Senate Bill No. 1002

Introduced by Senator De León

February 13, 2014

An act to amend Section 14005.37 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 1002, as introduced, De León. Medi-Cal: redetermination.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

Existing law generally requires a county to redetermine a Medi-Cal beneficiary’s eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiary’s circumstances that may affect his or her eligibility for Medi-Cal benefits. Under existing law, when a redetermination is performed due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county must begin a new 12-month eligibility period.

This bill would require a county, when a redetermination is performed due to a change in circumstances, and the county received the information about the change in circumstance in a CalFresh application, or gathered the information about the change in circumstances during a CalFresh redetermination, and the beneficiary is determined eligible to receive CalFresh benefits, to begin the new 12-month eligibility period on a date that would align the beneficiary’s Medi-Cal eligibility period with his or her household CalFresh certification period. The bill would also require the county, in certain circumstances, to begin a new 12-month Medi-Cal eligibility period that would align a beneficiary’s eligibility period with his or her CalFresh household certification period. The bill would provide that these provisions only be implemented to the extent permitted by federal law and to the extent that they do not violate federal maintenance of effort rules. By imposing additional duties on counties, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

This act shall be known, and may be cited, as
The Aligning Opportunities for Health Act of 2014.

SEC. 2.  

Section 14005.37 of the Welfare and Institutions Code
is amended to read:

14005.37.  

(a) Except as provided in begin insert subdivision (n) and in end insert
Section 14005.39, a county shall perform redeterminations of
eligibility for Medi-Cal beneficiaries every 12 months and shall
promptly redetermine eligibility whenever the county receives
information about changes in a beneficiary’s circumstances that
may affect eligibility for Medi-Cal benefits. The procedures for
redetermining Medi-Cal eligibility described in this section shall
apply to all Medi-Cal beneficiaries.

(b)  Loss of eligibility for cash aid under begin delete that program end delete
begin insert CalWORKs end insert shall not result in a redetermination under this section
unless the reason for the loss of eligibility is one that would result
in the need for a redetermination for a person whose eligibility for
Medi-Cal under Section 14005.30 was determined without a
concurrent determination of eligibility for cash aid under the
CalWORKs program.

(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.

(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section and a beneficiary’s Medi-Cal eligibility
shall not be terminated under this section until the county makes
a specific determination based on facts clearly demonstrating that
the beneficiary is no longer eligible for Medi-Cal benefits under
any basis and due process rights guaranteed under this division
have been met. For the purposes of this subdivision, for a
beneficiary who is subject to the use of MAGI-based financial
methods, the determination of whether the beneficiary is eligible
for Medi-Cal benefits under any basis shall include, but is not
limited to, a determination of eligibility for Medi-Cal benefits on
a basis that is exempt from the use of MAGI-based financial
methods only if either of the following occurs:

(A) The county assesses the beneficiary as being potentially
eligible under a program that is exempt from the use of
MAGI-based financial methods, including, but not limited to, on
the basis of age, blindness, disability, or the need for long-term
care services and supports.

(B) The beneficiary requests that the county determine whether
he or she is eligible for Medi-Cal benefits on a basis that is exempt
from the use of MAGI-based financial methods.

(e) (1) For purposes of acquiring information necessary to
conduct the eligibility redeterminations described in this section,
a county shall gather information available to the county that is
relevant to the beneficiary’s Medi-Cal eligibility prior to contacting
the beneficiary. Sources for these efforts shall include information
contained in the beneficiary’s file or other information, including
more recent information available to the county, including, but not
limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
beneficiary or of any of his or her immediate family members,
which are open, or were closed within the last 90 days, information
accessed through any databases accessed under Sections 435.948,
435.949, and 435.956 of Title 42 of the Code of Federal
Regulations, and wherever feasible, other sources of relevant
information reasonably available to the county or to the county
via the department.

(2) In the case of an annual redetermination, if, based upon
information obtained pursuant to paragraph (1), the county is able
to make a determination of continued eligibility, the county shall
notify the beneficiary of both of the following:

(A) The eligibility determination and the information it is based
on.

(B) That the beneficiary is required to inform the county via the
Internet, by telephone, by mail, in person, or through other
commonly available electronic means, in counties where such
electronic communication is available, if any information contained
in the notice is inaccurate but that the beneficiary is not required
to sign and return the notice if all information provided on the
notice is accurate.

(3) The county shall make all reasonable efforts not to send
multiple notices during the same time period about eligibility. The
notice of eligibility renewal shall contain other related information
such as if the beneficiary is in a new Medi-Cal program.

(4) In the case of a redetermination due to a change in
circumstances, if a county determines that the change in
circumstances does not affect the beneficiary’s eligibility status,
the county shall not send the beneficiary a notice unless required
to do so by federal law.

(f) (1) In the case of an annual eligibility redetermination, if
the county is unable to determine continued eligibility based on
the information obtained pursuant to paragraph (1) of subdivision
(e), the beneficiary shall be so informed and shall be provided with
an annual renewal form, at least 60 days before the beneficiary’s
annual redetermination date, that is prepopulated with information
that the county has obtained and that identifies any additional
information needed by the county to determine eligibility. The
form shall include all of the following:

(A) The requirement that he or she provide any necessary
information to the county within 60 days of the date that the form
is sent to the beneficiary.

(B) That the beneficiary may respond to the county via the
Internet, by mail, by telephone, in person, or through other
commonly available electronic means if those means are available
in that county.

(C) That if the beneficiary chooses to return the form to the
county in person or via mail, the beneficiary shall sign the form
in order for it to be considered complete.

(D) The telephone number to call in order to obtain more
information.

(2) The county shall attempt to contact the beneficiary via the
Internet, by telephone, or through other commonly available
electronic means, if those means are available in that county, during
the 60-day period after the prepopulated form is mailed to the
beneficiary to collect the necessary information if the beneficiary
has not responded to the request for additional information or has
provided an incomplete response.

(3) If the beneficiary has not provided any response to the
written request for information sent pursuant to paragraph (1)
within 60 days from the date the form is sent, the county shall
terminate his or her eligibility for Medi-Cal benefits following the
provision of timely notice.

(4) If the beneficiary responds to the written request for
information during the 60-day period pursuant to paragraph (1)
but the information provided is not complete, the county shall
follow the procedures set forth in paragraph (3) of subdivision (g)
to work with the beneficiary to complete the information.

(5) (A) The form required by this subdivision shall be developed
by the department in consultation with the counties and
representatives of eligibility workers and consumers.

(B) For beneficiaries whose eligibility is not determined using
MAGI-based financial methods, the county may use existing
renewal forms until the state develops prepopulated renewal forms
to provide to beneficiaries. The department shall develop
prepopulated renewal forms for use with beneficiaries whose
eligibility is not determined using MAGI-based financial methods
by January 1, 2015.

(g) (1) In the case of a redetermination due to change in
circumstances, if a county cannot obtain sufficient information to
redetermine eligibility pursuant to subdivision (e), the county shall
send to the beneficiary a form that is prepopulated with the
information that the county has obtained and that states the
information needed to renew eligibility. The county shall only
request information related to the change in circumstances. The
county shall not request information or documentation that has
been previously provided by the beneficiary, that is not absolutely
necessary to complete the eligibility determination, or that is not
subject to change. The county shall only request information for
nonapplicants necessary to make an eligibility determination or
for a purpose directly related to the administration of the state
Medicaid plan. The form shall advise the individual to provide
any necessary information to the county via the Internet, by
telephone, by mail, in person, or through other commonly available
electronic means and, if the individual will provide the form by
mail or in person, to sign the form. The form shall include a
telephone number to call in order to obtain more information. The
form shall be developed by the department in consultation with
the counties, representatives of consumers, and eligibility workers.
A Medi-Cal beneficiary shall have 30 days from the date the form
is mailed pursuant to this subdivision to respond. Except as
provided in paragraph (2), failure to respond prior to the end of
this 30-day period shall not impact his or her Medi-Cal eligibility.

(2) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in this
subdivision marked as undeliverable shall result in an immediate
notice of action terminating Medi-Cal eligibility.

(3) During the 30-day period after the date of mailing of a form
to the Medi-Cal beneficiary pursuant to this subdivision, the county
shall attempt to contact the beneficiary by telephone, in writing,
or other commonly available electronic means, in counties where
such electronic communication is available, to request the
necessary information if the beneficiary has not responded to the
request for additional information or has provided an incomplete
response. If the beneficiary does not supply the necessary
information to the county within the 30-day limit, a 10-day notice
of termination of Medi-Cal eligibility shall be sent.

(h) Beneficiaries shall be required to report any change in
circumstances that may affect their eligibility within 10 calendar
days following the date the change occurred.

(i) If within 90 days of termination of a Medi-Cal beneficiary’s
eligibility or a change in eligibility status pursuant to this section,
the beneficiary submits to the county a signed and completed form
or otherwise provides the needed information to the county,
eligibility shall be redetermined by the county and if the beneficiary
is found eligible, or the beneficiary’s eligibility status has not
changed, whichever applies, the termination shall be rescinded as
though the form were submitted in a timely manner.

(j) If the information available to the county pursuant to the
redetermination procedures of this section does not indicate a basis
of eligibility, Medi-Cal benefits may be terminated so long as due
process requirements have otherwise been met.

(k) The department shall, with the counties and representatives
of consumers, including those with disabilities, and Medi-Cal
eligibility workers, develop a timeframe for redetermination of
Medi-Cal eligibility based upon disability, including ex parte
review, the redetermination forms described in subdivisions (f)
and (g), timeframes for responding to county or state requests for
additional information, and the forms and procedures to be used.
The forms and procedures shall be as consumer-friendly as possible
for people with disabilities. The timeframe shall provide a
reasonable and adequate opportunity for the Medi-Cal beneficiary
to obtain and submit medical records and other information needed
to establish eligibility for Medi-Cal based upon disability.

(l) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary’s vision has
improved beyond the applicable definition of blindness contained
in the plan.

(m) The county shall consider disability as continuing until the
review team determines that a beneficiary’s disability no longer
meets the applicable definition of disability contained in the plan.

(n)  begin insert (1) end insert begin insert   end insert In the case of a redetermination due to a change in
circumstances, if a county determines that the beneficiary remains
eligible for Medi-Cal benefits, the county shall begin a new
12-month eligibility period. begin insert If the county received the information
about the change in circumstances in a CalFresh application or
gathered the information about the change in circumstances during
a CalFresh recertification, and the beneficiary is determined
eligible to receive CalFresh benefits, then the county shall begin
the new 12-month eligibility period on a date that aligns the
beneficiary’s eligibility period with his or her household CalFresh
certification period. end insert

begin insert

(2) (A) If a county receives an application for CalFresh benefits
from a Medi-Cal beneficiary who is not receiving CalWORKs
benefits, or redetermines or recertifies eligibility for CalFresh
benefits for a Medi-Cal beneficiary who is not receiving
CalWORKs benefits, and no information contained in the CalFresh
application, or no information gathered during the CalFresh
redetermination or recertification process, requires the county to
redetermine the beneficiary’s eligibility for Medi-Cal pursuant to
this section, and the beneficiary is determined eligible to receive
CalFresh benefits, the county shall begin a new 12-month Medi-Cal
eligibility period that aligns the beneficiary’s eligibility period
with his or her CalFresh household certification period, unless
doing so would increase the beneficiary’s share of cost or reduce
Medi-Cal benefits for any member of the beneficiary’s CalFresh
family budget unit, in which case the beneficiary’s Medi-Cal
eligibility period and CalFresh certification period shall remain
unaligned.

end insert begin insert

(B) This paragraph shall not be construed to permit a CalFresh
recipient who is otherwise ineligible for Medi-Cal benefits to
receive Medi-Cal benefits.

end insert begin insert

(3) This subdivision shall be implemented to the extent permitted
by federal law and to the extent that this action does not violate
federal maintenance of effort rules.

end insert

(o) For individuals determined ineligible for Medi-Cal by a
county following the redetermination procedures set forth in this
section, the county shall determine eligibility for other insurance
affordability programs and if the individual is found to be eligible,
the county shall, as appropriate, transfer the individual’s electronic
account to other insurance affordability programs via a secure
electronic interface.

(p) Any renewal form or notice shall be accessible to persons
who are limited-English proficient and persons with disabilities
consistent with all federal and state requirements.

(q) The requirements to provide information in subdivisions (e)
and (g), and to report changes in circumstances in subdivision (h),
may be provided through any of the modes of submission allowed
in Section 435.907(a) of Title 42 of the Code of Federal
Regulations, including an Internet Web site identified by the
department, telephone, mail, in person, and other commonly
available electronic means as authorized by the department.

(r) Forms required to be signed by a beneficiary pursuant to this
section shall be signed under penalty of perjury. Electronic
signatures, telephonic signatures, and handwritten signatures
transmitted by electronic transmission shall be accepted.

(s) For purposes of this section, “MAGI-based financial
methods” means income calculated using the financial
methodologies described in Section 1396a(e)(14) of Title 42 of
the United States Code, and as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152), and any subsequent
amendments.

(t) When contacting a beneficiary under paragraphs (2) and (4)
of subdivision (f), and paragraph (3) of subdivision (g), a county
shall first attempt to use the method of contact identified by the
beneficiary as the preferred method of contact, if a method has
been identified.

(u) The department shall seek federal approval to extend the
annual redetermination date under this section for a three-month
period for those Medi-Cal beneficiaries whose annual
redeterminations are scheduled to occur between January 1, 2014,
and March 31, 2014.

(v) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations by July 1, 2017, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10231.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the
Government Code, until regulations have been adopted.

(w) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.

(x) This section shall become operative on January 1, 2014.

SEC. 3.  

If the Commission on State Mandates determines that
this act contains costs mandated by the state, reimbursement to
local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division
4 of Title 2 of the Government Code.