BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 4|
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THIRD READING
Bill No: SB 4
Author: Lara (D), et al.
Amended: 6/1/15
Vote: 21
SENATE HEALTH COMMITTEE: 7-0, 4/15/15
AYES: Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
NO VOTE RECORDED: Nguyen, Nielsen
SENATE APPROPRIATIONS COMMITTEE: 5-2, 5/28/15
AYES: Lara, Beall, Hill, Leyva, Mendoza
NOES: Bates, Nielsen
SUBJECT: Health care coverage: immigration status
SOURCE: Author
DIGEST: This bill extends eligibility for full-scope Medi-Cal
benefits to individuals under age 19 who are otherwise eligible
for those benefits but for their immigration status. Extends
Medi -Cal eligibility for full-scope Medi-Cal benefits to
individuals age 19 and older if sufficient funding is available,
and grants the Department of Health Care Services the authority
to determine the number of individuals who may be enrolled.
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 (QHPs).
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ANALYSIS:
Existing 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.
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:
1) Makes individuals under age 19 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.
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2) Requires counties, for individuals age 19 and older who
meet Medi-Cal eligibility requirements except for their
immigration status, to transmit this information to DHCS to
determine if sufficient funding is available for the
individual to receive full-scope Medi-Cal benefits.
Requires, if sufficient funding is available, the individual
to be eligible for full-scope benefits, and if sufficient
funding is not available, the individual to be eligible for
limited scope Medi-Cal benefits.
3) Prohibits eligibility for full scope Medi-Cal benefits for
individuals age 19 and older who meet Medi-Cal eligibility
requirements except for their immigration status from being
an entitlement. Grants DHCS the authority to determine
eligibility, determine the number of individuals who may be
enrolled, establish limits on the number of individuals who
may be enrolled, and establish processes for waiting lists
needed to maintain program expenditures within available
funds.
4) Requires individuals eligible for full scope Medi-Cal
benefits under this bill to enroll in 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.
5) 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.
6) Requires that individuals under age 19 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 individuals
under age 19 who are 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
these individuals may choose any available Medi-Cal managed
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care plan and primary care provider.
7) 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.
8) 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.
9) 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.
10) Makes the above-described Section 1332 waiver-related
provisions operative upon federal approval of the waiver.
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 children that qualify for Medi-Cal based on
income level, this bill would allow children to enroll in
Medi-Cal, and would create a capped enrollment program to
extend coverage to undocumented adults with sufficient funding
is available. Expanding access to health care will make a real
difference in the lives of thousands of hard working
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Californian families. The author states the state has 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
undocumented individuals at a total funds cost of $1.4 billion
($690 million General Fund).
3)Covered California and the individual market. Undocumented
immigrants are prohibited from purchasing coverage in Covered
California under federal law. Because federal advance premium
tax credits 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.
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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;
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
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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
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.
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FISCAL EFFECT: Appropriation: Yes Fiscal
Com.: Yes Local: Yes
According to the Senate Appropriations Committee, the fiscal
estimates below are subject to a great deal of uncertainty. The
rates at which undocumented immigrants are likely to apply for
either Medi-Cal or unsubsidized coverage are unknown at this
time and are likely to be heavily influenced by concerns over
coming to the attention of immigration authorities and language
barriers. In addition, the age and health status of those who
ultimately would enroll in Medi-Cal will have a significant
impact on the costs to provide coverage. At this time, there is
limited information available to accurately project the cost to
provide coverage to this population. Finally, a pending
executive action by the President Obama would shield about half
of California's undocumented immigrant population from
deportation. If that executive action stands, those individuals
would be eligible for full-scope Medi-Cal coverage under current
law.
The costs for the Medi-Cal expansion below reflect two
scenarios. The first scenario does not assume that the courts
uphold the President's Executive Action and therefore the
state's current undocumented population remains the same. The
second scenario assumes that the courts uphold the President's
Executive Action, which would make a significant number of
undocumented immigrants eligible for full scope Medi-Cal under
current law. This would significantly reduce the undocumented
population who would be made eligible for full scope Medi-Cal
under this bill.
Increased Medi-Cal costs for children without the President's
Executive Action. Likely annual increase in Medi-Cal spending
between $7 million and $135 million per year (General Fund).
Under current law, undocumented immigrants are eligible for
limited scope Medi-Cal benefits such as Emergency Medi-Cal and
Pregnancy-Only Medi-Cal. Under current practice, the federal
government provides funding for those services both in the
fee-for-service system and for undocumented immigrants who are
enrolled in managed care. Based on current practice, about 60
percent of Medi-Cal managed care costs for individuals covered
by this bill would be eligible for federal matching funds
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(i.e. about 60 percent of Medi-Cal managed care costs for
immigrants are for services such as emergency services and
pregnancy-related services). This analysis assumes that on the
low end about 50 percent of eligible undocumented immigrants
under age 19 would enroll in Medi-Cal under the bill - which
is roughly the number of undocumented immigrants under age 19,
on average, who access emergency- or pregnancy-related
Medi-Cal services each year. On the high end, this analysis
assumes that about 60 percent of eligible individuals under
age 19 enroll in Medi-Cal - which is equal to the
pre-Affordable Care Act enrollment rate for Medi-Cal eligible
individuals in the state.
The costs above reflect the annual cost to provide full-scope
Medi-Cal coverage to the enrolling individuals, accounting for
available federal matching funds, less the current state
spending to provide limited scope Medi-Cal services, as the
state is already incurring those costs. The analysis assumes
that the per member per month cost to provide coverage to
children will be similar to such costs for the existing
Medi-Cal population.
The analysis also assumes that there will be reductions in
state spending on certain state-only health care programs
(such as FamilyPACT and the Every Woman Counts programs) due
to undocumented immigrants currently receiving services from
those programs shifting to full-scope Medi-Cal coverage.
Finally, by shifting individuals from fee-for-service Medi-Cal
into Medi-Cal managed care and enrolling additional
individuals in managed care, the state will receive additional
tax revenue under the Managed Care Organization Tax.
Increased Medi-Cal costs for children under the President's
Executive Action. Likely increase in Medi-Cal spending between
$4 million and $83 million per year (General Fund). Based on
estimates by the Pew Research Center, the pending Executive
Action would protect about 900,000 of the state's 2.5 million
undocumented immigrants from deportation. Under current law,
those individuals would be eligible for full-scope Medi-Cal.
Thus, the cost to provide coverage to those individuals would
not be attributable to this bill. The costs above reflect the
projected cost to provide full-scope Medi-Cal to the remaining
income-eligible undocumented population under 19 years of age
who would not be protected from deportation (assuming similar
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enrollment rates as discussed above).
Unknown costs to provide full-scope Medi-Cal benefits to
undocumented adults (General Fund). Under the amendments, DHCS
would be authorized to enroll adults who would otherwise be
eligible for Medi-Cal, but for their immigration status, if
sufficient funding is available. In practice, DHCS would be
authorized to enroll adults into full scope Medi-Cal based on
the funding that is provided in the annual Budget Act, similar
to previous state health care programs such as MRMIP and PCIP.
Unknown, but potentially significant savings to the state
under realignment (General Fund). Under current law, the state
has set up a system to direct funds from the counties to the
state, under the premise that expansion of Medi-Cal will
reduce county expenditures for health care services to the
uninsured. This process is generally governed by formulas that
take into account historic and actual expenses by the
counties. Under the system, there is a maximum amount of
funding that can be redirected to the state. By expanding
Medi-Cal coverage, this bill will further reduce county health
care expenditures (in counties that are currently providing
health care services to the undocumented) and should increase
redirected funding to the state. The size of this impact is
unknown and would depend on enrollment in Medi-Cal, actual
reductions in county spending, and the amount of additional
redirections that would be allowed under the current system.
Annual, fee-supported costs in the tens of millions per year
to provide coverage through Covered California (special fund).
The bill authorizes undocumented immigrants to purchase health
care coverage, without subsidy, through Covered California or
a parallel exchange. Individuals who purchase such coverage
would pay for the administrative costs of the Exchange, via a
participation fee that Covered California assesses on
qualified health plans. Because coverage through Covered
California would be unsubsidized and because undocumented
immigrants tend to be low-income, enrollment rates through
Covered California are not likely to be high. If 20% of
undocumented immigrants who are not income eligible for
Medi-Cal enroll through Covered California, the administrative
costs and the fees collected to pay those costs would be about
$25 million per year.
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SUPPORT: Verified (5/27/15)
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 Association of Public Hospitals and Health Systems
California Black Health Network
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 Employees Association
California School-Based Health Alliance
California State Council of the Service Employees International
Union
California Teachers Association
Cal-Islanders Humanitarian Association
Campaign for a Healthy California
Children's Defense Fund California
Clínica Monseñor Oscar A. Romero
Community Clinic Consortium
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Congregations Building Community
Consumers Union
Council of Mexican Federations
Educators for Fair Consideration
Equality California
Friends Committee on Legislation of California
Gray Panthers of San Francisco
Greenlining Institute
Having Our Say Coalition
Health Access
HOPE (Hispanas Organized for Political Equality)
Insurance Commissioner Dave Jones
Korean Resource Center
La Familia Family Counseling Center, Inc.
Latino Coalition for a Healthy California
Mexican American Legal Defense and Educational Fund
March of Dimes Foundation
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
San Francisco Bay Area Physicians for Social Responsibility
SEIU California
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
OPPOSITION: Verified (5/27/15)
None received
Prepared by:Scott Bain / HEALTH /
6/1/15 19:05:03
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