BILL ANALYSIS Ó
SB 10
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Date of Hearing: April 26, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
10 (Lara) - As Amended April 13, 2016
SENATE VOTE: Not relevant.
SUBJECT: Health care coverage: immigration status.
SUMMARY: Requires the Secretary of California Health and Human
Services Agency (CHHSA) to apply for a waiver under Section 1332
of the Patient Protection and Affordable Care Act (ACA) to allow
persons otherwise not able to obtain coverage by reason of
immigration status to obtain coverage through California's
Health Benefit Exchange (Exchange, now known as Covered
California or CoveredCa). Specifically, this bill:
1)Requires the CHHSA Secretary to apply to the United States
(U.S.) Department of Health and Human Services (DHHS) for a
waiver to allow persons otherwise not able to obtain coverage
by reason of immigration status to obtain coverage through
California's Exchange.
2)Requires the Exchange to offer qualified health plans (QHPs)
to persons otherwise not able to obtain coverage by reason of
immigration status, and subject to all of the requirements
applicable to QHPs, as set forth in the Exchange's program
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requirements.
3)Requires eligible persons to pay the full cost of coverage
without federal advanced premium tax credit (APTC), federal
cost-sharing reduction, or any other federal assistance.
4)Defines, for the purposes of this bill, a California QHP as a
product offered to persons not otherwise eligible to purchase
coverage from the Exchange by reason of immigration status
that complies with state law and the Exchange requirements for
a QHP.
5)Makes provisions of this bill operative upon federal approval
of the Section 1332 waiver.
EXISTING LAW:
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income persons receive health care benefits and,
in part, governed and funded by federal Medicaid program
provisions. Authorizes DHCS to extend continuous Medi-Cal
eligibility to children 19 years of age and younger.
2)Extends eligibility for full-scope Medi-Cal benefits to
individuals under 19 years of age who do not have, or are
unable to establish, satisfactory immigration status,
commencing after the DHCS Director determines that systems
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have been programmed for implementation of this extension,
but in no case sooner than May 1, 2016. Requires these
individuals to enroll in a Medi-Cal managed care health plan
in those counties in which a Medi-Cal managed care health
plan is available.
3)Prohibits Medicaid matching funds for medical assistance for
an undocumented individual, except for care and services
necessary for the treatment of an emergency medical condition,
as defined, for an individual who otherwise meets the
eligibility requirements for medical assistance under the
state's Medicaid State Plan.
4)Establishes the ACA, which enacts various health care coverage
market reforms. Requires, each state, by January 1, 2014, to
establish an Exchange that makes QHPs available to qualified
individuals and qualified employers. Requires, if a state
does not establish an Exchange, the federal government to
administer the Exchange. Establishes requirements for the
Exchange and for QHPs participating in the Exchange, and
defines who is eligible to purchase coverage in the Exchange.
Limits enrollment in the Exchanges to citizens or U.S.
nationals of the U.S., or an alien lawfully present in the
U.S.
5)Allows, under the ACA and effective January 1, 2014, eligible
individual taxpayers, whose household income is between 100%
and 400% of the federal poverty level (FPL), an APTC based on
the individual's income for coverage under a QHP offered in
the Exchange. Requires a reduction in cost-sharing for
individuals with incomes below 250% of FPL, and a lower
maximum limit on out-of-pocket expenses for individuals whose
incomes are between 100% and 400% of FPL. Provides that legal
immigrants with household incomes less than 100% of FPL who
are ineligible for Medi-Cal because of their immigration
status are also eligible for the APTC and the cost-sharing
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reductions.
6)Establishes the CoveredCa within state government, as an
independent public entity not affiliated with an agency or
department, and requires the Exchange to compare and make
available through selective contracting health insurance for
individual and small business purchasers as authorized under
the ACA. Specifies the powers and duties of the board
governing the Exchange, and requires the board to facilitate
the purchase of QHPs though the Exchange by qualified
individuals and small employers.
7)Provides that an individual is not a qualified individual
eligible for coverage under a QHP if that individual is not a
citizen or national of the U.S. or an alien lawfully present
in the U.S.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. The author states that this bill
directs the state to apply for a federal waiver to allow
undocumented Californians to buy health insurance with their
own money through Covered California. According to the
author, this bill affirms California's commitment to embrace
and integrate our immigrant community, to lead where the
federal government has failed, and to acknowledge the hard
work and sacrifice of a community that contributes billions of
dollars to our gross domestic product. If successful, this
bill will allow 390,000 immigrants who earn an income too high
to qualify for Medi-Cal to purchase healthcare through the
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Exchange under the ACA. This bill will make California the
first state in the nation to make this petition to the federal
government. Additionally, the author states that prohibiting
immigrants from buying insurance from the Exchange with their
own money is irrational. Furthermore, the author contends
that this is a discriminatory policy that does not reflect our
California values. Through a waiver request to the federal
government, the author states that we can fix that.
2)BACKGROUND.
a) ACA. The ACA includes new health insurance subsidies
for those with incomes up to 400% FPL and establishes an
essential health benefits package that all plans in the
Exchanges, or offered in the individual and small group
markets outside the Exchanges, must provide at minimum.
Qualified non-citizens will be eligible for subsidies,
regardless of how long they have been in the U.S and access
to the Exchange and available subsidies will be the same as
for citizens, and will represent a substantial increase in
the affordability of insurance for low and moderate income
immigrants. Lawfully present immigrants with five years or
less of U.S. residency, without access to employer
sponsored insurance, will be able to receive both APTC and
cost sharing reductions toward approved plans that meet the
essential benefits package outlined in the ACA. This
includes lawfully present immigrants whose incomes are
below 133% FPL and, but for immigration status, would be
eligible for Medicaid.
Unauthorized immigrants are not allowed to purchase
insurance from Exchanges, receive subsidies for Exchange
coverage, or enroll in full-scope Medicaid and thus will
likely remain uninsured under the ACA. Their access to
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primary and other forms of outpatient care will depend on
the ability and willingness of local safety net providers,
such as community health centers, to serve them, which will
likely vary from area to area. The UC Berkeley Center for
Labor Research and Education indicated that more than 2.7
million Californians are expected to remain uninsured under
the ACA in 2019.
b) Section 1332 State Innovation Waivers. Under Section
1332 of the ACA, the Secretaries of DHHS and the Treasury
(Secretaries), as appropriate, may exercise their
discretion to approve a request for a State Innovation
Waiver (Section 1332 waiver) only if the Secretaries
determine that the proposal meets the following four
requirements:
i) Provides coverage to at least a comparable number of
the state's residents as would be provided absent the
waiver;
ii) Provides coverage and cost-sharing protections
against excessive out-of-pocket spending that are at
least as affordable for the state's residents as would be
provided absent the waiver;
iii) Provides coverage that is at least as comprehensive
for the state's residents as would be provided absent the
waiver; and,
iv) Does not increase the Federal deficit. The
Secretaries retain their discretionary authority under
Section 1332 to deny waivers when appropriate given
consideration of the application as whole, including the
four requirements.
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As under similar waiver authorities, the Secretaries
reserve the right to suspend or terminate a waiver, in
whole or in part, any time before the date of expiration,
if the Secretaries determine that the state materially
failed to comply with the terms and conditions of the
Waiver, including any of the requirements discussed in the
guidance. Additionally, states are required to enact
legislation to provide Waiver authority and must submit an
application that includes economic, actuarial, and budget
analysis, in addition to the analysis regarding how the
Section 1332 Waiver is consistent with federal
requirements. These Section 1332 Waivers can be effective
as early January 1, 2017.
c) CoveredCa and Section 1332 Waiver proposals. CoveredCa
engaged stakeholders to discuss potential Section 1332
waiver proposals and compiled an Analysis and Report on
California's 2016 Section 1332 State Innovation Waiver
Proposals. According to CoveredCa, its focus is the
continued effective implementation of the ACA in
California. CoveredCa notes that a Section 1332 waiver
would require considerable CoveredCa staff time and
resources which will divert resources for improvements and
advancements of proposals that are possible without a
waiver. CoveredCa requests consideration of the following
factors when pursuing a Section 1332 Waiver:
i) Proposals should be directly related to CoveredCa's
mission;
ii) Proposals should achieve cost savings or
administrative simplification for CoveredCa's enrollees
and potential enrollees, for CoveredCa and for
CoveredCa's contracted providers and health plans;
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iii) Due to CoveredCa's existing strategic priorities,
the primary focus of a Section 1332 Waiver should be to
improve processes rather than redesign processes; and,
iv) Proposals that violate the U.S. Treasury's budget
neutrality requirement or add liabilities to California's
General Funds should not be considered.
CoveredCa states that there was significant public comment
in support of expanding coverage to additional populations
such as undocumented Californians, specifically that all
members of mixed immigration status families would be able
to apply for coverage directly through CoveredCa. This
proposal would simplify the family health insurance
shopping and enrollment experience. CoveredCa also notes
that there was not conclusive data presented regarding the
demand for CoveredCa enrollment from undocumented
Californians. Expert opinion indicated that there could be
an increase in overall enrollment in CoveredCa due to mixed
families being more likely to apply through one-stop
shopping and because of reduced fears related to
immigration status of undocumented family members. The
estimated potential enrollment presented to CoveredCa
during the stakeholder discussions was 50,000. Currently,
undocumented Californians can enroll off the Exchange and
similar to this bill, these products whether purchased on
or off the Exchange, would not be subsidized with APTC or
cost sharing reductions.
d) December 2015 federal guidance. Federal guidance in
December 2015 provided additional information about Section
1332 waiver requirements that must be met, the application
review procedures, the amount of pass-through funding,
certain analytical requirements, and operational
considerations.
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e) Other states. For the 2015 legislative sessions, 11
states proposed bills affecting, examining, or authorizing
Section 1332 Waivers, including Arkansas, California,
Maine, Minnesota, New Mexico, Ohio, Rhode Island, South
Carolina, Texas, and Vermont. Five states enacted measures
related to Section 1332 Waivers, including Hawaii,
Minnesota, Ohio, Rhode Island, and Texas. California
appears to be the only state considering a Section 1332
Waiver with respect to on Exchange coverage for
undocumented individuals.
f) Current scope of Medi-Cal coverage. In order to be
Medi-Cal eligible, an individual must be a state resident
and generally must be low-income. Recent legal immigrants
and undocumented immigrant adults who meet income and
residency requirements are Medi-Cal-eligible, but the scope
of that coverage depends on the immigration status of the
immigrant. Under existing state and federal law,
undocumented immigrants are not eligible for full scope
services, and are instead eligible for "limited scope"
Medi-Cal benefits. Limited-scope services are long-term
care, pregnancy-related benefits, and emergency services.
Medi-Cal also provides coverage for undocumented
individuals needing breast and cervical cancer treatment,
family planning services through the Family Planning,
Access, Care, and Treatment program, and through temporary
presumptive eligibility programs. Specifically, DHCS is
currently implementing the Affordability and Benefit
Program for Newly Qualified Immigrants. Individuals who
participate in this program will enroll in a Covered
California health plan and receive Medi-Cal coverage for
any Medi-Cal-covered services not included in the CoveredCa
plan. Enrollment opportunities for this program are
planned for the Covered California 2016 open enrollment
period beginning in November 2016, with QHP enrollment
beginning on January 1, 2017. For individuals who
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participate in this program, all costs related to the
CoveredCa plan will be paid by the state after federal APTC
are applied.
g) Current California law extended full-scope Medi-Cal
benefits to children, specifically, SB 75 requires DHCS to
provide full-scope Medi-Cal benefits to children, under age
19, who do not have satisfactory immigration status or are
unable to establish satisfactory immigration status. DHCS
identified May 16 as the projected implementation date.
Full-scope eligibility will be retroactive to May 1. After
DHCS' Director communicates to California's Department of
Finance that the system is ready to enroll these children
into full-scope coverage, actual enrollment will begin.
DHCS has been working collaboratively with interested
stakeholders on implementation efforts, and updates are
provided at biweekly Immigration Workgroup meetings.
3)SUPPORT. The Western Center on Law and Poverty (WCLP) states
that California needs to adopt inclusionary health coverage
policies because immigrants without satisfactory immigration
status were left out of federal health reform. WCLP contends
that this bill would take another important step in allowing
the whole family regardless of status to obtain coverage
together on CoveredCa. WCLP notes that undocumented
immigrants contribute substantially to the California economy
and should benefit from our public program.
Health Access California (Health Access) contends that
California's health system, and Californians in general, are
healthier and stronger when every Californian has the
opportunity to have affordable, comprehensive health coverage.
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Existing law allows undocumented individuals to buy coverage
as individuals in the market off the Exchange. If, however,
an undocumented individual or a family with an undocumented
family member shows up at CoveredCa, the undocumented
individual is barred from purchasing covered through CoveredCa
and must be turned away. Health Access states that while
affordability will continue to be a barrier, this bill would
provide a practical benefit to many families with mixed
immigration status, so that CoveredCa could assist the entire
family in signing up for coverage, even if some will be
subsidized and others not. Health Access contends that over
70% of undocumented Californians are in families with legal
residents.
Consumer Watchdog states that improving health access and
allowing more immigrant families to purchase health coverage
through Covered Ca are important steps toward making the ACA
more inclusive. The National Health Law Program states that
California can be a model for this nation by removing an
unjust exclusion to CoveredCa based on immigration status and
immigrant families will be better serviced when CoveredCa is
accessible to the entire family.
The California Immigrant Policy Center (CIPC) states that the
ACA explicitly excluded undocumented immigrants and immigrants
approved for deferred action through the Deferred Action for
Childhood Arrivals Program of 2012 from purchasing health
insurance through CoveredCa due to immigration status. On
June 15, 2012, the Secretary of Homeland Security announced
that certain people who came to the U.S. as children and meet
several key guidelines may request consideration of deferred
action for a period of two years, subject to renewal, and
would then be eligible for work authorization.The CIPC states
that improving health access and allowing people to buy health
coverage through CoveredCa are important steps toward making
the ACA more inclusive.
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4)PREVIOUS LEGISLATION.
a) SB 4 (Lara), Chapter 709, Statutes of 2015, requires
children under the age of 19 enrolled in restricted scope
Medi-Cal be enrolled in full-scope Medi-Cal.
b) SB 75 (Committee on Budget and Fiscal Review), Chapter
18, Statutes of 2015, the Omnibus Health Trailer Bill for
2015-16, contains changes related to the Budget Act of 2015
and includes provisions expanding full-scope Medi-Cal
coverage to children, regardless of immigration status, who
currently would be eligible for Medi-Cal if not for
immigration status. Requires children eligible in this
category to enroll in Medi-Cal managed care. Requires DHCS
to seek federal financial participation (FFP), but requires
coverage to be provided regardless of FFP. Requires DHCS
to provide a semiannual status report to the Legislature
until regulations have been adopted.
c) SB 1005 (Lara) of 2014 would have established the
California Health Exchange Program for All Californians
(CHEPFAC) within state government and would have required
that CHEPFAC be governed by the Executive Board that
governs CoveredCa. SB 1005 would have required CoveredCa,
by January 1, 2016, to facilitate the enrollment of
individuals who would have been eligible to purchase
coverage through CoveredCa but for their immigration status
and extend eligibility for full-scope Medi-Cal benefits to
individuals who were otherwise eligible for those benefits
but for their immigration status. SB 1005 was held on the
Senate Appropriations suspense file.
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d) SB 900 (Alquist), Chapter 659, Statutes of 2010,
establishes CoveredCa as an independent public entity
within state government, and requires CoveredCa to be
governed by a board composed of the CHSSA Secretary, or his
or her designee, and four other members appointed by the
Governor and the Legislature who meet specified criteria.
e) AB 1602 (John A. Pérez), Chapter 655, Statutes of 2010,
specifies the powers and duties of Covered California
relative to determining eligibility for enrollment in the
CoveredCa and arranging for coverage under qualified health
plans.
5)PROPOSED AMENDMENTS. The author intends to include an urgency
clause such that this bill will become effective immediately
upon enactment.
REGISTERED SUPPORT / OPPOSITION:
Support
Advancement Project
Alameda Health Consortium
Alliance for Boys and Men of Color
American Academy of Pediatrics, California
American Federation of State, County and
Municipal Employees, AFL-CIO
Asian Americans Advancing Justice
Asian Law Alliance
ASPIRE
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California Academy of Family Physicians
California Alliance for Retired Americans
California Asian Pacific Islander Budget Partnership
California Black Health Network
California Coverage & Health Initiatives
California Family Resources Association
California Immigrant Policy Center
California Labor Federation
California Latinas for Reproductive Justice
California Lesbian, Gay, Bisexual, and Transgender Health and
Human Services Network
California National Organization for Women
California Pan-Ethnic Health Network
California Partnership
California Primary Care Association
California Rural Legal Assistance Foundation
California School Employees Association
California Teachers Association
Campaign for a Healthy California
Children Now
Children's Defense Fund California
Children's Health Coverage Coalition
Children's Partnership
Coalition for Humane Immigrant Rights of Los Angeles
Coalition of California Welfare Rights Organizations, Inc.
Coalition of Orange County Community Health Centers
Community Clinic Association of Los Angeles County
Community Clinic Consortium
Community Health Councils, Inc.
Community Health Initiative of Orange County
Consumer Watchdog
Fathers & Families of San Joaquin
Having Our Say
Health Access California
Korean Community Center of the East Bay
L.A. Care Health Plan
Latino Health Access
Long Beach Immigrant Rights Coalition
Los Angeles LGBT Center
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Maternal and Child Health Access
National Association of Social Workers, California Chapter
National Health Law Program
National Immigrant Law Center
NICOS Chinese Health Coalition
Older Women League
People Demanding Action
Physicians for a National Health Program
PICO California
Planned Parenthood Affiliates of California
Planned Parenthood Mar Monte
Providence Health & Services
Public Law Center
Reach Out
San Francisco Community Clinic Consortium
SEIU California
Senior and Disability Action
Single Payer Now
South Asian Network
Southeast Asian Resource Action Center
Street Level Health Project
United Steel Workers Local 675
United Way Fresno and Madera Counties
United Way of Stanislaus County
United Way of the Bay Area
United Ways of California
Visión y Compromiso
Western Center on Law and Poverty
Young Invincibles
Opposition
None in file.
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Analysis Prepared by:Kristene Mapile / HEALTH / (916)
319-2097