BILL NUMBER: AB 1296 AMENDED
BILL TEXT
AMENDED IN SENATE SEPTEMBER 1, 2011
AMENDED IN SENATE AUGUST 30, 2011
AMENDED IN SENATE JULY 13, 2011
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 Reform Eligibility,
Enrollment, and Retention Planning 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 state health
subsidy programs, as defined, 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 provide specified information to the
Legislature by July 1, 2012, regarding policy changes needed to
implement the bill. The application development requirements of 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 REFORM ELIGIBILITY, ENROLLMENT, AND
RETENTION PLANNING ACT
15925. (a) This part shall be known, and may be cited, as the
Health Care Reform Eligibility, Enrollment, and Retention Planning
Act.
(b) (1) 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), the California Office
of Systems Integration, counties, health care service plans, consumer
advocates, and other stakeholders shall undertake a planning and
development process to implement regarding
this part and aspects of 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), and regulations or guidance issued pursuant to these
acts, related to eligibility for, and enrollment and retention in,
public health coverage state health subsidy
programs.
(2) The planning and development process shall provide
stakeholders the opportunity to provide meaningful input into the
planning and development of the aspects of eligibility, enrollment,
and retention identified in this section. This process shall be
completed in time for all of the following to occur:
(A) The certification and approval of the eligibility, enrollment,
and retention system, as required by PPACA and regulations and
guidance issued thereunder.
(B) The approval of enhanced federal funding for Medi-Cal
eligibility system development, implementation, and maintenance.
(C) The readiness of the eligibility, enrollment, and retention
processes to accept and process applications, as required by
October 2013. federal law.
(3) The planning and development process shall consider issues,
including, but not limited to, all of the following:
(A) 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.
(B) What process to use for Medi-Cal eligibility determinations
for non-Modified Adjusted Gross Income (MAGI) populations, including
whether to develop a supplemental application form and how the
applications will be processed.
(C) Whether to 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.
(D) What data collection standards to utilize for the collection
of race, ethnicity, primary language, and disability status.
(E) Whether to create a process to allow recipients to provide an
update to eligibility information in between renewal dates and to
have the option to renew eligibility at the time of the update,
resetting the renewal date.
(F) Whether to renew eligibility for a state health subsidy
program based on information from a public benefits program, if the
recipient is otherwise eligible.
(F)
(G) Protections for the confidentiality of personal
information.
(G)
(H) What process to use to enable applicants determined
eligible for and recipients of a public health coverage
state health subsidy program to choose a health
plan, if applicable.
(4) The agency shall provide the appropriate fiscal and policy
committees of the Legislature with information reflecting the process
conducted pursuant to paragraph (1) by July 1, 2012, regarding
policy and statutory changes needed to develop and implement the
eligibility, enrollment, and retention system for health coverage in
compliance with this part.
(c) The information reporting requirement imposed under paragraph
(4) of 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 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 speaking English
less than very well. not speaking English as one's
primary language and having a limited ability to read, speak, write,
or understand English.
(3) "State health subsidy programs" means the programs described
in Section 1413(e) of PPACA.
(b) An individual shall have the option to apply for state health
subsidy programs in person, by mail, online, by facsimile, or by
telephone.
(c) (1) A single, accessible, standardized paper, electronic, and
telephone application for state health subsidy 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 state health subsidy programs and by their agents.
(2) The application shall be tested and operational by the date as
required or permitted by the federal Secretary of
the Health and Human Services.
(3) The application forms form
shall, to the extent not inconsistent with federal statutes,
regulations, and guidance, satisfy all of the following criteria:
(A) Include simple, user-friendly language and instructions.
(B) Do not ask for information related to a nonapplicant that is
not necessary to determine eligibility in the applicant's particular
circumstances.
(C) Require only information necessary to support the eligibility
and enrollment processes for state health subsidy programs.
(D) May be used for, but shall not be limited to, screening.
(E) Ask , or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through a state health subsidy 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) 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.
(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
public health coverage state health subsidy
programs or other health programs that differs from the application
form described in subdivision (c), and related enrollment procedures.
(e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with consent of
the applicant in accordance with the state and federal
rules governing state health subsidy 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 renewal form or, if available,
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 state health subsidy programs may accept self-attestation,
instead of requiring an individual to produce a document, with
respect to all information needed to determine the eligibility of an
applicant or recipient, except for citizenship and
immigration status documents that may be required by the federal
Secretary of Health and Human Services. 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 PPACA and
implementing federal regulations and guidance.
(4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.
(5) An applicant shall not be denied eligibility
have his or her eligibility delayed or denied
for any state health subsidy program without being 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
(d) 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 state health subsidy 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. The responsible
entity shall adopt any available federal option as may be necessary
to ensure that an otherwise eligible applicant receives benefits
immediately.
(g) The eligibility, enrollment, and retention system shall
ensure that offer an applicant and
recipient has available assistance with his or her
application or renewal for state health subsidy programs
a state health subsidy program in person, over
the telephone, and online, 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 a public health coverage program shall
ensure that an eligible applicant and recipient of state health
subsidy programs that meets all program eligibility requirements and
complies with all necessary requests for information moves
seamlessly 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 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) An individual screened as not eligible for Medi-Cal on the
basis of Modified Adjusted Gross Income (MAGI) household income but
who may be potentially eligible for Medi-Cal on another basis shall
have his or her application or case forwarded to the Medi-Cal program
for an eligibility determination. During the period this application
or case is processed for a non-MAGI Medi-Cal eligibility
determination, the applicant or recipient shall be enrolled
or remain enrolled in the program for which the available information
indicates the applicant or recipient is eligible. if
the applicant or recipient is otherwise eligible for a state health
subsidy 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, and online renewal.
(4) Eligibility for public health coverage programs shall be
automatically renewed whenever any public benefits program renewal is
conducted if the recipient is otherwise eligible for a state health
subsidy program.
(5)
(4) An applicant who is not eligible for a state health
subsidy 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, all both of
the following shall occur:
(1) 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.
(2) The applicant shall be fully informed of
the penalty for failure to have minimum essential health coverage.
(3) The applicant shall be given the option to decline immediate
enrollment while final eligibility is being determined.
(j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among state health subsidy programs using the least
restrictive rules and requirements permitted by federal and
state law. This process shall include the coordination
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 Medi-Cal managed
care.
(l) The eligibility, enrollment, and retention system shall be
both transparent and accountable to the public by complying with, but
not limited to, all of the following:
(1) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board, as defined in Section 100500
of the Government Code, shall provide a forum in which the public,
including consumers and their advocates, may on a regular basis, and
no less than quarterly, give feedback in person on the eligibility,
enrollment, and retention system for state health subsidy 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 provide for an annual postimplementation evaluation by an
independent expert to ensure that the business rules comply with the
correct eligibility rules of the health programs. This evaluation
shall be made available to the public.
(3) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board under this subdivision shall
have the duty to monitor and oversee private, as well as public,
organizational entities engaged in screening for eligibility for a
public health coverage program to ensure that the correct eligibility
rules and requirements are being used.
(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, the Confidentiality of Medical Information Act of
1996 (CMIA) (Part 2.6 (commencing with Section 56) of Division 1 of
the Civil Code), the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) (42 U.S.C. Sec. 1320d et seq.), and the Health
Information Technology for Economic and Clinical Health Act (HITECH)
(Public Law 111-5), the Medi-Cal program, and the Healthy Families
Program are strictly incorporated and followed. This includes, but is
not limited to, securing protected health information transmitted
through electronic media and adopting and implementing policies and
procedures to ensure all of the following:
(1) Only 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, in a manner consistent
with the privacy and disclosure requirements set forth in HIPPA,
CMIA, and HITECH.
(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 in a manner consistent with the privacy and
disclosure requirements set forth in HIPPA and HITECH.
(4) Responses to
security breaches shall be conducted according to the requirements of
privacy and confidentiality laws. 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 and after January 1, 2014.