BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 438
S
AUTHOR: Yee
B
AMENDED: April 23, 2009
HEARING DATE: April 29, 2009
4
CONSULTANT:
3
Dunstan/cjt
8
SUBJECT
Medi-Cal: accelerated enrollment
SUMMARY
Requires the Department of Health Care Services (DHCS), to
seek federal approval for an option to accelerate Medi-Cal
enrollment for children and pregnant women who apply for
Medi-Cal at a county welfare office. Transfers Healthy
Families program eligibility determination to county
welfare offices.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes the Medicaid program which provides
comprehensive health coverage to low-income eligible
individuals and families, including children; the aged,
blind, and disabled; and pregnant women, through a program
that reimburses states for the Medicaid programs in the
individual states. Existing federal law establishes the
Children's Health Insurance Program (CHIP) which provides
matching funds for state health insurance programs.
Provides specific guidance for determining eligibility for
Medicaid and CHIP while preserving flexibility for states
to administer according to the needs of the state.
Continued---
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 2
Existing state law:
Establishes the state's Medicaid program known as Medi-Cal,
administered by DHCS, which provides comprehensive health
benefits to low-income children; their parents or caretaker
relatives; pregnant women; elderly, blind or disabled
persons; nursing home residents; and refugees who meet
specified eligibility criteria.
Authorizes DHCS to establish an accelerated enrollment for
children making enrollment changes between Healthy Families
and Medi-Cal, for children enrolling in Medi-Cal through
the Child Health and Disability Program, children who apply
for free lunches through the National School Lunch program
and for children enrolling through the single point of
entry, a centralized administrative entity.
Establishes the Healthy Families program to provide
low-cost insurance, including health, dental and vision
coverage to children who do not have health insurance, do
not qualify for free Medi-Cal and are in families at or
below 250 percent of the federal poverty level.
Provides that the Managed Risk Medical Insurance Board
(MRMIB) administers Healthy Families.
This bill:
Requires MRMIB to transfer eligibility determination to
counties beginning January 1, 2011 and requires MRMIB and
stakeholders to consult regarding the procedure for
transferring eligibility determinations.
Authorizes MRMIB to continue to contract with a private
entity for other administrative activities.
Requires DHCS to exercise the option for accelerated
enrollment for pregnant women and children who apply for
Medi-Cal at a county welfare office, provided that federal
financial participation is available.
Directs DHCS to seek federal approval for any state plan
amendments required to implement this bill.
Allows DHCS to implement this bill through all-county
letters initially and then adopt regulations for any
subsequent actions.
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 3
Directs a county, if it determines that a pregnant woman or
a child appears eligible for Medi-Cal, to grant them
accelerated enrollment into Medi-Cal.
Requires counties to perform a complete eligibility
determination and, if the pregnant woman or child is found
to be ineligible, report that to DHCS so that benefits can
be discontinued.
FISCAL IMPACT
Unknown.
BACKGROUND AND DISCUSSION
According to the author, this bill seeks to expand access
to health care services by streamlining enrollment in the
state's Medi-Cal program. The author argues that this bill
will accelerate and simplify enrollment by allowing the
county welfare office to immediately enroll children who
appear to meet the eligibility requirements. The author
points out that accelerated enrollment is allowed through
the state's single point of entry, the Child Health and
Disability Program and between the Healthy Families and
Medi-Cal programs. Ironically, the traditional point of
entry for many applying for Medi-Cal is the one place where
they cannot get the accelerated enrollment, the county
welfare office.
Uninsured children
There are approximately 700,000 children in California who
are not covered by health insurance, according to
researchers. Many of these uninsured children come from
low-income working families. As a result of the lack of
insurance, they are less likely to visit a doctor, less
likely to receive preventive services, and may delay
seeking necessary care. Often when they seek care, they
have more serious conditions and require more extensive and
costly treatment.
According to the UCLA Center for Health Policy Research, of
the nearly 700,000 children who are uninsured, over half
are eligible for two of California's public health
insurance programs; approximately 200,000 for Medi-Cal and
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 4
180,000 for Healthy Families. Another 150,000 are eligible
for local children's programs, although these are not
offered in all counties. Approximately the same number are
not eligible for either of the state programs because of
income or immigration status.
Studies have reported that when parents of uninsured
children who are potentially eligible for Medi-Cal were
asked why their children were not enrolled, only eight
percent reported being unsure about their children's
eligibility as the reason for not applying, and less than
one percent did not know the program existed. However,
parents of about one in eight uninsured eligible children
objected to some characteristics of the program,
particularly the onerous paperwork.
Consequences of being uninsured
Again, according to a report by the UCLA Center for Health
Policy Research, uninsured children reported slightly lower
health status than those enrolled in Medi-Cal or Healthy
Families. Over three-fourths of insured children or their
parents reported their health as "excellent" or "very
good," while less than half of uninsured children reported
the same. Uninsured children were also more than three
times as likely to report their health status as "fair" or
"poor" than those with job-based coverage. Nearly half of
the uninsured reported no usual source of care and were
only half as likely as those with Medi-Cal to list a
doctor's office or health maintenance organization as their
usual source of care and only one-third as likely as those
with job-based coverage or individually purchased private
insurance. Over 50 percent of the uninsured cited lack of
insurance or cost as a reason for not having a usual source
of care, compared to about 33 percent of those with
Medi-Cal or other public coverage and less than one percent
of those with job-based or individually purchased coverage.
Previous efforts to ease program requirements
The state has implemented a number of eligibility
streamlining changes for children that this bill would
build on. For example, the Child Health and Disability
Prevention Program (CHDP) "Gateway" provides access for
uninsured children to the Medi-Cal or the Healthy Families
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 5
program through an automated pre-enrollment process.
Another effort to streamline enrollment that the state has
embarked on is "Express Enrollment." This concept was
established after it was noted that many children eligible
for, but not enrolled in, health insurance programs, were
participating in existing public programs such as School
Lunches, Food Stamps, and Women, Infants, and Children
(WIC). Under the state's Express Enrollment program, the
application for the school lunch program is used, when the
parent or guardian consents, for determining Medi-Cal
eligibility. If the child is eligible for free lunches,
the application is forwarded to the county, and a
determination is made regarding eligibility for no-cost
Medi-Cal. If the child is eligible only for reduced-cost
lunches, no Medi-Cal determination is made.
Related legislation
SB 1 (Steinberg), among its other provisions, would have
established presumptive eligibility for children in
families applying for Medi-Cal at county eligibility
offices. This bill is in Senate Health Committee.
Prior legislation
SB 1459 (Yee) of 2008, among its other provisions, would
have established presumptive eligibility for children in
families applying for Medi-Cal at county eligibility
offices. This bill was held in Senate Appropriations
Committee.
SB 32 (Steinberg) of 2008 among its other provisions, would
have established presumptive eligibility for children in
families applying for Medi-Cal at county eligibility
offices. SB 32 was held in the Assembly.
AB 1 (Laird) of 2008 among its other provisions, would have
established presumptive eligibility for children in
families applying for Medi-Cal at county eligibility
offices. AB 1 was held in the Assembly.
SB 437 (Escutia), Chapter 328, Statutes of 2006,
established the Healthy Families Presumptive Eligibility
Program and would have required the DHCS to implement a
process for self-certification of assets and income for
various eligibility categories under the Medi-Cal program.
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 6
AB 624 (Monta?ez) of 2005 would have required the DHS and
the MRMIB to, by July 1, 2007, include an application
process to be used at the option of the person applying on
the child's behalf, to simultaneously pre-enroll and apply
for enrollment into the Healthy Families or Medi-Cal
programs. This bill was vetoed by Governor Schwarzenegger.
Arguments in support
The California Nurses Association, the bill's sponsor,
states that two-thirds of the children in California that
are uninsured are eligible for one of the state's public
programs. They argue that SB 438 will close those ranks by
allowing counties to grant accelerated enrollment of
children and pregnant women into Medi-Cal. They also point
out that full eligibility determinations will still be done
to ensure if benefits will be continued. The Western
Center on Law and Poverty (WCLP) points out that there is
currently a strange anomaly whereby if a child applies
through the state's single point of entry, they can get
Medi-Cal in a few days. However, if that same child
applies through a county welfare office and provides the
same information, the process is slower. WCLP argues that
the current screen done by the single point of entry is
incomplete because it looks at eligibility for only a few
of the many eligibility categories of Medi-Cal. WCLP
states that counties are best equipped to accurately make
Medi-Cal determinations, apply the program's many complex
eligibility rules, and sort through the program's varying
income level and rules.
County Welfare Directors of California argues that this
bill will create equity for children and pregnant women
whose applications for Medi-Cal are filed directly with the
county human services departments rather than mailed in
through the single point of entry. They point out that
this process is already in use by other entities than
counties.
COMMENTS
1. The author is proposing an amendment to eliminate
provisions of the bill related to Healthy Families. As
currently drafted the bill would require the Managed Risk
Medical Insurance Board to shift eligibility determinations
for Healthy Families to the county welfare offices. The
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 7
author proposes to amend the bill by deleting those
provisions.
Proposed amendment
Page 3, delete lines 4 through 25.
SEC. 2. Section 12693.766 is added to the Insurance Code,
to read: 12693.766.
(a) Notwithstanding any other provision of this part, on or
before July 1, 2010, the board, in consultation with the
State Department of Health Care Services, shall begin the
transfer of initial and ongoing eligibility determinations
for the program to the county departments. The counties
shall assume full responsibility for the eligibility
determinations for the program by January 1, 2011.
(b) The board and the department shall consult with
stakeholders, including counties and advocates for program
clients, in the development of procedures for transferring
the responsibility for determinations to the county level.
(c) Upon transfer of program eligibility determinations to
the county level, the collection of family contributions
and participating health plan selection may continue to be
contracted to a private entity. In order to maximize
efficiency, it is the intent of the Legislature that plan
selection and collection of contributions be incorporated,
to the extent possible, into the Medi-Cal managed care
enrollment broker contract administered by the State
Department of Health Care Services.
Technical amendment
Page 9, beginning line 20
(f) Upon the receipt of an application for a child directly
from the parent pregnant woman or from another source on
behalf of the child, or an application for a pregnant woman
directly from the pregnant woman parent or another source
on behalf of the pregnant woman, the county shall determine
whether the child or pregnant woman appears eligible for
Medi-Cal benefits and, if so, grant accelerated enrollment
to the child or pregnant woman. Upon the granting of
accelerated enrollment for a child or pregnant woman, the
county shall determine whether the child or pregnant woman
is eligible for Medi-Cal benefits. If the county determines
that the child or pregnant woman does not meet the
eligibility requirements for participation in the Medi-Cal
program, the county shall report this finding to the
Medical Eligibility Data System so that accelerated
enrollment coverage benefits are discontinued. If the
STAFF ANALYSIS OF SENATE BILL SB 438 (Yee) Page 8
county determines that the child is eligible for the
Medi-Cal program with a share of cost, the county shall
enroll the child in the Medi-Cal program and forward the
application to the Managed Risk Medical Insurance Board for
an evaluation of the child's eligibility for the Healthy
Families Program.
POSITIONS
Support: California Nurses Association (sponsor)
County Welfare Directors of California
Western Center on Law and Poverty
Previous version of bill
American Federation of State, County and Municipal
Employees
California Medical Association
California Primary Care Association
California Psychological Association
Oppose: None received
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