BILL ANALYSIS �
AB 1296
Page 1
Date of Hearing: May 3, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1296 (Bonilla) - As Amended: April 25, 2011
SUBJECT : Health Care Eligibility, Enrollment, and Retention
Act.
SUMMARY : Enacts the Health Care Eligibility, Enrollment, and
Retention Act. Specifically, this bill :
1)Requires, by January 1, 2012, the California Health and Human
Services Agency (CHHSA), in consultation with the Department
of Health Care Services (DHCS), Managed Risk Medical Insurance
Board (MRMIB), the California Health Benefit Exchange
(Exchange), counties, health care services plans, consumer
advocates, and other stakeholders to undertake a planning
process to develop plans and procedures to implement the
federal Patient Protections and Affordable Care Act (PPACA)
related to eligibility, enrollment, and retention with regard
to public health coverage programs.
2)Requires CHHSA to submit a report to the health committees of
both houses of the Legislature by April 1, 2012 regarding
policy changes needed to develop the eligibility, enrollment,
and retention system for health coverage.
3)Defines Medi-Cal, public health coverage programs, and
real-time determination for the purposes of this bill.
4)Requires that a person have the option to apply for public
health coverage in person, by mail, online, and by telephone.
5)Requires DHCS to develop, in consultation with MRMIB and the
Exchange, a single standardized paper, electronic, and
telephone application form to be used by all entities
authorized to make eligibility determinations and that meets
specified criteria as follows:
a) Uses simple, user friendly language and instructions;
b) Requires only the information necessary to determining
eligibility for the applicant's particular circumstances;
and,
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c) May be used for screening, but shall be an application.
6)Requires the entity receiving the application to treat it as
an application for all public coverage programs and enroll the
applicant in the most beneficial program the applicant is
eligible for.
7)Prohibits an applicant from being required to submit new
information that is not necessary to determine eligibility if
an application is transferred to other entities for processing
and requires the applicant to be informed as to how to obtain
information regarding the status of the application.
8)Requires the application and process to be designed to
identify infants who are in the category to be deemed eligible
at birth and to be automatically enrolled without the
necessity of completing the application process.
9)Authorizes the existing provider-based application and process
used for the Child Health and Disability Prevention (CHDP)
Gateway and presumptive eligibility for pregnant women in
families with income up to 200% of the federal poverty level
(FPL) program to be modified in the simplest possible way and
used as an application for ongoing coverage for Medi-Cal and
the Healthy Families Program (HFP) and for a program of
accelerated enrollment from the medical point of service.
Requires DHCS to adopt a process for prenatal care providers
to submit the application form for pregnant women online and
for hospitals to enroll eligible infants online immediately
without an application.
10)Requires applicants or recipients seeking renewal to be
provided with an option that prepopulates the application
fields or is electronically verified in real time or both and
includes opportunities to provide additional information or
make corrections.
11)Requires eligibility and enrollment into a public coverage
program to be granted immediately if possible, and if not,
requires presumptive eligibility until a determination of
ineligibility to the fullest extent permitted under federal
law and also requires that prior to the online enrollment of a
person into the Exchange, the person is to be informed of
overpayment penalties and the ability to avoid them by prompt
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reporting, the penalty for failure to have minimum coverage,
and is given the option to decline immediate enrollment while
final eligibility is determined.
12)Requires the eligibility, enrollment, and retention system to
ensure assistance with understanding decisions to be made
including hardship exemptions, individual mandate, premium tax
credit and cost sharing reductions for the Exchange, penalties
for overpayments, verification, and plan choice.
13)Requires applicants and recipients to be given an opportunity
to provide information that ensures enrollment in the most
beneficial program for which they are eligible.
14)Requires seamless transition between programs at application,
renewal, and transition without breaks in coverage and without
the person being required to provide duplicative or
unnecessary verification, forms, or other information.
15)Requires DHCS to develop procedures to ensure continuity at
specified changes in circumstances.
16)Requires DHCS, in coordination with MRMIB and the Exchange to
streamline and coordinate eligibility rules and requirements
among the Medi-Cal, HFP, and Exchange premium tax credit and
reduced cost-sharing programs using the least restrictive
rules and requirements to ensure that applicants with family
income under 400% FPL obtain enrollment and that all entities
that are processing applications use the least restrictive
methodologies.
17)Requires renewal procedures to be coordinated across all
public health coverage programs so as to enable the use of
relevant information already in a person's or parent or
child's case file or electronic database, as allowable under
federal law, to in order to renew or transfer seamlessly and
without a break in coverage.
18)Requires renewal procedures to be as simple and user-friendly
as possible, requires only the provision of information that
has changed and allows face-to-face, telephone, and online
renewal.
19)Requires, to the maximum extent permitted under federal law,
a recipient be allowed to update eligibility information at
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any point and an option to renew eligibility
20)Requires all programs to use standardized forms and notices
to timely inform recipients in advance regarding the
information required for renewal, whether transfer to another
program is to occur and how the transfer will affect the
recipients cost, access to care, delivery system, and
responsibilities.
21)Requires the eligibility, enrollment, and retention system to
be transparent and accountable by requiring DHCS, CHHSA,
MRMIB, and the Exchange to provide a public forum on a regular
basis for in person feedback including public or private
entities providing application screening and other activities.
22)Requires DHCS, MRMIB, and the Exchange to provide for a
publicly available evaluation of the information technology
programming by an independent expert.
23)Requires a publicly available annual postimplementation
evaluation by an independent expert using data points
developed in consultation with stakeholders.
24)Specifies that the duties of the CHHSA, MRMIB, DHCS and the
Exchange include the duty to monitor and oversee private as
well as public entities that are screening for eligibility.
25)Requires that DHCS , MRMIB, and the Exchange ensure that all
privacy and confidentiality rights under specified state and
federal law are strictly incorporated and followed to ensures:
a) Only information strictly necessary is requested;
b) Verification from a third party or database is sought
only with regard to information required under federal law;
c) Applicants and recipients are given clear and complete
information regarding the use of the information;
d) Informed consent is obtained and an option to decline
online screening and electronic verification;
e) A plan to respond to any breach including notice to
anyone whose personal information has been the subject of
unauthorized access.
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EXISTING LAW :
1)Establishes the federal Medicaid Program, Medi-Cal in
California, administered by DHCS, to provide comprehensive
health care services and long-term care to pregnant women,
children, and people who are aged, blind, and disabled.
2)Requires each state, by January 1, 2014, to establish an
American Health Benefit Exchange that makes qualified health
plans available to qualified individuals and qualified
employers.
3) Requires, under federal law, by January 2014, that states
offer Medicaid coverage to all adults, under age 65, with
income up to 133% of FPL and authorizes a phase-in.
4)Requires, under federal law, by January 2014, that state
enrollment systems for persons eligible for health subsidy
programs meet specified standards.
5)Establishes MRMIB and authorizes it to administer HFP, the
Access for Infants & Mothers (AIM) Program, the Major Risk
Medical Insurance Program (MRMIP), and the Pre-Existing
Condition Insurance Pan (PCIP).
6) Requires DHCS to seek federal approval of a Comprehensive
Medicaid Demonstration Waiver and establishes the
county-optional Low-Income Health Program (LIHP) and Medicaid
Coverage Expansion as a Demonstration Waiver.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, AB 1602 (John
A. P�rez), Chapter 655, Statues of 2010, and SB 900 (Alquist)
Chapter 659, Statutes of 2010, initiated the process to offer
health care coverage options to Californians by, among other
things, creating the structure and basic duties of the
Exchange. The author argues that the prior bills did not
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establish the system required by PPACA to determine
eligibility for enrolling consumers in health coverage.
According to the author, the PPACA requires a seamless "no
wrong door" application system so that wherever a consumer
applies he/she is enrolled into the program for which he/she
is eligible.
The author explains that by enacting the Health Care
Eligibility, Enrollment and Retention Act, this bill
implements the PPACA requirement to create a single statewide
application to be used by all entities accepting and
processing applications for enrolling consumers in health
coverage. The author argues that the system must be available
to apply by phone, in person, by mail, or online for enrolling
into Medi-Cal, HFP, the Exchange, and county health programs.
2)BACKGROUND . Under the new federal health reform law, most
U.S. citizens and legal residents will be required to have
health insurance beginning in 2014. It is estimated that 4.7
million California children and adults who were uninsured
during some part of 2009 will be eligible for health coverage
under PPACA. The new law establishes a state-based system of
health insurance Exchanges and expands Medicaid to make
coverage readily available to millions of uninsured people.
The PPACA requires states to change their Medicaid and State
Children's Health Insurance Program (SCHIP), (HFP in
California) eligibility rules in three fundamental ways: a)
states must change the way income is counted for the purpose
of determining eligibility; b) states must eliminate the asset
test for most populations; and, c) states must make a
series of changes intended to improve the process for
determining and maintaining eligibility for their public
programs. According to a Kaiser Family Foundation (KFF),
October 2010 Report, "Explaining Health Reform: Building
Enrollment Systems that Meet the Expectation of the Affordable
Care Act" Congress included strong provisions designed to
ensure that state enrollment policies and procedures and
supporting technology systems genuinely help individuals and
families enroll and stay covered, and also foster efficient
administration.
3)EXCHANGE . California exercised the option under PPACA to
establish a California Exchange. The Exchange Board has five
members (four of which have been appointed) and held its first
meeting April 20. 2011. The Board voted to pursue a Level II
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federal planning grant to support the establishment of the
Exchange and to submit the grant on September 30, 2011. The
Board will meet next on May 11of this year and will discuss
health insurance markets, program integration of public health
care programs, public health and social services programs, the
Basic Health Plan option, and the Small Business Health
Options Program Exchange requirements. California previously
received a $1 million State Planning and Establishment Grant.
4)ENROLLMENT SIMPLIFICATION . The PPACA includes provisions
aimed at simplifying eligibility and enrollment procedures for
Medicaid and SCHIP, and ensuring coordination with coverage
available through the newly created state Exchanges.
According to the KFF Report, by January 1, 2014, California
must implement a series of procedures that simplify enrollment
in Medi-Cal and HFP and coordinate with the State's Exchange,
or risk losing federal Medi-Cal and HFP funding. Required
enrollment simplification and coordination procedures include:
a) Utilizing a single, streamlined application form for
Medi-Cal, HFP, subsidies for coverage through the Exchange,
and the Basic Health Program;
b) Establishing a Website that permits individuals to apply
to, enroll in, and renew enrollment in Medi-Cal, and to
consent to enrollment or reenrollment in such coverage
through electronic signature;
c) Ensuring that individuals who seek coverage through
Medi-Cal, HFP, or the Exchange are concurrently screened
for eligibility for all three options (including Exchange
coverage subsidies and the Basic Health Program) and
referred to the appropriate program for enrollment, without
having to submit additional or separate applications for
each program;
d) Requiring development of secure electronic interfaces to
exchange available data to the maximum extent practicable
to establish, verify, and update eligibility; and,
e) Establishing procedures for conducting outreach to and
enrolling vulnerable populations, including children,
homeless youth, children and youth with special health care
needs, pregnant women, and racial and ethnic minorities.
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5)CURRENT ELIGIBILITY AND ENROLLMENT . There are a multiplicity
of existing rules and mechanisms for the enrollment,
eligibility and renewal for persons covered by public programs
which varies depending on the program and the person's
individual circumstances. Below is a non-exhaustive
description of the most significant:
a) Automatic eligibility . Some individuals may be eligible
for Medi-Cal without an application such as persons who are
low-income seniors or persons with disabilities. These
individuals also qualify for programs such as the
Supplemental Security Income/State Supplementary Payment
(SSI/SSP) program. Individuals or families in other cash
assistance programs such as Cal WORKS and Foster Care
children are also automatically eligible but an application
must be processed by the county.
b) Application submission . Generally, those who do not get
Medi-Cal automatically must apply. Applications can be
submitted in person, by mail, or online to the local
Department of Social Services. The application process can
also be started over the phone with the county, though the
process must be completed in person or by mail. This
category includes children and families and the eligibility
rules vary depending on the child's age and the income
level of the family which is expressed as a percentage of
FPL.
c) Seniors and Persons with Disabilities not on SSI .
Seniors and Persons with Disabilities, including children,
in addition to those receiving SSI, may be eligible for
Medi-Cal but must submit an application and there are
maximum income and property limits.
d) Medi-Cal/HFP Single Point of Entry (SPE) . SPE screens
pregnant women and children for eligibility in either
Medi-Cal or HFP and an application may be submitted by mail
or online through Health-e-App. SPE conducts an initial
screening for Medi-Cal and HFP. Enrollment in HFP is
through a vendor.
e) Non HFP children . For a child who appears eligible for
Medi-Cal after the SPE screening, the actual Medi-Cal
eligibility determination does not occur until the
application is forwarded to the county and a county
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eligibility worker makes the Medi-Cal eligibility
determination. Children are continuously eligible for one
year without the requirement of a redetermination.
Children who appear to qualify for full-scope, no share of
cost Medi-Cal and whose joint application is sent to SPE
are eligible for Accelerated Enrollment. Accelerated
Enrollment for children offers temporary, free Medi-Cal
benefits after the child's application has been screened by
SPE and is awaiting a final Medi-Cal determination by the
county welfare department.
f) Out stationing . Pregnant women and children can
complete a short-form application at certain hospitals and
clinics where county eligibility workers are stationed.
California provides temporary Medi-Cal coverage to pregnant
women while their Medi-Cal applications are being
processed. Pregnant women who have completed a shortened
application and are found to be presumptively eligible for
Medi-Cal receive ambulatory prenatal services. For
pregnant women found to be eligible for regular Medi-Cal,
their presumptive eligibility period ends when the positive
Medi-Cal determination is made. For those women found to
be ineligible for regular Medi-Cal, their presumptive
eligibility period ends the last day of the month in which
the negative Medi-Cal determination is made.
g) Infants . Infants born to a mother on Medi-Cal are
automatically eligible for Medi-Cal for their first year.
The mother is required to notify the county eligibility
office.
h) Provider eligibility . Doctors can request immediate
temporary Medi-Cal coverage for pregnant women and children
while they apply for the Medi-Cal Program.
i) Breast and Cervical Cancer Treatment Program (BCCTP) .
Women who appear to qualify for the federal BCCTP can also
obtain Accelerated Enrollment. Under Accelerated
Enrollment, they receive temporary, full-scope Medi-Cal
coverage while the State's eligibility specialist makes a
final eligibility determination.
j) CHDP . Children receiving CHDP Program services may
pre-enroll in Medi-Cal or HFP through the CHDP provider
while they await an eligibility determination for those
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programs. The temporary services are provided for two
months, or until the child is determined eligible for
Medi-Cal or HFP, whichever comes later.
aa) Express Lane Eligibility . Families who receive food
stamps can permit information from their Food Stamp Program
application to be used to determine their eligibility for
Medi-Cal and HFP. Additionally, Express Lane Eligibility
allows schools to release information from a child's
National School Lunch Program application in order to
pre-enroll a child receiving free meals into Medi-Cal until
a final determination is made by the county welfare
department.
bb) Program transfer . A Medi-Cal beneficiary's eligibility
for all Medi-Cal programs must be evaluated before the
individual's benefits can be terminated. If the
beneficiary is found eligible for another Medi-Cal program
an eligibility worker into that program can automatically
transfer the enrollee into the other program. This
process should always occur without the need for a
beneficiary to submit a new application. If, however,
continued Medi-Cal eligibility cannot be established by ex
parte review, then the county must attempt to contact the
beneficiary by telephone.
cc) AIM, MRMIP and PCIP . MRMIB also administers AIM, MRMIP
and PCIP. AIM is a subsidized insurance program for
mid-income pregnant women and the application is by mail.
Children born to AIM mothers are eligible for HFP. MRMIP
and PCIP are subsidized insurance programs for persons who
are uninsurable due to pre-existing conditions. There is a
joint application for the two programs and it is done by
mail.
dd) County health programs . Counties are required to
provide medical services for medically indigent persons.
Each county establishes its own eligibility and application
process. The Section 1115 Medi-Cal Demonstration waiver
"Bridge to Reform" and AB 342 (John A. P�rez), Chapter 723,
Statutes of 2010, establishes the county-optional LIHP and
Medicaid Coverage Expansion as a Demonstration Waiver to
cover low-income childless adults under age 65. Counties
are allowed to set eligibility levels up to 200% of FPL but
must cover up all persons up to 133% FPL before allowing
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persons above 133% to enroll. Counties set eligibility
income standards, methodologies, and procedures. The
federal Center for Medicare and Medicaid Services (CMS)
required eligibility determination to be made by state or
local government employees.
6)SUPPORT . Western Center on Law and Poverty (WCLP), sponsor of
this bill, states in support that in today's health care
market the onus is largely on the consumer to figure out what
health coverage program to apply for and to submit a new
application when moving from one health coverage program for
another. For example, a consumer who applies for California's
high risk pools but is eligible for Medi-Cal would have to
submit a separate application to Medi-Cal. According to WCLP,
there is currently no mechanism for the state to transfer an
adult's application for one program to initiate an application
for another program. WCLP further argues that the PPACA
changes that - requiring that for example if someone applies
for Medi-Cal but is eligible for the Exchange they are
enrolled into the Exchange, and vice versa. According to
WCLP, California does have a joint application for children
for Medi-Cal and HFP, but will now have to integrate the
process for applying for the Exchange and county health
coverage programs with applying for Medi-Cal. This will
require a new level of coordination among agencies and
departments including CHHSA, DHCS which administers the
Medi-Cal Program, MRMIB which administers HFP, the new
California Exchange Board, and counties which determine
eligibility for Medi-Cal and administer their own county
health programs. WCLP further states that it is important
both that these entities coordinate on developing and
implementing the eligibility, enrollment, and retention system
and that if a particular department or entity has overall
responsibility for a particular component of the system that
that is explicitly laid out. Clear lines of authority are
needed so that if problems arise stakeholders know what entity
has responsibility for what pieces of the system.
7)RELATED AND PRIOR LEGISLATION .
a) AB 714 (Atkins) of 2011 requires a notification to
individuals who have ceased to be enrolled in specified
public health care coverage programs and to individuals
receiving services under specified health programs
regarding potential eligibility for health care coverage
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through the Exchange. AB 714 is pending in the Assembly
Appropriations Committee.
b) AB 792 (Bonilla) of 2011 requires the disclosure of
information on health care coverage through the Exchange,
under specified circumstances, by health care service
plans, health insurers, employers, employee associations,
the Employment Development Department, upon an initial
claim for disability benefits, or by the court, upon the
filing of a petition for dissolution of marriage, nullity
of marriage, legal separation, or adoption. AB 792 is
pending in the Assembly Appropriations Committee.
c) AB 43(Monning) of 2011 expands Medi-Cal coverage to
persons with income that does not exceed 133% FPL,
effective January 1, 2014. AB 43 is pending in the
Assembly Appropriations Committee.
d) AB 1066 (John A. P�rez) of 2011 enacts technical and
conforming statutory changes necessary to conform to the
Special Terms and Conditions required by CMS in the
approval of the Bridge to Reform Demonstration, including
changing the name of the LIHP from Coverage Expansion and
Enrollment Projects to Medi-Cal Coverage Expansion and the
Health Care Coverage Initiative. AB 1066 is pending in the
Assembly Appropriations Committee.
e) AB 342 (John A. P�rez), Chapter 723, Statutes of 2010,
enacted the LIHP and Coverage Expansion and Enrollment
Projects to provide health care benefits to uninsured
adults up to 200% of the FPL, at county option through a
Medi-Cal waiver demonstration project.
f) SB 208 (Steinberg), Chapter 714, Statutes of 2010,
implemented provisions of the 2010 Section 1115 replacement
waiver including the Delivery System Reinvestment and
Improvement Pool, authorized DHCS to require the mandatory
enrollment of seniors and people with disabilities in a
Medi-Cal managed care plan and required DHCS to implement
pilot projects to provide coordinated care to children in
the California Children's Services and to persons who are
eligible for Medi-Cal and Medicare.
g) AB 1595 (Jones) of 2010, would have required DHCS to
expand Medi-Cal eligibility to individuals with family
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income up to 133% of FPL without regard to family status by
January 1, 2014. AB 1595 died on suspense in the Assembly
Appropriations Committee.
h) AB 1602 (John A. P�rez), Chapter 655, Statutes of 2010,
establishes the Exchange as an independent public entity to
purchase health insurance on behalf of Californians with
incomes of between 100% and 400% FPL and employees of small
businesses. Clarifies the powers and duties of the board
governing the Exchange relative to the administration of
the Exchange, determining eligibility and enrollment in the
Exchange, and arranging for coverage under qualified
carriers
i) SB 900 (Alquist), Chapter 659, Statutes of 2010,
establishes the Exchange. Requires the Exchange to be
governed by a five-member board, as specified.
8)TECHNICAL AMENDMENTS . The author is proposing the following
technical amendments:
a) Page 3 line 16:
(b) An individual shall have the option to apply for public
health coverage programs in person, by mail, online, and or
by telephone.
b) Page 3 line 22:
(c) A single, standardized paper, electronic, and telephone
application form for public health coverage programs shall
be developed by the department in consultation with MRMIB
and the Exchange Board 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 stakeholders including
counties and consumer advocates in the development of the
application. The application shall be tested and
operational by July 1, 2013. The application forms:
c) Page 3 line 28:
screening. The application form instead shall be an
application
d) P. 5 line 6:
electronically verified in real time, or both, using person al
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e) Page 5 line 25:
(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 in Medi-Cal
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.
f) Page 6 line 17:
(i) The Eligibility, Enrollment, and Retention system shall
ensure that applicants and recipients receive assistance
with their application or renewal for public health
coverage programs t o understand decisions they may make ,
including but not limited to those concerning hardship
exemptions from the individual mandate, the premium tax
credit and cost-sharing reductions for the Exchange and
penalties for overpayments, verifications, and plan choice.
Applicants and recipients shall also be given a meaningful
opportunity to provide information on their applications
and renewal forms that ensures their enrollment in, and
retention of, health care coverage, in the most beneficial
program for which they are eligible.
g) Page 7 line 32:
(1) To the maximum extent allowed under federal law, a A
recipient shall be permitted to update her or his
eligibility information at any point and thereby restart
the period for her or his annual redetermination . 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 with sufficient information to renew health
coverage is conducted.
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REGISTERED SUPPORT / OPPOSITION :
Support
Western Center on Law and Poverty (sponsor)
100% Campaign
American Federation of State, County and Municipal Employees,
AFL-CIO
California Academy of Family Physicians
California Children's Health Initiative
California Communities United Institute
California Mental Health Directors Association
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation
California School Health Centers Association
California State Association of Counties
Children Now
Children's Defense Fund
Contra Costa County Board of Supervisors
County Health Executives Association of California
County Welfare Directors Association
Health Access California
National Alliance on Mental Illness, California
PICO California
The Children's Partnership
United Nurses Association of California/Union of Health Care
Professionals
United Way
Urban Counties Caucus
Youth Law Center
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097