BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1223
AUTHOR: Committee on Veterans Affairs
AMENDED: August 24, 2011
HEARING DATE: June 20, 2012
CONSULTANT: Bain
SUBJECT : Medi-Cal: Public Assistance Reporting Information
System (PARIS).
SUMMARY : Makes the PARIS program, which requires the Department
of Health Care Services (DHCS) to identify veterans and their
dependents enrolled in Medi-Cal and assist them in obtaining
federal veteran health care benefits, a permanent statewide
program, and eliminates the requirement that the PARIS program
be implemented in three consenting counties on a pilot program
basis.
Existing law:
1.Requires DHCS, by July 1, 2009, to establish a two-year pilot
program to utilize the federal PARIS to identify veterans and
their dependents or survivors who are enrolled in the Medi-Cal
program and assist them in obtaining federal veteran health
care benefits.
2.Requires DHCS to select three consenting counties that have in
operation a United States Department of Veterans Affairs
(USDVA) medical center to participate in the pilot program.
3.Requires DHCS to exchange information with PARIS and identify
veterans and their dependents or survivors who are receiving
Medi-Cal benefits in the pilot program counties.
4.Requires DHCS to refer identified Medi-Cal beneficiaries who
are receiving high-cost services, including long-term care, to
county veteran service officers (CVSOs) to obtain information
and assistance in obtaining USDVA benefits.
5.Requires DHCS, prior to commencement of the pilot program, to
do all of the following:
a. Enter into an agreement with the California Department
of Veterans Affairs (CDVA) to perform CVSO outreach
services in connection with the pilot program-requires the
CDVA agreement to contain performance standards that would
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AB 1223 | Page 2
allow DHCS to measure the effectiveness of the pilot
program;
b. Enter into any agreements that are required by the
federal government to utilize PARIS; and
c. Perform any information technology activities necessary
to utilize PARIS.
6.Requires DHCS to monitor the two-year pilot program, evaluate
the outcomes and savings, and provide the legislative fiscal
committees with a report on its findings and recommendations.
Permits DHCS, if it determines that the PARIS pilot program is
cost-effective, to implement PARIS statewide at any time and
continue operation of the PARIS program indefinitely.
7.Permits DHCS to implement, interpret, or make specific the
PARIS-related provisions by means of written directives
without taking further regulatory action under the
Administrative Procedure Act.
8.Exempts contracts under the PARIS-related provisions from the
Public Contract Code and from provisions governing interagency
services and transactions.
This bill:
1.Requires DHCS to utilize PARIS, eliminates the requirement
that the PARIS program be a two-year pilot program, and
eliminates the requirement that DHCS select three consenting
counties that have in operation a USDVA medical center to
participate in the program (thereby making the PARIS pilot a
permanent statewide program).
2.Continues the existing PARIS-related statutory provisions,
except for DHCS authority to expand the PARIS program
statewide, and the requirement that DHCS monitor the two-year
PARIS pilot program, evaluate outcomes and savings, and report
to the Legislature.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1.Additional administrative costs to DHCS and CDVA, likely in
the range of $300,000 (50 percent General Fund �GF]) to expand
the pilot project statewide. Activities would include
identification, outreach, and facilitation of enrollment of
veterans into the federal USDVA benefits. Costs would subside
in future years as fewer veterans are identified in the
Medi-Cal system.
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3
2.Potentially significant cost savings to the Medi-Cal program.
According to the Legislative Analyst's Office (LAO), full
implementation of the PARIS match system and subsequent
enrollment of identified veterans in federal veterans' health
care benefits could save the state as much as $500 million
($250 million GF) annually. The amount and timing of actual
cost savings will depend on how quickly the project is
implemented throughout the state.
3.DHCS has already implemented a pilot program that is expected
to have resulted in cost savings. Additional savings
specifically related to this bill will depend on the level of
cost savings the state is currently experiencing due to the
pilot program.
PRIOR VOTES :
Assembly Veterans Affairs:9- 0
Assembly Health: 18- 0
Assembly Appropriations:17- 0
Assembly Floor: 79- 0
Senate Veterans Affairs:7- 0
COMMENTS :
1.Author's statement. An analysis conducted by the LAO in 2007
stated that implementing PARIS could save the state millions of
dollars annually in GF costs by shifting eligible veterans
enrolled in Medi-Cal to the USDVA health care system. According to
the LAO report, 144,000 veterans and dependents on Medi-Cal
coverage could be eligible for comprehensive medical care and
health services through the USDVA health care system. It is
estimated that connecting only 10 percent of these veterans will
save the state $25 million annually.
2.DHCS report to the Legislature. PARIS was established through
the health budget trailer bill of 2008 (AB 1183 �Committee on
Budget], Chapter 758, Statutes of 2008) to improve the
identification of Medi-Cal beneficiaries who are veterans (or
dependents or survivors) and assist them in obtaining health
benefits provided by the USDVA. The rationale for conducting
this pilot program was two-fold: veterans may have access to
enhanced health benefits and greater asset protection by using
USDVA health benefits, and the state could achieve savings by
shifting veterans from Medi-Cal program to USDVA health
benefits. AB 1183 required DHCS to monitor the two-year pilot
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program, evaluate the outcomes and savings, and report its
findings and recommendations to legislative fiscal committees.
In April 2012, DHCS issued a report to the Legislature on PARIS.
In its report, DHCS stated PARIS is an information-sharing
data match system operated by the federal Department of Health
and Human Services' Administration for Children and Families
(ACF), which allows state and federal agencies to verify
public assistance client circumstances affecting Medicaid
program eligibility. The PARIS-Veterans data match is one of
three different data matches operated by ACF, and it allows
states to compare their beneficiary information with the
USDVA. The premise of PARIS was to identify Medi-Cal
beneficiaries who have a veteran status and were subsequently
flagged and then evaluated for potential eligibility for USDVA
health benefits. CDVA, using CVSOs, conducted outreach
activities in the pilot counties to inform identified
beneficiaries of USDVA health benefits and in some cases,
assisted them in applying for such benefits. CSVOs indicate
that one of the disadvantages for veterans receiving skilled
nursing facility services through Medi-Cal is that DHCS can
recover long-term care costs from the beneficiary's estate,
whereas this does not occur in the USDVA health system.
However, veterans are also informed that there are
requirements on the use of USDVA benefits through the nearest
USDVA medical facility which may be some distance away from
the beneficiary's place of residence.
The report stated the pilot project, in partnership with the
CDVA, began operations in July 2009. The pilot started with
three counties (Fresno, San Bernardino and San Diego) in the
first year, and over the course of the second year, the pilot
was expanded to seven additional counties (Alameda, Orange,
Sacramento, San Mateo, San Francisco, Santa Clara, and
Solano).
DHCS' report indicated no additional funds were appropriated for
DHCS to conduct or evaluate the pilot program, and no funding
was provided to CDVA or CVSOs for their efforts related to the
pilot program. To implement the PARIS program, DHCS entered
into a memorandum of understanding (MOU) with CDVA. Under the
terms of the MOU, DHCS was responsible for administering PARIS
with the federal government, filtering match results, and
sending outreach referrals to CDVA. The MOU required CDVA to
select the pilot counties, receive outreach referrals from
DHCS, send referrals to CVSOs, and provide outcomes to DHCS.
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DHCS submitted lists of Medi-Cal beneficiaries to USDVA for
health benefit verification on a quarterly basis. USDVA
returned lists of Medi-Cal beneficiaries receiving USDVA
benefits. DHCS examined the lists and individuals to determine
the potential for enrollment in USDVA health benefits. DHCS
focused on high-cost and/or long-term care beneficiaries
because they were the most likely to qualify for USDVA health
benefits based on their military service or the service of
immediate family members. DHCS sent CDVA referrals each
quarter for each CVSO in the pilot. Once CVSOs contacted the
veteran and performed the outreach services, CVSOs reported
back to DHCS the outcome of the referral (for example, the
veteran's eligibility status for USDVA benefits).
During the two-year reporting period for the pilot, DHCS
identified 16,387 veterans who were also enrolled in Medi-Cal.
Of the positive data matches, DHCS focused on those
beneficiaries who may have had high Medi-Cal expenditures
(based on several criteria, including those with a
service-connected disability), those who could have veteran
benefits restored, and survivors who appeared eligible for the
Civilian Health and Medical Program of USDVA. This resulted in
3,933 referrals to CVSOs resulting in approximately 990
contacts, reaching 158 high-cost beneficiaries with both
Medi-Cal and USDVA health benefits coverage. Of the 158
beneficiaries, 117 came from San Bernardino, 24 from San
Diego, 10 from Fresno, 5 from Sacramento, and 0 from the other
6 counties. Of the 158 individuals, 24 discontinued their
Medi-Cal coverage and chose to continue health coverage
through USDVA.
Based on the overall analysis of the pilot, DHCS' report
states it was able to accurately identify veterans who were
Medi-Cal beneficiaries and achieved modest success in
redirecting utilization to USDVA health benefits. The report
states this redirection resulted in $1.634 million in total
cost avoidance and savings for the Medi-Cal program over the
two years of the pilot program. DHCS incurred costs of
$150,000, for a net cost avoidance/savings of $1.484 million.
In its recommendations, DHCS states the state can continue its
current path in redirecting limited resources to maintain the
level of effort put forth in the pilot. The state can also
consider directing more resources for the pilot, or consider
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additional or alternative measures to increase utilization of
USDVA benefits. By implementing one or more of the following
recommendations, DHCS could achieve additional Medi-Cal cost
reductions:
a. Direct more dedicated resources to DHCS, CDVA, and CVSOs
to act upon referrals . For the pilot, DHCS temporarily
redirected analytical staff to complete PARIS assignments
on an as-needed basis. Limitations on project management
were a constraint that did not allow for maximum success.
Follow-up on the 832 cases identified in the pilot as being
enrolled in Medi-Cal and also identified as a veteran would
likely identify additional individuals who may choose to
shift from Medi-Cal to USDVA benefits. Going forward,
dedicated staff resources for DHCS and CDVA to operate
PARIS statewide could be considered. DHCS' existing
workload does not permit redirection of staff to fully
support the functions necessary to operate PARIS to its
fullest potential with the same being true for CDVA. As the
lead agency for PARIS, DHCS indicates it could explore the
possibility of partnering with other assistance programs,
such as county General Relief.
b. Initiate direct contact between DHCS and beneficiaries .
DHCS could consider increasing its presence in the veteran
benefit enhancement efforts. For example, DHCS could post
information on its website to educate veterans enrolled in
Medi-Cal that they may qualify for USDVA health benefits.
The website would take the value proposition directly to
veterans and explain that using USDVA health benefits may
give them more benefits, save them money, improve their
care, protect their family's assets, and free up state
Medi-Cal benefits for needy non-veterans. DHCS is already
developing efforts to add information to their website. In
another direct approach, DHCS could send letters to
veterans and surviving veteran dependents receiving
Medi-Cal explaining USDVA health benefits and how to
enroll.
c. Assist CVSOs to educate veteran Medi-Cal beneficiaries
of the advantages of USDVA health benefits over Medi-Cal .
This education could include providing additional
opportunities of conveying this information as part of
other contacts with local veterans as well as looking at
opportunities for CDVA and CVSOs to include information on
health care options as part of informational materials that
may be provided to veterans.
DHCS also reviewed best practices from other states in its
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report. One state of note was Pennsylvania, which participated
in PARIS since its inception. Pennsylvania estimated
annualized cost avoidance/savings of approximately $27.8
million from a period covering nine quarters. Pennsylvania
worked 40,769 cases, resulting in reducing 4,448 cases from
its Medicaid program.
3.LAO. In 2007, as part of its analysis of Governor
Schwarzenegger's proposed budget, the LAO wrote an analysis of
PARIS and recommended its implementation. The LAO stated a
2005 survey performed by the U.S. Census Bureau indicates that
approximately 144,000 veterans in California received Medi-Cal
benefits. According to the LAO, the ability to identify
veterans enrolled in Medi-Cal using PARIS would allow DHCS to
work with CVSOs to promote a voluntary shift of veterans from
Medi-Cal to the USDVA system of health care. The LAO states if
all of the 144,000 veterans currently enrolled in Medi-Cal
shifted to USDVA health care, the LAO estimates a savings to
the Medi-Cal Program of about $250 million from the GF.
However, the LAO believes it is more likely that there would
be a more gradual shift. If 10 percent of veterans switched
from Medi-Cal to USDVA health care, the estimated savings
would be approximately $25 million.
The LAO also estimates savings of $6 million ($3 million GF)
from eliminating unnecessary payments to Medi-Cal managed care
plans for those beneficiaries who have moved out of state. The
LAO also estimates additional savings of $7 million ($4
million GF) by identifying duplicate public program payments
made through the CalWORKs and Food Stamps programs.
4.Governor's 2012-13 proposed budget. The Governor's May budget
estimates savings on a cash basis from PARIS of $742,000
($371,000 GF) in 2012-13. This assumes 80 veterans will
discontinue their Medi-Cal benefits in 2012-13, of which 33
will be managed care and 47 will be fee-for-service.
5.Double referral. This bill was heard in the Senate Veterans
Affairs Committee on April 11, 2012, and passed on consent
with a 7-0 vote.
6.Related legislation. AB 1869 (John A. P�rez) would require the
Office of Patient Advocate, commencing January 1, 2013, to
provide information and assistance about federal veterans'
health benefits. AB 1869 is set for hearing on June 20, 2012
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in this Committee.
7.Prior legislation. AB 1568 (Committee on Veterans Affairs)
from 2009 would have made PARIS a permanent, statewide
program. AB 1568 was gutted and amended and used for a
different subject matter.
AB 3082 (Veterans Affairs Committee) of 2008 would have
required any state or public assistance agency using PARIS to
identify veterans enrolled in the Medi-Cal program for the
purpose of assisting them in obtaining federal health care
benefits. Additionally, the measure required CDVA to develop a
plan for disseminating data-match information to CVSOs. AB
3082 was held on the Senate Appropriations Suspense File.
AB 1183 (Assembly Budget Committee), Chapter 758, Statutes of
2008, established the current PARIS pilot program.
8.Support. Several organizations representing veterans,
including the American Legion, California State Commanders
Veterans Council, and the Vietnam Veterans of America write in
support of this bill, arguing the pilot program has proved
successful and should be implemented statewide to identify and
assist California veterans in obtaining federal benefits for
which they are eligible.
SUPPORT AND OPPOSITION :
Support: American Legion - Department of California
AMVETS-Department of California
California Association of County Veterans Service
Officers
California State Commanders Veterans Council
Vietnam Veterans of America-California State Council
Oppose: None received.
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