Amended in Senate April 5, 2016

Senate Bill No. 1300

Introduced by Senator Hernandez

February 19, 2016

An act to begin delete amend Section 15926 end delete begin insert add Article 3.91 (commencing with Section 14129) to Chapter 7 of Part 3 of Division 9 end insert of the Welfare and Institutions Code, relating to begin delete health care. end delete begin insert Medi-Cal, making an appropriation therefor, and declaring the urgency thereof, to take effect immediately. end insert

LEGISLATIVE COUNSEL’S DIGEST

SB 1300, as amended, Hernandez. begin delete Health care: eligibility and enrollment. end delete begin insert Medi-Cal: emergency medical transport providers: quality assurance fee. end insert

begin insert

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes a quality assurance fee program for skilled nursing and intermediate care facilities, as prescribed.

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This bill, commencing July 1, 2017, and subject to federal approval, would impose a quality assurance fee for each transport provided by an emergency medical transport provider, as defined, subject to the quality assurance fee in accordance with a prescribed methodology. The bill would authorize the director to exempt categories of emergency medical transport providers from the quality assurance fee if necessary to obtain federal approval. The bill would require the Director of Health Care Services to deposit the collected quality assurance fee into the Medi-Cal Emergency Medical Transport Fund, which the bill would create in the State Treasury, to be continuously appropriated, thereby making an appropriation, to the department to be used exclusively in a specified order of priority to enhance federal financial participation for ambulance services under the Medi-Cal program, and to provide additional reimbursement to, and to support quality improvement efforts of, emergency medical transport providers, to pay for state administrative costs, and to provide funding for health care coverage for Californians. The bill, on or before August 15, 2016, would require each emergency medical transport provider to report to the department specified data, including data on gross receipts, as defined, from the provision of emergency medical transports, as specified, in a manner and form prescribed by the department and, commencing on October 1, 2016, and each fiscal quarter thereafter, would require each emergency medical transport provider to report this data to the department. The bill would authorize the department to establish an Internet Web site for the submission of these data reports. The bill would authorize the department to require a certification by each emergency medical transport provider, under penalty of perjury, of the truth of these data reports. By expanding the scope of the crime of perjury, the bill would impose a state-mandated local program. The bill would authorize the department, upon written notice to the emergency medical transport provider, to impose a $100 per day penalty against the provider for each day that the provider fails to make a report within 5 business days of the date upon which the data report was due. The bill would provide that the failure to make a report under these provisions within 90 days of the date upon which the report was due shall be considered a violation that relates to his or her licensed activities for purposes of a specified section of the Vehicle Code, which authorizes the Commissioner of the California Highway Patrol to suspend, revoke, or take other disciplinary action against a license if the licensee violates any section of the Vehicle Code that relates to his or her licensed activities.

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The bill, commencing July 1, 2017, and subject to federal approval, would increase the Medi-Cal reimbursement to private emergency medical transport providers for emergency medical transports, including both fee-for-service transports paid by the department and managed care transports paid by Medi-Cal managed care health plans, as specified.

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The bill would authorize the department to adopt regulations as necessary to implement these provisions, as specified.

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The bill would provide that the provisions of the bill shall cease to be implemented if any of certain conditions, including continued federal approval, are no longer satisfied.

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The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

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This bill would provide that no reimbursement is required by this act for a specified reason.

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This bill would declare that it is to take effect immediately as an urgency statute.

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Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the State’s Children’s Health Insurance Program. Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act (PPACA), and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans, and facilitating the purchase of qualified health plans through the Exchange. Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, requires the State Department of Social Services in consultation with specified entities, to establish standardized single, accessible, application forms and related renewal procedures for insurance affordability programs, as defined, in accordance with specified requirements relating to the forms and notices developed for these purposes.

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This bill would make technical, nonsubstantive changes to those provisions.

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Vote:  begin delete majority end delete begin insert ²⁄₃ end insert . Appropriation:  begin delete no end delete begin insert yes end insert . Fiscal committee:  begin delete no end delete begin insert yes end insert . State-mandated local program:  begin delete no end delete begin insert yes end insert .

The people of the State of California do enact as follows:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Article 3.91 (commencing with Section 14129) is
added to Chapter 7 of Part 3 of Division 9 of the end insert begin insert Welfare and
Institutions Code end insert begin insert , to read: end insert

begin insert

 

Article begin insert 3.91. end insert   Medi-Cal Emergency Medical Transportation
Reimbursement Act

 

begin insert 14129. end insert   

The Legislature finds and declares all of the following:

(a) The Legislature recognizes the essential role that emergency
medical transport providers play in serving the state’s Medi-Cal
beneficiaries. To that end, it has been and remains the intent of
the Legislature to improve funding for emergency medical transport
providers and obtain all available federal funds to make
supplemental Medi-Cal payments to emergency medical transport
providers.

(b) It is the intent of the Legislature to impose a quality
assurance fee to be paid by emergency medical transport providers,
which will be used to increase federal financial participation in
order to increase Medi-Cal payments to emergency medical
transport providers.

(c) It is the intent of the Legislature to increase the Medi-Cal
emergency medical transport reimbursement by increasing the
fee-for-service payment schedule for emergency medical transports
to support quality improvement efforts by emergency medical
transport providers, including, but not limited to, the provision of
advanced life support services, as defined in Section 1797.52 of
the Health and Safety Code.

(d) It is the further intent of the Legislature that the increased
fee-for-service payment schedule amounts pursuant to this article
shall not result in any expenditure from the General Fund.

begin insert 14129.1. end insert   

For purposes of this article, the following definitions
shall apply:

(a) “Annual quality assurance fee rate” means the quality
assurance fee assessed on each emergency medical transport
applicable to each state fiscal year.

(b) “Aggregate fee schedule increase amount” means the
product of the quotient described in paragraph (2) of subdivision
(a) of Section 14129.4 and the Medi-Cal emergency medical
transports, including both fee-for-service transports paid by the
department and managed care transports paid by Medi-Cal
managed care health plans, utilizing the billing codes for
emergency medical transport for the state fiscal year.

(c) “Available fee amount” shall be calculated as the sum of
the following:

(1) The amount deposited in the Medi-Cal Emergency
Transportation Fund established under Section 14129.3 during
the applicable state fiscal year, less the amounts described in
subparagraphs (A) and (B) of paragraph (2) of subdivision (f) of
Section 14129.3.

(2) Any federal financial participation obtained as a result of
the deposit of the amount described in paragraph (1) in the
Medi-Cal Emergency Transportation Fund for the applicable fiscal
year.

(d) “Department” means the State Department of Health Care
Services.

(e) “Director” means the Director of Health Care Services.

(f) “Effective state medical assistance percentage” means a
ratio of the aggregate expenditures from state-only sources for
the Medi-Cal program divided by the aggregate expenditures from
state and federal sources for the Medi-Cal program for a state
fiscal year.

(g) “Emergency medical transport” means the act of
transporting an individual from any point of origin to the nearest
medical facility capable of meeting the emergency medical needs
of the patient by an ambulance licensed, operated, and equipped
in accordance with applicable state or local statutes, ordinances,
or regulations that are billed with billing codes A0429 BLS
Emergency, A0427 ALS Emergency, and A0433 ALS2, and any
equivalent, predecessor, or successor billing codes as may be
determined by the director. “Emergency medical transports” shall
not include transportation of beneficiaries by passenger car,
taxicabs, litter vans, wheelchair vans, or other forms of public or
private conveyances, nor shall it include transportation by an air
ambulance provider. An “emergency medical transport” does not
occur when, following evaluation of a patient, a transport is not
provided.

(h) “Gross receipts” means gross payments received as patient
care revenue for emergency medical transports, determined on a
cash basis of accounting.

(i) “Emergency medical transport provider” means any provider
of emergency medical transports.

(j) “Emergency medical transport provider subject to the fee”
means all emergency medical transport providers that bill and
receive patient care revenue from the provision of emergency
medical transports, except emergency medical transport providers
that are exempt pursuant to subdivision (c) of Section 14129.8.

(k) “Medi-Cal managed care health plan” means a “managed
health care plan” as that term is defined in subdivision (ab) of
Section 14169.51.

begin insert 14129.2. end insert   

(a) On or before August 15, 2016, each emergency
medical transport provider shall report to the department data on
the number of actual emergency medical transports by payor type,
including, without limitation, Medi-Cal fee-for-service emergency
medical transports and Medi-Cal managed care emergency
medical transports, and gross receipts from the provision of
emergency medical transports provided in each quarter from July
1, 2015, through June 30, 2016, inclusive, in a manner and format
prescribed by the department.

(b) Commencing with the fiscal quarter beginning on October
1, 2016, and each fiscal quarter thereafter, on or before the 45th
day of the quarter, each emergency medical transport provider
shall report to the department data on the number of actual
emergency medical transports by payor type, including, without
limitation, Medi-Cal fee-for-service emergency medical transports
and Medi-Cal managed care emergency medical transports, and
gross receipts from the provision of emergency medical transports
provided in the quarter preceding the quarter in which the report
is due, in a manner and format prescribed by the department.

(c) The department may establish an Internet Web site for the
submission of reports required by this section.

(d) The department may require a certification by each
emergency medical transport under penalty of perjury of the truth
of the reports required under this section. Upon written notice to
an emergency medical transport provider, the department may
impose a penalty of one hundred dollars ($100) per day against
an emergency medical transport provider for every day that an
emergency medical transport provider fails to make a report
required by this section within five days of the date upon which
the report was due. If an emergency medical transport provider
has not made a report as required by this section within 90 days
of the date upon which the report was due, the failure to make the
report shall be considered a violation of a section of the Vehicle
Code that relates to the emergency medical transport provider’s
licensed activities for the purposes of Section 2542 of the Vehicle
Code.

begin insert 14129.3. end insert   

(a) Commencing with the state fiscal quarter
beginning on July 1, 2017, and continuing each fiscal quarter
thereafter, there shall be imposed a quality assurance fee for each
transport provided by each emergency medical transport provider
subject to the fee in accordance with this section.

(b) (1) On or before June 15, 2017, and each June 15 thereafter,
the director shall calculate the annual quality assurance fee rate
applicable to the following state fiscal year based on the most
recently collected data collected from emergency medical transport
providers pursuant to Section 14129.2, and publish the annual
quality assurance fee rate on its Internet Web site. In no case shall
the fees calculated pursuant to this subdivision and collected
pursuant to this article exceed the amounts allowable under federal
law.

(A) For state fiscal year 2017-18, the annual quality assurance
fee rate shall be calculated by multiplying the projected total
annual gross receipts for all emergency medical transport
providers subject to the fee by 5.5 percent, which resulting product
shall be divided by the projected total annual emergency medical
transports by all emergency medical transport providers subject
to the fee for the state fiscal year.

(B) For state fiscal years 2018-19 and thereafter, the annual
quality assurance fee rate shall be calculated by a ratio, the
numerator of which shall be the sum of the product of the projected
aggregate fee schedule amount and the effective state medical
assistance percentage, and the amount described in subparagraph
(A) of paragraph (2) of subdivision (f), and the denominator of
which shall be 95 percent of the projected total annual emergency
medical transports by all emergency medical transport providers
subject to the fee for the state fiscal year.

(2) On or before June 15, 2017, and each June 15 thereafter,
the director shall publish the annual quality assurance fee rate on
its Internet Web site.

(3) In no case shall the fees calculated pursuant to this
subdivision and collected pursuant to this article exceed the
amounts allowable under federal law.

(4) If, during a state fiscal year, the actual or projected available
fee amount exceeds or is less than the actual or projected
aggregate fee schedule amount by more than 1 percent, the director
shall adjust the annual quality assurance fee rate so that the
available fee amount for the state fiscal year will approximately
equal the aggregate fee schedule amount for the state fiscal year.
The available fee amount for a state fiscal year will be considered
to equal the aggregate fee schedule amount for the state fiscal
year if the difference between the available fee amount for the
state fiscal year and the aggregate fee schedule amount for the
state fiscal year constitutes less than 1 percent of the aggregate
fee schedule amount for the state fiscal year.

(c) (1) Each emergency medical transport provider subject to
the fee shall remit to the department an amount equal to the annual
quality assurance fee rate for the 2017-18 state fiscal year
multiplied by the number of transports reported or that should
have been reported by the emergency medical transport provider
pursuant to subdivision (b) of Section 14129.2 in the quarter
commencing April 1, 2017, based on a schedule established by the
director. The schedule established by the director for the fee
payment described in this paragraph shall not require payment of
any of the fee payment prior to July 1, 2017, and shall not require
payment of more than 50 percent of the fee payment prior to August
1, 2017.

(2) Commencing with the state fiscal quarter beginning on
October 1, 2017, and each fiscal quarter thereafter, on or before
the first day of each state fiscal quarter, each emergency medical
transport provider subject to the fee shall remit to the department
an amount equal to the annual quality assurance fee rate for the
applicable state fiscal year multiplied by the number of transports
reported or that should have been reported by the emergency
medical transport provider pursuant to subdivision (b) of Section
14129.2 in the immediately preceding quarter.

(d) (1) Interest shall be assessed on quality assurance fees not
paid on the date due at the greater of 10 percent per annum or the
rate at which the department assesses interest on Medi-Cal
program overpayments to hospitals that are not repaid when due.
Interest shall begin to accrue the day after the date the payment
was due and shall be deposited in the Medi-Cal Emergency
Medical Transport Fund established in subdivision (f).

(2) In the event that any fee payment is more than 60 days
overdue, the department may deduct the unpaid fee and interest
owed from any Medi-Cal reimbursement payments owed to the
provider until the full amount of the fee and interest are recovered.
Any deduction made pursuant to this subdivision shall be made
only after the department gives the provider written notification.
Any deduction made pursuant to this subdivision may be deducted
over a period of time that takes into account the financial condition
of the provider.

(3) In the event that any fee payment is more than 60 days
overdue, a penalty equal to the interest charge described in
paragraph (1) shall be assessed and due for each month for which
the payment is not received after 60 days.

(e) The department shall accept an emergency medical transport
provider’s payment even if the payment is submitted in a rate year
subsequent to the rate year in which the fee was assessed.

(f) (1) The director shall deposit the quality assurance fee
collected pursuant to this section in the Medi-Cal Emergency
Medical Transport Fund, which is hereby created in the State
Treasury and, notwithstanding Section 13440 of the Government
Code, is continuously appropriated without regard to fiscal years
to the department for the purposes specified in this article.
Notwithstanding Section 16305.7 of the Government Code, the
fund shall also include interest and dividends earned on moneys
in the fund.

(2) The moneys in the Medi-Cal Emergency Medical Transport
Fund, including any interest and dividends earned on money in
the fund, shall be available exclusively to enhance federal financial
participation for ambulance services under the Medi-Cal program
and to provide additional reimbursement to, and to support quality
improvement efforts of, emergency medical transport providers,
as well as to pay for the state’s administrative costs and to provide
funding for health care coverage for Californians, in the following
order of priority:

(A) To pay for the department’s staffing and administrative
costs directly attributable to implementing this article, not to
exceed three hundred fifty thousand dollars ($350,000) for each
fiscal year, exclusive of any federal matching funds.

(B) To pay for the health care coverage in each fiscal year in
the amount of 5 percent of the projected quality assurance fee
revenue for that fiscal year, as calculated by the department on
or before June 15 preceding that fiscal year, exclusive of any
federal matching funds.

(C) To make increased payments to emergency medical transport
providers pursuant to this article.

(D) To provide additional support for health care coverage of
Californians.

begin insert 14129.4. end insert   

(a) Effective July 1, 2017, the Medi-Cal
fee-for-service payment schedule governing reimbursement to
emergency medical transport providers for emergency medical
transports shall be increased. The resulting fee-for-service payment
schedule amounts after the application of this section shall be
equal to the sum of (1) the Medi-Cal fee-for-service payment
schedule amount for the state fiscal year 2015-16 and (2) the
quotient of the projected available fee amount for the state fiscal
year 2017-18, divided by the total projected Medi-Cal emergency
medical transports, including both fee-for-service transports paid
by the department and managed care transports paid by Medi-Cal
managed care health plans, utilizing these billing codes for the
state fiscal year 2016-17. The department shall calculate the
projections required by this subdivision based on the data
submitted pursuant to Section 14129.2.

(b) Each Medi-Cal managed care health plan shall satisfy its
obligation under Section 438.114(c) of Title 42 of the Code of
Federal Regulations for emergency medical transports by
providing payment to emergency medical transport providers that
is equal to the amount of payment described in Section
1396u-2(b)(2)(D) of Title 42 of the United States Code.

(c) The fee-for-service payment schedule increase established
pursuant to this section shall be funded solely from the following:

(1) The quality assurance fee set forth in Section 14129.3, along
with any interest or other investment income thereon.

(2) Federal reimbursement and any other related federal funds.

(d) The proceeds of the quality assurance fee set forth in Section
14129.3, the matching amount provided by the federal government,
and any interest earned on those proceeds shall be used to
supplement existing funding for emergency medical transports
provided by emergency transport providers and not supplant this
funding.

begin insert 14129.5. end insert   

If there is a delay in the implementation of this article
for any reason, including a delay in any required approval of the
quality assurance fee and reimbursement methodology specified
by the federal Centers for Medicare and Medicaid Services, all of
the following shall apply:

(a) An emergency transport provider subject to the fee may be
assessed the amount the provider would be required to pay to the
department if the fee-for-service payment schedule increases
described in Section 14129.4 were already approved, but shall not
be required to pay the fee until the fee-for-service payment schedule
increases described in Section 14129.4 are approved. The director
shall establish a schedule for payment of retroactive fees pursuant
to this subdivision in consultation with emergency medical
transport providers to minimize the disruption to the cash flow of
emergency medical transport providers.

(b) The department may retroactively increase and make
payment of supplemental rates to emergency medical transport
providers pursuant to Section 14129.4.

begin insert 14129.6. end insert   

(a) The director shall administer this article.

(b) The director may adopt regulations as are necessary to
implement this article. These regulations may be adopted as
emergency regulations in accordance with the rulemaking
provisions of the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code). For purposes of this article, the first
adoption of regulations shall be deemed an emergency and
necessary for the immediate preservation of the public peace,
health and safety, or general welfare. The regulations shall include,
but need not be limited to, any regulations necessary for any of
the following purposes:

(1) The administration of this article, including the proper
imposition of the quality assurance fee and process for its
collection, reporting, and refunds. The costs associated with the
administration of this article are not to exceed the amounts
reasonably necessary to administer this article.

(2) The development of any forms necessary to obtain required
information from providers subject to the quality assurance fee.

(3) The provision of details, definitions, formulas, and other
requirements.

(c) As an alternative to subdivision (b), and notwithstanding
the rulemaking provisions of the Administrative Procedure Act
(Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code), the director may
implement this article, in whole or in part, by means of a provider
bulletin, or other similar instructions, without taking regulatory
action, provided that no such bulletin or other similar instructions
shall remain in effect after June 30, 2018. It is the intent of the
Legislature that the regulations adopted pursuant to subdivision
(b) be adopted on or before June 30, 2018.

(d) The director shall ensure that the quality assurance fee per
transport imposed pursuant to this article is collected.

begin insert 14129.7. end insert   

The moneys in the Medi-Cal Emergency Medical
Transport Fund, and any federal matching funds, shall be
continuously appropriated, notwithstanding Section 13340 of the
Government Code, without regard to fiscal years to the department
for the purpose of the increased Medi-Cal fee-for-service payment
schedule governing reimbursement to emergency medical transport
providers for emergency medical transports described in Section
14129.4.

begin insert 14129.8. end insert   

(a) The department shall request approval from the
federal Centers for Medicare and Medicaid Services for the use
of fees collected pursuant to this article for the purpose of receiving
federal matching funds.

(b) The director may alter the methodology specified in this
article to the extent necessary to meet the requirements of federal
law or regulations or to obtain federal approval. If the director,
after consulting with affected emergency medical transport
providers, determines that an alteration is needed, the director
shall execute a declaration stating that this determination has been
made. The director shall retain the declaration and provide a copy,
within five working days of the execution of the declaration, to the
fiscal and appropriate policy committees of the Legislature.

(c) The director may add categories of exempt emergency
medical transport providers or apply a nonuniform fee per
transport to emergency medical transport providers that are subject
to the fee in order to meet requirements of federal law or
regulations. The director may exempt categories of emergency
medical transport providers from the fee if necessary to obtain
federal approval.

begin insert 14129.9. end insert   

(a) This article shall be implemented only if, and as
long as, both of the following conditions are met:

(1) The state receives federal approval of the quality assurance
fee from the federal Centers for Medicare and Medicaid Services.

(2) The state receives federal approval for the increased
fee-for-service payment schedule increases described in subdivision
(a) of Section 14129.4.

(b) This article shall cease to be implemented if one of the
following conditions is no longer met:

(1) The federal Centers for Medicare and Medicaid Services
continues to allow the use of the provider assessment provided in
this article.

(2) The Medi-Cal fee-for-service payment schedule increase
described in subdivision (a) of Section 14129.4 remains in effect.

(3) The quality assurance fee assessed and collected pursuant
to this article remains available for the purposes specified in this
article.

(c) If all of the conditions in subdivision (a) are met, this article
is implemented. If, subsequently, any one of the conditions in
subdivision (b) is not met, this article shall become inoperative
notwithstanding that the condition or conditions subsequently may
be met.

(d) Notwithstanding subdivisions (a), (b), and (c), in the event
of a final judicial determination made by any state or federal court
that is not appealed, or by a court of appellate jurisdiction that is
not further appealed, in any action by any party, or a final
determination by the administrator of the federal Centers for
Medicare and Medicaid Services, that federal financial
participation is not available with respect to any payment made
under the methodology implemented pursuant to this article
because the methodology is invalid, unlawful, or contrary to any
provision of federal law or regulations or of state law, this article
shall become inoperative.

end insert

begin insert

begin insert SEC. 2. end insert   

end insert begin insert

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.

end insert

begin insert

begin insert SEC. 3. end insert   

end insert begin insert

This act is an urgency statute necessary for the
immediate preservation of the public peace, health, or safety within
the meaning of Article IV of the Constitution and shall go into
immediate effect. The facts constituting the necessity are:

end insert begin insert

In order to make the necessary changes to increase Medi-Cal
payments to emergency ambulance providers and to improve
access, at the earliest possible time, to allow this act to be operative
as soon as approval from the federal Centers for Medicare and
Medicaid Services is obtained by the State Department of Health
Care Services, it is necessary that this act take effect immediately.

end insert

begin delete

SECTION 1.  

Section 15926 of the Welfare and Institutions
Code is amended to read:

15926.  

(a) The following definitions apply for purposes of
this part:

(1) “Accessible” means in compliance with Section 11135 of
the Government Code, Section 1557 of the PPACA, and regulations
or guidance adopted pursuant to these statutes.

(2) “Limited-English-proficient” means not speaking English
as one’s primary language and having a limited ability to read,
speak, write, or understand English.

(3) “Insurance affordability program” means a program that is
one of the following:

(A) The Medi-Cal program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.).

(B) The state’s children’s health insurance program (CHIP)
under Title XXI of the federal Social Security Act (42 U.S.C. Sec.
1397aa et seq.).

(C) A program that makes available to qualified individuals
coverage in a qualified health plan through the California Health
Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code with advance
payment of the premium tax credit established under Section 36B
of the Internal Revenue Code.

(4) A program that makes available coverage in a qualified
health plan through the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500)
of the Government Code with cost-sharing reductions established
under Section 1402 of PPACA and any subsequent amendments
to that act.

(b) An individual shall have the option to apply for insurance
affordability programs in person, by mail, online, by telephone,
or by other commonly available electronic means.

(c) (1) A single, accessible, standardized paper, electronic, and
telephone application for insurance affordability programs shall
be developed by the department in consultation with MRMIB and
the board governing the Exchange as part of the stakeholder process
described in subdivision (b) of Section 15925. The application
shall be used by all entities authorized to make an eligibility
determination for any of the insurance affordability programs and
by their agents.

(2) The department may develop and require the use of
supplemental forms to collect additional information needed to
determine eligibility on a basis other than the financial
methodologies described in Section 1396a(e)(14) of Title 42 of
the United States Code, as added by the federal Patient Protection
and Affordable Care Act (Public Law 111-148), and as amended
by the federal Health Care and Education Reconciliation Act of
2010 (Public Law 111-152) and any subsequent amendments, as
provided under Section 435.907(c) of Title 42 of the Code of
Federal Regulations.

(3) The application shall be tested and operational by the date
as required by the federal Secretary of Health and Human Services.

(4) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:

(A) The form shall include simple, user-friendly language and
instructions.

(B) The form may not ask for information related to a
nonapplicant that is not necessary to determine eligibility in the
applicant’s particular circumstances.

(C) The form may require only information necessary to support
the eligibility and enrollment processes for insurance affordability
programs.

(D) The form may be used for, but shall not be limited to,
screening.

(E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through an insurance affordability program for the infant’s birth,
for the purpose of automatically enrolling the infant into the
applicable program without the family having to complete the
application process for the infant.

(F) The form may include questions that are voluntary for
applicants to answer regarding demographic data categories,
including race, ethnicity, primary language, disability status, and
other categories recognized by the federal Secretary of Health and
Human Services under Section 4302 of the PPACA.

(G) Until January 1, 2016, the department shall instruct counties
to not reject an application that was in existence prior to January
1, 2014, but to accept the application and request any additional
information needed from the applicant in order to complete the
eligibility determination process. The department shall work with
counties and consumer advocates to develop the supplemental
questions.

(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
insurance affordability programs or other health programs that
differs from the application form described in subdivision (c), and
related enrollment procedures. Nothing in this section shall
preclude the use of a joint application, developed by the department
and the State Department of Social Services, that allows for an
application to be made for multiple programs, including, but not
limited to, CalWORKs, CalFresh, and insurance affordability
programs.

(e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of
the applicant in accordance with the state and federal rules
governing insurance affordability programs.

(f) (1) If the eligibility, enrollment, and retention system has
the ability to prepopulate an application form for insurance
affordability programs with personal information from available
electronic databases, an applicant shall be given the option, with
his or her informed consent, to have the application form
prepopulated. Before a prepopulated application is submitted to
the entity authorized to make eligibility determinations, the
individual shall be given the opportunity to provide additional
eligibility information and to correct any information retrieved
from a database.

(2) All insurance affordability programs may accept
self-attestation, instead of requiring an individual to produce a
document, for age, date of birth, family size, household income,
state residence, pregnancy, and any other applicable criteria needed
to determine the eligibility of an applicant or recipient, to the extent
permitted by state and federal law.

(3) An applicant or recipient shall have his or her information
electronically verified in the manner required by the PPACA and
implementing federal regulations and guidance and state law.

(4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.

(5) The eligibility of an applicant shall not be delayed beyond
the timeliness standards as provided in Section 435.912 of Title
42 of the Code of Federal Regulations or denied for any insurance
affordability program unless the applicant is given a reasonable
opportunity, of at least the kind provided for under the Medi-Cal
program pursuant to Section 14007.5 and paragraph (7) of
subdivision (e) of Section 14011.2, to resolve discrepancies
concerning any information provided by a verifying entity.

(6) To the extent federal financial participation is available, an
applicant shall be provided benefits in accordance with the rules
of the insurance affordability program, as implemented in federal
regulations and guidance, for which he or she otherwise qualifies
until a determination is made that he or she is not eligible and all
applicable notices have been provided. Nothing in this section
shall be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.

(g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for an insurance affordability program in person, over the
telephone, by mail, online, or through other commonly available
electronic means and in a manner that is accessible to individuals
with disabilities and those who are limited-English proficient.

(h) (1) During the processing of an application, renewal, or a
transition due to a change in circumstances, an entity making
eligibility determinations for an insurance affordability program
shall ensure that an eligible applicant and recipient of insurance
affordability programs that meets all of the program eligibility
requirements and complies with all of the necessary requests for
information moves between programs without any breaks in
coverage and without being required to provide any forms,
documents, or other information or undergo verification that is
duplicative or otherwise unnecessary. The individual shall be
informed about how to obtain information about the status of his
or her application, renewal, or transfer to another program at any
time, and the information shall be promptly provided when
requested.

(2) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross
Income (MAGI) household income but who may be eligible on
the basis of being 65 years of age or older, or on the basis of
blindness or disability, shall be forwarded to the Medi-Cal program
for an eligibility determination. During the period the application
or case is processed for a non-MAGI Medi-Cal eligibility
determination, if the applicant or recipient is otherwise eligible
for an insurance affordability program, he or she shall be
determined eligible for that program.

(3) Renewal procedures shall include all available methods for
reporting renewal information, including, but not limited to,
face-to-face, telephone, mail, and online renewal or renewal
through other commonly available electronic means.

(4) An applicant who is not eligible for an insurance affordability
program for a reason other than income eligibility, or for any reason
in the case of applicants and recipients residing in a county that
offers a health coverage program for individuals with income above
the maximum allowed for the Exchange premium tax credits, shall
be referred to the county health coverage program in his or her
county of residence.

(i) Notwithstanding subdivisions (e), (f), and (j), before an online
applicant who appears to be eligible for the Exchange with a
premium tax credit or reduction in cost sharing, or both, may be
enrolled in the Exchange, both of the following shall occur:

(1) The applicant shall be informed of the overpayment penalties
under the federal Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011
(Public Law 112-9), if the individual’s annual family income
increases by a specified amount or more, calculated on the basis
of the individual’s current family size and current income, and that
penalties are avoided by prompt reporting of income increases
throughout the year.

(2) The applicant shall be informed of the penalty for failure to
have minimum essential health coverage.

(j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among insurance affordability programs using the
least restrictive rules and requirements permitted by federal and
state law. This process shall include the consideration of
methodologies for determining income levels, assets, rules for
household size, citizenship and immigration status, and
self-attestation and verification requirements.

(k) (1) Forms and notices developed pursuant to this section
shall be accessible and standardized, as appropriate, and shall
comply with federal and state laws, regulations, and guidance
prohibiting discrimination.

(2) Forms and notices developed pursuant to this section shall
be developed using plain language and shall be provided in a
manner that affords meaningful access to limited-English-proficient
individuals, in accordance with applicable state and federal law,
and at a minimum, provided in the same threshold languages as
required for Medi-Cal managed care plans.

(l) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall establish a process
for receiving and acting on stakeholder suggestions regarding the
functionality of the eligibility systems supporting the Exchange,
including the activities of all entities providing eligibility screening
to ensure the correct eligibility rules and requirements are being
used. This process shall include consumers and their advocates,
be conducted no less than quarterly, and include the recording,
review, and analysis of potential defects or enhancements of the
eligibility systems. The process shall also include regular updates
on the work to analyze, prioritize, and implement corrections to
confirmed defects and proposed enhancements, and to monitor
screening.

(m) In designing and implementing the eligibility, enrollment,
and retention system, the department, MRMIB, and the Exchange
board shall ensure that all privacy and confidentiality rights under
the PPACA and other federal and state laws are incorporated and
followed, including responses to security breaches.

(n) Except as otherwise specified, this section shall be operative
on January 1, 2014.

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