BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 4
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|AUTHOR: |Lara |
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|VERSION: |April 6, 2015 |
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|HEARING DATE: |April 15, 2015 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Health care coverage: immigration status
SUMMARY : Extends eligibility for full-scope Medi-Cal benefits to
individuals who are otherwise eligible for those benefits but
for their immigration status. Requires the Secretary of
California Health and Human Services Agency to apply to the
federal Department of Health and Human Services for a Section
1332 innovation waiver in order to allow persons otherwise not
able to obtain coverage through Covered California because of
their immigration status to obtain coverage without premium or
cost-sharing subsidies by waiving the requirement that Covered
California offer only qualified health plans. Establishes the
California Health Exchange Program for All Californians as a
state exchange for individuals ineligible for Covered California
because of their immigration status in the event federal
approval of the Section 1332 waiver is not granted.
Existing federal law:
1.Requires, under the Patient Protection and Affordable Care Act
(ACA, Public Law 111-148), as amended by the Health Care
Education and Reconciliation Act of 2010 (Public Law 111-152),
each state, by January 1, 2014, to establish an American
Health Benefit Exchange that makes qualified health plans
(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 citizen or nationals of the United States, or an
alien lawfully present in the United States.
2.Allows, under the ACA and effective January 1, 2014, eligible
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individual taxpayers, whose household income is between 100
and 400 percent of the Federal Poverty Level (FPL), an
advanceable and refundable premium tax credit (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 percent of the FPL, and a
lower maximum limit on out-of-pocket expenses for individuals
whose incomes are between 100 and 400 percent of the FPL.
Legal immigrants with household incomes less than 100 percent
of the FPL who are ineligible for Medicaid because of their
immigration status are also eligible for the APTC and the
cost-sharing reductions.
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.Authorizes, under Section 1332 of the ACA, waivers for state
innovation under which states can seek federal approval to
waive major provisions of the ACA, including the requirement
for Exchanges, QHPs, premium tax credits and cost-sharing
reductions, the individual mandate and the employer
responsibility requirement, provided federal requirements are
met for comprehensive benefits, affordability, and comparable
coverage are met and the state proposal does not increase the
federal deficit.
Existing state law:
1.Establishes the California Health Benefit Exchange (Covered
California) in state government, and specifies its duties and
authority. Requires Covered California to be governed by a
board that includes the Secretary of the California Health and
Human Services Agency (Agency) and four members with specified
expertise who are appointed by the Governor and the
Legislature.
2.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which low
income individuals are eligible for medical coverage. Medi-Cal
provides coverage to adults to adults and parents with incomes
up to 138 percent of the FPL who are under age 65, and to
children with incomes up to 266 percent of the FPL.
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3.Makes undocumented individuals, who are otherwise eligible for
Medi-Cal services, eligible only for care and services that
are necessary for the treatment of an emergency medical
condition and medical care directly related to the emergency,
as defined in federal law. Makes low-income undocumented
individuals Medi-Cal eligible for pregnancy-only coverage,
breast and cervical cancer-related treatment services, and
long-term care services.
4.Defines, under state law, an "emergency medical condition" as
a medical condition (including emergency labor and delivery)
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in:
a. Placing the patient's health in serious jeopardy;
b. Serious impairment to bodily functions; or,
c. Serious dysfunction of any bodily organ or part.
This bill:
Full-Scope Medi-Cal Benefits
1.Makes individuals who meet all of the eligibility requirements
for full-scope Medi-Cal benefits, except for their immigration
status, eligible for full-scope Medi-Cal benefits. Requires
these individuals to enroll into Medi-Cal managed care health
plans, and to pay copayments and premium contributions to the
extent required of otherwise eligible Medi-Cal recipients who
are similarly situated.
2.Requires Medi-Cal benefits for services to be provided with
state-only funds only if federal financial participation (FFP)
is not available for those services. Requires DHCS to maximize
FFP in implementing this provision to the extent allowable.
3.Requires that individuals who are enrolled in restricted scope
Medi-Cal as of December 31, 2015, who are eligible under this
bill to be transitioned directly to full-scope coverage under
the Medi-Cal program. Requires DHCS to develop a transition
plan for those currently enrolled in restricted scope Medi-Cal
that provides notice, assigns them to a Medi-Cal managed care
plan that contains their emergency care provider (defined as a
hospital in the county of residence there the individual
received emergency care), and that the individuals may choose
any available Medi-Cal managed care plan and primary care
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provider.
Section 1332 State Innovation Waiver provisions
4.Requires the Secretary of Agency to apply to the federal
Department of Health and Human Services for a Section 1332
waiver in order to allow persons otherwise not able to obtain
coverage by reason of immigration status through Covered
California to obtain coverage from Covered California by
waiving the requirement that Covered California offer only
QHPs.
5.Requires Covered California to offer QHPs, which are required
to be subject to the requirements of the existing Covered
California statute, including all of those requirements
applicable to qualified health plans.
6.Requires persons eligible to purchase California QHPs to pay
the cost of coverage without federal advanced premium tax
credit, federal cost sharing reduction, or any other federal
assistance.
7.Makes the above-described Section 1332 waiver-related
provisions operative upon federal approval of the waiver.
Requires, if these provisions do not become operative on or
before January 1, 2017, the California Health Exchange Program
for All Californians (the Program) provisions of this bill to
become operative. Sunsets the Section 1332 waiver-related
provisions if the Program is implemented.
California Health Exchange Program for All Californians
8.Establishes in state government the California Health Exchange
Program for All Californians as an independent public entity
not affiliated with an agency or department and requires the
Program to be covered by the Executive Board of Covered
California.
9.Defines, for purposes of the Program, "eligible individuals"
as individuals who would have been eligible to purchase
coverage through Covered California but for his or her
immigration status and who is not eligible for full-scope
Medi-Cal coverage under state law.
10.Establishes the mandatory duties and discretionary duties of
the Program board, which is generally modeled on the existing
statute of Covered California. These include enrolling
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eligible individuals, certifying and contracting with health
plans, facilitating enrollment, providing a choice of health
plan coverage, employing staff, and assessing a charge on
health plans to support the development and operations of the
Program.
11.Authorizes the Program to make available premium subsidies
and cost-sharing reductions to the extent funding is
available.
12.Creates the California Health Trust Fund for All Californians
as a continuously appropriated fund.
Requirements on Health Plans and Insurers in the Program
13.Places the same requirements on health plans and insurers
(plans) participating in the Program as exists under existing
law for Covered California-participating plans, including
requirements to fairly and affirmatively offer, market and
sell in the Program at least one product within each of the
five levels of coverage, to sell products in the Program to
individuals purchasing coverage outside the Program, and to
require plans participating in the Program to charge the same
rate for the same product whether that product is offered
through the Program or in the outside market.
Findings and Declarations and Legislative Intent
14.Makes legislative findings and declarations that longstanding
California law provides full-scope Medi-Cal to United States
citizens, lawful permanent residents, and individuals
permanently residing in the United States under color of law,
including those granted deferred action.
15.States legislative intent in enacting this bill:
a. To extend full-scope Medi-Cal eligibility to
California residents who are currently ineligible for
Medi-Cal due to their immigration status, as long as
they meet the other requirements of Medi-Cal;
b. That all Californians, regardless of
immigration status, have access to health coverage and
care;
c. That all Californians who are otherwise
eligible for Medi-Cal, a QHP offered through Covered
California, or affordable employer-based health
coverage, enroll in that coverage and obtain the care
that they need; and,
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d. To ensure that all Californians be included in
eligibility for coverage without regard to immigration
status.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, implementation of
the ACA provided health care coverage to millions of
Californians through Medi-Cal expansion and the Covered
California health care exchange. But those reforms excluded
undocumented immigrants from coverage provided through
Medi-Cal, and even prohibited individuals from purchasing
their own insurance through the health care exchange. Without
access to affordable, quality health insurance, people are
forced to rely on emergency care, which means they delay
treatment until they are sicker and treatment is more
expensive. This bill will allow undocumented Californians who
are denied access to the Covered California exchange, to buy
insurance with their own money through a federal waiver
process. For individuals that qualify for Medi-Cal, based on
income level, this bill would allow them to enroll in
Medi-Cal. Expanding access to health care will make a real
difference in the lives of thousands of hard working
Californian families. The author states we've made enormous
strides to reduce California's uninsured population with the
implementation of the ACA, but only when we include everyone
can we have a truly healthy California.
2.Current scope of Medi-Cal coverage for immigrants. 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 immigrants 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 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 Family PACT, and through temporary
presumptive eligibility programs. In 2015-16, DHCS estimates
providing Medi-Cal funded health care services to 786,600
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undocumented individuals at a total funds cost of $1.4 billion
($690 million GF).
3.Covered California and the individual market. Undocumented
immigrants are prohibited from purchasing coverage in Covered
California under federal law. Because APTCs and cost-sharing
subsidies are only available for individuals purchasing
coverage in Covered California, undocumented individuals are
also not eligible for these subsidies intended to make health
insurance and the cost of care more affordable. In the
individual market outside Covered California, plans and
insurers are required to fairly and affirmatively offer,
market and sell to all individuals and dependents in each
service area the plan or insurer provides services. Plans and
insurers are required to limit enrollment in individual
products to open enrollment periods and special enrollment
periods.
4.Section 1332 Waivers. This bill requires the Secretary of
Agency to apply for a Section 1332 waiver in order to allow
persons who cannot obtain coverage through Covered California
because of their immigration status to obtain such coverage.
Section 1332 of the ACA permits states to apply to the federal
government for a waiver of major provisions of the ACA
beginning in 2017. Known as "innovation waivers," the
provisions of the ACA that can be waived under Section 1332
include any or all parts of the provisions relating to QHPs
(including the essential health benefits package requirement),
the Exchanges, premium tax credits and cost-sharing
reductions, the minimum coverage requirement (individual
mandate), and the employer responsibility requirements.
If a state is granted a Section 1332 waiver, the state can fund
its reforms through the aggregate amount of federal funding
that otherwise would have been paid out within the state for
premium tax credits, cost-sharing reduction payments, and
small business tax credits. However, to qualify for an
innovation waiver, the state must establish that its reform
plan would provide coverage that:
a. Will provide coverage that is least as comprehensive as
ACA coverage;
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b. Will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at least
as affordable as the as ACA coverage;
c. Will provide coverage to at least a comparable number of
its residents as the ACA would provide; and,
d. Will not increase the federal deficit.
1.Presidential action on immigration. In November 2014,
President Obama announced that the federal Department of
Homeland Security (DHS) would not deport certain undocumented
parents of U.S. citizens and parents of lawful permanent
residents (LPRs). President Obama also announced an expansion
of the Deferred Action for Childhood Arrivals (DACA) program
for youth who came to the United States as children. Under a
directive from the secretary of DHS, these parents and youth
may be granted a type of temporary permission to stay in the
U.S. called "deferred action." Deferred action is a form of
administrative relief from deportation whereby DHS authorizes
a noncitizen to remain in the U.S. temporarily. These
individuals may also apply for an employment authorization
document (a work permit) during the deferred action period. A
grant of deferred action is temporary and does not grant
citizenship or permanent lawful status. However, a person
granted deferred action is considered by the federal
government to be lawfully present for as long as the grant of
deferred action status. These actions are expected to affect
up to 4.4 million people, according to DHS.
The United States Citizenship and Immigration Services (USCIS)
announced that, due to a federal court order, it would not
begin accepting requests for the expansion of DACA on February
18, 2015 as originally planned and has suspended
implementation of Deferred Action for Parents of Americans and
Lawful Permanent Residents (DAPA). The court's temporary
injunction, issued February 16, 2015, does not affect the
existing DACA and individuals can continue to request an
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initial grant of DACA or renewal of DACA under the original
guidelines.
If the President's deferred action proposal is implemented, it
would reduce the state costs associated with this bill as
individuals eligible for deferred action are eligible for
full-scope Medi-Cal.
2.The ACA and the remaining uninsured. A January 2015 report
from the UC Berkeley Center for Labor Research and Education
and the UCLA Center for Health Policy Research estimated the
ACA is expected to reduce California's uninsured rate by at
least half by 2019, at which time the ACA will be fully
implemented, as they estimate 6.5 million Californians would
have remained uninsured by 2019 without the ACA. The report
indicates that between 2.7 and 3.4 million Californians will
remain uninsured by 2019. Overall, between 1.4 and 1.5 million
undocumented immigrants in California are projected to remain
uninsured in 2019, comprising up to half of all Californians
remaining uninsured. The model used to provide these estimates
had not yet incorporated Medi-Cal eligibility and enrollment
among immigrants with deferred action.
A March 2015 Policy Brief from the UC Berkeley Center for
Labor Research and Education and the UCLA Center for Health
Policy Research estimated that 1.25 million of the estimated
2.45 million undocumented residents in California would be
eligible for DAPA or DACA. More than two-thirds (68 percent)
of Californians eligible for DACA and 65 percent of those
eligible for DAPA were low-income by Medi-Cal income
eligibility standards in 2013. Up to 60 percent of
Californians eligible for DACA and up to 56 percent of those
eligible for DAPA were low-income, lacked health insurance,
and are predicted to be eligible for Medi-Cal under state
policy if granted relief (as previously indicated, individuals
granted deferred action are eligible for full-scope Medi-Cal).
The Policy Brief indicates that between 360,000 and 500,000
Californians in need of health insurance could be eligible for
comprehensive Medi-Cal if between 50 and 70 percent of
Californians eligible for DACA or DAPA are granted deferred
action.
3.Prior legislation. SB 1005 (Lara), was similar to this bill,
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except SB 1005 would have provided the same amount of premium
and cost-sharing subsidies as individuals receive in Covered
California, using state funds instead of federal funds. In
addition, SB 1005 did not require the state to seek a Section
1332 waiver. SB 1005 was held on the Senate Appropriations
suspense file.
SB 900 (Alquist), Chapter 659, Statutes of 2010, establishes
Covered California as an independent public entity within
state government, and requires Covered California to be
governed by a board composed of the Secretary of the Agency,
or his or her designee, and four other members appointed by
the Governor and the Legislature who meet specified criteria.
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 Covered
California and arranging for coverage under QHPs.
AB X1 1 (Perez), Chapter 3, Statutes of 2013-14 First
Extraordinary Session, implemented specified Medicaid
provisions of the ACA, including the expansion of federal
Medicaid coverage to low-income adults with incomes between 0
and 138 percent of the FPL. AB X1 1 also implemented a number
of the Medicaid ACA provisions to simplify the eligibility,
enrollment and renewal processes for Medi-Cal.
SB X1 1 (Hernandez and Steinberg), Chapter 4, Statutes of
2013-14 First Extraordinary Session, established the existing
Medi-Cal benefit package as the benefit package for the
expansion population eligible under the ACA and expanded the
Medi-Cal benefit package for the existing population and newly
eligible under the ACA to include mental health services and
substance use disorder services required under the essential
health benefit legislation adopted in 2012 that were not
currently covered by Medi-Cal. SB X1 1 also implemented a
number of the Medicaid ACA-related provisions to simplify the
eligibility, enrollment and renewal processes for Medi-Cal.
SB X1 1 also makes recent immigrant childless adults, who
would be eligible for Medicaid funding under the ACA except
for the five-year bar who are enrolled in Covered California
with an APTC, also eligible for Medi-Cal benefits not covered
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by their Covered California plan. For these individuals, DHCS
would be required to pay the individual's premium and
cost-sharing (referred to as a "Medi-Cal wrap"). The Medi-Cal
wrap has not yet been implemented. Until this provision is
implemented, these recent legal immigrant adults are Medi-Cal
eligible.
4.Support. This bill is supported by individuals, low-income,
labor, consumer, health care providers, immigrant, religious,
and community groups who write the "Health For All Act" will
address a critical need facing the state's large immigrant
communities by expanding access to health care coverage for
all Californians, regardless of immigration status. Supporters
argue an estimated 1.5 million Californians will remain
uninsured who are not eligible for coverage due to immigration
status following the implementation of the ACA, and these
individuals cannot even use their own money to buy health
insurance in Covered California. Supporters argue the
prolonged and continued exclusion of undocumented immigrants,
who contribute greatly to the state's economy, from federal
and state health programs is contrary to the long held
American value of fairness and equal opportunity for
integration, as well as promoting the health and well-being of
everyone in society. Supporters argue it does not reflect the
state's values or serve the common good to leave hundreds of
thousands of workers, students, and family members without
treatment for preventable ailments. Proponents state that, in
many cases, health problems that could have been avoided with
preventive care or treated early for little cost become
significant and costly health issues, resulting in lost
productivity, increased demand on emergency services, and
increased costs in the health care system. Supporters argue
denying immigrants access to health care simply because of
their immigration status is counter intuitive in ensuring the
state has healthy residents and a healthy workforce, and this
bill will ensure that everyone in the state has access to
quality, affordable health care.
5.Amendments. This bill permits the change from limited scope to
full scope Medi-Cal benefits to be implemented initially via
policy letters or similar instructions and subsequently
requires regulations to be adopted by July 1, 2018. Similar
authority may need to be provided to DHCS to implement the
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Medi-Cal transition plan provisions of this bill.
This bill is intended to establish a "California QHP" that
would meet the same requirements as a QHP and which would be
offered to people in the Program. Amendments are needed to
distinguish between the two different types of QHP. In
addition, the Program established by this bill is generally
modeled on the Covered California statute, but differs in
several instances related to recently enacted legislation
affecting Covered California that need clarifying.
SUPPORT AND OPPOSITION :
Support:
ACCESS Women's Health Justice
ACT for Women and Girls
Advancement Project
Advancing Justice - Asian Law Caucus
AltaMed Health Services Corporation
American Academy of Pediatrics
American Civil Liberties Union of California
Asian Americans Advancing Justice Sacramento
Asian Health Services
ASPIRE Los Angeles
California Alliance of Retired Americans
California Asian Pacific Islander Budget Partnership
California Chapter National Association of Social Workers
California Chapter National Council of Jewish Women
California Communities United Institute
California Coverage and Health Initiatives
California Immigrant Policy Center
California Family Health Council
California Family Resource Association
California Labor Federation
California Latinas for Reproductive Justice
California Lesbian, Gay, Bisexual, and Transgender Health and
Human Services Network
California Nurse-Midwife Association
California Nurses Association
California Pan-Ethnic Health Network
California Partnership
California Primary Care Association
California Program of All-Inclusive Care for the Elderly
California Rural Legal Assistance Foundation
California School-Based Health Alliance
California State Council of the Service Employees International
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Union
Cal-Islanders Humanitarian Association
Campaign for a Healthy California
Children's Defense Fund California
Clínica Monseñor Oscar A. Romero
Community Clinic Consortium
Congregations Building Community
Consumers Union
Council of Mexican Federations
Educators for Fair Consideration
Friends Committee on Legislation of California
Gray Panthers of San Francisco
Having Our Say Coalition
Health Access
Korean Resource Center
La Familia Family Counseling Center, Inc.
Latino Coalition for a Healthy California
Mexican American Legal Defense and Educational Fund
National Council of La Raza
National Health Law Program
National Immigration Law Center
Orange County Immigrant Youth United
Planned Parenthood Affiliates of California
Planned Parenthood Mar Monte
Sacramento Covered
St. Anthony Foundation
St. John's Well Child & Family Center
The Children's Partnership
United Christian Centers of the Greater Sacramento Area, Inc.
United Domestic Workers/AFSCME Local 3930
United Way Silicon Valley
United Ways of California
Western Center on Law & Poverty
Young Invincibles
Oppose: None received
-- END --
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