BILL ANALYSIS                                                                                                                                                                                                    Ó




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          |SENATE RULES COMMITTEE            |                        SB 997|
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                                   THIRD READING 


          Bill No:  SB 997
          Author:   Lara (D) 
          Amended:  5/31/16  
          Vote:     21 

           SENATE HEALTH COMMITTEE:  7-1, 4/13/16
           AYES:  Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
           NOES:  Nielsen
           NO VOTE RECORDED:  Nguyen

           SENATE APPROPRIATIONS COMMITTEE:  5-2, 5/27/16
           AYES: Lara, Beall, Hill, McGuire, Mendoza
           NOES: Bates, Nielsen

           SUBJECT:   Health care coverage:  immigration status


          SOURCE:    Health Access California

          DIGEST:  This bill requires undocumented children eligible for  
          full-scope Medi-Cal benefits who were enrolled in a  
          comprehensive, low-cost coverage provided by Kaiser Permanente  
          (Kaiser) or a Medi-Cal managed care plan as of May 1, 2016 to be  
          enrolled in full-scope Medi-Cal with Kaiser or their Medi-Cal  
          managed care plan if the undocumented child is determined  
          eligible for full-scope Medi-Cal benefits.

          ANALYSIS:
          
          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  








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            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. (Full scope Medi-Cal coverage for  
            undocumented children began in May 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  
            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)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 or a Medi-Cal managed care plan as  
            of May 1, 2016 to be enrolled in full-scope Medi-Cal with  








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            Kaiser or their Medi-Cal managed care if the undocumented  
            child is determined eligible for full-scope Medi-Cal benefits,  
            notwithstanding any other law.

          2)Requires DHCS, using information provided to it by health  
            plans, 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 in  
               Kaiser 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 DHCS-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  








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               change his or her health plan and primary care provider;  
               and,
             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.

          4)Requires Kaiser, Medi-Cal managed care plans, and their  
            designees to work with DHCS and its designees to facilitate  
            continuity of care and data sharing to the extent permissible  
            by state and federal law for purposes of implementing this  
            bill.

          5)Limits the application of this bill only to an enrollee in a  
            service area of Kaiser or the Medi-Cal managed care as of the  
            effective date of this bill.

          6)Sunsets the provisions of this bill on January 1, 2019.

          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  
            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. 








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          2)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. 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); 
             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; and, 
             e)   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 (Committee on Budget and Fiscal  
               Review, Chapter 18, Statutes of 2015).

            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). 

          3)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. 








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            Under Medi-Cal managed care, Medi-Cal beneficiaries generally  
            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 Medi-Cal 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.



          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No


          According to the Senate Appropriations Committee:
           
          1)Likely one-time administrative costs of about $1 million for  
            DHCS to coordinate with health plans and determine Medi-Cal  
            eligibility for current low-cost coverage enrollees (General  
            Fund [GF]). DHCS will need to collect information from health  
            plans about their current low-cost coverage enrollees who are  
            likely to gain full-scope Medi-Cal eligibility, determine  
            eligibility for those individuals, and set up a special  
            process for those individuals to be directly enrolled with the  
            same health plan under full scope Medi-Cal. Because this is  
            not the normal process for determining Medi-Cal eligibility  
            and assigning enrollees to a Medi-Cal managed health plan,  
            there will be additional workload for DHCS. (Because  
            undocumented immigrants are generally not eligible for federal  
            financial participation, all costs will be GF costs.)

          2)Likely increased Medi-Cal costs in the millions per year due  
            to increased enrollment in Medi-Cal under the bill (General  
            Fund). Under current law, undocumented immigrants under 19  
            years of age will be eligible for full-scope Medi-Cal on or  
            after May 1, 2016. The undocumented children who are the  
            subject of this bill will soon become eligible for full scope  








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            Medi-Cal. However, without the bill, those children's' parents  
            will need to enroll them in Medi-Cal through the normal  
            application process. Given that these children are already  
            enrolled in health care coverage (often with a modest monthly  
            fee per child), it is likely that a high percentage of these  
            children's' parents will enroll them in Medi-Cal. However,  
            there is likely to be a small share of the current population  
            that will not enroll in Medi-Cal through the normal enrollment  
            process. Under the bill, the streamlined enrollment into  
            Medi-Cal is likely to reduce the number of individuals who  
            would lose coverage during the transition. For example, if 10%  
            of current program participants would not have transitioned to  
            Medi-Cal coverage without the bill and the bill reduces that  
            share to 5% losing coverage, the state cost for that  
            additional Medi-Cal coverage would be about $7 million per  
            year.


          SUPPORT:   (Verified5/31/16)


          Health Access California (source) 
          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 


          OPPOSITION:   (Verified5/31/16)


          California Association of Health Plans 
          California Coverage & Health Initiatives








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          Community Health Initiative Napa County
          Give for a Smile
          Community Health Initiative of Orange County

          ARGUMENTS IN SUPPORT: This bill is sponsored by Health Access  
          California (HAC) so that undocumented children who currently  
          have coverage through the Kaiser's CHP or a Medi-Cal managed  
          care plan can more easily stay with their current plan if they  
          chose to. This bill will help make it easier for children to  
          remain with Kaiser or their Medi-Cal managed care plan when they  
          transition to full-scope Medi-Cal. HAC argues these families  
          should not face unnecessary barriers to keep their children with  
          their current plan, 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 subcontractor of another Medi-Cal  
          managed care plan in most counties, 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.

          ARGUMENTS IN 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  








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          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 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.



          Prepared by:Scott Bain / HEALTH /
                                  5/31/16 20:45:32