BILL NUMBER: AB 1296 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 28, 2011
AMENDED IN ASSEMBLY MAY 27, 2011
AMENDED IN ASSEMBLY MAY 10, 2011
AMENDED IN ASSEMBLY APRIL 25, 2011
INTRODUCED BY Assembly Member Bonilla
FEBRUARY 18, 2011
An act to add Part 3.8 (commencing with Section 15925) to Division
9 of the Welfare and Institutions Code, relating to public health.
LEGISLATIVE COUNSEL'S DIGEST
AB 1296, as amended, Bonilla. Health Care Eligibility, Enrollment,
and Retention Act.
Existing law provides for various programs to provide health care
coverage to persons with limited financial resources, including the
Medi-Cal program and the Healthy Families Program. Existing law
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care. Existing law, the
federal Patient Protection and Affordable Care Act (PPACA), requires
each state to, by January 1, 2014, establish an American Health
Benefit Exchange that facilitates the purchase of qualified health
plans by qualified individuals and qualified small employers, as
specified, and meets certain other requirements. Existing law, the
California Patient Protection and Affordable Care Act, creates the
California Health Benefit Exchange (Exchange), specifies the powers
and duties of the board governing the Exchange relative to
determining eligibility for enrollment in the Exchange and arranging
for coverage under qualified health plans, and requires the board to
facilitate the purchase of qualified health plans through the
Exchange by qualified individuals and qualified small employers by
January 1, 2014.
This bill would enact the Health Care Eligibility, Enrollment, and
Retention Act, which would require the California Health and Human
Services Agency, in consultation with specified entities, to
establish standardized single , accessible application
forms and related renewal procedures for Medi-Cal, the Healthy
Families Program, and the Exchange, in accordance with specified
requirements. The bill would specify the duties of the agency and the
State Department of Health Care Services under the act, and would
require the agency to report provide
specified information to the Legislature by April 1, 2012,
regarding policy changes needed to implement the bill. The bill would
otherwise be operative January 1, 2014, except as specified.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Part 3.8 (commencing with Section 15925) is added to
Division 9 of the Welfare and Institutions Code, to read:
PART 3.8. HEALTH CARE ELIGIBILITY, ENROLLMENT, AND RETENTION
ACT
15925. (a) This part shall be known, and may be cited, as the
Health Care Eligibility, Enrollment, and Retention Act.
(b) (1) By January 1, 2012, the California Health and Human
Services Agency, in consultation with the State Department of Health
Care Services (department), Managed Risk Medical Insurance Board
(MRMIB), the California Health Benefit Exchange (Exchange), counties,
health care service plans, consumer advocates, and other
stakeholders shall have undertaken a planning process to develop
plans and procedures to implement this part and the federal Patient
Protection and Affordable Care Act (PPACA) (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152), related to eligibility for, and
enrollment and retention in, public health coverage programs.
(2) The agency shall submit a report to the health
committees of both houses of the Legislature provide
the appropriate fiscal and policy committees of the Legislature with
information reflecting the process conducted pursuant to
paragraph (1) by April 1, 2012, regarding policy changes needed to
develop the eligibility, enrollment, and retention system for health
coverage in compliance with this part.
(c) The requirement for submitting a report imposed under
subdivision (b) is inoperative on January 1, 2016, pursuant to
Section 10231.5 of the Government Code.
15926. (a) The following definitions apply for purposes of this
part:
(1) "Accessible" means in compliance with the requirements of
state and federal accessibility laws, including Sections 504 and 508
of the federal Rehabilitation Act of 1973, as amended (29 U.S.C.
Secs. 794 and 794d), the federal Americans with Disabilities Act of
1990 (42 U.S.C. 12101 et seq.), Title VI of the Civil Rights Act of
1964, Section 1557 of the PPACA (42 U.S.C. Sec. 18116), and Section
11135 of the Government Code.
(2) "Limited-English-proficient" means unable to speak English
fluently.
(1)
(3) "Medi-Cal" includes all Medi-Cal programs, both
full scope and limited scope benefits, and includes Medi-Cal with a
share-of-cost.
(2)
(4) "Public health coverage programs" means Medi-Cal,
the Healthy Families Program, or the Exchange
program of premium tax credits and reduced cost sharing.
credits, or reduced-cost sharing, o r both,
the Access for Infants and Mothers Program (AIM), and, if enacted,
the Basic Health Program, as set forth in SB 703 of the 2011-12
Regular Session.
(3)
(5) "Real-time determination of eligibility" means a
final determination of eligibility made at the time the application
or retention information is submitted online.
(b) An individual shall have the option to apply for public health
coverage programs in person, by mail, online, or by telephone.
(c) A single , accessible , standardized paper,
electronic, and telephone application for public health coverage
programs shall be developed by the department in consultation with
MRMIB and the board governing the Exchange and shall be used by all
entities authorized to make an eligibility determination for any of
the public health coverage programs and by their agents. The
department shall consult with counties and stakeholders, including
consumer advocates, regarding whether to use the application
developed by the federal Secretary of Health and Human Services,
pursuant to Section 1413 of the PPACA (42 U.S.C. Sec. 18083), or
whether to develop a separate state form. If developing a state form,
the department shall consult with stakeholders in development of the
application. The application shall be tested and operational by July
1, 2013. The application forms shall satisfy all of the following
criteria:
(1) Include simple, user-friendly language and instructions.
(2) Be readily available in alternative formats and translations
including, but not limited to, braille, large font print, compact
disc, audio recording, and threshold languages. For purposes of this
part, "threshold languages" means languages spoken by at least 20,000
or more limited-English-proficient health care consumers in
California.
(2)
(3) Require only that information that is necessary to
determine eligibility for the applicant's particular circumstances.
(3)
(4) May be used for screening, but shall not be limited
to screening. The application shall be an application for public
health coverage programs at all stages of submittal, receipt, or
acceptance at any location authorized to receive or accept an
application for any of the public health coverage programs.
(5) Include questions that are voluntary for applicants to answer,
regarding demographic data categories, including race, ethnicity,
sex, primary language, disability status, and other categories
recognized by the federal Secretary of Health and Human Services
under Section 4302 of the PPACA. For race, ethnicity, and primary
language, the state shall incorporate data collection standards
recommended by the Institute of Medicine. For disability, data
collection shall include information relating to functional
limitations and impairments, such as those incorporated into the
federal American Community Survey, to collect data on disability
status.
(d) All locations of any kind where applications for any of the
public health coverage programs are received or accepted, including
physical and telephone locations and Internet Web portals or other
electronic systems, shall treat the applications described in
subdivision (c) as an application for all of the public health
coverage programs. The entity making the eligibility determination
shall enroll the applicant in the public health coverage program for
which the applicant is eligible. If an application is forwarded or
transferred between or among entities for processing, this process
shall not require the applicant to submit any new information that is
not necessary to determine her or his eligibility. The applicant
shall be informed at the time of application how to obtain
information about the status of his or her application at any time
and the information shall be promptly provided when requested.
(e) The application form described in subdivision (c) shall be
designed to identify infants under the age of one year who are deemed
eligible at birth without an application to Medi-Cal under Section
1396a(e)(4) of Title 42 of the United States Code or to the Healthy
Families Program under Section 12693.70 of the Insurance Code. An
infant who is deemed eligible shall be enrolled upon identification,
and the infant's family shall not be required to complete the
application process.
(f) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures
for public health coverage programs or other health
programs that differs from the application form described in
subdivision (c) , and related enrollment procedures, to
comply with , at a minimum, any of the following:
(1) The form and procedures used by the Child Health and
Disability Prevention Program (CHDP) Gateway under Section 14011.7 of
the Welfare and Institutions Code and by Medi-Cal's presumptive
eligibility program for pregnant women under Section 14148.7 of the
Welfare and Institutions Code for children and pregnant women in
families with income at or below 200 percent of the federal poverty
level shall be modified in the simplest way permitted by federal law
to do both of the following:
(A) Serve as an accessible application for ongoing
coverage to Medi-Cal, and, for children, to the Healthy Families
Program.
(B) Provide for a program of accelerated enrollment through which
children and pregnant women screened eligible are immediately
enrolled from the medical point of service into coverage with
benefits continuing until a final eligibility determination is made.
(2) The department shall adopt a process for prenatal care
providers to submit the application form for pregnant women required
by paragraph (1) online.
(3) The department shall adopt a process for hospitals to enroll
infants deemed eligible for Medi-Cal under Section 1396a(e)(4) of
Title 42 of the United States Code or the Healthy Families Program
under Section 12693.70 of the Insurance Code immediately online,
without an application.
(g) An applicant or recipient of a public health coverage program
shall be given the option, with his or her informed consent, to have
the application or renewal form prepopulated or electronically
verified in real time, or both, using personal information from his
or her own public health coverage program or other public benefits
case file or that of a parent or child or electronic databases
required by the PPACA.
(1) An applicant or recipient who chooses a prepopulated
application or renewal shall be given an opportunity, before the
application or renewal form is submitted to the entity authorized to
make eligibility determinations, to provide additional eligibility
information and to correct any information retrieved from a database.
(2) An applicant or recipient who chooses electronic real-time
verification shall be permitted to provide additional eligibility
information and to correct information retrieved from a database any
time before or after a final eligibility determination is made. An
applicant shall not be denied eligibility for any public health
coverage program without being given a reasonable opportunity, of at
least the kind provided for under the Medi-Cal program for
citizenship documentation, to resolve discrepancies concerning any
information provided by a verifying entity. Applicants shall receive
the benefits for which they otherwise qualify pending this reasonable
opportunity period.
(h) (1) Eligible applicants shall be granted eligibility and
immediately enrolled into a public health coverage program whenever
possible. When granting eligibility immediately is not possible for
an applicant who appears to be eligible based on the information
provided in the application, both of the following shall apply to the
fullest extent permitted by federal law with federal financial
participation:
(A) The applicant shall be immediately enrolled into a program of
presumptive eligibility for children, pregnant women, and adults.
(B) Presumptive eligibility shall continue until the applicant is
enrolled in ongoing coverage through a public health coverage
program, or found to be ineligible for all of these programs and
informed of the denial of coverage in accordance with all applicable
due process requirements.
(2) Notwithstanding paragraph (1), 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,
all of the following shall occur:
(A) The applicant shall be clearly informed of the overpayment
penalties under the 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.
(B) The applicant shall be fully informed of the penalty for
failure to have minimum essential health coverage.
(C) The applicant shall be given the option to decline immediate
enrollment while final eligibility is being determined.
(3) An applicant who is not eligible for a public health coverage
program for a reason other than income eligibility, or for any
reason if the individual resides in a county that offers a health
program for individuals with income above the maximum allowed for the
Exchange subsidies or tax credits, shall be referred to the
county health coverage program in his or her county of residence.
(i) The eligibility, enrollment, and retention system shall ensure
that applicants and recipients receive have
available assistance with their application or renewal for
public health coverage programs. Applicants and recipients shall also
be given a meaningful opportunity to provide information on their
applications and renewal forms. Applicants and recipients shall
be provided with reasonable accommodations and policy modifications
as necessary to ensure meaningful access to benefits by persons with
disabilities and limited-English-proficient individuals, including,
but not limited to, the reading aloud of information over the
telephone, assistance with filling out forms, and the ready
availability of information concerning all benefit programs in
alternative formats and translations, including interpretation in any
language and translation in threshold languages. The department
shall effectively communicate notice of the availability of the
assistance described in this section to all applicants and
recipients.
(j) At application, renewal, or a transition due to a change in
circumstances, entities making eligibility determinations for public
health coverage programs shall ensure that eligible applicants and
recipients of public health coverage programs meeting all program
eligibility requirements move seamlessly between programs without any
breaks in coverage and without being required to provide duplicative
or otherwise unnecessary verification, forms, or other information.
(k) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among Medi-Cal, the Healthy Families Program,
and the Exchange premium tax credit and reduced cost-sharing
requirements among public health coverage programs
using the least restrictive rules and requirements to ensure
that all applicants whose income is less than 400 percent of the
federal poverty level shall be determined eligible for Medi-Cal, the
Healthy Families Program, or the Exchange when they meet the
eligibility requirements and that all entities processing
applications use the same least restrictive methodologies. This
process shall include coordination of rules for determining income
levels, assets, household size, citizenship and immigration status,
and documentation and verification requirements.
(l) Renewal procedures shall be coordinated across all public
health coverage programs and among entities that accept and make
eligibility determinations so as to use all relevant information
already included in the individual's Medi-Cal, other public benefits,
the Healthy Families Program, or Exchange case file, or that of the
individual's parent or child, or electronic databases authorized for
data sharing by the PPACA to renew benefits or transfer eligible
recipients seamlessly between programs without a break in coverage
and without requiring a recipient to provide redundant information.
Renewal procedures shall be as simple and user-friendly as possible,
accessible, and shall require recipients to provide only
information that has changed, if any, and shall use all available
methods for reporting renewal information, including, but not limited
to, face-to-face, telephone, and online renewal. Families shall
be able to renew coverage at the same time for all family
members enrolled in any public health coverage program, including
when family members are enrolled in more than one public health
coverage program. A recipient shall be permitted to update his
or her eligibility information at any point.
(1) A recipient providing an update to his or her eligibility
information in between renewal dates shall be given the option to
renew eligibility at the time of the update.
(2) Eligibility for public health coverage programs shall be
automatically renewed whenever any public benefits program renewal is
conducted.
(m) The eligibility, enrollment, and retention system shall be
both transparent and accountable to the public by complying with, but
not limited to, the following:
(1) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall provide a forum in which
the public, including consumers and their advocates, may on a regular
basis, and no less than once a month, give feedback in person on the
implementation of the eligibility, enrollment, and retention
system, including system for public health
coverage programs, including, but not limited to, activities of
any public or private entity or individual providing eligibility
screening or application or retention assistance, for timely
corrective action by the department, MRMIB, and the Exchange board.
(2) In designing and implementing the eligibility, enrollment, and
retention system, the department, MRMIB, and the Exchange board
shall do both of the following:
(A) Provide for evaluation of information technology (IT)
programming by an independent expert before implementation, by
testing functionality, compliance with eligibility rules, and
accuracy of enrollment decisions. This evaluation shall be made
available to the public sufficiently in advance of implementation to
allow for an opportunity for review and comment.
(B) Provide for annual postimplementation evaluation by an
independent expert using data points developed in consultation with
stakeholders, including consumers and their advocates. This
evaluation shall be made available to the public within a reasonable
time period.
(3) The duties of the department, the California Health and Human
Services Agency, MRMIB, and the Exchange board under this subdivision
shall include the duty to monitor and oversee private as well as
public entities engaged in screening for eligibility for a public
health coverage program to ensure that the correct eligibility rules
and requirements are being used by the screener when informing an
individual about his or her potential eligibility, that updates to
the eligibility rules and requirements used by the screener are made
correctly and on a timely basis , that the screener satisfies
the assistance and accessibility provisions of subdivision (i)
, and that the screener strictly adheres to the privacy and
confidentiality provisions of subdivision (n).
(n) 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, other federal and California laws and regulations, the
Medi-Cal Program, and the Healthy Families' Program are strictly
incorporated and followed. This includes, but is not limited to,
adopting and implementing policies and procedures to ensure all of
the following:
(1) Only that information that is strictly necessary for an
eligibility determination for the individual who is seeking
enrollment in or renewal for a public health coverage program shall
be requested in the application, retention, and renewal process for
that program.
(2) Verification from a third party or database shall be sought
only with respect to information required to be obtained or verified
under federal law to determine eligibility for the public health
coverage program at issue for an individual.
(3) Applicants and recipients shall be given clear, complete,
user-friendly information regarding how their personal information
will be used, disseminated, secured, verified, and retained by public
health coverage programs.
(4) An applicant or recipient shall not be required by the
department, MRMIB, the Exchange board, or any public or private
entity or individual providing eligibility screening or application
or retention assistance to agree to the sharing of his or her
personal information without informed consent as a condition of being
screened for, applying to, or renewing eligibility for a public
health coverage program. Applicants and recipients shall have the
option to decline online screening, application, renewal, and
electronic verification and instead may apply or renew in person, by
mail, or by telephone.
(5) Responses to security breaches shall be conducted according to
the strictest requirements of privacy and confidentiality laws,
including, but not limited to, implementation of a plan to directly
provide information about the breach to anyone whose personal
information has been confirmed or suspected to have been compromised,
stolen, or viewed by anyone without authorized access.
(o) All programs shall use accessible standardized
forms and notices, as appropriate, to timely inform recipients in
advance of all of the following:
(1) What information, if any, is required from them for renewal.
(2) Whether transfer to another public health coverage program is
to occur.
(3) How the transfer will affect the recipient's cost, access to
care, delivery system, and responsibilities.
15927. Except as otherwise specified, this part shall become
operative on January 1, 2014.