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. The bill would require an individual’s case information and eligibility determination to be sent to his or her county of residence within 3 business days if the individual is determined newly eligible for Medi-Cal through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The bill would require those cases to be processed by the county according to specified timelines.
begin 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.end delete
The bill would generally prohibit, if an individual is eligible to enroll in a qualified health plan through the Exchange, Medi-Cal benefits from being terminated until at least 20 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. The bill would provide that this provision shall only be implemented to the extent that federal financial participation is available.
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
17(b) Loss of eligibility for cash aid under that program shall not
18result in a redetermination under this section unless the reason for
19the loss of eligibility is one that would result in the need for a
20redetermination for a person whose eligibility for Medi-Cal under
21Section 14005.30 was determined without a concurrent
22 determination of eligibility for cash aid under the CalWORKs
24(c) A loss of contact, as evidenced by the return of mail marked
25in such a way as to indicate that it could not be delivered to the
26intended recipient or that there was no forwarding address, shall
27require a prompt redetermination according to the procedures set
28forth in this section.
P4 1(d) Except as otherwise provided in this section, Medi-Cal
2eligibility shall continue during the redetermination process
3described in this section and a beneficiary’s Medi-Cal eligibility
4shall not be terminated under this section until the county makes
5a specific determination based on facts clearly demonstrating that
6the beneficiary is no longer eligible for Medi-Cal benefits under
7any basis and due process rights guaranteed under this division
8have been met. For the purposes of this subdivision, for a
9beneficiary who is subject to the use of MAGI-based financial
10methods, the determination of whether the beneficiary is eligible
11for Medi-Cal benefits under any basis shall include, but is not
12limited to, a determination of eligibility for Medi-Cal benefits on
13a basis that is exempt from the use of MAGI-based financial
14methods only if either of the following occurs:
15(1) The county assesses the beneficiary as being potentially
16eligible under a program that is exempt from the use of
17MAGI-based financial methods, including, but not limited to, on
18the basis of age, blindness, disability, or the need for long-term
19care services and supports.
20(2) The beneficiary requests that the county
21he or she is eligible for Medi-Cal benefits on a basis that is exempt
22from the use of MAGI-based financial methods.
23(e) (1) For purposes of acquiring information necessary to
24conduct the eligibility redeterminations described in this section,
25a county shall gather information available to the county that is
26relevant to the beneficiary’s Medi-Cal eligibility prior to contacting
27the beneficiary. Sources for these efforts shall include information
28contained in the beneficiary’s file or other information, including
29more recent information available to the county, including, but not
30limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
31beneficiary or of any of his or her immediate family members,
32which are open, or were closed within the last 90 days, information
33accessed through any databases accessed under Sections 435.948,
34435.949, and 435.956 of Title 42 of the Code of Federal
35Regulations, and wherever feasible, other sources of relevant
36information reasonably available to the county or to the county
37via the department.
38(2) In the case of an annual redetermination, if, based upon
39information obtained pursuant to paragraph (1), the county is able
P5 1to make a determination of continued eligibility, the county shall
2notify the beneficiary of both of the following:
3(A) The eligibility determination and the information it is based
5(B) That the beneficiary is required to inform the county via the
6Internet, by telephone, by mail, in person, or through other
7commonly available electronic means, in counties where such
8electronic communication is available, if any information contained
9in the notice is inaccurate but that the beneficiary is not required
10to sign and return the notice if all information provided on the
11notice is accurate.
12(3) The county shall make all reasonable efforts not to send
13multiple notices during the same time period about eligibility. The
14notice of eligibility renewal shall contain other related information
15such as if the beneficiary is in a new Medi-Cal program.
16(4) In the case of a redetermination due to a change in
17circumstances, if a county determines that the change in
18circumstances does not affect the beneficiary’s eligibility status,
19the county shall not send the beneficiary a notice unless required
20to do so by federal law.
21(f) (1) In the case of an annual eligibility redetermination, if
22the county is unable to determine continued eligibility based on
23the information obtained pursuant to paragraph (1) of subdivision
24(e), the beneficiary shall be so informed and shall be provided with
25an annual renewal form, at least 60 days before the beneficiary’s
26annual redetermination date, that is prepopulated with information
27that the county has obtained and that identifies any additional
28information needed by the county to determine eligibility. The
29form shall include all of the following:
30(A) The requirement that he or she provide any necessary
31information to the county within 60 days of the date that the form
32is sent to the beneficiary.
33(B) That the beneficiary may respond to the county via the
34Internet, by mail, by telephone, in person, or through other
35commonly available electronic means if those means are available
36in that county.
37(C) That if the beneficiary chooses to return the form to the
38county in person or via mail, the beneficiary shall sign the form
39in order for it to be considered complete.
P6 1(D) The telephone number to call in order to obtain more
3(2) The county shall attempt to contact the beneficiary via the
4Internet, by telephone, or through other commonly available
5electronic means, if those means are available in that county, during
6the 60-day period after the prepopulated form is mailed to the
7beneficiary to collect the necessary information if the beneficiary
8has not responded to the request for additional information or has
9provided an incomplete response.
10(3) If the beneficiary has not provided any response to the
11written request for information sent pursuant to paragraph (1)
12within 60 days from the date the form is sent, the county shall
13terminate his or her eligibility for Medi-Cal benefits following the
14provision of timely notice.
15(4) If the beneficiary responds to the written request for
16information during the 60-day period pursuant to paragraph (1)
17but the information provided is not complete, the county shall
18follow the procedures set forth in paragraph (3) of subdivision (g)
19to work with the beneficiary to complete the information.
20(5) (A) The form required by this subdivision shall be developed
21by the department in consultation with the counties and
22representatives of eligibility workers and consumers.
23(B) For beneficiaries whose eligibility is not determined using
24MAGI-based financial methods, the county may use existing
25renewal forms until the state develops prepopulated renewal forms
26to provide to beneficiaries. The department shall develop
27prepopulated renewal forms for use with beneficiaries whose
28eligibility is not determined using MAGI-based financial methods
29by January 1, 2015.
30(g) (1) In the case of a redetermination due to change in
31circumstances, if a county cannot obtain sufficient information to
32redetermine eligibility pursuant to subdivision (e), the county shall
33send to the beneficiary a form that is prepopulated with the
34information that the county has obtained and that states the
35information needed to renew eligibility. The county shall only
36request information related to the change in circumstances. The
37county shall not request information or documentation that has
38been previously provided by the beneficiary, that is not absolutely
39necessary to complete the eligibility determination, or that is not
40subject to change. The county shall only request information for
P7 1nonapplicants necessary to make an eligibility determination or
2for a purpose directly related to the administration of the state
3Medicaid plan. The form shall advise the individual to provide
4any necessary information to the county via the Internet, by
5telephone, by mail, in person, or through other commonly available
6electronic means and, if the individual will provide the form by
7mail or in person, to sign the form. The form shall include a
8telephone number to call in order to obtain more information. The
9form shall be developed by the department in consultation with
10the counties, representatives of consumers, and eligibility workers.
11A Medi-Cal beneficiary shall have 30 days from the date the form
12is mailed pursuant to this subdivision to respond. Except as
13provided in paragraph (2), failure to respond prior to the end of
14this 30-day period shall not impact his or her Medi-Cal eligibility.
15(2) If the purpose for a redetermination under this section is a
16loss of contact with the Medi-Cal beneficiary, as evidenced by the
17return of mail marked in such a way as to indicate that it could not
18be delivered to the intended recipient or that there was no
19forwarding address, a return of the form described in this
20subdivision marked as undeliverable shall result in an immediate
21notice of action terminating Medi-Cal eligibility.
22(3) During the 30-day period after the date of mailing of a form
23to the Medi-Cal beneficiary pursuant to this subdivision, the county
24shall attempt to contact the beneficiary by telephone, in writing,
25or other commonly available electronic means, in counties where
26such electronic communication is available, to request the
27necessary information if the beneficiary has not responded to the
28request for additional information or has provided an incomplete
29response. If the beneficiary does not supply the necessary
30information to the county within the 30-day limit, a 10-day notice
31of termination of Medi-Cal eligibility shall be sent.
32(h) Beneficiaries shall be
required to report any change in
33circumstances that may affect their eligibility within 10 calendar
34days following the date the change occurred.
35(i) If within 90 days of termination of a Medi-Cal beneficiary’s
36eligibility or a change in eligibility status pursuant to this section,
37the beneficiary submits to the county a signed and completed form
38or otherwise provides the needed information to the county,
39eligibility shall be redetermined by the county and if the beneficiary
40is found eligible, or the beneficiary’s eligibility status has not
P8 1changed, whichever applies, the termination shall be rescinded as
2though the form were submitted in a timely manner.
3(j) If the information available to the county pursuant to the
4redetermination procedures of this section does not indicate a basis
5of eligibility, Medi-Cal benefits may be terminated so long as due
6process requirements have otherwise been met.
7(k) The department shall, with the counties and representatives
8of consumers, including those with disabilities, and Medi-Cal
9eligibility workers, develop a timeframe for redetermination of
10Medi-Cal eligibility based upon disability, including ex parte
11review, the redetermination forms described in subdivisions (f)
12and (g), timeframes for responding to county or state requests for
13additional information, and the forms and procedures to be used.
14The forms and procedures shall be as consumer-friendly as possible
15for people with disabilities. The timeframe shall provide a
16reasonable and adequate opportunity for the Medi-Cal beneficiary
17to obtain and submit medical records and other information needed
18to establish eligibility for Medi-Cal based upon disability.
19(l) The county shall consider blindness as continuing until the
20reviewing physician determines that a beneficiary’s vision has
21improved beyond the applicable definition of blindness contained
22in the plan.
23(m) The county shall consider disability as continuing until the
24review team determines that a beneficiary’s disability no longer
25meets the applicable definition of disability contained in the plan.
26(n) In the case of a redetermination due to a change in
27circumstances, if a county determines that the beneficiary remains
28eligible for Medi-Cal benefits, the county shall begin a new
2912-month eligibility period.
30(o) (1) For individuals determined ineligible for Medi-Cal by
31a county following the redetermination procedures set forth in this
32section, the county shall determine eligibility for other insurance
33affordability programs and if the individual is found to be eligible,
34the county shall, as appropriate, transfer the individual’s electronic
35account to other insurance affordability programs via a secure
37(2) If the individual is eligible to enroll in a qualified health
38plan through the California Health Benefit Exchange established
39pursuant to Title 22 (commencing with Section 100500) of the
40Government Code, Medi-Cal benefits shall not be terminated until
P9 1at least 20 days after the county sends the notice of action
2terminating Medi-Cal eligibility. The notice of action shall inform
3the individual of the date by which he or she must select and enroll
4in a qualified health plan through the Exchange to avoid being
5uninsured. If the individual has effectuated his or her enrollment
6in a qualified health plan through the Exchange before the
7termination date specified in the notice, Medi-Cal eligibility shall
8be terminated as of the date of enrollment in the qualified health
9plan. This paragraph shall only be implemented to the extent that
10federal financial participation is available.
11(p) Any renewal form or notice shall be accessible to persons
12who are limited-English proficient and persons with disabilities
13consistent with all federal and state requirements.
14(q) The requirements to provide information in subdivisions (e)
15and (g), and to report changes in circumstances in subdivision (h),
16may be provided through any of the modes of submission allowed
17in Section 435.907(a) of Title 42 of the Code of Federal
18Regulations, including an Internet Web site identified by the
19department, telephone, mail, in person, and other commonly
20available electronic means as authorized by the department.
21(r) Forms required to be signed by a beneficiary pursuant to this
22section shall be signed under penalty of perjury. Electronic
23signatures, telephonic signatures, and handwritten signatures
24transmitted by electronic transmission shall be accepted.
25(s) For purposes of this section, “MAGI-based financial
26methods” means income calculated using the financial
27methodologies described in Section 1396a(e)(14) of Title 42 of
28the United States Code, and as added by the federal Patient
29Protection and Affordable Care Act (Public Law 111-148), as
30amended by the federal Health Care and Education Reconciliation
31Act of 2010 (Public Law 111-152), and any subsequent
33(t) When contacting a beneficiary under paragraphs (2) and (4)
34of subdivision (f), and paragraph (3) of subdivision (g), a county
35shall first attempt to use the method of contact identified by the
36beneficiary as the preferred method of contact, if a method has
38(u) The department shall seek federal approval to extend the
39annual redetermination date under this section for a three-month
40period for those Medi-Cal beneficiaries whose annual
P10 1redeterminations are scheduled to occur between January 1, 2014,
2and March 31, 2014.
3(v) Notwithstanding Chapter 3.5 (commencing with Section
411340) of Part 1 of Division 3 of Title 2 of the Government Code,
5the department, without taking any further regulatory action, shall
6implement, interpret, or make specific this section by means of
7all-county letters, plan letters, plan or provider bulletins, or similar
8instructions until the time regulations are adopted. The department
9shall adopt regulations by July 1, 2017, in accordance with the
10requirements of Chapter 3.5 (commencing with Section 11340) of
11Part 1 of Division 3 of Title 2 of the Government Code. Beginning
12six months after the effective date of this section, and
13notwithstanding Section 10231.5 of the Government Code, the
14department shall provide a status report to the Legislature on a
15semiannual basis, in compliance with Section 9795 of the
16Government Code, until regulations have been adopted.
17(w) This section shall be implemented only if and to the extent
18that federal financial participation is available and any necessary
19federal approvals have been obtained.
Section 15927 is added to the Welfare and Institutions
21Code, immediately following Section 15926, to read:
(a) If an individual who has been enrolled in a qualified
23health plan through the Exchange is determined newly eligible for
24Medi-Cal through the California Healthcare Eligibility, Enrollment
25and Retention System (CalHEERS) developed under Section
2615926, the individual’s case information and eligibility
27determination shall be sent to his or her county of residence within
28three business days.
29(b) (1) Cases received by the county prior to the 15th day of
30the month shall be processed for final Medi-Cal eligibility by the
31county by the end of that month.
(2) Cases received by the county after the 15th day of the month
33shall be processed for final Medi-Cal eligibility by the 15th day
34of the following month.
35(c) An individual described in subdivision (a) who is newly
36eligible for Medi-Cal shall be enrolled in the Medi-Cal program
37according to the following procedures:
38(1) In a county that provides Medi-Cal services under the
39two-plan model or the geographic managed care plan model
40pursuant to Article 2.7 (commencing with Section 14087.3), Article
P11 12.81 (commencing with Section 14087.96), and Article 2.91
2(commencing with Section 14089), the individual shall be enrolled
3in a Medi-Cal managed care plan according to either of the
5(A) If the qualified health plan the individual was enrolled in
6through the Exchange is an available Medi-Cal managed care plan
7in his or her county and that plan has the same or substantially
8similar provider network, the individual shall be assigned to that
10(B) The individual shall be assigned to a plan using the usual
11Medi-Cal managed care default algorithm.
12(2) In a county that provides Medi-Cal services under a county
13organized health system pursuant to Article 2.8 (commencing with
14Section 14087.5), the individual shall be enrolled into the county
15organized health system plan on the first date of Medi-Cal coverage
16and shall be sent the provider directory for the managed care plan.
If the Commission on State Mandates determines that
18this act contains costs mandated by the state, reimbursement to
19local agencies and school districts for those costs shall be made
20pursuant to Part 7 (commencing with Section 17500) of Division
214 of Title 2 of the Government Code.