BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1341
AUTHOR: Mitchell
AMENDED: April 7, 2014
HEARING DATE: April 30, 2014
CONSULTANT: Bain
SUBJECT : Medi-Cal: Statewide Automated Welfare System.
SUMMARY : Requires the Statewide Automated Welfare System to be
the system of record for Medi-Cal and to contain all Medi-Cal
eligibility rules and case management functionality. Authorizes
the California Healthcare Eligibility, Enrollment, and Retention
System to house the business rules necessary for an eligibility
determination to be made for a Modified Adjusted Gross Income
eligibility determination. Specifies the manner in which the
functionality to create and send notices of action for Medi-Cal
and advanced premium tax credits would be implemented.
Existing law:
1.Requires the Office of Systems Integration (OSI) to implement
a statewide automated welfare system for the following public
assistance programs:
a. The CalWORKs program;
b. CalFresh;
c. The Medi-Cal program;
d. The foster care program;
e. The refugee program; and,
f. County medical services programs.
2.Requires statewide implementation of the Statewide Automated
Welfare System (SAWS) for the programs listed in 1) above to
be achieved through no more than four county consortia,
including the Interim SAWS Consortium, and the Los Angeles
Eligibility, Automated Determination, Evaluation, and
Reporting System (LEADER). Requires OSI to oversee the
migration of the 39 counties composing the C-IV Consortium
into a system jointly designed by the 39 counties plus Los
Angeles County under the LEADER Replacement System contract.
Requires this migration to result in a new consortium to
replace the LEADER and C-IV Consortia.
This bill:
Continued---
SB 1341 | Page 2
1.Requires SAWS to be the system of record for Medi-Cal, and
requires SAWS to contain all Medi-Cal eligibility rules and
case management functionality.
2.Permits, as an exception to 1) above, the business rules
necessary for an eligibility determination to be made under
the Modified Adjusted Gross Income (MAGI) rules pursuant to
the federal Patient Protection and Affordable Care Act (ACA)
to be housed in the California Healthcare Eligibility,
Enrollment, and Retention System (CALHEERS). Requires, if DHCS
implements this authority to house the MAGI business rules in
CalHEERS, these business rules to be made available to the
SAWS consortia through an automated interface in order for the
consortia to determine eligibility for Medi-Cal under the MAGI
rules.
3.Requires, effective January 1, 2016, the functionality to
create and send notices of action for Medi-Cal and advanced
premium tax credits (APTC), to be implemented consistent with
the following:
a. Requires SAWS to be used to generate noticing
language and NOA documents, and to send NOA documents
for all Medi-Cal programs (MAGI and non-MAGI).
b. Requires CalHEERS to be used to:
i. Generate noticing language for
APTC, including, but not limited to, Medi-Cal
denial noticing language related to APTC
approvals; and,
ii. Generate and send NOA documents for
the APTC only program. These two provisions apply
if DHCS exercises its authority to house the MAGI
business rules in CalHEERS.
c. Requires SAWS to be used to combine the
noticing language for Medi-Cal programs generated by
SAWS and the noticing language for APTCs generated by
CalHEERS into one notice, and requires SAWS to be used
to send the document as one combined notice for all
programs in any mixed eligibility cases that include
an approval or approvals for MAGI Medi-Cal eligibility
determinations, non-MAGI Medi-Cal eligibility
determinations, or both, and APTC approvals. This
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provision applies if DHCS exercises its authority to
house the MAGI business rules in CalHEERS.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, this bill will
clarify the respective roles of SAWS and CalHEERS in order to
minimize confusion and errors related to Medi-Cal eligibility
under the ACA. This bill will also ensure that NOAs are able
to be tailored in the manner consistent with legal
requirements, and will protect the counties' ability to
correct erroneous denials or benefits assignments.
2.Background. The federal ACA changed the income eligibility
rules for Medicaid for the newly eligible and some of the
currently eligible to a tax-based system for counting
individual or household income called Modified Adjusted Gross
Income (MAGI). These MAGI income counting eligibility rules
are also used to calculate eligibility for APTCs and
cost-sharing subsidies in Covered California.
CalHEERS contains the business rules for MAGI eligibility
determinations and is used by both Covered California and
counties in determining eligibility for APTC and MAGI
Medi-Cal. CalHEERS is a web-based application portal where
individuals and small businesses can research, compare, check
their eligibility for, apply, and purchase health coverage.
CalHEERS was designed to interface with various federal,
state, and local information technology systems to perform the
administrative functions necessary for the purchase of health
insurance. For example, CalHEERS is required to interface with
a federal data hub (a database that consolidates data from the
Internal Revenue Service, Social Security Administration, and
other federal entities) to assess income, citizenship, and
other data necessary to determine eligibility for various ACA
health coverage options. CalHEERS must interface with the
three SAWS consortia, which have their own eligibility
determination functionality built into their own system (the
three consortia are LEADER, California Work Opportunity and
Responsibility to Kids Information Network [CalWin], and
Consortium IV [C-IV]). The interface between SAWS and CalHEERS
went live on January 21, 2014, but it continues to be
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upgraded.
3.Notices of Action. Existing law requires county social service
departments to notify beneficiaries in writing of their
Medi-Cal-only eligibility or ineligibility, and of any changes
made in their eligibility status or share of cost. These
notifications are called a "Notice of Action." NOAs inform
Medi-Cal beneficiaries of:
a. Any approval, denial or discontinuance of
eligibility;
b. A change in the beneficiary's share of cost;
c. The reason an action is being taken and the
law or regulation that requires the action (if the
action is a denial, discontinuance or increase in
share of cost); and,
d. The right to request a state hearing.
NOAs must also include the name and telephone number of the
eligibility worker who completed the eligibility
determination, and the date the form was completed. As
currently designed, CalHEERS does not allow counties to
create, edit, and send NOAs for Medi-Cal.
1.Prior legislation. AB 1296 (Bonilla), Chapter 641, Statutes of
2013 enacts the Health Care Eligibility, Enrollment and
Retention Act, requiring state entities who administer health
care coverage programs to undertake a variety of activities
related to eligibility, enrollment and renewal of health care
coverage through Medi-Cal, the Healthy Families Program, and
Covered California. AB 1296 required that an individual
screened as not eligible for MAGI Medi-Cal but who may be
potentially eligible for Medi-Cal on another basis to have his
or her application or case forwarded to the Medi-Cal program
for an eligibility determination.
2.Support. This bill is jointly sponsored by the County Welfare
Directors Association (CWDA) and the Service Employees
International Union. CWDA argues, in light of the decision to
build CalHEERS, an agreement was reached between the
Administration, Covered California, and the counties that
reflected existing statute naming SAWS as the system of record
for Medi-Cal and requiring Medi-Cal eligibility functions to
be in SAWS. Per the agreement, CalHEERS would serve as the
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system that applies the new MAGI rules, and SAWS was to
proceed with all other eligibility and enrollment case
functions. CWDA states the intent of SAWS serving as the
system of record is to ensure program efficiency, efficacy,
continuity, and cohesiveness via multi-program case
management, and to allow for ease of access to Medi-Cal while
providing a more simplified process. This bill would codify
the agreed upon automation approach designed to
comprehensively and seamlessly serve families' needs for both
their health care and human service needs. This approach
allows families and individuals to obtain coordinated
services, both when they initially apply and as their
circumstances change.
The second component of this bill is which entities issue NOAs.
CWDA states a key issue with the design of CalHEERS is that is
it does not enable counties to create, edit, and send NOAs for
Medi-Cal. NOAs are the documents that inform applicants and
beneficiaries of their eligibility results and provide them
with information on how to appeal decisions made about their
case. Without the ability to customize notices in the manner
consistent legal requirements, CWDA states clients will
receive significantly less informative or incomplete notices,
leading to increased questions and confusion about what is
happening with their case and potentially making it more
difficult for them to exercise their due process rights.
Western Center on Law & Poverty (WCLP) writes it supports
state law making clear that SAWS is the system of record for
Medi-Cal and should have all the Medi-Cal eligibility rules -
with the caveat that the SAWS can access the new Medi-Cal
rules through an interface with CalHEERS. WCLP states, as
advocates for low-income consumers, it knows that many of its
clients qualify for multiple public programs such as CalWORKs,
CalFresh and Medi-Cal, and having one system and entity
maintaining their benefits is both consumer-friendly for
Californians and efficient administratively. Regarding NOAs,
WCLP states it has advocated for understandable, thorough,
timely notices telling consumers about their eligibility and
their rights. Sadly, this goal has been elusive and the
notices neither understandable nor timely. Given the many
competing demands on CalHEERS, WCLP says it has determined
that consumers' interests would be better served by having the
Medi-Cal notices generated in SAWS with the important caveat
that consumers should receive consolidated notices advising
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them about their eligibility for both Medi-Cal and Covered
California.
3.Drafting issue. Under existing law, until July 1, 2015,
CalHEERS is jointly managed by DHCS and Covered California.
This bill designates DHCS as the entity that would be
authorized to decide if the business rules necessary for a
MAGI eligibility determination are housed in CalHEERS. In
discussions with the one of the bill's sponsors, they
indicated it was not intending that this bill change which
entity makes the decision on this issue. An amendment is
needed to clarify that the decision-making entity is not
changed by this bill.
SUPPORT AND OPPOSITION :
Support: County Welfare Directors Association (co-sponsor)
Services Employees International Union California (co-sponsor)
Tehama County Department of Social Services
(co-sponsor)
Alameda County Social Services Agency
American Federation of State, County and Municipal
Employees, AFL-CIO
California State Association of Counties
County of San Bernardino
County of San Diego
Del Norte County Board of Supervisors
San Mateo County Board of Supervisors
Santa Cruz County Board of Supervisors
Sonoma County Board of Supervisors
Ventura County Board of Supervisors
Western Center on Law & Poverty
Oppose: None received
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