BILL ANALYSIS �
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THIRD READING
Bill No: AB 1296
Author: Bonilla (D)
Amended: 8/30/11 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 6-3, 7/6/11
AYES: Hernandez, Alquist, De Le�n, DeSaulnier, Rubio, Wolk
NOES: Strickland, Anderson, Blakeslee
SENATE APPROPRIATIONS COMMITTEE : 6-3, 8/25/11
AYES: Kehoe, Alquist, Lieu, Pavley, Price, Steinberg
NOES: Walters, Emmerson, Runner
ASSEMBLY FLOOR : 51-27, 6/2/11 - See last page for vote
SUBJECT : Health Care Eligibility, Enrollment, and
Retention Act
SOURCE : Western Center on Law and Poverty
DIGEST : This bill establishes the Health Care
Eligibility, Enrollment, and Retention Act. This bill
requires the California Health and Human Services Agency,
by January 1, 2012, in consultation with other state
departments and stakeholders, to have undertaken a planning
process to develop plans and procedures to implement these
provisions relating to enrollment in public programs and
federal law. This bill requires that an individual would
have the option to apply for public programs through a
variety of avenues, would specify the application form,
CONTINUED
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establish presumptive eligibility for all populations, and
establish other requirements related to renewal and
transfer of coverage between programs.
ANALYSIS : Existing federal law:
1. Requires, under the federal Patient Protection and
Affordable Care Act (PPACA) (Public Law 111-148), as
amended by the Health Care Education and Reconciliation
Act of 2010 (Public Law 111-152), each state, by January
1, 2014, to establish an American Health Benefit
Exchange (federal Exchange) that makes qualified health
plans available to qualified individuals and qualified
employers. If a state does not establish a federal
Exchange, the federal government administers the federal
Exchange.
2. Establishes requirements for the federal Exchange, for
health plans participating in the Exchange, and defines
who is eligible to receive coverage in the federal
Exchange. Among other duties, the federal Exchange is
required to inform individuals of eligibility
requirements for the Medicaid program (Medi-Cal in
California), the Children's Health Insurance Program
(CHIP is known as the Healthy Families Program, or HFP,
in California), or any applicable state or local public
program. The federal Exchange is required if, through
screening of the application, the federal Exchange
determines that such individuals are eligible for any
such program, to enroll such individuals in such
program.
3. Allows through PPACA, effective January 1, 2014,
eligible individual taxpayers whose household income
equals or exceeds 100 percent, but does not exceed 400
percent of the federal poverty level (FPL), an
advanceable and refundable tax credit for a percentage
of the cost of premiums for coverage under a qualified
health plan offered in the Exchange. PPACA also
requires a reduction in cost sharing for individuals
with incomes below 250 percent of the FPL, and a lower
maximum limit on out-of-pocket expenses for individuals
whose incomes are between 100 percent and 400 percent of
the FPL. Legal immigrants with household incomes less
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than 100 percent of the FPL who are ineligible for
Medicaid because of their immigration status are also
eligible for the premium tax credit and the cost sharing
reductions.
4. Requires, through PPACA, numerous changes to Medicaid,
including simplifying Medicaid enrollment, requiring
coordination with the federal Exchange, expanding
Medicaid eligibility to adults without minor children
with incomes equal to or less than 133 percent of the
FPL, disregarding (or not counting) an additional five
percent in income (making the Medicaid income
eligibility effectively 138 percent of the FPL),
eliminating the asset test for individuals under age 65
and switching to a new method for calculating income
known as modified adjusted gross income for certain
populations.
5. Requires, through PPACA, the federal Secretary of Health
and Human Services (HHS) to establish a system meeting
specified requirements under which residents of each
state can apply for enrollment, receive a determination
of eligibility for participation, and continue
participation in, applicable state health subsidy
programs (defined as Medicaid, CHIP, Exchange, and the
Basic Health Program �BHP]).
6. Requires this system to ensure that if an individual
applying to an Exchange is found through screening to be
eligible for medical assistance under Medicaid, or
eligible for enrollment under CHIP, the individual to be
enrolled for assistance under such plan or program.
7. Requires, through PPACA, each individual, with specified
exceptions, and any dependent of the individual, to
maintain minimum essential coverage; provides exemptions
from the individual mandate, such as for affordability,
hardship, and for individuals with incomes below the
income tax filing threshold, and establishes penalties
for violations.
Existing state law:
1. Provides for the Medi-Cal program, which is administered
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by the Department of Health Care Services (DHCS), under
which qualified, low-income individuals receive health
care services.
2. Establishes the Exchange in state government, and
specifies the duties and authority of the Exchange.
Requires the Exchange be governed by a board that
includes the Secretary of the California Health and
Human Services Agency (CHHS) and four members with
specified expertise who are appointed by the Governor
and the Legislature.
This bill requires CHHS, by January 1, 2012, in
consultation with the DHCS, the Managed Risk Medical
Insurance Board (MRMIB), the California Health Benefit
Exchange (Exchange), counties, health care service plans,
consumer advocates, and other stakeholders, to have
commenced a planning process to develop plans and
procedures to implement the enrollment and renewal
requirements established by these provisions and by PPACA.
CHHS would be required to provide information on the
process regarding policy changes needed to develop the
eligibility, enrollment, and retention system for health
care coverage to the Legislature by April 1, 2012. This
bill requires DHCS to develop a standardized application
for all public health coverage programs. These provisions,
except where otherwise specified, become operative January
1, 2014.
This bill permits an individual to have the option to apply
for public health coverage programs in person, by mail,
online, or by telephone. This bill specifies that there
should be a program of accelerated enrollment through which
children and pregnant women may enter public coverage at
the point of medical service, that infants would be deemed
eligible without an application at a hospital, real-time
verification, information pre-population, and presumptive
eligibility for children, pregnant women, and other adults,
among other specified requirements.
This bill, commencing January 1, 2012, would:
1. Require the planning process to be led by CHHS to allow
for stakeholders to provide meaningful input into the
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planning and development of the aspects of eligibility,
enrollment, and retention identified in these
provisions;
2. Require the planning and development process to consider
at least the following issues:
A. Whether or not to develop a state specific
enrollment form;
B. What process to use to establish Medi-Cal
eligibility for non-modified adjusted gross income
individuals;
C. A hospital process to immediately enroll infants
eligible for Medi-Cal and the Healthy Families
Program;
D. What data collection standards should be utilized
to collect specified information;
E. A process to allow individuals to update
eligibility information at times other than renewal
and to have the option to renew eligibility at the
time of the update;
F. Confidentiality protections;
G. How to enable applicants to select health plans.
This bill, commencing January 1, 2014, would:
1. Permit an individual to apply for coverage via
facsimile;
2. Require DHCS to develop a single, accessible application
as part of the planning process above and require the
form to be used by all entities permitted to determine
eligibility for state subsidy programs.
3. Require the application to be tested and operational by
the date as required by the CHHS Secretary.
4. Modify the prepopulation requirements to be dependent
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upon the capabilities of the yet to be developed
eligibility and enrollment system;
5. Permit state health subsidy programs to accept
self-attestation;
6. Require electronic verification in a manner as provided
by PPACA;
7. Provide for automatic renewal if the recipient is
otherwise eligible for a public health coverage program.
Note:
According to the Senate Appropriations Committee, the
latest version of this bill eliminates "costly provisions
of the bill including the requirement to provide
presumptive eligibility and other requirements that would
have decreased CHHS' flexibility in implementing the PPACA.
Thus costs would be reduced significantly. The planning
process would likely require resources in the hundreds of
thousands of dollars and would be federally funded. Actual
expenditures would depend on the scope, extent, and
duration of the planning process. It is unknown what the
provisions commencing January 1, 2014, would require in
terms of resources, but it is likely to be significant and
would probably be integrated into the respective Exchange,
Medi-Cal, and Healthy Families eligibility divisions as
well as the development and implementation of the
enrollment information technology system, which would be
100 percent federally funded."
Background
Federal health care reform and coverage expansions
Federal health care reform makes numerous changes to reduce
the number of uninsured Americans. According to estimates
in a 2011 study in the health policy journal, Health
Affairs, by Peter Long and Jonathan Gruber, PPACA will
provide health insurance for an additional 3.4 million
people in California in 2016. The authors state this will
mean that nearly 96 percent of documented residents of
California under age 65 will be insured. The authors
estimate enrollment in Medi-Cal is expected to increase by
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1.7 million people, while 4.0 million people are expected
to enroll in the state's Exchange. Employer-sponsored
insurance and spending on health insurance will decline
slightly. The authors conclude that low-income households
will experience substantial financial benefits, but
families at the highest income levels will pay more.
PPACA changes to eligibility and enrollment processing
Under state law, counties, except for certain applicants,
perform eligibility and enrollment on behalf of the state
for Medi-Cal. Medi-Cal eligibility is complex, with over
160 different aid codes, and different income and asset
rules for particular groups.
Applicants can apply in person and through the internet.
Unless there is good cause, counties are required to
complete the determination of eligibility as quickly as
possible, but no later than any of the following: (a) 45
days following the date the application, reapplication or
request for restoration is filed, and (b) 90 days following
the date the application, reapplication or request for
restoration is filed when eligibility depends on
establishing disability or blindness. Federal law requires
eligibility determination for participation in a state
Medicaid program to be determined by a public agency.
In addition to the county eligibility process, Medi-Cal
permits a health care provider to "presume" a pregnant
woman is eligible for Medi-Cal based on her answers to a
few income and residency questions through the presumptive
eligibility program. To encourage early prenatal care, a
woman can be presumptively enrolled into Medi-Cal through a
qualified provider or clinic with the agreement that she
will later complete an application for Medi-Cal. The
beneficiary must then start the formal Medi-Cal application
process by the end of the month following the month the
temporary presumptive benefits started. The CHDP Gateway
allows eligible children and youth to receive up to two
months of full-scope Medi-Cal pre-enrollment eligibility.
CHDP providers can pre-enroll eligible patients into
Medi-Cal using the CHDP Gateway Internet transaction.
MRMIB contracts with enrollment contractors to perform
eligibility and enrollment for the four programs it
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administers, and applicants apply by phone and through the
mail (and through the internet for the HFP). MRMIB
establishes application processing timeframes through
regulation (10 to 30 days, depending upon the MRMIB
program).
California does have a common application that can be used
for all public health programs, although the state has a
joint application for children for Medi-Cal and HFP that is
used to screen applicants to determine if they are
income-eligible for either program. Children who complete
the joint application apply through the Single Point of
Entry (SPE), and those that appear eligible for Medi-Cal
receive immediate, accelerated enrollment. Accelerated
enrollment begins on the first day of the month that the
SPE receives the application and continues until the child
is determined eligible for Medi-Cal or the end of the month
in which the child is found ineligible.
PPACA makes numerous changes to simplify enrollment in
public health coverage programs. PPACA requires that an
enrollment system be created that allows state residents to
apply for enrollment, receive an eligibility determination,
and renew participation in state health subsidy programs.
In addition, PPACA requires the Secretary of DHHS to
develop and provide to each state a single, streamlined
form that:
1. May be used to apply for all applicable state health
subsidy programs (Medi-Cal, HFP, Exchange, and the BHP);
2. May be filed online, in person, by mail, or by
telephone;
3. May be filed with an Exchange or with state officials
operating one of the other applicable state health
subsidy programs;
4. Is structured to maximize an applicant's ability to
complete the form satisfactorily, taking into account
the characteristics of individuals who qualify for
applicable state health subsidy programs.
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PPACA permits a state to develop and use its own single,
streamlined form as an alternative to the federal form if
the alternative form is consistent with standards
promulgated by the Secretary.
PPACA also requires each state to develop, for all
applicable state health subsidy programs, a secure,
electronic interface allowing an exchange of data,
including information contained in the application forms,
that allows a determination of eligibility for all such
programs based on a single application.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
Fiscal Impact (in thousands)
Major Provisions 2011-12 2012-13 2013-14 Fund
CHHS planning process likely in the hundreds of
thousands of Federal
dollars through January 1, 2014, and
possibly beyond
Ongoing administration unknown, potentially
significant, General/
commencing January 1, 2014Federal/
Special
*50 percent General Fund, 50 percent federal funds, unless
additional federal or private funds are made available.
SUPPORT : (Verified 8/29/11)
Western Center on Law and Poverty (source)
100% Campaign
American Federation of State, County and Municipal
Employees
California Academy of Family Physicians
California Children's Health Initiatives
California Chiropractic Association
California Communities United Institute
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California Coverage and Health Initiatives
California Family Resource Association
California Optometric Association
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation
California School Health Centers Association
Children Now
Congress of California Seniors
Consumers Union
Contra Costa County Board of Supervisors
Disability Rights California
Disability Rights Education and Defense Fund
Disability Rights Legal Center
First 5 Association of California
Having Our Say
Health Access California
Latino Coalition for a Healthy California
Latino Health Alliance
Maternal and Child Health Access Children's Defense Fund -
California
National Alliance on Mental Illness California
National Association of Social Workers, California Chapter
PICO California
Southeast Asia Resource Action Center
The Children's Partnership
United Nurses Associations of California/Union of Health
Care Professionals
United Ways of California
Youth Law Center
ARGUMENTS IN SUPPORT : This bill is sponsored by the
Western Center on Law and Poverty (WCLP) to establish the
framework for the eligibility, enrollment and retention
system for public health coverage programs, as required by
PPACA. WCLP states that PPACA requires states to have a
seamless, "no wrong door" system for determining
eligibility for and enrolling people into public health
coverage programs. WCLP states this bill would implement
these components of PPACA in a way that works for health
care consumers by requiring:
1. The creation of unified applications - paper, telephone
and online - for Medi-Cal, the Exchange, HFP, AIM and
BHP;
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2. Real-time determination of eligibility when possible;
3. Use of the same eligibility rules regardless of which
"application door" a consumer uses;
4. Enrollment of consumers in the most beneficial program
for which they are eligible;
5. Assistance for consumers with their application and the
ability for consumers to correct or update their
information;
6. Seamless renewal between health programs;
7. Disability and language accessibility standards;
8. Transparency and accountability standards for the IT
system; and
9. Privacy protections for consumers.
WCLP states that 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 to 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, and there is currently no mechanism for the
state to transfer an adult's application for one program to
initiate an application for another program. PPACA changes
this by requiring that if someone applies for Medi-Cal but
is eligible for the Exchange, they are enrolled in the
Exchange, and vice versa. WCLP states this will require a
new level of coordination among agencies and departments,
and it is important both that these entities coordinate on
developing and implementing the eligibility, enrollment and
retention system. In addition to making sure that the
initial application process enrolls consumers into the
right program, the programs must also coordinate during
consumers' annual renewal of coverage, and when
circumstances change so that a consumer moves between
health coverage programs seamlessly.
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WCLP concludes that California is required to have this new
system tested by June 2013 to allow for enrollment to begin
in mid to late 2013. With less than two and a half years
to make and implement numerous important policy decisions,
develop applications and renewal forms and processes, and
build and test IT components, this legislation is urgently
needed, and significant federal funding (100 percent for
the Exchange and 90 percent for Medi-Cal) is available to
build the health care infrastructure system.
ASSEMBLY FLOOR : 51-27, 6/2/11
AYES: Alejo, Allen, Ammiano, Atkins, Beall, Block,
Blumenfield, Bonilla, Bradford, Brownley, Buchanan,
Butler, Charles Calderon, Campos, Carter, Cedillo,
Chesbro, Davis, Dickinson, Eng, Feuer, Fong, Fuentes,
Furutani, Galgiani, Gatto, Gordon, Hayashi, Roger
Hern�ndez, Hill, Huber, Hueso, Huffman, Lara, Bonnie
Lowenthal, Ma, Mendoza, Mitchell, Monning, Pan, Perea, V.
Manuel P�rez, Portantino, Skinner, Solorio, Swanson,
Torres, Wieckowski, Williams, Yamada, John A. P�rez
NOES: Achadjian, Bill Berryhill, Conway, Cook, Donnelly,
Fletcher, Beth Gaines, Garrick, Grove, Hagman, Halderman,
Harkey, Jeffries, Jones, Knight, Logue, Mansoor, Miller,
Morrell, Nestande, Nielsen, Norby, Olsen, Silva, Smyth,
Valadao, Wagner
NO VOTE RECORDED: Gorell, Hall
CTW:kc 8/29/11 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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