BILL ANALYSIS                                                                                                                                                                                                    Ó

                                                                       SB 4

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          Date of Hearing:  September 9, 2015

                            ASSEMBLY COMMITTEE ON HEALTH

                                  Rob Bonta, Chair

          4 (Lara) - As Amended September 4, 2015

          SENATE VOTE:  Not relevant

          SUBJECT:  Health care coverage: immigration status.

          SUMMARY:  Requires children enrolled in restricted scope  
          Medi-Cal be enrolled in full-scope Medi-Cal if otherwise  
          eligible when 2015 Budget bill language making undocumented  
          children under the age of 19 eligible for full-scope Medi-Cal  
          benefits is implemented.  Specifically, this bill:  

          1)Requires, when 2015 Budget bill language is implemented to  
            make undocumented children under the age of 19 eligible for  
            full scope Medi-Cal benefits, that children enrolled in  
            restricted scope Medi-Cal at that time to be enrolled in full  
            scope Medi-Cal if otherwise eligible, pursuant to an  
            eligibility and enrollment plan.

          2)Requires the eligibility and enrollment plan to include  
            outreach strategies developed by the Department of Health Care  
            Services (DHCS) in consultation with stakeholders including,  
            but not limited to, counties, health care service plans,  
            consumer advocates, and the Legislature.


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          3)Requires an individual made eligible for full-scope Medi-Cal  
            under these provisions to enroll in a Medi-Cal managed care  
            (MCMC) plan if the individual would otherwise have been  
            required to enroll in the plan.

          4)Specifies that enrollment in a MCMC health plan does not  
            preclude a beneficiary from being enrolled in any other  
            children's Medi-Cal specialty program that he or she would  
            otherwise be eligible for.

          5)Requires DHCS to seek any necessary federal approvals to  
            obtain federal financial participation (FFP) in implementing  
            these provisions, and requires benefits for services under  
            these provisions to be provided with state-only funds only if  
            federal financial participation is not available for those  

          6)Requires DHCS to implement these provisions by means of  
            all-county letters, plan letters, plan or provider bulletins,  
            or similar instructions until the time any necessary  
            regulations are adopted.

          7)Requires DHCS, commencing six months after the effective date  
            of these provisions, to provide a status report to the  
            Legislature on a semiannual basis, until regulations have been  

          8)Allows DHCS, in implementing these provisions, to contract as  
            necessary on a bid, or nonbid basis.



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          1)Establishes the Medi-Cal program, administered by DHCS, under  
            which low income individuals are eligible for health care  

          2)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.  These services are referred to as  
            limited-scope Medi-Cal services.

          3)Expands, through the 2015-16 Health Budget trailer bill,  
            full-scope Medi-Cal coverage to children, regardless of  
            immigration status, who currently would be eligible for  
            Medi-Cal if not for immigration status, beginning when DHCS  
            declares that systems are ready for implementation, but no  
            sooner than May 1, 2016.  Requires children eligible in this  
            category to enroll in MCMC in those counties in which a  
            managed care plan is available.  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.


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          EXISTING FEDERAL LAW 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.  

          FISCAL EFFECT:  According to the Assembly Appropriations  
          Committee, negligible increased costs associated with a 30-day  
          timeline to transition children to full-scope Medi-Cal.  The  
          2015-16 Budget assumed transition by June 1, 2016.


          1)PURPOSE OF THIS BILL.  According to the author, 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.  The author  
            also notes that the Legislature and the Governor, through the  
            enactment of the Budget Act of 2015 (SB 97 (Committee on  
            Budget and Fiscal Review), Chapter 11, Statutes of 2015)  
            expanded Medi-Cal eligibility for children under the age of  
            19, regardless of immigration status, to ensure that no child  
            in California who is income-eligible will be denied access to  
            health care coverage.  These provisions are slated to go into  
            effect some time on or after May 1, 2016.  This bill will make  
            certain that children currently eligible for limited scope  
            Medi-Cal are quickly transitioned to full-scope Medi-Cal.    
            The author concludes, we've made enormous strides to reduce  
            California's uninsured population with the implementation of  
            the Patient Protection and Affordable Care Act (ACA), but only  
            when we include everyone can we have a truly healthy  



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             a)   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 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.  

             b)   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. President Obama also announced an  
               expansion of the Deferred Action for Childhood Arrivals  
               program for undocumented 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  


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               action status.  These actions are expected to affect up to  
               4.4 million people, according to DHS.

             c)   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. 
          3)SUPPORT.  Health Access California supports this bill as it is  
            proposed to be amended because it would assure that kids do  
            not need to reapply to transition from restricted scope  
            Medi-Cal to full scope and kids who would not be in MCMC if  
            they were citizens or lawful residents will not be required to  
            enroll in Managed care.  The National Immigration Law Center  
            (NILC) states, individuals and communities suffer when people  
            are uninsured.  NILC notes, the uninsured are more likely to  
            be diagnosed with cancer at an advanced state, to die after a  
            heart attack or accident, and to suffer poor outcomes from a  
            stroke.  NILC concludes we are all better off when everyone  
            has access to health insurance.  The Western Center on Law and  
            Poverty supports this bill, noting as California leads the way  
            in implementing the ACA, providing comprehensive health  
            coverage for undocumented children is just the humane thing to  

          4)OPPOSITION.  We the People Rising opposes a previous version  
            of this bill, stating that U.S. Veterans and their children,  
            children in foster care, homeless families, and the unemployed  
            should be the focus of legislation in Sacramento - not  


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            individuals residing unlawfully in California.

          5)RELATED LEGISLATION.  SB 10 (Lara) was recently amended to  
            make 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.  SB 10 is  
            currently pending a hearing in the Assembly Judiciary  
            Committee; however SB 10  will most likely be re-referred to  
            Assembly Health Committee.


             a)   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 Covered California.  SB 1005 would have required  
               Covered California, by January 1, 2016, to facilitate the  
               enrollment of individuals who would have been eligible to  
               purchase coverage through Covered California 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.

             b)   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 California Health and Human Services Agency,  
               or his or her designee, and four other members appointed by  
               the Governor and the Legislature who meet specified  


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             c)   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  
               qualified health plans. 

             d)   AB X1 1 (John A. Pérez), 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% of the federal poverty level. AB X1 1 also  
               implemented a number of the Medicaid ACA provisions to  
               simplify the eligibility, enrollment and renewal processes  
               for Medi-Cal.

             e)   SB X1 1 (Ed 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 and also made  
               recent immigrant childless adults, who would be eligible  
               for Medicaid funding under the ACA except for the five-year  


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               bar who are enrolled in Covered California with an Advanced  
               Premium. Tax Credit, eligible for Medi-Cal benefits not  
               covered 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 it is, these recent legal immigrant adults are  
               Medi-Cal eligible.

          7)TECHNICAL AMENDMENTS.   The author is proposing technical and  
            clarifying amendments which will: 
             a)   Clarify that kids currently enrolled in restricted scope  
               emergency Medi-Cal will not be required to submit a new  
               application when they transition to full-scope coverage.

             b)   Ensure that kids currently enrolled in restricted scope  
               emergency Medi-Cal will be transferred to full scope  
               services immediately, as soon the program is operational  
               (May 1, 2016).

             c)   Require DHCS to provide monthly updates to the  
               appropriate policy and fiscal committees of the Legislature  
               on the status of the implementation of these provisions.


          Support (previous version)


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          Advancement Project
          AIDS Project Los Angeles
          Alliance for Boys and Men of Color

          Alliance of Catholic Healthcare
          American Civil Liberties Union of California

          American Federation of State, County and

            Municipal Employees

          Anti-Defamation League

          Asian Americans Advancing Justice


          Asian Law Alliance

          ASPIRE Los Angeles

          California Alliance of Retired Americans

          California Asian Pacific Islander Budget



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          California Association of Public Hospitals and

            Health Systems

          California Black Health Network

          California Chapter of the American College of

            Emergency Physicians

          California Communities United Institute

          California Coverage and Health Initiatives 
          California Faculty Association

          California Family Health Council

          California Family Resource Association

          California Healthy Nail Collaborative

          California Immigrant Policy Center
          California Labor Federation

          California Latinas for Reproductive Justice


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          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 
          Campaign for a Healthy California

          Central California Alliance for Health

          Center for Empowering Refugees and



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          Children Now 
          Children's Defense Fund California 
          Children's Partnership
          Coalition for Humane Immigrant Rights of

            Los Angeles

          Community Action Fund of Planned

            Parenthood of Orange and

            San Bernardino Counties

          Community Clinic Association of

            Los Angeles County

          Community Health Partnership

          Consumers Union

          Equality California
          Friends Committee on Legislation of California

          Health Access 
          Health Care for All - Contra Costa County


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          HOPE (Hispanas Organized for Political


          Instituto Familiar de la Raza, Inc.

          Korean Resource Center

          Lutheran Office of Public Policy, California
          March of Dimes California
          Mexican American Legal Defense and

            Educational Fund

          National Association of Social Workers,

            California Chapter

          National Health Law Program

          National Immigrant Law Center
          Pacific Asian Counseling Service

          PICO California

          Planned Parenthood Action Fund of Santa


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            Barbara, Ventura and San Luis Obispo


          Planned Parenthood Action Fund of the Pacific


          Planned Parenthood Advocacy Project

            Los Angeles County

          Planned Parenthood Affiliates of California

          Planned Parenthood Pasadena and

            San Gabriel Valley

          Planned Parenthood Northern California

            Action Fund

          Planned Parenthood Mar Monte

          San Francisco Community Clinic Consortium


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          Santa Cruz Women's Health Center

          St. Anthony Foundation

          St. John's Well Child & Family Center

          San Francisco Bay Area Physicians for Social


          United Domestic Workers/AFSCME

            Local 3930

          United Ways of California
          Western Center on Law and Poverty
          Young Invincibles


          Opposition (previous version)

          We The People Rising


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          Analysis Prepared by:Lara Flynn / HEALTH / (916)