BILL ANALYSIS
SB 1091
Page 1
Date of Hearing: June 29, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1091 (Hancock) - As Amended: May 4, 2010
SENATE VOTE : 35-0
SUBJECT : Medi-Cal: individuals in county juvenile detention
facilities.
SUMMARY : Enables counties to receive Medi-Cal reimbursement for
medical and mental health services they provide to eligible
individuals less than 21 years of age entering county juvenile
detention facilities as specified. Specifically, this bill :
1)Requires the Department of Health Care Services (DHCS) to seek
federal approval or waiver as necessary in order to obtain
federal financial participation (FFP) for Medi-Cal benefits
provided to an individual under 21 for the shorter of 30 days
or until adjudication.
2)Conditions the implementation on a county voluntarily agreeing
to pay the state's share.
3)Limits eligibility to an individual who is receiving Medi-Cal
benefits at the time of admission or is subsequently
determined to be eligible.
4)Requires the provisions to be implemented on the later of
January 1, 2010 or when all federal approvals or waivers have
been obtained, whichever is later.
5)Specifies that this bill shall not be construed to require a
county to pay for the costs of Medi-Cal benefits that the
state is obligated to provide under administrative action of
final court order.
6)Authorizes initial implementation by all-county letter and by
regulation thereafter.
EXISTING LAW :
1)Establishes the Medi-Cal Program, administered by DHCS, to
provide comprehensive health care services and long-term care
SB 1091
Page 2
to pregnant women, children, and people who are aged, blind,
and disabled.
2)Establishes a schedule of benefits under the Medi-Cal Program
but excludes from the definition of "health care services,"
care or services for any individual who is an inmate of an
institution (except as a patient in a medical institution),
except to the extent permitted by federal law.
3)Allows, under federal law, continued Medicaid (Medi-Cal in
California) eligibility even when an inmate of a public
institution is prohibited from receiving benefits, and states
that an individual is not considered to be living in a public
institution if the individual is in a public institution for a
temporary period pending other arrangements.
4)Provides that a juvenile who is an inmate of a public
institution shall have their Medi-Cal benefits suspended, as
specified.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12 2012-13 Fund
Federal funds match to likely in the millions of dollars
County/
counties for Medi-Cal benefits annually *Federal
DHCS administration likely up to $100 annually
ongoingCounty/
*Federal
*About 50% county funds, 50% federal funds
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
intended to enable counties to use dollars they are already
spending for medical and mental health services they provide
to eligible youth in their detention facilities as the match
for federal Medicaid funds. The author argues that this bill
would help counties reduce the amount they already spend by
almost half by substituting federal funds for county dollars.
The author states that counties that choose to participate
SB 1091
Page 3
will match the state's share through an intergovernmental
transfer of funds.
The sponsor, Alameda County, points out that every county has an
obligation to tend to the health care needs of the detained
persons. However, this obligation had been challenging due to
severe reduction in county revenues. This bill, according to
the sponsor is intended to take advantage of federal authority
to use federal Medicaid funds to reduce the cost the county is
already incurring for the first 30 days of a youth's stay in
juvenile hall. According to the sponsor, the average length
of stay is 24 days.
2)BACKGROUND . Medi-Cal regulations make individuals who are
inmates of public institutions ineligible for Medi-Cal.
However, a 1997 letter from the federal Department of Health
and Human Services indicates FFP is available through Medicaid
when an inmate becomes a patient in a medical institution on
an inpatient basis. Additionally, a 2004 letter to State
Medicaid directors from the federal Centers for Medicare and
Medicaid Services encourages states to "suspend" and not
"terminate" benefits while a person is in a public institution
or Institute for Mental Disease, noting the payment exclusion
(known as the "inmate exception") under Medicaid does not
affect the eligibility of an individual for the Medicaid
program. This policy was codified with regard to juveniles in
SB 1147 (Calderon and Yee), Chapter 546, Statutes of 2008.
DHCS indicated that the necessary protocols were issued in
March 2010.
3)TEMPORARY CUSTODY . Federal regulations also appear to allow
states to claim FFP for all Medicaid services provided to a
person in a public institution for a temporary period pending
other arrangements as an exception to unavailability of FFP
for services provided to inmates. Supporting material
supplied by the sponsor indicate that Pennsylvania and New
Mexico have taken advantage of this opportunity.
Specifically, a letter from the New Mexico Human Services
Department in 2005 interpreted this to mean that an individual
is temporarily placed until adjudication or up to 60 days
whichever occurs first. A bulletin from the Pennsylvania
Department of Public Welfare in 2001 also indicates that FFP
is available for Medicaid benefits for juveniles placed
"temporarily" in juvenile detention centers while other
arrangements are made.
SB 1091
Page 4
4)BERNALILLO COUNTY, NM . According to the Juvenile Offenders
Community Health Services Project, Medicaid is a critical
funding source for an onsite mental health clinic at the
Bernalillo County (NM) Juvenile Detention and Youth Services
Center, where rates of recidivism a year after release among
youth in need of mental health treatment fell from 88% to 22%.
In 2000, the detention center convinced the state Medicaid
office to interpret detention as a temporary period of custody
pending other arrangements, so that juveniles in detention are
not considered inmates of a government institution. With this
change, the detention center can keep youths covered under
Medicaid for up to 60 days-which is longer than most juveniles
are in detention.
At booking, detention center staff verifies juveniles' Medicaid
status and enroll those juveniles who are eligible but not yet
enrolled. The detention center bills Medicaid roughly
$370,000 a year for health care services provided to youth in
detention. The detention center closed several residential
units in response to a drop in its population. Staff members
affected by the closures were trained as case managers for
juveniles, acting as liaisons between the juvenile court, the
probation office, and the mental health clinic. These case
managers also work with youth in the community after they are
released from the detention center. The reduction in
recidivism occurred after this new case management program was
implemented.
5)MENTAL HEALTH SERVICES . Federal regulations also provide that
FFP is available for an individual under the age of 22
receiving inpatient psychiatric services. A lawsuit brought
by San Francisco and Santa Clara in 2007, ( City and County of
San Francisco, County of Santa Clara v. State of California,
California Department of Health Care Services , Case No.
CGC-07-468241 (Cal. Super. Ct. Oct. 16, 2007)), challenged the
state's practice and policy of denying Medi-Cal coverage of
inpatient psychiatric hospital services provided to youths who
are in custody. (The lawsuit also challenged the legality of
terminating wards because of their status as inmates. This
cause of action is moot due to the passage of SB 1147.) On
April 5, 2010, the County of San Francisco Superior Court
ruled that this practice violates federal and state law and
ordered the state to provide Medi-Cal coverage of inpatient
psychiatric hospital services for individuals under age 21
SB 1091
Page 5
regardless of their status as detainees. To preserve the
ruling in this case, this bill provides that it shall not be
construed to require a county to pay for services that are the
obligation of the state. It is unknown if the state will
appeal.
6)SUPPORT . Alameda County, sponsor of this bill, writes in
support that the current cost to the county of providing
medical and mental health services to this population is $7
million annually and is provided through a system of full
service health, dental, and mental health services and
facilities. According to the Alameda Department of Health, up
to 80% of the population is eligible for Medi-Cal and the
average length of stay is 24 days. Allowing matching funds
would therefore reduce the costs to the county by almost half.
In addition, the county points to the New Mexico experience
and the fact that 80% of juvenile hospitalizations are
psychiatric to make the case that providing mental health
services and medications will save additional funds by
reducing recidivism. These funds, they argue, can be used to
enhance medical and mental health services similarly to the
New Mexico experience. The City and County of San Francisco
writes in support that its Department of Public Health (DPH)
currently spends $4.9 million annually to provide primary care
and behavioral health services to youth incarcerated at the
Youth Guidance Center. Based on the services provided in
2008-09 and an assumption that at least half would be eligible
for Medi-Cal, DPH would, at a minimum, receive $1.2 million in
matching federal funds at no cost to the state.
7)PRIOR LEGISLATION :
a) SB 648 (Calderon) of 2007 would have required DHCS to
suspend rather than terminate the Medi-Cal benefits of an
incarcerated minor. SB 648 was referred to Senate Health
Committee but was not heard.
b) SB 1469 (Cedillo), Chapter 657, Statutes of 2007,
requires county juvenile detention facilities, following
the issuance of an order of the juvenile court committing a
county ward to a juvenile hall, camp, or ranch for 30 days
or longer, to provide the county welfare department with
the ward's name, his or her scheduled or actual release
date, any known information regarding the ward's Medi-Cal
status prior to disposition, and sufficient information,
SB 1091
Page 6
when available, for the county welfare department to begin
the process of determining the ward's Medi-Cal eligibility.
REGISTERED SUPPORT / OPPOSITION :
Support
Alameda County (sponsor)
Accessing Health Services for California's Children in Foster
Care Task Force
California Medical Association
California Probation, Parole and Correctional Association
California State Association of Counties
Chief Probation Officers
Children's Advocacy Institute
City and County of San Francisco
County Health Executives Association of California
Kern County Board of Supervisors
Marin County Board of Supervisors
Public Counsel
Sacramento County Board of Supervisors
Santa Clara County Board of Supervisors
Taxpayers for Improving Public Safety
Urban Counties Caucus
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097