BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 997
---------------------------------------------------------------
|AUTHOR: |Lara |
|---------------+-----------------------------------------------|
|VERSION: |April 6, 2016 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |April 13, 2016 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Scott Bain |
---------------------------------------------------------------
SUBJECT : Health care coverage: immigration status
SUMMARY :1. Requires undocumented children eligible for full-scope
Medi-Cal benefits who were enrolled in comprehensive, low-cost
coverage provided by a Kaiser Permanente (Kaiser) as of May 1,
2016 to be enrolled in full-scope Medi-Cal with Kaiser if the
undocumented child is determined eligible for full-scope
Medi-Cal benefits, in order to maximize continuity of care and
coverage.
Existing law:
1)Establishes the Medi-Cal program, which is administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
Medi-Cal provides coverage to children in families with
incomes up to 266% of the federal poverty level (FPL (266% of
the FPL is at or below $53,626 for a family of 3 in 2016).
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
have been programmed for implementation, but in no case sooner
than May 1, 2016.
3)Requires that individuals under 19 years of age enrolled in
limited scope Medi-Cal at the time the DHCS director makes the
determination to be enrolled in the full scope of Medi-Cal
benefits, if otherwise eligible, pursuant to an eligibility
and enrollment plan. Prohibits these individuals from being
required to file a new application for Medi-Cal.
4)Requires an undocumented child eligible for full scope
SB 997 (Lara) Page 2 of ?
coverage to enroll in a Medi-Cal managed care health plan to
the extent permitted by state and federal law. Prohibits
enrollment in a Medi-Cal managed care health plan from
precluding a beneficiary from being enrolled in any other
children's Medi-Cal specialty program for which he or she
would otherwise be eligible.
5)Prohibits, through regulation, Medi-Cal managed care plan
representatives from contacting prospective members for the
purposes of marketing, except in cases where the contact is
initiated by the prospective member, unless that contact is
approved in writing by and coordinated through DHCS.
6)Requires, at the time of determining or redetermining the
eligibility of a Medi-Cal program applicant or beneficiary who
resides in an area served by a managed health care plan or
pilot program in which beneficiaries may enroll, each
applicant or beneficiary to be informed of the managed care
and fee-for-service options available regarding methods of
receiving Medi-Cal benefits. This is referred to as the
"health care options" process.
This bill:
1)Requires, in order to maximize continuity of care and
coverage, undocumented children eligible for full-scope
Medi-Cal benefits who were enrolled in comprehensive, low-cost
coverage provided by Kaiser as of May 1, 2016 to be enrolled
in full-scope Medi-Cal with Kaiser if the undocumented child
is determined eligible for full-scope Medi-Cal benefits,
notwithstanding any other law or existing Medi-Cal managed
care contract.
2)Requires Kaiser to provide the following information to the
child's representative:
a) How the child may be determined eligible for full-scope
Medi-Cal benefits;
b) How the child enrolled in Kaiser as of May 1, 2016 may
remain enrolled with Kaiser, if the child's representative
chooses; and,
c) How the child may obtain coverage from another Medi- Cal
managed care health plan contracting with DHCS, or through
fee-for-service Medi-Cal, consistent with law.
SB 997 (Lara) Page 3 of ?
1)Requires the information in 2) to be provided to be provided
in a fair and accurate manner consistent with the regulations
adopted by the California Health Benefit Exchange for the
regulation of certified plan-based enrollers (these
regulations establish requirements for plan employees
enrolling people in Covered California, and require the
plan-based enroller to provide a choice of plans).
2)Requires DHCS, using its third-party liability database, to
determine whether prior to May 1, 2016, an undocumented child
who is eligible for full-scope Medi-Cal benefits was enrolled
in Kaiser coverage.
3)Requires DHCS, before the child's transition to full-scope
Medi-Cal, to provide the child's representative with timely,
linguistically appropriate notice of the transition. Requires
the notice to contain all of the following information:
a) Which Medi-Cal managed care plan or plans contain the
child's existing primary care provider in those counties in
which the health plan does not directly contract as a
Medi-Cal managed care health plan with DHCS;
b) That the child, subject to his or her ability to change
his or her health plan (as described below), will be
assigned to his or her existing health plan if enrolled in
full-scope Medi-Cal benefits after May 1, 2016, and that if
the child wants to keep his or her primary care provider,
no additional action will be required;
c) That if the child's existing primary care provider is
not contracted with any Medi-Cal managed care plan in the
enrollee's county of residence or if the enrollee's
existing health plan is not an available Medi-Cal managed
care plan in the child's county of residence, he or she
will receive all provider and health plan information
required to be sent to new enrollees. If the child does not
affirmatively select one of the available Medi-Cal managed
care plans within 30 days of receipt of the notice, he or
she will automatically be assigned a plan through the
department-prescribed auto-assignment process;
d) That the child may choose any available Medi-Cal managed
care plan and primary care provider in his or her county of
residence, if more than one such plan is available in the
county where he or she resides, and he or she will receive
all provider and health plan information required to be
sent to new enrollees and instructions on how to choose or
SB 997 (Lara) Page 4 of ?
change his or her health plan and primary care provider;
e) That the child does not need to take any action to
retain his or her health plan and primary care provider if
he or she is enrolled in full-scope Medi-Cal benefits;
f) That the child may choose not to transition into the
Medi-Cal program, and what this choice will mean for his or
her health care coverage and access to health care
services; and,
g) That in counties where no Medi-Cal managed care health
plans are available, the child will be transitioned into
fee-for-service Medi-Cal, and provided with all information
that is required to be sent to new Medi-Cal enrollees,
including the assistance telephone number for
fee-for-service beneficiaries, and that, if a Medi-Cal
managed care health plan becomes available in the residence
county, he or she will be enrolled in a Medi-Cal managed
care health plan according to the enrollment procedures in
place at that time.
1)Requires Kaiser and its designees to work with DHCS and its
designees to facilitate continuity of care and data sharing
for the purposes of delivering Medi-Cal services.
2)Limits the application of this bill only to an enrollee in a
service area of Kaiser approved as of January 1, 2017.
3)Sunsets the provisions of this bill on January 1, 2019.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, last year's
historic enactment of Health4All Kids, allows all low-income
California children, regardless of immigration status, to
enroll in Medi-Cal. Starting in May, all income-eligible
children will have access to comprehensive, zero-cost or
low-cost Medi-Cal benefits, including dental and mental health
coverage as well as the full array of health benefits
(doctors, hospitals, prescription drugs, and more). Currently,
over 120,000 undocumented children are enrolled in restricted
scope, emergency-only Medi-Cal and an additional 64,000
undocumented children have comprehensive health coverage
through Kaiser Permanente. That coverage was provided well
SB 997 (Lara) Page 5 of ?
before the passage of Health4All Kids, when families with
undocumented children had very limited options for health
care. The children on restricted scope Medi-Cal will be
automatically shifted to full-scope Medi-Cal when Health4All
Kids is implemented in May 2016. Families will have an option
to select a health plan, or transition directly into a default
coverage option. This bill will ensure a seamless transition
to full-scope Medi-Cal coverage for eligible children who were
already enrolled in a comprehensive, low-cost health plan
prior to the enactment of Health4All Kids.
2)Change in scope of Medi-Cal coverage for undocumented
children. 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. Last year, SB 4 (Lara) was introduced to extend
eligibility for full-scope Medi-Cal benefits to adults and
children who are otherwise eligible for those benefits but for
their immigration status. The health budget trailer bill of
2015, SB 75 (Committee on Budget and Fiscal Review, Chapter
18, Statutes of 2015), extended full scope Medi-Cal
eligibility to all children who meet income eligibility
requirements, regardless of immigration status.
The Governor's proposed 2016-17 budget assumes implementation of
full scope coverage begins March 1, 2016, and that there are
170,000 undocumented children under the age of 19 who are
eligible for Medi-Cal, of whom 114,981 are currently enrolled
in restricted scope Medi-Cal. DHCS estimates the restricted
scope Medi-Cal children will transition to full-scope coverage
in May 2016, and 50% of the remaining 55,019 undocumented
children will take up coverage over 12 months. The Governor's
Budget assumes costs of $26.2 million ($20.4 million General
Fund) in 2015-16 and $177.2 million ($142.8 million GF) in
2016-17.
3)Kaiser local coverage program for uninsured children. Kaiser
Permanente's Child Health Program (CHP) offers health coverage
to children under 19 who do not have access to health
insurance. CHP members are enrolled in the Kaiser Permanente
Platinum 90 HMO plan and receive financial help in two ways:
a) Help paying the monthly health plan payment (depending
SB 997 (Lara) Page 6 of ?
on family size and income, monthly payments are $0, $10, or
$20 per child, for up to 3 children, with additional
children are covered at no extra charge); and,
b) Coverage of out-of-pocket costs for most covered
services at Kaiser Permanente facilities.
Eligibility for CHP is for uninsured children regardless of
immigration status if they meet the following criteria:
a) Live in a Kaiser Permanente service area;
b) Are under the age of 19;
c) Live in a household with incomes up to 300% of the FPL
(for example: $60,270 for a family of 3, $72,900 for a
family of 4 per 2016 guidelines), and,
d) Do not have access to any other public or private health
coverage including, but not limited to, Medi-Cal, Medicare,
a job-based health plan or coverage through Covered
California.
Kaiser's CHP has an enrollment of approximately 64,000
children statewide, and Kaiser believes approximately 95% of
them will meet the income requirements for full scope Medi-Cal
under SB 75.
1)Medi-Cal Managed Care Models and Health Care Options Process.
When an individual applies for and initially qualifies for
Medi-Cal, they are initially covered under Medi-Cal FFS.
However, most individuals (including most children) must
mandatorily enroll in a Medi-Cal managed care plan.
Beneficiaries receive information on their plan choices
through what is known as the Health Care Option process, which
is administered by a vendor (Maximus) that contracts with
DHCS. Medi-Cal beneficiaries must choose a health plan within
30 days, and if they do not choose a plan within 30 days, a
plan is selected for them.
Under Medi-Cal managed care, Medi-Cal beneficiaries generally
SB 997 (Lara) Page 7 of ?
have a choice of at least two Medi-Cal managed care plans in
each county (except in COHS counties, which have one plan for
all beneficiaries). However, within the two-plan model and
COHS counties, Medi-Cal managed care plans subcontract with
other plans (including Kaiser). Outside of the geographic
managed care model, 79% of Kaiser's enrollment (515,911
individuals) are in Kaiser through sub-contracting
arrangements, where beneficiaries enrolled in the
subcontracting plan are considered to be enrollees of the main
contracting plan. As drafted, this bill establishes a narrow
exception to the COHS and two plan Medi-Cal managed care
contracting models that would keep undocumented children
currently enrolled with Kaiser in their current coverage so
they can maintain continuity of care and coverage.
2)Kaiser Participation in Medi-Cal Managed Care. Kaiser has
total Medi-Cal enrollment of approximately 651,000, either as
a direct contracting plan or as a subcontracting health plan.
Kaiser participates in Medi-Cal managed care as a direct
contractor in the geographic managed care model (in San Diego,
Sacramento, Placer, Amador and El Dorado counties). Kaiser
also participates in Medi-Cal by subcontracts with the
following Medi-Cal managed care plan partners (entities who
have a direct Medi-Cal managed care contract with DHCS) as a
Medi-Cal managed care provider:
a) Alameda Alliance for Health (Alameda);
b) CalOptima (Orange);
c) CalViva (Fresno, Kings, Madera)
d) Contra Costa Health Plan (Contra Costa);
e) Gold Coast Health Plan (Ventura);
f) Inland Empire Health Plan (San Bernardino and
Riverside);
SB 997 (Lara) Page 8 of ?
g) Kern Family Health Plan (Kern);
h) LA Care Health Plan (Los Angeles);
i) Partnership Health Plan (Marin, Napa, Solano, Sonoma,
Yolo)
j) San Francisco Health Plan (San Francisco);
aa) Health Plan of San Joaquin (San Joaquin)
bb) San Mateo Health Plan (San Mateo); and,
cc) Santa Clara Family Health Plan (Santa Clara)
1)State implementation plan for SB 75. DHCS has published an "SB
75 Eligibility and Enrollment Plan" for implementation of the
expansion of full scope benefits to undocumented children. For
the new enrollee population (undocumented children not
currently in limited scope Medi-Cal), DHCS does not propose
bypassing the Health Care Options process for eligible
children who already have coverage through a local children's
coverage program. For the new enrollees living in a non-county
organized health system (COHS) county, DHCS' plans to send a
Health Care Options choice packet, which provides information
about Medi-Cal Managed Care Plans in the county and their
providers. Eligible children will have 30 days to choose a
plan, and if no plan choice is made, DHCS will assign them to
a plan in their county.
Because the Medi-Cal eligibility determination process can take
up to 45 days, and the Health Care Options process follows a
determination of full scope Medi-Cal eligibility, children
transitioning from other local coverage programs (such as
Kaiser's CHP) will move from their current plan coverage to
FFS Medi-Cal and then to a Medi-Cal managed care plan (which
may be the plan they were originally in if Kaiser is an option
in their area). In areas where Kaiser is a Medi-Cal
SB 997 (Lara) Page 9 of ?
subcontracting plan, Kaiser is not clearly identified as a
plan option. For example, in San Francisco, Kaiser is
identified as "KP," which families may not identify as Kaiser.
DHCS' stated reason for this approach is children in local
coverage programs are not known to the state (they are not in
the Medi-Cal eligibility system) and they have do not know of
their eligibility for Medi-Cal or their health coverage until
they are enrolled in the program.
2)Related legislation. SB 10 (Lara) would extend full scope
Medi-Cal benefits to adults who would otherwise be eligible,
except for their immigration status. SB 10 would also create a
new health benefit exchange, to provide subsidized health care
coverage to individuals who cannot purchase health care
coverage through Covered California due to their immigration
status. SB 10 is awaiting hearing in the Assembly Health
Committee.
3)Prior legislation. SB 4 (Lara, Chapter 709 Statutes of 2015)
requires undocumented individuals who are under 19 years of
age enrolled in Medi-Cal at the time the DHCS director makes
the determination to be enrolled in full scope of Medi-Cal
benefits, if otherwise eligible, pursuant to an eligibility
and enrollment plan.
SB 75 (Committee on Budget and Fiscal Review, Chapter 18,
Statutes of 2015), the health budget trailer bill, extended
Medi-Cal eligibility to all children who meet income
eligibility requirements, regardless of immigration status,
among other provisions.
SB 1005 (Lara of 2014) would have extended full scope Medi-Cal
benefits to individuals who would otherwise be eligible,
except for their immigration status. The bill would also have
created a new health benefit exchange, to provide subsidized
health care coverage to individuals who cannot purchase health
care coverage through Covered California due to their
immigration status. SB 1005 was held on the Senate
Appropriations suspense file.
4)Support. This bill is sponsored by Health Access California
(HAC) so that undocumented children who currently have
coverage through the Kaiser's CHP can more easily stay with
Kaiser if they chose to. HAC writes that over 60,000
undocumented children have comprehensive health coverage
SB 997 (Lara) Page 10 of ?
through Kaiser. This bill will help make it easier for them to
remain with Kaiser when they transition to full-scope
Medi-Cal. HAC argues these families should not face
unnecessary barriers to keep their children with Kaiser, if
they choose to do so. While moving the kids currently in
Kaiser to Medi-Cal seems like it should be an easy thing to
do, HAC states there are a number of statutory, administrative
and logistical barriers. One of the major barriers is that
Kaiser is a direct Medi-Cal managed care contractor in the
geographic managed care model counties, while in other
counties, Kaiser is a subcontractor of another Medi-Cal
managed care plan, making it confusing for families to figure
out how to stay with Kaiser. Ensuring the undocumented
children covered by Kaiser can maintain their Kaiser coverage
is made easier for the families if there is an exception to
the current rules that govern Medi-Cal managed care will help
minimize unnecessary barriers so that the undocumented
children covered by Kaiser can more easily stay with Kaiser,
if they choose to.
5)Opposition. The California Association of Health Plans (CAHP)
writes in opposition to the previous version of this bill that
that this bill will move undocumented children from a
privately funded health insurance program into full-scope
Medi-Cal, using an approach that does not give these families
the opportunity to choose a different Medi-Cal Managed Care
Plan. CAHP believes that these kids should follow the normal
eligibility, enrollment and default process for Medi-Cal
managed care which allows for a health plan choice to be made.
CAHP concludes that one of the unintended consequences of
designating one plan for enrollment is that it appears to be
giving an exclusive direct contract for this population, which
circumvents the current procurement process.
The California Coverages & Health Initiatives (CCHI) writes in
opposition to the previous version of this bill that many
families may opt to receive their health care services from a
provider that is closer to their home, which in many cases
will not be a Kaiser facility. CCHI states that Kaiser is not
a Medi-Cal plan in 13 of the counties where Kaiser CHP
enrollees reside, meaning these children will have to travel
outside their county to reach a Kaiser Medi-Cal provider. CCHI
states that many children enrolled in CHP will already be
enrolled in restricted scope Medi-Cal by the time this bill
takes effect, or will have chosen a plan other than Kaiser
SB 997 (Lara) Page 11 of ?
Medi-Cal, which will create confusion as children will have to
switch back. CCHI concludes that the majority of children
enrolled in CHP have a sibling or parent in a Medi-Cal managed
care plan, and it would be best for families to add the child
to their family's Medi-Cal case and allow them to choose which
health plan best meets their needs.
6)Policy issues.
a) Other local children's coverage programs. In
addition to the 64,000 children enrolled in Kaiser's CHP,
a 2015 publication of the California HealthCare
Foundation identified an additional 13,111 children
enrolled in local Healthy Kids programs in 10 counties
(Los Angeles, Riverside, San Francisco, San Mateo, Santa
Barbara, Santa Clara, Santa Cruz, Solano, Ventura, and
Yolo). More recent information from the Local Health
Plans of California regarding eight of their local
initiative or county organized health system plans is
approximately 12,620 children are enrolled in their
member plans local children's coverage programs. In
addition to LHPC plans, there are additional children
enrolled in a local coverage program in Los Angeles
County. The author intends to amend this bill to include
other local coverage options in this bill.
b) How to keep children in current coverage. One of the
logistical issues in implementing this bill is how to
keep undocumented children who are currently enrolled in
Kaiser in Kaiser once these children apply for and are
determined eligible for full scope Medi-Cal coverage. The
information hurdle to overcome is these children are not
currently enrolled in Medi-Cal and their health coverage
status is not known to the state or the Health Care
Options vendor at the time of application. Under current
law, when these children apply and are determined
eligible for full-scope Medi-Cal, they would be enrolled
in fee-for-service Medi-Cal and receive a choice package
from Health Care Options telling them to pick a plan.
This bill seeks to use information about coverage in DHCS'
Third-Party Liability (TPL) database, to determine
whether prior to May 1, 2016, an undocumented child who
is eligible for full-scope Medi-Cal benefits was enrolled
in Kaiser coverage. DHCS'Third Party Liability and
SB 997 (Lara) Page 12 of ?
Recovery Division (TPLRD) is responsible for ensuring
that the Medi-Cal program complies with state and federal
laws and regulations relating to the legal liability of
third parties for health care services to beneficiaries,
and of taking all reasonable measures to ensure that the
Medi-Cal program is the payer of last resort. Under
existing law, health plans, health insurer and
self-insured plans among other entities are required to
maintain a centralized file of the subscribers',
policyholders', or enrollees' names, mailing addresses,
and social security numbers or date of birth, and where
available, for all other covered persons, the names and
social security numbers or date of birth. These entities
are required to make this information available to DHCS
upon reasonable request. DHCS uses this information to
compare to Medi-Cal beneficiaries enrolled in its MEDS
eligibility system for purposes of cost avoidance and
third party billing.
It is not clear whether having TPLRD furnish information on
children enrolled in Kaiser is a viable option for DHCS
to identify undocumented children enrolled in Kaiser as
of May 1, 2016 who are now full-scope Medi-Cal eligible
so that these children's Kaiser coverage is continued
(instead of going to FFS Medi-Cal). Another option to
using the TPL to provide this information is to require
Kaiser (and other local health coverage programs) to
furnish information on their undocumented children
enrollees to DHCS so that they could be "flagged" to
remain with their current coverage.
c) Kaiser required to contact its undocumented children
CHP enrollees directly. Current Medi-Cal regulations
prohibit Medi-Cal managed care plan representatives from
contacting prospective members for the purposes of
marketing, except in cases where the contact is initiated
by the prospective member, unless that contact is
approved in writing by and coordinated through DHCS.
These regulations require all marketing materials,
including but not limited to, all printed materials,
illustrated materials, videotaped and media scripts to be
approved in writing by DHCS prior to distribution to
members or prospective members. This bill requires the
information provided by Kaiser to include how the child
may be determined eligible for full-scope Medi-Cal
SB 997 (Lara) Page 13 of ?
benefits, how the child may remain enrolled with Kaiser
and how the child can obtain coverage from another plan.
This bill does not affirmatively require the information
provided by Kaiser to be approved by DHCS prior to its
use. To provide a consumer protection, this bill requires
this information be provided in a fair and accurate
manner consistent with the Covered California regulation
of certified plan-based enrollees. These regulations
apply to the conduct of individuals in Covered California
(not Medi-Cal), and require informing applicants about
the availability of other qualified health plan products
or dental plans available through Covered California.
d) Notice language modeled on Low Income Health Program
transition. The Low Income Health Program (LIHP)
provided, at county option, federal Medicaid funding
under the state's Section 1115 Medicaid for coverage for
low-income adults without minor children who were
ineligible for Medi-Cal prior to the implementation of
the expansion of coverage under the Affordable Care Act
in January 1, 2014. AB X1 1 (Perez, Chapter 3, Statutes
of 2013) contained notice language on the LIHP transition
as adults moved from LIHP coverage to Medi-Cal coverage
on January 1, 2014. However, the LIHP transition notices
were aimed at keeping LIHP beneficiaries with the
Medi-Cal managed care plan that contained their LIHP
primary care physician (PCP). If their PCP did not
contract with a Medi-Cal managed care plan, the
transition notice informed beneficiaries of their
options, and the default process if the beneficiary did
not pick a plan. These latter scenarios are not
applicable to the transition in this bill. Amendments are
needed to tailor the DHCS transition notice to the
specific circumstances of this transition.
e) Timing of bill. The Administration has indicated
that the expansion to full scope coverage for
undocumented children will begin May 2016. Kaiser has
indicated it will continue its CHP until the fall of this
year. In order for the change proposed by this bill to
take effect, an urgency clause is needed.
SUPPORT AND OPPOSITION :
Support: Health Access California (sponsor)
SB 997 (Lara) Page 14 of ?
American Federation of State, County and Municipal
Employees, AFL-CIO
California Chapter of the American College of
Emergency Physicians
California Black Health Network
California Immigrant Policy Collaborative
California Latinas for Reproductive Justice
California Pan Ethnic Health Network
Coalition of California Welfare Rights Organizations,
Inc.
Pre-Health Dreamers
National Immigration Law Center
Service Employees International Union of California
Vision y Compromiso
Oppose: California Association of Health Plans
California Coverage & Health Initiatives
Community Health Initiative Napa County
Give for a Smile
Community Health Initiative of Orange County
-- END --