have 30 days from the date the form
23is mailed pursuant to this subdivision to respond. Except as
24provided in paragraph (2), failure to respond prior to the end of
25this 30-day period shall not impact his or her Medi-Cal eligibility.
26(2) If the purpose for a redetermination under this section is a
27loss of contact with the Medi-Cal beneficiary, as evidenced by the
28return of mail marked in such a way as to indicate that it could not
29be delivered to the intended recipient or that there was no
30forwarding address, a return of the form described in this
31subdivision marked as undeliverable shall result in an immediate
32notice of action terminating Medi-Cal eligibility.
33(3) During the 30-day period after the date of mailing of a form
34to the Medi-Cal beneficiary pursuant to this subdivision, the county
35shall attempt to contact the beneficiary by telephone, in writing,
36or other commonly available electronic means, in counties where
37such electronic communication is available, to request the
38necessary information if the beneficiary has not responded to the
39request for additional information or has provided an incomplete
40response. If the beneficiary does not supply the necessary
P8 1information to the county within the 30-day limit, a 10-day notice
2of termination of Medi-Cal eligibility shall be sent.
3(h) Beneficiaries shall be required to report any change in
4circumstances that may affect their eligibility within 10 calendar
5days following the date the change occurred.
6(i) If within 90 days of termination of a Medi-Cal beneficiary’s
7eligibility or a change in eligibility status pursuant to this section,
8the beneficiary submits to the county a signed and completed form
9or otherwise provides the needed information to the county,
10eligibility shall be redetermined by the county and if the beneficiary
11is found eligible, or the beneficiary’s eligibility status has not
12changed, whichever applies, the termination shall be rescinded as
13though the form were submitted in a timely manner.
14(j) If the information available to the county pursuant to the
15redetermination procedures of this section does not indicate a basis
16of eligibility, Medi-Cal benefits may be terminated so long as due
17process requirements have otherwise been met.
18(k) The department shall, with the counties and representatives
19of consumers, including those with disabilities, and Medi-Cal
20eligibility workers, develop a timeframe for redetermination of
21Medi-Cal eligibility based upon disability, including ex parte
22review, the redetermination forms described in subdivisions (f)
23and (g), timeframes for responding to county or state requests for
24additional information, and the forms and procedures to be used.
25The forms and procedures shall be as consumer-friendly as possible
26for people with disabilities. The timeframe shall provide a
27reasonable and adequate opportunity for the Medi-Cal beneficiary
28to obtain and submit medical records and other information needed
29to establish eligibility for Medi-Cal based upon disability.
30(l) The county shall consider blindness as continuing until the
31reviewing physician determines that a beneficiary’s vision has
32improved beyond the applicable definition of blindness contained
33in the plan.
34(m) The county shall consider disability as continuing until the
35review team determines that a beneficiary’s disability no longer
36meets the applicable definition of disability contained in the plan.
37(n) In the case of a redetermination due to a change in
38circumstances, if a county determines that the beneficiary remains
39eligible for Medi-Cal benefits, the county shall begin a new
4012-month eligibility period.
P9 1(o) (1) For individuals
determined ineligible for Medi-Cal by
2a county following the redetermination procedures set forth in this
3section, the county shall determine eligibility for other insurance
4affordability programs and if the individual is found to be eligible,
5the county shall, as appropriate, transfer the individual’s electronic
6account to other insurance affordability programs via a secure
8(2) If the individual is eligible to enroll in a qualified health
9plan through the California Health Benefit Exchange established
10pursuant to Title 22 (commencing with Section 100500) of the
begin delete Code under any insurance affordability program,end delete
12 Medi-Cal benefits shall not be terminated until at least
begin delete 30end delete
13 days after the county sends the notice of action terminating
14Medi-Cal eligibility. The notice of action shall inform the
15individual of the date by which he or she must select and enroll in
16a qualified health plan through the Exchange to avoid being
17uninsured. If the individual has effectuated his or her enrollment
18in a qualified health plan through the Exchange before the
19termination date specified in the notice, Medi-Cal eligibility shall
20be terminated as of the date of enrollment in the qualified health
23(p) Any renewal form or notice shall be accessible to persons
24who are limited-English proficient and persons with disabilities
25consistent with all federal and state requirements.
26(q) The requirements to provide information in subdivisions (e)
27and (g), and to report changes in circumstances in subdivision (h),
28may be provided through any of the modes of submission allowed
29in Section 435.907(a) of Title 42 of the Code of Federal
30Regulations, including an Internet Web site identified by the
31department, telephone, mail, in person, and other commonly
32available electronic means as authorized by the department.
33(r) Forms required to be signed by a beneficiary pursuant to this
34section shall be signed under penalty of perjury. Electronic
35signatures, telephonic signatures, and handwritten signatures
36transmitted by electronic transmission shall be accepted.
37(s) For purposes of this section, “MAGI-based financial
38methods” means income calculated using the financial
39methodologies described in Section 1396a(e)(14) of Title 42 of
40the United States Code, and as added by the federal Patient
P10 1Protection and Affordable Care Act (Public Law 111-148), as
2amended by the federal Health Care and Education Reconciliation
3Act of 2010 (Public Law 111-152), and any subsequent
5(t) When contacting a beneficiary under paragraphs (2) and (4)
6of subdivision (f), and paragraph (3) of subdivision (g), a county
7shall first attempt to use the method of contact identified by the
8beneficiary as the preferred method of contact, if a method has
10(u) The department shall seek federal approval to extend the
11annual redetermination date under this section for a three-month
12period for those Medi-Cal beneficiaries whose annual
13redeterminations are scheduled to occur between January 1, 2014,
14and March 31, 2014.
15(v) Notwithstanding Chapter 3.5 (commencing with Section
1611340) of Part 1 of Division 3 of Title 2 of the Government Code,
17the department, without taking any further regulatory action, shall
18implement, interpret, or make specific this section by means of
19all-county letters, plan letters, plan or provider bulletins, or similar
20instructions until the time regulations are adopted. The department
21shall adopt regulations by July 1, 2017, in accordance with the
22requirements of Chapter 3.5 (commencing with Section 11340) of
23Part 1 of Division 3 of Title 2 of the Government Code. Beginning
24six months after the effective date of this section, and
25notwithstanding Section 10231.5 of the Government Code, the
26department shall provide a status report to the Legislature on a
27semiannual basis, in compliance with Section 9795 of the
28Government Code, until regulations have been adopted.
29(w) This section shall be implemented only if and to the extent
30that federal financial participation is available and any necessary
31federal approvals have been obtained.
Section 15927 is added to the Welfare and Institutions
33Code, immediately following Section 15926, to read:
(a) If an individual enrolled in a qualified health plan
35through the California Health Benefit Exchange established under
36Title 22 (commencing with Section 100500) of the Government
37Code reports a change in circumstances, goes through the renewal
38process, or is reevaluated for eligibility and there is a change
39affecting his or her eligibility for any insurance affordability
40program, the individual’s case shall be run through the California
P11 1Healthcare Eligibility, Enrollment, and Retention System
2(CalHEERS) developed under Section 15926. If CalHEERS
3receives information indicating that an individual who has been
4enrolled in a qualified health plan through the Exchange is newly
5eligible for Medi-Cal, the individual’s case file shall be sent to his
6or her county of residence within three business days.
7(b) (1) If the county of residence receives a case file regarding
8an individual described in subdivision (a) who is newly eligible
9for Medi-Cal, the county shall not treat this as a new Medi-Cal
11(A) Case files
19 received by the county prior to the 15th day of
20the month shall be processed for final Medi-Cal eligibility by the
21county by the end of that month.
22(B) Case filesend delete
23 received by the county after the 15th day of the month
24shall be processed for final Medi-Cal eligibility by the 15th day
25of the following month.
26(2) For individuals described in subdivision (a) who are newly
27eligible for Medi-Cal, the county shall issue a notice at least 15
28days before the individual’s enrollment in a qualified health plan
29through the Exchange ends that advises the individual of all of the
31(A) He or she will be enrolled into Medi-Cal.
32(B) Instructions on how to select a Medi-Cal managed care
34(C) His or her right to appeal an action related to the individual’s
35eligibility for or enrollment in an insurance affordability program
36pursuant to Section 100506.1 of the Government Code.
37(D) Instructions on how to request continued enrollment in a
38qualified health benefit plan pending the outcome of his or her
39appeal of an action related to the individual’s eligibility for or
40enrollment in an insurance affordability program.
P12 1(3) If information is needed by the county to verify income, the
2 county shall follow the procedures set forth in subdivisions (f) and
3(g) of Section 14005.37 to obtain that information.
4(c) An individual described in subdivision (a) who is newly
5eligible for Medi-Cal shall be enrolled in the Medi-Cal program
6according to the following procedures:
begin delete(A)end delete begin delete end deleteIn a county that provides Medi-Cal services under the
8two-plan model or the geographic managed care plan model
9pursuant to Article 2.7 (commencing with Section 14087.3), Article
102.81 (commencing with Section 14087.96), and Article 2.91
11(commencing with Section 14089), the individual shall be enrolled
12in a Medi-Cal managed care plan according to either of the
15 If the qualified health plan the individual was enrolled in
16through the Exchange is an available Medi-Cal managed care plan
17in his or her county and that plan has the same or substantially
18similar provider network, the individual shall be assigned to that
21 The individual shall be assigned to a plan
using the usual
22Medi-Cal managed care default algorithm.
23(B) The 15-day notice issued to the individual newly eligible
24for Medi-Cal shall advise him or her of all of the following
26(i) The Medi-Cal managed care plan to which he or she will be
27assigned if the individual does not take any action.
28(ii) The individual may choose any available Medi-Cal managed
30(iii) A description of the Medi-Cal managed care plans available
31in his or her county.
32(iv) Instructions on how the individual may change Medi-Cal
33managed care plans.
34(2) In a county that provides Medi-Cal services under a county
35organized health system pursuant to Article 2.8 (commencing with
36Section 14087.5), the individual shall be enrolled into the county
37organized health system plan on the first date of Medi-Cal coverage
38and shall be sent the provider directory for the managed care plan.
If the Commission on State Mandates determines that
40this act contains costs mandated by the state, reimbursement to
P13 1local agencies and school districts for those costs shall be made
2pursuant to Part 7 (commencing with Section 17500) of Division
34 of Title 2 of the Government Code.