Bill Text: CA ABX11 | 2013-2014 | Regular Session | Chaptered
Bill Title: Medi-Cal: eligibility.
Spectrum: Partisan Bill (Democrat 17-0)
Status: (Passed) 2013-06-27 - Chaptered by Secretary of State. Chapter 3, Statutes of 2013-14 First Extraordinary Session. [ABX11 Detail]
Download: California-2013-ABX11-Chaptered.html
BILL NUMBER: ABX1 1 CHAPTERED
BILL TEXT
CHAPTER 3
FILED WITH SECRETARY OF STATE JUNE 27, 2013
APPROVED BY GOVERNOR JUNE 27, 2013
PASSED THE SENATE JUNE 15, 2013
PASSED THE ASSEMBLY JUNE 15, 2013
AMENDED IN SENATE JUNE 14, 2013
AMENDED IN SENATE JUNE 4, 2013
INTRODUCED BY Assembly Member John A. Pérez
(Coauthors: Assembly Members Alejo, Blumenfield, Bocanegra,
Campos, Eggman, Garcia, Gomez, Roger Hernández, Pan, V. Manuel Pérez,
and Quirk-Silva)
(Coauthors: Senators Calderon, Correa, De León, Hueso, and Lara)
JANUARY 28, 2013
An act to amend Section 12698.30 of the Insurance Code, and to
amend Sections 14005.36 and 15926 of, to amend and repeal Sections
14005.38, 14011.16, 14011.17, and 14012 of, to amend, repeal, and add
Sections 14005.30, 14005.37, 14016.5, and 14016.6 of, to add
Sections 14005.60, 14005.61, 14005.64, 14013.3, 14015.7, 14015.8,
14055, 14102.5, and 14103 to, and to add and repeal Section 14015.5
of, the Welfare and Institutions Code, relating to health.
LEGISLATIVE COUNSEL'S DIGEST
AB 1, John A. Pérez. Medi-Cal: eligibility.
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.
This bill would, commencing January 1, 2014, implement various
provisions of the federal Patient Protection and Affordable Care Act
(Affordable Care Act), as amended, by, among other things, modifying
provisions relating to determining eligibility for certain groups.
The bill would, in this regard, extend Medi-Cal eligibility to
specified adults and would require that income eligibility be
determined based on modified adjusted gross income (MAGI), as
prescribed. The bill would prohibit the use of an asset or resources
test for individuals whose financial eligibility for Medi-Cal is
determined based on the application of MAGI. The bill would require
that individuals who are enrolled in the Low Income Health Program as
of December 31, 2013, under a specified waiver who are at or below
133% of the federal poverty level be transitioned directly to the
Medi-Cal program, as prescribed. The bill would provide that the
implementation of the optional expansion of Medi-Cal benefits to
adults who meet specified eligibility requirements shall be
contingent on the federal medical assistance percentage (FMAP)
payable to the state under the Affordable Care Act is not being
reduced below specified percentages, as specified.
Because counties are required to make Medi-Cal eligibility
determinations and this bill would expand Medi-Cal eligibility, the
bill would impose a state-mandated local program.
The bill would require the California Health Benefit Exchange
(Exchange) to implement a workflow transfer protocol, as prescribed,
for persons calling the customer service center operated by the
Exchange for the purpose of applying for an insurance affordability
program, to ascertain which individuals are potentially eligible for
Medi-Cal. This bill would also prescribe the authority the
department, the Exchange, and the counties would have, until July 1,
2015, to perform Medi-Cal eligibility determinations. The bill would
require the department to verify the accuracy of certain information
that is provided as part of the application or redetermination
process when determining whether an individual is eligible for
Medi-Cal benefits, as prescribed. The bill would require the
department, any other government agency that is determining
eligibility for, or enrollment in, the Medi-Cal program or any other
program administered by the department, or collecting protected
information for those purposes, and the Exchange to share specified
information with each other as necessary to enable them to perform
their respective statutory and regulatory duties under state and
federal law.
Existing law requires an applicant or beneficiary, as specified,
who resides in an area served by a managed health care plan or pilot
program in which beneficiaries may enroll, to personally attend a
presentation at which the applicant or beneficiary is informed of
managed care and fee-for-service options for receiving Medi-Cal
benefits. Existing law requires the applicant or beneficiary to
indicate in writing his or her choice of health care options and
provides that if the applicant or beneficiary does not make a choice,
he or she shall be assigned to and enrolled in an appropriate
Medi-Cal managed care plan, pilot project, or fee-for-service case
management provider providing service within the area in which the
beneficiary resides. Existing law requires the department to develop
a program, as specified, to implement these provisions.
This bill would revise these provisions to, among other things,
require the department to develop a program to allow individuals or
their authorized representatives to select Medi-Cal managed care
plans via the California Healthcare Eligibility, Enrollment, and
Retention System (CalHEERs).
Existing law requires Medi-Cal beneficiaries, with some
exceptions, to file semiannual status reports to ensure that
beneficiaries make timely and accurate reports of any change in
circumstance that may affect their eligibility and requires, with
some exceptions, a county to promptly redetermine eligibility
whenever a county receives information about changes in a beneficiary'
s circumstances that may affect eligibility for Medi-Cal benefits.
This bill would, commencing January 1, 2014, revise these
provisions to, among other things, delete the semiannual status
report requirement and require a county to perform redeterminations
every 12 months. The bill would require any forms signed by the
beneficiary for purposes of redetermining eligibility to be signed
under penalty of perjury. By expanding the crime of perjury, the 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 with regard to certain mandates no
reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that,
if the Commission on State Mandates determines that the bill contains
costs so mandated by the state, reimbursement for those costs shall
be made pursuant to the statutory provisions noted above.
This bill would become operative only if SB 1 of the 2013-14 First
Extraordinary Session is enacted and takes effect.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) The United States is the only industrialized country in the
world without a universal health insurance system.
(b) (1) In 2006, the United States Census reported that 46 million
Americans did not have health insurance.
(2) In California in 2009, according to the UCLA Center for Health
Policy Research's "The State of Health Insurance in California:
Findings from the 2009 California Health Interview Survey," 7.1
million Californians were uninsured in 2009, amounting to 21.1
percent of nonelderly Californians who had no health insurance
coverage for all or some of 2009, up nearly 2 percentage points from
2007.
(c) On March 23, 2010, President Obama signed the Patient
Protection and Affordable Care Act (Public Law 111-148), which was
amended by the Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and together are referred to as the Affordable
Care Act of 2010 (Affordable Care Act).
(d) The Affordable Care Act is the culmination of decades of
movement toward health reform, and is the most fundamental
legislative transformation of the United States health care system in
40 years.
(e) As a result of the enactment of the Affordable Care Act,
according to estimates by the UCLA Center for Health Policy Research
and the UC Berkeley Labor Center, using the California Simulation of
Insurance Markets, in 2019, after the Affordable Care Act is fully
implemented:
(1) Between 89 and 92 percent of Californians under 65 years of
age will have health coverage.
(2) Between 1.2 and 1.6 million individuals will be newly enrolled
in Medi-Cal.
(f) It is the intent of the Legislature to ensure full
implementation of the Affordable Care Act, including the Medi-Cal
expansion for individuals with incomes below 133 percent of the
federal poverty level, so that millions of uninsured Californians can
receive health care coverage.
SEC. 2. Section 12698.30 of the Insurance Code is amended to read:
12698.30. (a) (1) Subject to paragraph (2), at a minimum,
coverage shall be provided to subscribers during one pregnancy, and
for 60 days thereafter, and to children less than two years of age
who were born of a pregnancy covered under this program to a woman
enrolled in the program before July 1, 2004.
(2) Commencing January 1, 2014, at a minimum, coverage shall be
provided to subscribers during one pregnancy, and until the end of
the month in which the 60th day thereafter occurs, and to children
less than two years of age who were born of a pregnancy covered under
this program to a woman enrolled in the program before July 1, 2004.
(b) Coverage provided pursuant to this part shall include, at a
minimum, those services required to be provided by health care
service plans approved by the United States Secretary of Health and
Human Services as a federally qualified health care service plan
pursuant to Section 417.101 of Title 42 of the Code of Federal
Regulations.
(c) Coverage shall include health education services related to
tobacco use.
(d) Medically necessary prescription drugs shall be a required
benefit in the coverage provided under this part.
SEC. 3. Section 14005.30 of the Welfare and Institutions Code is
amended to read:
14005.30. (a) (1) To the extent that federal financial
participation is available, Medi-Cal benefits under this chapter
shall be provided to individuals eligible for services under Section
1396u-1 of Title 42 of the United States Code, including any options
under Section 1396u-1(b)(2)(C) made available to and exercised by the
state.
(2) The department shall exercise its option under Section 1396u-1
(b)(2)(C) of Title 42 of the United States Code to adopt less
restrictive income and resource eligibility standards and
methodologies to the extent necessary to allow all recipients of
benefits under Chapter 2 (commencing with Section 11200) to be
eligible for Medi-Cal under paragraph (1).
(3) To the extent federal financial participation is available,
the department shall exercise its option under Section 1396u-1(b)(2)
(C) of Title 42 of the United States Code authorizing the state to
disregard all changes in income or assets of a beneficiary until the
next annual redetermination under Section 14012. The department shall
implement this paragraph only if, and to the extent that the State
Child Health Insurance Program waiver described in Section 12693.755
of the Insurance Code extending Healthy Families Program eligibility
to parents and certain other adults is approved and implemented.
(b) To the extent that federal financial participation is
available, the department shall exercise its option under Section
1396u-1(b)(2)(C) of Title 42 of the United States Code as necessary
to expand eligibility for Medi-Cal under subdivision (a) by
establishing the amount of countable resources individuals or
families are allowed to retain at the same amount medically needy
individuals and families are allowed to retain, except that a family
of one shall be allowed to retain countable resources in the amount
of three thousand dollars ($3,000).
(c) To the extent federal financial participation is available,
the department shall, commencing March 1, 2000, adopt an income
disregard for applicants equal to the difference between the income
standard under the program adopted pursuant to Section 1931(b) of the
federal Social Security Act (42 U.S.C. Sec. 1396u-1) and the amount
equal to 100 percent of the federal poverty level applicable to the
size of the family. A recipient shall be entitled to the same
disregard, but only to the extent it is more beneficial than, and is
substituted for, the earned income disregard available to recipients.
(d) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec. 401
et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the federal
poverty level requires the department to modify the income disregard
pursuant to subdivision (c) and in which new income limits for the
program established by this section are adopted by the department.
(e) Subdivision (b) shall be applied retroactively to January 1,
1998.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement, without taking regulatory action,
subdivisions (a) and (b) of this section by means of an all-county
letter or similar instruction. Thereafter, the department shall adopt
regulations 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.
(g) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 4. Section 14005.30 is added to the Welfare and Institutions
Code, to read:
14005.30. (a) (1) Medi-Cal benefits under this chapter shall be
provided to individuals eligible for services under Section 1396u-1
of Title 42 of the United States Code.
(b) (1) When determining eligibility under this section, an
applicant's or beneficiary's income and resources shall be
determined, counted, and valued in accordance with the requirements
of Section 1396a(e)(14) of Title 42 of the United States Code, as
added by the ACA.
(2) When determining eligibility under this section, an applicant'
s or beneficiary's assets shall not be considered and deprivation
shall not be a requirement for eligibility.
(c) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec. 401
et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the federal
poverty level requires the department to modify the income disregard
pursuant to subdivision (c) and in which new income limits for the
program established by this section are adopted by the department.
(d) The MAGI-based income eligibility standard applied under this
section shall conform with the maintenance of effort requirements of
Sections 1396a(e)(14) and 1396a(gg) of Title 42 of the United States
Code, as added by the ACA.
(e) For purposes of this section, the following definitions shall
apply:
(1) "ACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as originally enacted and as amended
by the federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152) and any subsequent amendments.
(2) "MAGI-based income" means income calculated using the
financial methodologies described in Section 1396a(e)(14) of Title 42
of the United States Code, as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148) and as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments.
(f) 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.
(g) This section shall become operative on January 1, 2014.
SEC. 5. Section 14005.36 of the Welfare and Institutions Code is
amended to read:
14005.36. (a) The county shall undertake outreach efforts to
beneficiaries receiving benefits under this chapter, in order to
maintain the most up-to-date home addresses, telephone numbers, and
other necessary contact information, and to encourage and assist with
timely submission of the annual reaffirmation form, and, when
applicable, transitional Medi-Cal program reporting forms and to
facilitate the Medi-Cal redetermination process when one is required
as provided in Section 14005.37. In implementing this subdivision, a
county may collaborate with community-based organizations, provided
that confidentiality is protected.
(b) The department shall encourage and facilitate efforts by
managed care plans to report updated beneficiary contact information
to counties.
(c) (1) The department and each county shall incorporate, in a
timely manner, updated contact information received from managed care
plans pursuant to subdivision (b) into the beneficiary's Medi-Cal
case file and into all systems used to inform plans of their
beneficiaries' enrollee status. Updated Medi-Cal beneficiary contact
information shall be limited to the beneficiary's telephone number,
change of address information, and change of name.
(2) When a managed care plan obtains a beneficiary's updated
contact information, the managed care plan shall ask the beneficiary
for approval to provide the beneficiary's updated contact information
to the appropriate county. If the managed care plan does not obtain
approval from the beneficiary to provide the appropriate county with
the updated contact information, the county shall attempt to verify
the plan is accurate, which may include, but is not limited to,
making contact with the beneficiary, before updating the beneficiary'
s case file. The contact shall first be attempted using the method of
contact identified by the beneficiary as the preferred method of
contact, if a method has been identified.
(d) This section shall be implemented only to the extent that
federal financial participation under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
(e) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
SEC. 6. Section 14005.37 of the Welfare and Institutions Code is
amended to read:
14005.37. (a) Except as provided in Section 14005.39, whenever a
county receives information about changes in a beneficiary's
circumstances that may affect eligibility for Medi-Cal benefits, the
county shall promptly redetermine eligibility. 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 that program 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. A Medi-Cal beneficiary's 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 under any basis and
due process rights guaranteed under this division have been met.
(e) For purposes of acquiring information necessary to conduct the
eligibility determinations described in subdivisions (a) to (d),
inclusive, a county shall make every reasonable effort to 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, but are 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 45 days, and wherever
feasible, other sources of relevant information reasonably available
to the counties.
(f) If a county cannot obtain information necessary to redetermine
eligibility pursuant to subdivision (e), the county shall attempt to
reach the beneficiary by telephone in order to obtain this
information, either directly or in collaboration with community-based
organizations so long as confidentiality is protected.
(g) If a county's efforts pursuant to subdivisions (e) and (f) to
obtain the information necessary to redetermine eligibility have
failed, the county shall send to the beneficiary a form, which shall
highlight the information needed to complete the eligibility
determination. 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 form shall be
accompanied by a simple, clear, consumer-friendly cover letter, which
shall explain why the form is necessary, the fact that it is not
necessary to be receiving CalWORKs benefits to be receiving Medi-Cal
benefits, the fact that receipt of Medi-Cal benefits does not count
toward any time limits imposed by the CalWORKs program, the various
bases for Medi-Cal eligibility, including disability, and the fact
that even persons who are employed can receive Medi-Cal benefits. The
cover letter shall include a telephone number to call in order to
obtain more information. The form and the cover letter shall be
developed by the department in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers. A Medi-Cal beneficiary shall have no less than 20 days
from the date the form is mailed pursuant to this subdivision to
respond. Except as provided in subdivision (h), failure to respond
prior to the end of this 20-day period shall not impact his or her
Medi-Cal eligibility.
(h) 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 subdivision (g)
marked as undeliverable shall result in an immediate notice of
action terminating Medi-Cal eligibility.
(i) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), a beneficiary does
not submit the completed form to the county, the county shall send
the beneficiary a written notice of action stating that his or her
eligibility shall be terminated 10 days from the date of the notice
and the reasons for that determination, unless the beneficiary
submits a completed form prior to the end of the 10-day period.
(j) If, within 20 days of the date of mailing of a form to the
Medi-Cal beneficiary pursuant to subdivision (g), the beneficiary
submits an incomplete form, the county shall attempt to contact the
beneficiary by telephone and in writing to request the necessary
information. If the beneficiary does not supply the necessary
information to the county within 10 days from the date the county
contacts the beneficiary in regard to the incomplete form, a 10-day
notice of termination of Medi-Cal eligibility shall be sent.
(k) If, within 30 days of termination of a Medi-Cal beneficiary's
eligibility pursuant to subdivision (h), (i), or (j), the beneficiary
submits to the county a completed form, eligibility shall be
determined as though the form was submitted in a timely manner and if
a beneficiary is found eligible, the termination under subdivision
(h), (i), or (j) shall be rescinded.
( l ) If the information reasonably available to the
county pursuant to the redetermination procedures of subdivisions
(d), (e), (g), and (m) does not indicate a basis of eligibility,
Medi-Cal benefits may be terminated so long as due process
requirements have otherwise been met.
(m) The department shall, with the counties and representatives of
consumers, including those with disabilities, and Medi-Cal
providers, develop a timeframe for redetermination of Medi-Cal
eligibility based upon disability, including ex parte review, the
redetermination form described in subdivision (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.
(n) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et
seq.) is available.
(o) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall, without taking any regulatory action, implement
this section by means of all-county letters or similar instructions.
Thereafter, the department shall adopt regulations 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. Comprehensive
implementing instructions shall be issued to the counties no later
than March 1, 2001.
(p) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 7. Section 14005.37 is added to the Welfare and Institutions
Code, to read:
14005.37. (a) Except as provided in 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 that program 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 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) 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.
(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.
Thereafter, the department shall adopt regulations 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 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. 8. Section 14005.38 of the Welfare and Institutions Code is
amended to read:
14005.38. (a) To the extent feasible, the department shall use
the redetermination form required by subdivision (g) of Section
14005.37 as the annual reaffirmation form.
(b) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 9. Section 14005.60 is added to the Welfare and Institutions
Code, to read:
14005.60. (a) Commencing January 1, 2014, the department shall
provide Medi-Cal benefits for individuals who meet eligibility
requirements of Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)
(VIII)).
(b) An individual eligible under this section shall not have
income that exceeds 133 percent of the federal poverty level as
determined, counted, and valued in accordance with the requirements
of Section 1396a(e)(14) of Title 42 of the United States Code, as
added by the federal Patient Protection and Affordable Care Act
(Public Law 111-148), and as amended by the federal Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152) and any
subsequent amendments.
(c) (1) Individuals who are eligible under this section shall be
required to mandatorily enroll into a Medi-Cal managed care health
plan in those counties where a Medi-Cal managed care health plan is
available.
(2) (A) Individuals residing in a county where no Medi-Cal managed
care health plan is available shall be provided services under the
Medi-Cal fee-for-service delivery system subject to subparagraph (B).
(B) If a Medi-Cal managed care health plan becomes available to
individuals referenced in subparagraph (A), those individuals shall
be enrolled in a Medi-Cal managed care health plan.
(d) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(e) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
SEC. 10. Section 14005.61 is added to the Welfare and Institutions
Code, to read:
14005.61. (a) Except as provided in subdivision (e), individuals
who are enrolled in a Low Income Health Program (LIHP) as of December
31, 2013, under California's Bridge to Reform Section 1115(a)
Medicaid Demonstration who are at or below 133 percent of the federal
poverty level shall be transitioned directly to the Medi-Cal program
in accordance with the requirements of this section and pursuant to
federal approval.
(b) Except as provided in paragraph (8) of subdivision (c),
individuals who are eligible under subdivision (a) shall be required
to enroll into Medi-Cal managed care health plans.
(c) Except as provided in subdivision (d), with respect to managed
care health plan enrollment, a LIHP enrollee shall be notified by
the department at least 60 days prior to January 1, 2014, in
accordance with the department's LIHP transition plan of all of the
following:
(1) Which Medi-Cal managed care health plan or plans contain his
or her existing primary care provider, if the department has this
information and the primary care provider is contracted with a
Medi-Cal managed care health plan.
(2) That the LIHP enrollee, subject to his or her ability to
change as described in paragraph (3), will be assigned to a health
plan that includes his or her primary care provider and enrolled
effective January 1, 2014. If the enrollee wants to keep his or her
primary care provider, no additional action will be required if the
primary care provider is contracted with a Medi-Cal managed care
health plan.
(3) That the LIHP enrollee may choose any available Medi-Cal
managed care health plan and primary care provider in his or her
county of residence prior to January 1, 2014, if more than one such
plan is available in the county where he or she resides, and he or
she will receive all provider and health plan information required to
be sent to new enrollees and instructions on how to choose or change
his or her health plan and primary care provider.
(4) That in counties with more than one Medi-Cal managed care
health plan, if the LIHP enrollee does not affirmatively choose a
plan within 30 days of receipt of the notice, he or she shall be
enrolled into the Medi-Cal managed care health plan that contains his
or her LIHP primary care provider as part of the Medi-Cal managed
care contracted primary care network, if the department has this
information about the primary care provider, and the primary care
provider is contracted with a Medi-Cal managed care health plan. If
the primary care provider is contracted with more than one Medi-Cal
managed care health plan, then the LIHP enrollee will be assigned to
one of the health plans containing his or her primary care provider
in accordance with an assignment process established to ensure the
linkage.
(5) That if the LIHP enrollee's existing primary care provider is
not contracted with any Medi-Cal managed care health plan, then he or
she will receive all provider and health plan information required
to be sent to new enrollees. If the LIHP enrollee does not
affirmatively select one of the available Medi-Cal managed care plans
within 30 days of receipt of the notice, he or she will
automatically be assigned a plan through the department-prescribed
auto-assignment process.
(6) That the LIHP enrollee does not need to take any action to be
transitioned to the Medi-Cal program or to retain his or her primary
care provider, if the primary care provider is available pursuant to
paragraph (2).
(7) That the LIHP enrollee may choose not to transition to the
Medi-Cal program, and what this choice will mean for his or her
health care coverage and access to health care services.
(8) That in counties where no Medi-Cal managed care health plans
are available, the LIHP enrollee will be transitioned into
fee-for-service Medi-Cal, and provided with all information that is
required to be sent to new Medi-Cal enrollees including the
assistance telephone number for fee-for-service beneficiaries, and
that, if a Medi-Cal managed care health plan becomes available in the
residence county, he or she will be enrolled in a Medi-Cal managed
care health plan according to the enrollment procedures in place at
that time.
(d) Individuals who qualify under subdivision (a) who apply and
are determined eligible for LIHP after the date identified by the
department that is not later than October 1, 2013, will be considered
late enrollees. Late enrollees shall be notified in accordance with
subdivision (c), except according to a different timeframe, but will
transition to Medi-Cal coverage on January 1, 2014. Late enrollees
after the date identified in this subdivision shall be transitioned
pursuant to the department's LIHP transition plan process.
(e) Individuals who qualify under subdivision (a) and are not
denoted as active LIHP enrollees according to the Medi-Cal
Eligibility Data System at any point within the date range identified
by the department that will start not sooner than December 20, 2013,
and continue through December 31, 2013, will not be included in the
LIHP transition to the Medi-Cal program. These individuals may apply
for Medi-Cal eligibility separately from the LIHP transition process.
(f) In conformity with the department's transition plan,
individuals who are enrolled in a LIHP at any point from September
2013 through December 2013, under California's Bridge to Reform
Section 1115(a) Medicaid Demonstration and are above 133 percent of
the federal poverty level will be provided information regarding how
to apply for an insurance affordability program, including submission
of an application by telephone, by mail, online, or in person.
(g) A Medi-Cal managed care health plan that receives a LIHP
enrollee during this transition shall assign the LIHP primary care
provider of the enrollee as the Medi-Cal managed care health plan
primary care provider of the enrollee, to the extent possible, if the
Medi-Cal managed care health plan contracts with that primary care
provider, unless the beneficiary has chosen another primary care
provider on his or her choice form. A LIHP enrollee who is enrolled
into a Medi-Cal managed care plan may work through the Medi-Cal
managed care plan to change his or her assigned primary care provider
or other provider, after enrollment and subject to provider
availability, according to the standard processes that are currently
available in Medi-Cal managed care for selecting providers.
(h) The director may, with federal approval, suspend, delay, or
otherwise modify the requirement for LIHP program eligibility
redeterminations in 2013 to facilitate the process of transitioning
LIHP enrollees to other health coverage in 2014.
(i) The county LIHPs and their designees shall work with the
department and its designees during the 2013 and 2014 calendar years
to facilitate continuity of care and data sharing for the purposes of
delivering Medi-Cal services in the 2014 calendar year.
(j) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available and
all necessary federal approvals have been obtained.
SEC. 11. Section 14005.64 is added to the Welfare and Institutions
Code, to read:
14005.64. (a) Effective January 1, 2014, and notwithstanding any
other provision of law, when determining eligibility for Medi-Cal
benefits, an applicant's or beneficiary's income and resources shall
be determined, counted, and valued in accordance with the
requirements of Section 1902(e)(14) of the federal Social Security
Act (42 U.S.C. 1396a(e)(14)), as added by the ACA, which prohibits
the use of an assets or resources test for individuals whose income
eligibility is determined based on modified adjusted gross income.
(b) When determining the eligibility of applicants and
beneficiaries using the MAGI-based financial methods, the 5-percent
income disregard required under Section 1902(e)(14)(B)(I) of the
federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(B)(I)) shall
be applied.
(c) (1) The department shall establish income eligibility
thresholds for those Medi-Cal eligibility groups whose eligibility
will be determined using MAGI-based financial methods. The income
eligibility thresholds shall be developed using the financial
methodologies described in Section 1396a(e)(14) of Title 42 of the
United States Code and in conformity with Section 1396a(gg) of Title
42 of the United States Code as added by the ACA.
(2) In utilizing state data or the national standard methodology
with Survey of Income and Program Participation data to develop the
converted modified adjusted gross income standard for Medi-Cal
applicants and beneficiaries, the department shall ensure that the
financial methodology used for identifying the equivalent income
eligibility threshold preserves Medi-Cal eligibility for applicants
and beneficiaries to the extent required by federal law. The
department shall report to the Legislature on the expected changes in
income eligibility thresholds using the chosen methodology for
individuals whose income is determined on the basis of a converted
dollar amount or federal poverty level percentage. The department
shall convene stakeholders, including the Legislature, counties, and
consumer advocates regarding the results of the converted standards
and shall review with them the information used for the specific
calculations before adopting its final methodology for the equivalent
income eligibility threshold level.
(d) The department shall include individuals under 19 years of
age, or in the case of full-time students, under 21 years of age, in
the household for purposes of determining eligibility under Section
1396a(e)(14) of Title 42 of the United States Code, as added by the
ACA.
(e) For purposes of this section, the following definitions shall
apply:
(1) "ACA" means the federal Patient Protection and Affordable Care
Act (Public Law 111-148) as originally enacted and as amended by the
federal Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152) and any subsequent amendments.
(2) "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 ACA.
(f) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(g) 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.
SEC. 12. Section 14011.16 of the Welfare and Institutions Code is
amended to read:
14011.16. (a) Commencing August 1, 2003, the department shall
implement a requirement for beneficiaries to file semiannual status
reports as part of the department's procedures to ensure that
beneficiaries make timely and accurate reports of any change in
circumstance that may affect their eligibility. The department shall
develop a simplified form to be used for this purpose. The department
shall explore the feasibility of using a form that allows a
beneficiary who has not had any changes to so indicate by checking a
box and signing and returning the form.
(b) Beneficiaries who have been granted continuous eligibility
under Section 14005.25 shall not be required to submit semiannual
status reports. To the extent federal financial participation is
available, all children under 19 years of age shall be exempt from
the requirement to submit semiannual status reports.
(c) For any period of time that the continuous eligibility period
described in paragraph (1) of subdivision (a) of Section 14005.25 is
reduced to six months, subdivision (b) shall become inoperative, and
all children under 19 years of age shall be required to file
semiannual status reports.
(d) Beneficiaries whose eligibility is based on a determination of
disability or on their status as aged or blind shall be exempt from
the semiannual status report requirement described in subdivision
(a). The department may exempt other groups from the semiannual
status report requirement as necessary for simplicity of
administration.
(e) When a beneficiary has completed, signed, and filed a
semiannual status report that indicated a change in circumstance,
eligibility shall be redetermined.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all-county
letters or similar instructions without taking regulatory action.
Thereafter, the department shall adopt regulations 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.
(g) This section shall be implemented only if and to the extent
federal financial participation is available.
(h) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 13. Section 14011.17 of the Welfare and Institutions Code is
amended to read:
14011.17. The following persons shall be exempt from the
semiannual reporting requirements described in Section 14011.16:
(a) Pregnant women whose eligibility is
based on pregnancy.
(b) Beneficiaries receiving Medi-Cal through Aid for Adoption of
Children Program.
(c) Beneficiaries who have a public guardian.
(d) Medically indigent children who are not living with a parent
or relative and who have a public agency assuming their financial
responsibility.
(e) Individuals receiving minor consent services.
(f) Beneficiaries in the Breast and Cervical Cancer Treatment
Program.
(g) Beneficiaries who are CalWORKs recipients and custodial
parents whose children are CalWORKs recipients.
(h) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 14. Section 14012 of the Welfare and Institutions Code is
amended to read:
14012. (a) Reaffirmation shall be filed annually and may be
required at other times in accordance with general standards
established by the department.
(b) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 15. Section 14013.3 is added to the Welfare and Institutions
Code, to read:
14013.3. (a) When determining whether an individual is eligible
for Medi-Cal benefits, the department shall verify the accuracy of
the information identified in this section that is provided as a part
of the application or redetermination process in conformity with
this section.
(b) Prior to requesting additional verification from an applicant
or beneficiary for information he or she provides as part of the
application or redetermination process, the department shall obtain
information about an individual that is available electronically from
other state and federal agencies and programs in determining an
individual's eligibility for Medi-Cal benefits or for potential
eligibility for an insurance affordability program offered through
the California Health Benefit Exchange established pursuant to Title
22 (commencing with Section 100500) of the Government Code. Needed
information shall be obtained from the following sources, as well as
any other source the department determines is useful:
(1) Information related to wages, net earnings from
self-employment, unearned income, and resources from any of the
following:
(A) The State Wage Information Collection Agency.
(B) The federal Internal Revenue Service.
(C) The federal Social Security Administration.
(D) The Employment Development Department.
(E) The state administered supplementary payment program under
Section 1382e of Title 42 of the United States Code.
(F) Any state program administered under a plan approved under
Titles I, X, XIV, or XVI of the federal Social Security Act.
(2) Information related to eligibility or enrollment from any of
the following:
(A) The CalFresh program pursuant to Chapter 10 (commencing with
Section 18900) of Part 6.
(B) The CalWORKS program.
(C) The state's children's health insurance program under Title
XXI of the federal Social Security Act (42 U.S.C. 1397aa et seq.).
(D) The California Health Benefit Exchange established pursuant
Title 22 (commencing with Section 100500) of the Government Code.
(E) The electronic service established in accordance with Section
435.949 of Title 42 of the Code of Federal Regulations.
(c) (1) If the income information obtained by the department
pursuant to subdivision (b) is reasonably compatible with the
information provided by or on behalf of the individual, the
department shall accept the information provided by or on behalf of
the individual as being accurate.
(2) If the income information obtained by the department is not
reasonably compatible with the information provided by or on behalf
of the individual, the department shall require that the individual
provide additional information that reasonably explains the
discrepancy.
(3) For the purposes of this subdivision, income information
obtained by the department is reasonably compatible with information
provided by or on behalf of an individual if any of the following
conditions are met:
(A) Both state that the individual's income is above the
applicable income standard or other relevant income threshold for
eligibility.
(B) Both state that the individual's income is at or below the
applicable income standard or other relevant income threshold for
eligibility.
(C) The information provided by or on behalf of the individual
states that the individual's income is above, and the information
obtained by the department states that the individual's income is at
or below, the applicable income standard or other relevant income
threshold for eligibility.
(4) If subparagraph (C) of paragraph (3) applies, the individual
shall be informed that the income information provided by him or her
was higher than the information that was electronically verified and
that he or she may request a reconciliation of the difference. This
paragraph shall be implemented no later than January 1, 2015.
(d) (1) The department shall accept the attestation of the
individual regarding whether she is pregnant unless the department
has information that is not reasonably compatible with the
attestation.
(2) If the information obtained by the department is not
reasonably compatible with the information provided by or on behalf
of the individual under paragraph (1), the department shall require
that the individual provide additional information that reasonably
explains the discrepancy.
(e) If any information not described in subdivision (c) or (d)
that is needed for an eligibility determination or redetermination
and is obtained by the department is not reasonably compatible with
the information provided by or on behalf of the individual, the
department shall require that the individual provide additional
information that reasonably explains the discrepancy.
(f) The department shall develop, and update as it is modified, a
verification plan describing the verification policies and procedures
adopted by the department to verify eligibility information. If the
department determines that any state or federal agencies or programs
not previously identified in the verification plan are useful in
determining an individual's eligibility for Medi-Cal benefits or for
potential eligibility, for an insurance affordability program offered
through the California Health Benefit Exchange, the department shall
update the verification plan to identify those additional agencies
or programs. The development and modification of the verification
plan shall be undertaken in consultation with representatives from
county human services departments, legal aid advocates, and the
Legislature. This verification plan shall conform to all federal
requirements and shall be posted on the department's Internet Web
site.
(g) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(h) 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.
(i) This section shall become operative on January 1, 2014.
SEC. 16. Section 14015.5 is added to the Welfare and Institutions
Code, to read:
14015.5. (a) Notwithstanding any other provision of state law,
the department shall retain or delegate the authority to perform
Medi-Cal eligibility determinations as set forth in this section.
(b) If after an assessment and verification for potential
eligibility for Medi-Cal benefits using the applicable MAGI-based
income standard of all persons that apply through an electronic or a
paper application processed by CalHEERS, which is jointly managed by
the department and the Exchange, and to the extent required by
federal law and regulation is completed, the Exchange and the
department is able to electronically determine the applicant's
eligibility for Medi-Cal benefits using only the information
initially provided online, or through the written application
submitted by, or on behalf of, the applicant, and without further
staff review to verify the accuracy of the submitted information, the
Exchange and the department shall determine that applicant's
eligibility for the Medi-Cal program using the applicable MAGI-based
income standard.
(c) Except as provided in subdivision (b) and Section 14015.7, the
county of residence shall be responsible for eligibility
determinations and ongoing case management for the Medi-Cal program.
(d) (1) Notwithstanding any other provision of state law, the
Exchange shall be authorized to provide information regarding
available Medi-Cal managed health care plan selection options to
applicants determined to be eligible for Medi-Cal benefits using the
MAGI-based income standard and allow those applicants to choose an
available managed health care plan.
(2) The Exchange is authorized to record an applicant's health
plan selection into CalHEERS for reporting to the department.
CalHEERS shall have the ability to report to the department the
results of an applicant's health plan selection.
(e) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(f) For the purposes of this section, the following definitions
shall apply:
(1) "ACA" means 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).
(2) "CalHEERS" means the California Healthcare Eligibility,
Enrollment, and Retention System developed under Section 15926.
(3) "Exchange" means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.
(4) "MAGI-based income" means income calculated using the
financial methodologies described in Section 1396a(e)(14) of Title 42
of the United States Code as added by ACA and any subsequent
amendments.
(g) 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.
(h) This section shall become operative on October 1, 2013.
(i) This section shall remain in effect only until July 1, 2015,
and as of that date is repealed, unless a later enacted statute, that
is enacted before July 1, 2015, deletes or extends that date.
SEC. 17. Section 14015.7 is added to the Welfare and Institutions
Code, to read:
14015.7. (a) (1) Notwithstanding any other provision of law, for
persons who call the customer service center operated by the Exchange
for the purpose of applying for an insurance affordability program,
the Exchange shall implement a workflow transfer protocol that
consists of only those questions that are essential to reliably
ascertain whether the caller's household appears to include any
individuals who are potentially eligible for Medi-Cal benefits and to
determine an appropriate point of transferral. The workflow transfer
protocol and transferral procedures used by the Exchange shall be
developed and implemented in conjunction with and subject to review
and approval by the department.
(2) (A) Except as provided in paragraph (3), if, after applying
the transfer protocol specified in paragraph (1), the Exchange
determines that the caller's household appears to include one or more
individuals who are potentially eligible for Medi-Cal benefits using
the applicable MAGI-based income standard, the Exchange shall
transfer the caller to his or her county of residence or other
appropriate county resource for completion of the federally required
assessment. The county shall proceed with the assessment and also
perform any required eligibility determination.
(B) Subject to any income limitations that may be imposed by the
Exchange, and subject to review and approval from the department, if
after applying the transfer protocol specified in paragraph (1) the
Exchange determines that the caller's household appears to include an
individual who is pregnant, or who is potentially eligible for
Medi-Cal benefits on a basis other than using a MAGI-based income
standard because an applicant is potentially disabled, 65 years of
age or older, or potentially in need of long-term care services, the
Exchange shall transfer the caller to his or her county of residence
or other appropriate county resource for completion of the federally
required assessment. The county shall proceed with the assessment and
also perform any required eligibility determination.
(3) Notwithstanding any other provision of law, only during the
initial open enrollment period established by the Exchange, and in no
case after June 30, 2014, if after applying the transfer protocol
specified in paragraph (1) the Exchange determines that the caller's
household appears to include both individuals who are potentially
eligible for Medi-Cal benefits using the applicable MAGI-based income
standard and individuals who are not potentially eligible for
Medi-Cal benefits, the Exchange shall proceed with its assessment and
if it is subsequently determined that an applicant or applicants are
potentially eligible for Medi-Cal benefits using the applicable
MAGI-based income standard, the Exchange shall initially determine
the applicant's or applicants' eligibility for Medi-Cal benefits. If
determined eligible, the applicant's or applicants' coverage shall
start on January 1, 2014, or on the date of the determination,
whichever is later. The county of residence shall be responsible for
final confirmation of eligibility determinations relying on data
provided by and verifications done by the Exchange and the county
shall perform only that additional work that is necessary for the
county to prepare and send out the required notice to the applicant
regarding the result of the eligibility determination and shall not
impose any additional burdens upon the applicant. The county of
residence shall be responsible for sending out the required notices
of all Medi-Cal eligibility determinations.
(4) Notwithstanding any other provision of law, if after applying
the transfer protocol specified in paragraph (1) the Exchange
determines that the caller's household appears to only include
individuals who are not potentially eligible for Medi-Cal benefits,
the Exchange shall proceed with its assessment of eligibility. If it
is subsequently determined that an applicant or applicants are
potentially eligible for Medi-Cal benefits using the applicable
MAGI-based income standard, the Exchange shall initially determine
the applicant or applicants eligibility for Medi-Cal benefits. If
determined eligible, the applicant's or applicants' coverage shall
start on January 1, 2014, or on the date of the determination,
whichever is later. The county of residence shall be responsible for
final confirmation of eligibility determinations relying on data
provided by and verifications done by the Exchange and the county
shall perform only that additional work that is necessary for the
county to prepare and send out the required notice to the applicant
regarding the result of the eligibility determination and shall not
impose any additional burdens upon the applicant. The county of
residence shall be responsible for sending out the required notices
of all Medi-Cal eligibility determinations.
(5) Subject to any income limitations that may be imposed by the
Exchange, and subject to review and approval from the department, if
after assessing the potential eligibility of an applicant, which
shall include enrolling the individual in Exchange-based coverage if
eligible and, if the determination is being made pursuant to
paragraph (3), initially determining eligibility for MAGI-based
Medi-Cal, the Exchange determines that the applicant is pregnant, or
is potentially eligible for Medi-Cal benefits on a basis other than
using a MAGI-based income standard because the applicant is
potentially disabled, 65 years of age or older, or potentially in
need of long-term care services, or if the applicant requests a full
Medi-Cal eligibility determination, the Exchange shall, consistent
with federal law and regulations, transmit all information provided
by or on behalf of the applicant, and any information obtained or
verified by the Exchange, to the applicant's county of residence or
other appropriate county resource via secure electronic interface,
promptly and without undue delay, for a full Medi-Cal eligibility
determination.
(6) Except as otherwise provided in this section and subdivision
(b) of Section 14015.5, the county of residence shall be responsible
for eligibility determinations and ongoing case management for the
Medi-Cal program.
(7) Implementation of the protocols and transferral procedures in
this subdivision shall be subject to the terms specified in the
agreements established under subdivision (b).
(b) The department, Exchange, and each county consortia shall
jointly enter into an interagency agreement that specifies the
operational parameters and performance standards pertaining to the
transfer protocol. After consulting with counties, consumer
advocates, and labor organizations that represent employees of the
customer service center operated by the Exchange and employees of
county customer service centers, the Exchange and the department
shall determine and implement the performance standards that shall be
incorporated into these agreements.
(c) Prior to October 1, 2014, the Exchange and the department, in
consultation with counties, consumer advocates, and labor
organizations that represent employees of the customer service center
operated by the Exchange and employees of county customer service
centers, shall review and determine the efficacy of the enrollment
procedures established in this section.
(d) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(e) For the purposes of this section, the following definitions
shall apply:
(1) "ACA" means 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).
(2) "CalHEERS" means the California Healthcare Eligibility,
Enrollment, and Retention System developed under Section 15926.
(3) "Exchange" means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.
(4) "MAGI-based income" means income calculated using the
financial methodologies described in Section 1396a(e)(14) of Title 42
of the United States Code as added by ACA and any subsequent
amendments.
(f) 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.
(g) The state shall be responsible for providing the
administrative funding to the counties for work associated with this
section. Funding shall be subject to the annual state budget process.
(h) This section shall become operative on October 1, 2013.
SEC. 18. Section 14015.8 is added to the Welfare and Institutions
Code, to read:
14015.8. The department, any other government agency that is
determining eligibility for, or enrollment in, the Medi-Cal program
or any other program administered by the department, or collecting
protected health information for those purposes, and the California
Health Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code, shall share information
with each other as necessary to enable them to perform their
respective statutory and regulatory duties under state and federal
law. This information shall include, but not be limited to, personal
information, as defined in subdivision (a) of Section 1798.3 of the
Civil Code, and protected health information, as defined in Parts 160
and 164 of Title 45 of the Code of Federal Regulations, regarding
individual beneficiaries and applicants.
SEC. 19. Section 14016.5 of the Welfare and Institutions Code is
amended to read:
14016.5. (a) At the time of determining or redetermining the
eligibility of a Medi-Cal program or Aid to Families with Dependent
Children (AFDC) program applicant or beneficiary who resides in an
area served by a managed health care plan or pilot program in which
beneficiaries may enroll, each applicant or beneficiary shall
personally attend a presentation at which the applicant or
beneficiary is informed of the managed care and fee-for-service
options available regarding methods of receiving Medi-Cal benefits.
The county shall ensure that each beneficiary or applicant attends
this presentation.
(b) The health care options presentation described in subdivision
(a) shall include all of the following elements:
(1) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in the fee-for-service sector.
(2) Each beneficiary or eligible applicant shall be provided with
the name, address, telephone number, and specialty, if any, of each
primary care provider, and each clinic participating in each prepaid
managed health care plan, pilot project, or fee-for-service case
management provider option. This information shall be provided under
geographic area designations, in alphabetical order by the name of
the primary care provider and clinic. The name, address, and
telephone number of each specialist participating in each prepaid
managed health care plan, pilot project, or fee-for-service case
management provider option shall be made available by contacting
either the health care options contractor or the prepaid managed
health care plan, pilot project, or fee-for-service case management
provider.
(3) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating
provider is a primary care provider or clinic contracting with any of
the prepaid managed health care plans, pilot projects, or
fee-for-service case management provider options available, has
available capacity, and agrees to continue to treat that beneficiary
or applicant.
(4) In areas specified by the director, each beneficiary or
eligible applicant shall be informed that if he or she fails to make
a choice, or does not certify that he or she has an established
relationship with a primary care provider or clinic, he or she shall
be assigned to, and enrolled in, a prepaid managed health care plan,
pilot project, or fee-for-service case management provider.
(c) No later than 30 days following the date a Medi-Cal or AFDC
beneficiary or applicant is determined eligible, the beneficiary or
applicant shall indicate his or her choice in writing, as a condition
of coverage for Medi-Cal benefits, of either of the following health
care options:
(1) To obtain benefits by receiving a Medi-Cal card, which may be
used to obtain services from individual providers, that the
beneficiary would locate, who choose to provide services to Medi-Cal
beneficiaries.
The department may require each beneficiary or eligible applicant,
as a condition for electing this option, to sign a statement
certifying that he or she has an established patient-provider
relationship, or in the case of a dependent, the parent or guardian
shall make that certification. This certification shall not require
the acknowledgment or guarantee of acceptance, by any indicated
Medi-Cal provider or health facility, of any beneficiary making a
certification under this section.
(2) (A) To obtain benefits by enrolling in a prepaid managed
health care plan, pilot program, or fee-for-service case management
provider that has agreed to make Medi-Cal services readily available
to enrolled Medi-Cal beneficiaries.
(B) At the time the beneficiary or eligible applicant selects a
prepaid managed health care plan, pilot project, or fee-for-service
case management provider, the department shall, when applicable,
encourage the beneficiary or eligible applicant to also indicate, in
writing, his or her choice of primary care provider or clinic
contracting with the selected prepaid managed health care plan, pilot
project, or fee-for-service case management provider.
(d) (1) In areas specified by the director, a Medi-Cal or AFDC
beneficiary or eligible applicant who does not make a choice, or who
does not certify that he or she has
an established relationship with a primary care provider
or clinic, shall be assigned to and enrolled in an appropriate
Medi-Cal managed care plan, pilot project, or fee-for-service case
management provider providing service within the area in which the
beneficiary resides.
(2) If it is not possible to enroll the beneficiary under a
Medi-Cal managed care plan, pilot project, or a fee-for-service case
management provider because of a lack of capacity or availability of
participating contractors, the beneficiary shall be provided with a
Medi-Cal card and informed about fee-for-service primary care
providers who do all of the following:
(A) The providers agree to accept Medi-Cal patients.
(B) The providers provide information about the provider's
willingness to accept Medi-Cal patients as described in Section
14016.6.
(C) The providers provide services within the area in which the
beneficiary resides.
(e) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select any primary care
provider who is available, the managed health care plan, pilot
project, or fee-for-service case management provider that was
selected by or assigned to the beneficiary shall ensure that the
beneficiary selects a primary care provider or clinic within 30 days
after enrollment or is assigned to a primary care provider within 40
days after enrollment.
(f) (1) The managed care plan shall have a valid Medi-Cal
contract, adequate capacity, and appropriate staffing to provide
health care services to the beneficiary.
(2) The department shall establish standards for all of the
following:
(A) The maximum distances a beneficiary is required to travel to
obtain primary care services from the managed care plan,
fee-for-service case management provider, or pilot project in which
the beneficiary is enrolled.
(B) The conditions under which a primary care service site shall
be accessible by public transportation.
(C) The conditions under which a managed care plan,
fee-for-service case management provider, or pilot project shall
provide nonmedical transportation to a primary care service site.
(3) In developing the standards required by paragraph (2), the
department shall take into account, on a geographic basis, the means
of transportation used and distances typically traveled by Medi-Cal
beneficiaries to obtain fee-for-service primary care services and the
experience of managed care plans in delivering services to Medi-Cal
enrollees. The department shall also consider the provider's ability
to render culturally and linguistically appropriate services.
(g) To the extent possible, the arrangements for carrying out
subdivision (d) shall provide for the equitable distribution of
Medi-Cal beneficiaries among participating managed care plans,
fee-for-service case management providers, and pilot projects.
(h) If, under the provisions of subdivision (d), a Medi-Cal
beneficiary or applicant does not make a choice or does not certify
that he or she has an established relationship with a primary care
provider or clinic, the person may, at the option of the department,
be provided with a Medi-Cal card or be assigned to and enrolled in a
managed care plan providing service within the area in which the
beneficiary resides.
(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with the
provider or managed care plan, pilot project, or fee-for-service case
management provider shall be allowed to select or be assigned to
another provider or managed care plan, pilot project, or
fee-for-service case management provider.
(j) The department or its contractor shall notify a managed care
plan, pilot project, or fee-for-service case management provider when
it has been selected by or assigned to a beneficiary. The managed
care plan, pilot project, or fee-for-service case management provider
that has been selected by, or assigned to, a beneficiary, shall
notify the primary care provider or clinic that it has been selected
or assigned. The managed care plan, pilot project, or fee-for-service
case management provider shall also notify the beneficiary of the
managed care plan, pilot project, or fee-for-service case management
provider or clinic selected or assigned.
(k) (1) The department shall ensure that Medi-Cal beneficiaries
eligible under Title XVI of the Social Security Act are provided with
information about options available regarding methods of receiving
Medi-Cal benefits as described in subdivision (c).
(2) (A) The director may waive the requirements of subdivisions
(c) and (d) until a means is established to directly provide the
presentation described in subdivision (a) to beneficiaries who are
eligible for the federal Supplemental Security Income for the Aged,
Blind, and Disabled Program (Subchapter 16 (commencing with Section
1381) of Chapter 7 of Title 42 of the United States Code).
(B) The director may elect not to apply the requirements of
subdivisions (c) and (d) to beneficiaries whose eligibility under the
Supplemental Security Income program is established before January
1, 1994.
( l ) In areas where there is no prepaid managed health
care plan or pilot program that has contracted with the department
to provide services to Medi-Cal beneficiaries, and where no other
enrollment requirements have been established by the department, no
explicit choice need be made, and the beneficiary or eligible
applicant shall receive a Medi-Cal card.
(m) The following definitions contained in this subdivision shall
control the construction of this section, unless the context requires
otherwise:
(1) "Applicant," "beneficiary," and "eligible applicant," in the
case of a family group, mean any person with legal authority to make
a choice on behalf of dependent family members.
(2) "Fee-for-service case management provider" means a provider
enrolled and certified to participate in the Medi-Cal fee-for-service
case management program the department may elect to develop in
selected areas of the state with the assistance of and in cooperation
with California physician providers and other interested provider
groups.
(3) "Managed health care plan" and "managed care plan" mean a
person or entity operating under a Medi-Cal contract with the
department under this chapter or Chapter 8 (commencing with Section
14200) to provide, or arrange for, health care services for Medi-Cal
beneficiaries as an alternative to the Medi-Cal fee-for-service
program that has a contractual responsibility to manage health care
provided to Medi-Cal beneficiaries covered by the contract.
(n) (1) Whenever a county welfare department notifies a public
assistance recipient or Medi-Cal beneficiary that the recipient or
beneficiary is losing Medi-Cal eligibility, the county shall include,
in the notice to the recipient or beneficiary, notification that the
loss of eligibility shall also result in the recipient's or
beneficiary's disenrollment from Medi-Cal managed health care or
dental plans, if enrolled.
(2) (A) Whenever the department or the county welfare department
processes a change in a public assistance recipient's or Medi-Cal
beneficiary's residence or aid code that will result in the recipient'
s or beneficiary's disenrollment from the managed health care or
dental plan in which he or she is currently enrolled, a written
notice shall be given to the recipient or beneficiary.
(B) This paragraph shall become operative and the department shall
commence sending the notices required under this paragraph on or
before the expiration of 12 months after the effective date of this
section.
(o) This section shall be implemented in a manner consistent with
any federal waiver required to be obtained by the department in order
to implement this section.
(p) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 20. Section 14016.5 is added to the Welfare and Institutions
Code, to read:
14016.5. (a) At the time of determining or redetermining the
eligibility of a Medi-Cal program or Aid to Families with Dependent
Children (AFDC) program applicant or beneficiary who resides in an
area served by a managed health care plan or pilot program in which
beneficiaries may enroll, each applicant or beneficiary shall be
informed of the managed care and fee-for-service options available
regarding methods of receiving Medi-Cal benefits.
(b) The information described in subdivision (a) shall include all
of the following elements:
(1) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in the fee-for-service sector.
(2) Each beneficiary or eligible applicant shall be provided with
the name, address, telephone number, and specialty, if any, of each
primary care provider, and each clinic participating in each prepaid
managed health care plan, pilot project, or fee-for-service case
management provider option. This information shall be provided under
geographic area designations, in alphabetical order by the name of
the primary care provider and clinic. The name, address, and
telephone number of each specialist participating in each prepaid
managed health care plan, pilot project, or fee-for-service case
management provider option shall be made available by contacting
either the health care options contractor or the prepaid managed
health care plan, pilot project, or fee-for-service case management
provider.
(3) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating
provider is a primary care provider or clinic contracting with any of
the prepaid managed health care plans, pilot projects, or
fee-for-service case management provider options available, has
available capacity, and agrees to continue to treat that beneficiary
or applicant.
(4) In areas specified by the director, each beneficiary or
eligible applicant shall be informed that if he or she fails to make
a choice, or does not certify that he or she has an established
relationship with a primary care provider or clinic, he or she shall
be assigned to, and enrolled in, a prepaid managed health care plan,
pilot project, or fee-for-service case management provider.
(c) No later than 30 days following the date a Medi-Cal or AFDC
beneficiary or applicant is determined eligible, the beneficiary or
applicant shall indicate his or her choice in writing, as a condition
of coverage for Medi-Cal benefits, of either of the following health
care options:
(1) To obtain benefits by receiving a Medi-Cal card, which may be
used to obtain services from individual providers, that the
beneficiary would locate, that choose to provide services to Medi-Cal
beneficiaries.
The department may require each beneficiary or eligible applicant,
as a condition for electing this option, to sign a statement
certifying that he or she has an established patient-provider
relationship, or in the case of a dependent, the parent or guardian
shall make that certification. This certification shall not require
the acknowledgment or guarantee of acceptance, by any indicated
Medi-Cal provider or health facility, of any beneficiary making a
certification under this section.
(2) (A) To obtain benefits by enrolling in a prepaid managed
health care plan, pilot program, or fee-for-service case management
provider that has agreed to make Medi-Cal services readily available
to enrolled Medi-Cal beneficiaries.
(B) At the time the beneficiary or eligible applicant selects a
prepaid managed health care plan, pilot project, or fee-for-service
case management provider, the department shall, when applicable,
encourage the beneficiary or eligible applicant to also indicate, in
writing, his or her choice of primary care provider or clinic
contracting with the selected prepaid managed health care plan, pilot
project, or fee-for-service case management provider.
(d) (1) In areas specified by the director, a Medi-Cal or AFDC
beneficiary or eligible applicant who does not make a choice, or who
does not certify that he or she has an established relationship with
a primary care provider or clinic, shall be assigned to and enrolled
in an appropriate Medi-Cal managed care plan, pilot project, or
fee-for-service case management provider providing service within the
area in which the beneficiary resides.
(2) If it is not possible to enroll the beneficiary under a
Medi-Cal managed care plan, pilot project, or a fee-for-service case
management provider because of a lack of capacity or availability of
participating contractors, the beneficiary shall be provided with a
Medi-Cal card and informed about fee-for-service primary care
providers who do all of the following:
(A) The providers agree to accept Medi-Cal patients.
(B) The providers provide information about the provider's
willingness to accept Medi-Cal patients as described in Section
14016.6.
(C) The providers provide services within the area in which the
beneficiary resides.
(e) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select any primary care
provider who is available, the managed health care plan, pilot
project, or fee-for-service case management provider that was
selected by or assigned to the beneficiary shall ensure that the
beneficiary selects a primary care provider or clinic within 30 days
after enrollment or is assigned to a primary care provider within 40
days after enrollment.
(f) (1) The managed care plan shall have a valid Medi-Cal
contract, adequate capacity, and appropriate staffing to provide
health care services to the beneficiary.
(2) The department shall establish standards for all of the
following:
(A) The maximum distances a beneficiary is required to travel to
obtain primary care services from the managed care plan,
fee-for-service case management provider, or pilot project in which
the beneficiary is enrolled.
(B) The conditions under which a primary care service site shall
be accessible by public transportation.
(C) The conditions under which a managed care plan,
fee-for-service case management provider, or pilot project shall
provide nonmedical transportation to a primary care service site.
(3) In developing the standards required by paragraph (2), the
department shall take into account, on a geographic basis, the means
of transportation used and distances typically traveled by Medi-Cal
beneficiaries to obtain fee-for-service primary care services and the
experience of managed care plans in delivering services to Medi-Cal
enrollees. The department shall also consider the provider's ability
to render culturally and linguistically appropriate services.
(g) To the extent possible, the arrangements for carrying out
subdivision (d) shall provide for the equitable distribution of
Medi-Cal beneficiaries among participating managed care plans,
fee-for-service case management providers, and pilot projects.
(h) If, under the provisions of subdivision (d), a Medi-Cal
beneficiary or applicant does not make a choice or does not certify
that he or she has an established relationship with a primary care
provider or clinic, the person may, at the option of the department,
be provided with a Medi-Cal card or be assigned to and enrolled in a
managed care plan providing service within the area in which the
beneficiary resides.
(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with the
provider or managed care plan, pilot project, or fee-for-service case
management provider shall be allowed to select or be assigned to
another provider or managed care plan, pilot project, or
fee-for-service case management provider.
(j) The department or its contractor shall notify a managed care
plan, pilot project, or fee-for-service case management provider when
it has been selected by or assigned to a beneficiary. The managed
care plan, pilot project, or fee-for-service case management provider
that has been selected by, or assigned to, a beneficiary, shall
notify the primary care provider or clinic that it has been selected
or assigned. The managed care plan, pilot project, or fee-for-service
case management provider shall also notify the beneficiary of the
managed care plan, pilot project, or fee-for-service case management
provider or clinic selected or assigned.
(k) (1) The department shall ensure that Medi-Cal beneficiaries
eligible under Title XVI of the federal Social Security Act are
provided with information about options available regarding methods
of receiving Medi-Cal benefits as described in subdivision (c).
(2) (A) The director may waive the requirements of subdivisions
(c) and (d) until a means is established to directly provide the
information described in subdivision (a) to beneficiaries who are
eligible for the federal Supplemental Security Income for the Aged,
Blind, and Disabled Program (Subchapter 16 (commencing with Section
1381) of Chapter 7 of Title 42 of the United States Code).
(B) The director may elect not to apply the requirements of
subdivisions (c) and (d) to beneficiaries whose eligibility under the
Supplemental Security Income program is established before January
1, 1994.
( l ) In areas where there is no prepaid managed health
care plan or pilot program that has contracted with the department
to provide services to Medi-Cal beneficiaries, and where no other
enrollment requirements have been established by the department, no
explicit choice need be made, and the beneficiary or eligible
applicant shall receive a Medi-Cal card.
(m) The following definitions contained in this subdivision shall
control the construction of this section, unless the context requires
otherwise:
(1) "Applicant," "beneficiary," and "eligible applicant," in the
case of a family group, mean any person with legal authority to make
a choice on behalf of dependent family members.
(2) "Fee-for-service case management provider" means a provider
enrolled and certified to participate in the Medi-Cal fee-for-service
case management program the department may elect to develop in
selected areas of the state with the assistance of and in cooperation
with California physician providers and other interested provider
groups.
(3) "Managed health care plan" and "managed care plan" mean a
person or entity operating under a Medi-Cal contract with the
department under this chapter or Chapter 8 (commencing with Section
14200) to provide, or arrange for, health care services for Medi-Cal
beneficiaries as an alternative to the Medi-Cal fee-for-service
program that has a contractual responsibility to manage health care
provided to Medi-Cal beneficiaries covered by the contract.
(n) (1) Whenever a county welfare department notifies a public
assistance recipient or Medi-Cal beneficiary that the recipient or
beneficiary is losing Medi-Cal eligibility, the county shall include,
in the notice to the recipient or beneficiary, notification that the
loss of eligibility shall also result in the recipient's or
beneficiary's disenrollment from Medi-Cal managed health care or
dental plans, if enrolled.
(2) Whenever the department or the county welfare department
processes a change in a public assistance recipient's or Medi-Cal
beneficiary's residence or aid code that will result in the recipient'
s or beneficiary's disenrollment from the managed health care or
dental plan in which he or she is currently enrolled, a written
notice shall be given to the recipient or beneficiary.
(o) This section shall be implemented in a manner consistent with
any federal waiver required to be obtained by the department in order
to implement this section.
(p) (1) If the functionality is available in the California
Healthcare Eligibility, Enrollment, and Retention System (CalHEERS),
individuals or their authorized representatives may select Medi-Cal
managed care plans via CalHEERS.
(A) Any person that assists a Medi-Cal beneficiary who is eligible
for the program based on modified adjusted gross income (MAGI) to
select a Medi-Cal managed care plan via CalHEERS shall complete a
training program that includes all of the following:
(i) The right to select a plan, to designate a plan at a later
date, to have plan choice materials sent by mail, and that if the
person does not select a plan, one will be selected for them.
(ii) All plan enrollment options and requirements with regard to
MAGI Medi-Cal eligibility.
(iii) Any applicable timeframes in which the plan choice must be
designated and the mechanism for designating plan choice.
(iv) How to use provider directories, how to identify which
providers are in a particular plan network, and the applicable
characteristics of primary care and specialty care providers and
providers of other services, such as languages spoken, whether they
are accepting new patients, and office locations.
(v) To the extent applicable, how to access Medi-Cal services
prior to plan enrollment, including the right to retroactive Medi-Cal
benefits.
(B) Any person that assists a Medi-Cal beneficiary who is not
eligible for Medi-Cal on the basis of MAGI to select a Medi-Cal
managed care plan shall complete a training program that includes all
of the following:
(i) All of the information included in the training program
described in subparagraph (A).
(ii) The enrollment options and requirements with regard to each
Medi-Cal eligibility category, including whether enrollment is
mandatory, how to obtain medical exemptions and continuity of care,
waiver programs, carved-out services, and the California Children's
Services Program, as applicable.
(2) The department shall consult with a group of stakeholders
through either a group currently in existence or convened for this
purpose that includes representatives of plans, providers, consumer
advocates, counties, eligibility workers, CalHEERS, the California
Health Benefit Exchange (Exchange), and the Legislature to review
process, timelines, scripts, training curricula, monitoring and
oversight plans, and plan marketing and informational materials.
(3) In developing materials, scripts, and processes, the
department and the Exchange shall consult with or test the materials,
scripts, and processes with stakeholders that have expertise in
health plan selection, and in assisting populations of diverse
demographic characteristics such as race, ethnicity, language spoken,
geographic region, sexual orientation, and gender identity or
preference.
(4) The department, CalHEERS, the Exchange, and counties may adopt
the recommendations of the advisory body convened in paragraph (2)
and specify the reasons if the recommendations are not adopted.
(q) This section shall become operative on January 1, 2014.
SEC. 21. Section 14016.6 of the Welfare and Institutions Code is
amended to read:
14016.6. The State Department of Health Care Services shall
develop a program to implement Section 14016.5 and to provide
information and assistance to enable Medi-Cal beneficiaries to
understand and successfully use the services of the Medi-Cal managed
care plans in which they enroll. The program shall include, but not
be limited to, the following components:
(a) (1) Development of a method to inform beneficiaries and
applicants of all of the following:
(A) Their choices for receiving Medi-Cal benefits including the
use of fee-for-service sector managed health care plans, or pilot
programs.
(B) The availability of staff and information resources to
Medi-Cal managed health care plan enrollees described in subdivision
(f).
(2) (A) Marketing and informational materials including printed
materials, films, and exhibits, to be provided to Medi-Cal
beneficiaries and applicants when choosing methods of receiving
health care benefits.
(B) The department shall not be responsible for the costs of
developing material required by subparagraph (A).
(C) (i) The department may prescribe the format and edit the
informational materials for factual accuracy, objectivity and
comprehensibility .
(ii) The department shall use the edited materials in informing
beneficiaries and applicants of their choices for receiving Medi-Cal
benefits.
(b) Provision of information that is necessary to implement this
program in a manner that fairly and objectively explains to
beneficiaries and applicants their choices for methods of receiving
Medi-Cal benefits, including information prepared by the department
emphasizing the benefits and limitations to beneficiaries of
enrolling in managed health care plans and pilot projects as opposed
to the fee-for-service system.
(c) Provision of information about providers who will provide
services to Medi-Cal beneficiaries. This may be information about
provider referral services of a local provider professional
organization. The information shall be made available to Medi-Cal
beneficiaries and applicants at the same time the beneficiary or
applicant is being informed of the options available for receiving
care.
(d) Training of specialized county employees to carry out the
program.
(e) Monitoring the implementation of the program in those county
welfare offices where choices are made available in order to assure
that beneficiaries and applicants may make a well-informed choice,
without duress.
(f) Staff and information resources dedicated to directly assist
Medi-Cal managed health care plan enrollees to understand how to
effectively use the services of, and resolve problems or complaints
involving, their managed health care plans.
(g) The responsibilities outlined in this section shall, at the
option of the department, be carried out by a specially trained
county or state employee or by an independent contractor paid by the
department. If a county sponsored prepaid health plan or pilot
program is offered, the responsibilities outlined in this section
shall be carried out either by a specially trained state employee or
by an independent contractor paid by the department.
(h) The department shall adopt any regulations as are necessary to
ensure that the informing of beneficiaries of their health care
options is a part of the eligibility determination process.
(i) This section shall remain in effect only until January 1,
2014, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2014, deletes or extends
that date.
SEC. 22. Section 14016.6 is added to the Welfare and Institutions
Code, to read:
14016.6.
The State Department of Health Care Services shall develop a program
to implement subdivision (p) of Section 14016.5 and to provide
information and assistance to enable Medi-Cal beneficiaries to
understand and successfully use the services of the Medi-Cal managed
care plans in which they enroll. The program shall include, but not
be limited to, the following components:
(a) (1) Development of a method to inform beneficiaries and
applicants of all of the following:
(A) Their choices for receiving Medi-Cal benefits including the
use of fee-for-service sector managed health care plans, or pilot
programs.
(B) The availability of staff and information resources to
Medi-Cal managed health care plan enrollees described in subdivision
(f).
(2) (A) Marketing and informational materials, including printed
materials, films, and exhibits, to be provided to Medi-Cal
beneficiaries and applicants when choosing methods of receiving
health care benefits.
(B) The department shall not be responsible for the costs of
developing material required by subparagraph (A).
(C) (i) The department may prescribe the format and edit the
informational materials for factual accuracy, objectivity, and
comprehensibility .
(ii) The department, the California Health Benefit Exchange
(Exchange), the California Healthcare Eligibility, Enrollment, and
Retention System (CalHEERS), and entities or persons designated
pursuant to subdivision (g) shall use the edited materials in
informing beneficiaries and applicants of their choices for receiving
Medi-Cal benefits.
(b) Provision of information that is necessary to implement this
program in a manner that fairly and objectively explains to
beneficiaries and applicants their choices for methods of receiving
Medi-Cal benefits, including information prepared by the department.
(c) Provision of information about providers who will provide
services to Medi-Cal beneficiaries. This may be information about
provider referral services of a local provider professional
organization. The information shall be made available to Medi-Cal
beneficiaries and applicants at the same time the beneficiary or
applicant is being informed of the options available for receiving
care.
(d) Training of specialized county employees to carry out the
program.
(e) Monitoring the implementation of the program at any location,
including online at the Exchange or at counties, where choices are
made available in order to assure that beneficiaries and applicants
may make a well-informed choice, without duress.
(f) Staff and information resources dedicated to directly assist
Medi-Cal managed health care plan enrollees to understand how to
effectively use the services of, and resolve problems or complaints
involving, their managed health care plans.
(g) Notwithstanding any other provision of state law, the
department, in consultation with the Exchange, may authorize specific
persons or entities, including counties, to provide information to
beneficiaries concerning their health care options for receiving
Medi-Cal benefits and assistance with enrollment. This subdivision
shall apply in all geographic areas designated by the director. This
subdivision shall be implemented in a manner consistent with federal
law.
(h) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(i) This section shall become operative on January 1, 2014.
SEC. 23. Section 14055 is added to the Welfare and Institutions
Code, to read:
14055. (a) For the purposes of this chapter, "caretaker relative"
means a relative of a dependent child by blood, adoption, or
marriage with whom the child is living, who assumes primary
responsibility for the child's care, and who is one of the following:
(1) The child's father, mother, grandfather, grandmother, brother,
sister, stepfather, stepmother, stepbrother, stepsister, great
grandparent, uncle, aunt, nephew, niece, great-great grandparent,
great uncle or aunt, first cousin, great-great-great grandparent,
great-great uncle or aunt, or first cousin once removed.
(2) The spouse or registered domestic partner of one of the
relatives identified in paragraph (1), even after the marriage is
terminated by death or divorce or the domestic partnership has been
legally terminated.
(b) This section shall become operative on January 1, 2014.
SEC. 24. Section 14102.5 is added to the Welfare and Institutions
Code, to read:
14102.5. (a) The department shall, in collaboration with the
Exchange, the counties, consumer advocates, and the Statewide
Automated Welfare System consortia, develop and prepare one or more
reports that shall be issued on at least a quarterly basis and shall
be made publicly available within 30 days following the end of each
quarter, for the purpose of informing the California Health and Human
Services Agency, the Exchange, the Legislature, and the public about
the enrollment process for all insurance affordability programs. The
reports shall comply with federal reporting requirements and shall,
at a minimum, include the following information, to be derived from,
as appropriate depending on the data element, CalHEERS, MEDS, or the
Statewide Automated Welfare System:
(1) For applications received for insurance affordability programs
through any venue, all of the following:
(A) The number of applications received through each venue.
(B) The number of applicants included on those applications.
(C) Applicant demographics, including, but not limited to, gender,
age, race, ethnicity, and primary language.
(D) The disposition of applications, including all of the
following:
(i) The number of eligibility determinations that resulted in an
approval for coverage.
(ii) The program or programs for which the individuals in clause
(i) were determined eligible.
(iii) The number of applications that were denied for any coverage
and the reason or reasons for the denials.
(E) The number of days for eligibility determinations to be
completed.
(2) With regard to health plan selection, all of the following:
(A) The health plans that are selected by applicants enrolled in
an insurance affordability program, reported by the program.
(B) The number of Medi-Cal enrollees who do not select a health
plan but are defaulted into a plan.
(3) For annual redeterminations conducted for beneficiaries, all
of the following:
(A) The number of redeterminations processed.
(B) The number of redeterminations that resulted in continued
eligibility for the same insurance affordability program.
(C) The number of redeterminations that resulted in a change in
eligibility to a different insurance affordability program.
(D) The number of redeterminations that resulted in a finding of
ineligibility for any program and the reason or reasons for the
findings of ineligibility.
(E) The number of days for redeterminations to be completed.
(4) With regard to disenrollments not related to a redetermination
of eligibility, all of the following:
(A) The number of beneficiary disenrollments.
(B) The reasons for the disenrollments.
(C) The number of disenrollments that are caused by an individual
disenrolling from one insurance affordability program and enrolling
into another.
(5) The number of applications for insurance affordability
programs that were filed with the help of an assister or navigator.
(6) The total number of grievances and appeals filed by applicants
and enrollees regarding eligibility for insurance affordability
programs, the basis for the grievance, and the outcomes of the
appeals.
(b) The department shall collect the information necessary for
these reports and develop these reports using data obtained from the
Statewide Automated Welfare System, CalHEERS, MEDS, and any other
appropriate state information management systems.
(c) For purposes of this section, the following definitions shall
apply:
(1) "CalHEERS" means the California Healthcare Eligibility,
Enrollment, and Retention System developed under Section 15926.
(2) "Exchange" means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500) of
the Government Code.
(3) "Statewide Automated Welfare System" means the system
developed pursuant to Section 10823.
(4) "MEDS" means the Medi-Cal Eligibility Data System that is
maintained by the department.
(d) 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.
Thereafter, the department shall adopt regulations 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 until
regulations have been adopted.
(e) This section shall become operative on January 1, 2014.
SEC. 25. Section 14103 is added to the Welfare and Institutions
Code, to read:
14103. (a) The implementation of the optional expansion of
Medi-Cal benefits to adults who meet the eligibility requirements of
Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), shall be
contingent upon the following:
(1) If the federal medical assistance percentage payable to the
state under the ACA for the optional expansion of Medi-Cal benefits
to adults is reduced below 90 percent, that reduction shall be
addressed in a timely manner through the annual state budget or
legislative process. Upon receiving notification of any reduction in
federal assistance pursuant to this paragraph, the Director of
Finance shall immediately notify the Chairpersons of the Senate and
Assembly Health Committees and the Chairperson of the Joint
Legislative Budget Committee.
(2) If, prior to January 1, 2018, the federal medical assistance
percentage payable to the state under the ACA for the optional
expansion of Medi-Cal benefits to adults is reduced to 70 percent or
less, the implementation of any provision in this chapter authorizing
the optional expansion of Medi-Cal benefits to adults shall cease 12
months after the effective date of the federal law or other action
reducing the federal medical assistance percentage.
(b) For purposes of this section, "ACA" means the federal Patient
Protection and Affordable Care Act (Public Law 111-148) as originally
enacted and as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) and any subsequent
amendments.
SEC. 26. Section 15926 of the Welfare and Institutions Code is
amended to read:
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 not speaking English as one'
s primary language and having a limited ability to read, speak,
write, or understand English.
(3) "Insurance affordability program" means a program that is one
of the following:
(A) The Medi-Cal program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.).
(B) The state's children's health insurance program (CHIP) under
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa
et seq.).
(C) A program that makes available to qualified individuals
coverage in a qualified health plan through the California Health
Benefit Exchange established pursuant to Title 22 (commencing with
Section 100500) of the Government Code with advance payment of the
premium tax credit established under Section 36B of the Internal
Revenue Code.
(4) A program that makes available coverage in a qualified health
plan through the California Health Benefit Exchange established
pursuant to Title 22 (commencing with Section 100500) of the
Government Code with cost-sharing reductions established under
Section 1402 of PPACA and any subsequent amendments to that act.
(b) An individual shall have the option to apply for insurance
affordability programs in person, by mail, online, by telephone, or
by other commonly available electronic means.
(c) (1) A single, accessible, standardized paper, electronic, and
telephone application for insurance affordability 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 insurance affordability programs and by their agents.
(2) The department may develop and require the use of supplemental
forms to collect additional information needed to determine
eligibility on a basis other than the financial methodologies
described in Section 1396a(e)(14) of Title 42 of the United States
Code, as added by the federal Patient Protection and Affordable Care
Act (Public Law 111-148), and as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152) and any
subsequent amendments, as provided under Section 435.907(c) of Title
42 of the Code of Federal Regulations.
(3) The application shall be tested and operational by the date as
required by the federal Secretary of Health and Human Services.
(4) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:
(A) The form shall include simple, user-friendly language and
instructions.
(B) The form may not ask for information related to a nonapplicant
that is not necessary to determine eligibility in the applicant's
particular circumstances.
(C) The form may require only information necessary to support the
eligibility and enrollment processes for insurance affordability
programs.
(D) The form may be used for, but shall not be limited to,
screening.
(E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through an insurance affordability 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) The form may 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.
(G) Until January 1, 2016, the department shall instruct counties
to not reject an application that was in existence prior to January
1, 2014, but to accept the application and request any additional
information needed from the applicant in order to complete the
eligibility determination process. The department shall work with
counties and consumer advocates to develop the supplemental
questions.
(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
insurance affordability programs or other health programs that
differs from the application form described in subdivision (c), and
related enrollment procedures. Nothing in this section shall preclude
the use of a joint application, developed by the department and the
State Department of Social Services, that allows for an application
to be made for multiple programs, including, but not limited to,
CalWORKs, CalFresh, and insurance affordability programs.
(e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of the
applicant in accordance with the state and federal rules governing
insurance affordability 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 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 insurance affordability programs may accept
self-attestation, instead of requiring an individual to produce a
document, for age, date of birth, family size, household income,
state residence, pregnancy, and any other applicable criteria needed
to determine the eligibility of an 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 the PPACA and
implementing federal regulations and guidance and state law.
(4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.
(5) The eligibility of an applicant shall not be delayed beyond
the timeliness standards as provided in Section 435.912 of Title 42
of the Code of Federal Regulations or denied for any insurance
affordability program unless the applicant is 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
(e) 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 insurance affordability 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. Nothing in this section shall
be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.
(g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for an insurance affordability program in person, over the
telephone, by mail, online, or through other commonly available
electronic means 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 an insurance affordability program
shall ensure that an eligible applicant and recipient of insurance
affordability programs that meets all program eligibility
requirements and complies with all necessary requests for information
moves 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 about 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) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross Income
(MAGI) household income but who may be eligible on the basis of being
65 years of age or older, or on the basis of blindness or
disability, shall be 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, if
the applicant or recipient is otherwise eligible for an insurance
affordability 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, mail, and online renewal or renewal through
other commonly available electronic means.
(4) An applicant who is not eligible for an insurance
affordability 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, both of the following shall occur:
(1) The applicant shall be informed of the overpayment penalties
under the federal 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 informed of the penalty for failure to
have minimum essential health coverage.
(j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among insurance affordability programs using the least
restrictive rules and requirements permitted by federal and state
law. This process shall include the 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 required for
Medi-Cal managed care plans.
(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 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 January 1, 2014.
SEC. 27. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution for
certain costs that may be incurred by a local agency or school
district because, in that regard, this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
However, if the Commission on State Mandates determines that this
act contains other 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.
SEC. 28. This act shall become operative only if Senate Bill 1 of
the 2013-14 First Extraordinary Session is enacted and takes effect.
