Bill Text: CA ABX11 | 2013-2014 | Regular Session | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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-Introduced.html
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-Introduced.html
BILL NUMBER: ABX1 1 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member John A. Pérez
(Coauthor: Assembly Member Pan)
JANUARY 28, 2013
An act to amend Section 12698.30 of the Insurance Code, and to
amend Sections 14005.31, 14005.32, 14132, and 15926 of, to amend and
repeal Sections 14008.85, 14011.16, and 14011.17 of, to amend,
repeal, and add Sections 14005.18, 14005.28, 14005.30, 14005.37,
14007.1, 14007.6, and 14012 of, and to add Sections 14005.60,
14005.62, 14005.63, 14005.64, 14005.65, and 14132.02 to, the Welfare
and Institutions Code, relating to health.
LEGISLATIVE COUNSEL'S DIGEST
AB 1, as introduced, 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 also add,
commencing January 1, 2014, benefits, services, and coverage
included in the essential health benefits package, as adopted by the
state and approved by the United States Secretary of Health and Human
Services, to the schedule of Medi-Cal benefits.
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 California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. 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) At (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 14005.18 of the Welfare and Institutions Code is
amended to read:
14005.18. (a) A woman is eligible, to the
extent required by federal law, as though she were pregnant, for all
pregnancy-related and postpartum services for a 60-day period
beginning on the last day of pregnancy.
For purposes of this section, "postpartum services" means those
services provided after childbirth, child delivery, or miscarriage.
(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. 4. Section 14005.18 is added to the Welfare and Institutions
Code, to read:
14005.18. (a) To help prevent premature delivery and low
birthweights, the leading causes of infant and maternal morbidity and
mortality, and to promote women's overall health, well-being, and
financial security and that of their families, it is imperative that
pregnant women enrolled in Medi-Cal be provided with all medically
necessary services. Therefore, a woman is eligible, to the extent
required by federal law, as though she were pregnant, for all
pregnancy-related and postpartum services for a 60-day period
beginning on the last day of pregnancy and continuing until the end
of the month in which the 60th day of postpartum occurs.
(b) For purposes of this section, the following definitions shall
apply:
(1) "Pregnancy-related services" means, at a minimum, all services
required under the state plan unless federal approval is granted
after January 1, 2014, pursuant to the procedure under the Preamble
to the Final Rule at page 17149 of volume 77 of the Federal Register
(March 23, 2012) to provide fewer benefits during pregnancy.
(2) "Postpartum services" means those services provided after
child birth, child delivery, or miscarriage.
(c) This section shall become operative January 1, 2014.
SEC. 5. Section 14005.28 of the Welfare and Institutions Code is
amended to read:
14005.28. (a) To the extent federal financial participation is
available pursuant to an approved state plan amendment, the
department shall exercise its option under Section 1902(a)
(10)(A)(XV) 1902(a)(10)(A)(ii)(XVII) of the
federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)
(XV)) 1396a(a)(10)(A)(ii)(XVII)) to extend
Medi-Cal benefits to independent foster care adolescents, as defined
in Section 1905(v)(1) 1905(w)(1) of the
federal Social Security Act (42 U.S.C. Sec. 1396d(v)(1))
1396d(w)(1)) .
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and if the
state plan amendment described in subdivision (a) is approved by the
federal Health Care Financing Administration, the department may
implement subdivision (a) without taking any regulatory action and 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.
(c) The department shall implement subdivision (a) on October 1,
2000, but only if, and to the extent that, the department has
obtained all necessary federal approvals.
(d) The department shall identify and track all former independent
foster care adolescents who, on or after January 1, 2013, lost
Medi-Cal coverage as a result of attaining 21 years of age.
(e) 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. 6. Section 14005.28 is added to the Welfare and Institutions
Code, to read:
14005.28. (a) Commencing January 1, 2014, and to the extent
federal financial participation is available pursuant to an approved
state plan amendment, the department shall implement Section 1902(a)
(10)(A)(i)(IX) of the federal Social Security Act (42 U.S.C. Sec.
1396a(a)(10)(A)(i)(IX)) to provide Medi-Cal benefits to a former
foster care adolescent until his or her 26th birthday.
(1) A foster care adolescent who was in foster care on his or her
18th birthday shall be deemed eligible for the benefits provided
pursuant to this section and shall be enrolled to receive these
benefits until his or her 26th birthday without any interruption in
coverage and without requiring a new application.
(2) The department shall develop procedures to identify
individuals who meet the criteria in paragraph (1), including, but
not limited to, former foster care adolescents who lost Medi-Cal
coverage as a result of attaining 21 years of age, and reenroll them
in Medi-Cal.
(3) The department shall develop and implement a simplified
redetermination form for this program. A recipient qualifying for the
benefits extended pursuant to this section shall fill out and return
this form only if information previously reported to the department
is no longer accurate. Failure to return the form alone will not
constitute a basis for termination of Medi-Cal. If the form is
returned as undeliverable and the county is otherwise unable to
establish contact, the recipient shall remain eligible for
fee-for-service Medi-Cal until such time as contact is reestablished
or ineligibility is established, and to the extent federal financial
participation is available. The department may terminate eligibility
if it determines that the recipient is no longer eligible only after
ineligibility is established and all due process requirements are met
in accordance with state and federal law.
(4) This section shall be implemented to the extent that federal
financial participation is available, and any necessary federal
approvals are obtained.
(b) This section shall become operative January 1, 2014.
SEC. 7. 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
and following) 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. 8. Section 14005.30 is added to the Welfare and Institutions
Code, 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, known as the Section
1931(b) program, 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).
(b) Commencing January 1, 2014, pursuant to Section 1396a(e)(14)
(C) of Title 42 of the United States Code, there shall be no assets
test and no deprivation test for any individual under this section.
(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) This section shall become operative January 1, 2014.
SEC. 9. Section 14005.31 of the Welfare and Institutions Code is
amended to read:
14005.31. (a) (1) Subject to paragraph (2), for any person whose
eligibility for benefits under Section 14005.30 has been determined
with a concurrent determination of eligibility for cash aid under
Chapter 2 (commencing with Section 11200), loss of eligibility or
termination of cash aid under Chapter 2 (commencing with Section
11200) shall not result in a loss of eligibility or termination of
benefits under Section 14005.30 absent the existence of a factor that
would result in loss of eligibility for benefits under Section
14005.30 for a person whose eligibility under Section 14005.30 was
determined without a concurrent determination of eligibility for
benefits under Chapter 2 (commencing with Section 11200).
(2) Notwithstanding paragraph (1), a person whose eligibility
would otherwise be terminated pursuant to that paragraph shall not
have his or her eligibility terminated until the transfer procedures
set forth in Section 14005.32 or the redetermination procedures set
forth in Section 14005.37 and all due process requirements have been
met.
(b) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform Medi-Cal beneficiaries whose
eligibility for cash aid under Chapter 2 (commencing with Section
11200) has ended, but whose eligibility for benefits under Section
14005.30 continues pursuant to subdivision (a), that their benefits
will continue. To the extent feasible, the notice shall be sent out
at the same time as the notice of discontinuation of cash aid, and
shall include all of the following:
(1) A statement that Medi-Cal benefits will continue even though
cash aid under the CalWORKs program has been terminated.
(2) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(3) (A) A statement that the Medi-Cal
beneficiary does not need to fill out monthly status reports in order
to remain eligible for Medi-Cal, but shall
may be required to submit a semiannual status report and annual
reaffirmation forms. The notice shall remind individuals whose cash
aid ended under the CalWORKs program as a result of not submitting a
status report that he or she should review his or her circumstances
to determine if changes have occurred that should be reported to the
Medi-Cal eligibility worker.
(B) Commencing January 1, 2014, the semiannual status report
requirement shall not be included in the statement described in
subparagraph (A).
(4) A statement describing the responsibility of the Medi-Cal
beneficiary to report to the county, within 10 days, significant
changes that may affect eligibility.
(5) A telephone number to call for more information.
(6) A statement that the Medi-Cal beneficiary's eligibility worker
will not change, or, if the case has been reassigned, the new worker'
s name, address, and telephone number, and the hours during which the
county's eligibility workers can be contacted.
(c) 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 (Title 42
(42 U.S.C. Sec. 1396 and following)
et seq.) is available.
(d) 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.
SEC. 10. Section 14005.32 of the Welfare and Institutions Code is
amended to read:
14005.32. (a) (1) If the county has evidence clearly
demonstrating that a beneficiary is not eligible for benefits under
this chapter pursuant to Section 14005.30, but is eligible for
benefits under this chapter pursuant to other provisions of law, the
county shall transfer the individual to the corresponding Medi-Cal
program. Eligibility under Section 14005.30 shall continue until the
transfer is complete.
(2) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform beneficiaries that their Medi-Cal
benefits have been transferred pursuant to paragraph (1) and to
inform them about the program to which they have been transferred. To
the extent feasible, the notice shall be issued with the notice of
discontinuance from cash aid, and shall include all of the following:
(A) A statement that Medi-Cal benefits will continue under another
program, even though aid under Chapter 2 (commencing with Section
11200) has been terminated.
(B) The name of the program under which benefits will continue,
and an explanation of that program.
(C) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(D) (i) A statement that the Medi-Cal
beneficiary does not need to fill out monthly status reports in order
to remain eligible for Medi-Cal, but shall
may be required to submit a semiannual status report and annual
reaffirmation forms. In addition, if the person or persons to whom
the notice is directed has been found eligible for transitional
Medi-Cal as described in Section 14005.8 , 14005.81,
or 14005.85, the statement shall explain the reporting
requirements and duration of benefits under those programs, and shall
further explain that, at the end of the duration of these benefits,
a redetermination, as provided for in Section 14005.37 shall be
conducted to determine whether benefits are available under any other
provision of law.
(ii) Commencing January 1, 2014, the semiannual status report
requirement shall not be included in the statement described in
clause (i).
(E) A statement describing the beneficiary's responsibility to
report to the county, within 10 days, significant changes that may
affect eligibility or share of cost.
(F) A telephone number to call for more information.
(G) A statement that the beneficiary's eligibility worker will not
change, or, if the case has been reassigned, the new worker's name,
address, and telephone number, and the hours during which the county'
s Medi-Cal eligibility workers can be contacted.
(b) No later than September 1, 2001, the department shall submit a
federal waiver application seeking authority to eliminate the
reporting requirements imposed by transitional medicaid under Section
1925 of the federal Social Security Act (Title 42 U.S.C. Sec.
1396r-6).
(c) 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 (Title 42
(42 U.S.C. Sec. 1396 and following)
et seq.) is available.
(d) 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.
SEC. 11. 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), (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 (Title 42
(42 U.S.C. Sec. 1396 and following)
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. 12. Section 14005.37 is added to the Welfare and Institutions
Code, 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) (1) For purposes of acquiring information necessary to conduct
the eligibility determinations described in subdivisions (a) to (d),
inclusive, 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,
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, information
accessed through any databases accessed by the agency 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 counties.
(2) If the county is able to renew eligibility based on such
information, the county shall notify the individual of both of the
following:
(A) The eligibility determination and basis.
(B) That the individual 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 individual 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 individual is in a new Medi-Cal program.
(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 and other commonly available
electronic means, in counties where such electronic communication is
available, 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 containing
information available to the county needed to renew eligibility. 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 not request information for
nonapplicants necessary to make an eligibility determination. The
form shall be accompanied by a simple, clear, consumer-friendly cover
letter, that 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 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 to sign the renewal form. 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, in writing, and other commonly available
electronic means, in counties where such electronic communication is
available, 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) (1) Until January 1, 2014, 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.
(2) Commencing January 1, 2014, if within 90 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 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) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary's vision has
improved beyond the definition of blindness contained in the plan.
(o) The county shall consider disability as continuing until the
review team determines that a beneficiary's disability no longer
meets the definition of disability contained in the plan.
(p) If a county has enough information available to it to renew
eligibility with respect to all eligibility criteria, the county
shall begin a new 12-month eligibility period.
(q) For individuals determined ineligible for Medi-Cal, the
county shall determine eligibility for other state health subsidy
programs and comply with the procedures in Section 15926.
(r) 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.
(s) This section shall become operative January 1, 2014.
SEC. 13. Section 14005.60 is added to the Welfare and Institutions
Code, to read:
14005.60. (a) Commencing January 1, 2014, the department shall
provide eligibility for Medi-Cal benefits for any person who meets
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)).
(b) Persons who qualify under subdivision (a) and are currently
enrolled in a Low Income Health Program (LIHP) under California's
Bridge to Reform Section 1115(a) Medicaid Demonstration shall be
transitioned to the Medi-Cal program under this section in accordance
with the transition plan as approved by the federal Centers for
Medicare and Medicaid Services. With respect to plan enrollment, a
LIHP enrollee shall be all of the following:
(1) Notified which Medi-Cal health plan or plans contain his or
her existing medical home provider.
(2) Notified that he or she can select a health plan that contains
his or her existing medical home provider.
(3) Provided the opportunity to choose a different health plan if
there is more than one plan available in the county where he or she
resides.
(4) Informed that if he or she does not affirmatively choose a
plan or there is only one plan in the county where he or she resides,
he or she shall be enrolled into the Medi-Cal managed care plan that
contains his or her LIHP medical home provider, if the medical home
provider contracts with a Medi-Cal managed care plan.
(c) In order to ensure that no persons lose health care coverage
in the course of the transition, the department shall require that
notices of the January 1, 2014, change be sent to LIHP enrollees upon
their LIHP redetermination in 2013 and again at least 90 days prior
to the transition. Pursuant to Section 1902(k)(1) and Section 1937(b)
(1)(D) of the federal Social Security Act (42 U.S.C. Sec. 1396a(k)
(1); 42 U.S.C. Sec. 1396u-7(b)(1)(D)), the department shall seek
approval from the United States Secretary of Health and Human
Services to establish a benchmark benefit package that includes the
same benefits, services, and coverage that are provided to all other
full-scope Medi-Cal enrollees, supplemented by any benefits,
services, and coverage included in the essential health benefits
package adopted by the state and approved by the United States
Secretary of Health and Human Services under Section 18022 of Title
42 of the United States Code.
SEC. 14. Section 14005.62 is added to the Welfare and Institutions
Code, to read:
14005.62. Commencing January 1, 2014, the department shall accept
an individual's attestation of information and verify information
pursuant to Section 15926.2.
SEC. 15. Section 14005.63 is added to the Welfare and Institutions
Code, to read:
14005.63. (a) Commencing January 1, 2014, a person who wishes to
apply for a state health subsidy program, as defined in subdivision
(a) of Section 15926, shall be allowed to file an application on his
or her own behalf or on behalf of his or her family. The individual
also has the right to be accompanied, assisted, and represented in
the application and renewal process by an individual or organization
of his or her own choice. If the individual for any reason is unable
to apply or renew on his or her own behalf, any of the following
persons may file the application for the applicant:
(1) The individual's guardian, conservator, or executor.
(2) A public agency representative.
(3) The individual's legal counsel, relative, friend, or other
spokesperson of his or her choice.
(b) A person who wishes to challenge a decision concerning his or
her eligibility for or receipt of benefits from a state health
subsidy program has the right to represent himself or herself or use
legal counsel, a relative, a friend, or other spokesperson of his or
her choice.
SEC. 16. Section 14005.64 is added to the Welfare and Institutions
Code, to read:
14005.64. (a) This section implements Section 1902(e)(14)(C) of
the federal Social Security Act (42 U.S.C. Sec. 1396a(e)(14)(C)) and
Section 435.603(g) of Title 42 of the Code of Federal Regulations,
which prohibits the use of an assets test for individuals whose
income eligibility is determined based on modified adjusted gross
income (MAGI), and Section 2002 of the federal Patient Protection and
Affordable Care Act (Affordable Care Act) (42 U.S.C. Sec. 1396a(e)
(14)(I)) and Section 435.603(d) of Title 42 of the Code of Federal
Regulations, which requires a 5-percent income disregard for
individuals whose income eligibility is determined based on MAGI.
(b) In the case of individuals whose financial eligibility for
Medi-Cal is determined based on the application of MAGI pursuant to
Section 435.603 of Title 42 of the Code of Federal Regulations, the
eligibility determination shall not include any assets or resources
test.
(c) The department shall implement the 5-percent income disregard
for individuals whose income eligibility is determined based on MAGI
in Section 2002 of the Affordable Care Act (42 U.S.C. Sec. 1396a(e)
(14)(I)) and Section 435.603(d) of Title 42 of the Code of Federal
Regulations.
(d) The department shall adopt an equivalent income level for each
eligibility group whose income level will be converted to MAGI. The
equivalent income level shall not be less than the dollar amount of
all income exemptions, exclusions, deductions, and disregards in
effect on March 23, 2010, plus the existing income level expressed as
a percent of the federal poverty level for each eligibility group so
as to ensure that the use of MAGI income methodology does not result
in populations who would have been eligible under this chapter and
Part 6.3 (commencing with Section 12695) of Division 2 of the
Insurance Code losing coverage.
(e) This section shall become operative on January 1, 2014.
SEC. 17. Section 14005.65 is added to the Welfare and Institutions
Code, to read:
14005.65. In accordance with the state's options under Section
435.603(h) of Title 42 of the Code of Federal Regulations, the
department shall adopt procedures to take into account projected
future changes in income and family size, for individuals whose
Medi-Cal income eligibility is determined using MAGI-based methods,
in order to grant or maintain eligibility for those individuals who
may be ineligible or become ineligible if only the current monthly
income and family size are considered.
(a) For current beneficiaries whose eligibility has already been
approved, the department shall base financial eligibility on
projected annual household income for the remainder of the current
calendar year if the current monthly income would render the
beneficiary ineligible due to fluctuating income.
(b) For applicants, the department shall, in determining the
current monthly household income and family size, base an initial
determination of eligibility on the projected annual household income
and family size for the upcoming year if considering the current
monthly income and family size in isolation would render an applicant
ineligible.
(c) In the procedures adopted pursuant to this section, the
department shall implement a reasonable method to account for a
reasonably predictable decrease in income and increase in family
size, as evidenced by a history of predictable fluctuations in income
or other clear indicia of a future decrease in income and increase
in family size. The department shall not assume potential future
increases in income or decreases in family size to make an applicant
or beneficiary ineligible in the current month.
(d) This section shall become operative on January 1, 2014.
SEC. 18. Section 14007.1 of the Welfare and Institutions Code is
amended to read:
14007.1. (a) The department shall adopt regulations for use by
the county welfare department in determining whether an applicant is
a resident of this state and of the county subject to the
requirements of federal law. The regulations shall require that state
residency is not established unless the applicant does both of the
following.
(1) The applicant produces one of the following:
(A) A recent California rent or mortgage receipt or utility bill
in the applicant's name.
(B) A current California motor vehicle driver's license or
California Identification Card issued by the California Department of
Motor Vehicles in the applicant's name.
(C) A current California motor vehicle registration in the
applicant's name.
(D) A document showing that the applicant is employed in this
state.
(E) A document showing that the applicant has registered with a
public or private employment service in this state.
(F) Evidence that the applicant has enrolled his or her children
in a school in this state.
(G) Evidence that the applicant is receiving public assistance in
this state.
(H) Evidence of registration to vote in this state.
(2) The applicant declares, under penalty of perjury, that all of
the following apply:
(A) The applicant does not own or lease a principal residence
outside this state.
(B) The applicant is not receiving public assistance outside this
state. As used in this subdivision, "public assistance" does not
include unemployment insurance benefits.
(b) A denial of a determination of residency may be appealed in
the same manner as any other denial of eligibility. The
Administrative Law Judge shall receive any proof of residency offered
by the applicant and may inquire into any facts relevant to the
question of residency. A determination of residency shall not be
granted unless a preponderance of the credible evidence supports the
applicant's intent to remain indefinitely in this state.
(c) 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. 19. Section 14007.1 is added to the Welfare and Institutions
Code, to read:
14007.1. (a) An individual 21 years of age or older shall be
considered a resident of this state for the purposes of determining
his or her eligibility for Medi-Cal benefits if he or she attests
that he or she lives in this state and that he or she either intends
to reside in this state or has entered this state with a job
commitment or to seek employment. The individual shall not be
required to have a fixed address or to be currently employed to be
considered a resident of this state.
(b) (1) An individual under 21 years of age shall be considered a
resident of this state for the purposes of determining his or her
eligibility for Medi-Cal benefits if he or she satisfies the
requirements of subdivision (a), is capable of indicating intent, and
is emancipated from his or her parent or parents or is married.
(2) An individual under 21 years of age who does not satisfy the
requirements of paragraph (1), and who is not living in an
institution, not eligible for Medi-Cal based on his or her receipt of
assistance under Title IV-E of the federal Social Security Act, and
not receiving a state supplementary payment, as defined in Section
435.403(f) of Title 42 of the Code of Federal Regulations, shall be
considered a resident of this state for the purposes of determining
his or her eligibility for Medi-Cal benefits if he or she lives in
this state, whether or not he or she has a fixed address, or his or
her parent or parents, or other caretaker, with whom he or she
resides satisfies the requirements of subdivision (a).
(c) The state of residency for an individual who is incapable of
stating intent or who is living in an institution shall be determined
in accordance with Section 435.403 of Title 42 of the Code of
Federal Regulations.
(d) A denial of a determination of residency may be appealed in
the same manner as any other denial of eligibility. The
administrative law judge shall receive any proof of residency offered
by the individual and may inquire into any facts relevant to the
question of residency. A determination of residency shall be granted
if a preponderance of the credible evidence supports a finding that
the individual meets the requirements of either subdivision (a) or
(b).
(e) This section shall be interpreted in a manner consistent with
federal law.
(f) This section shall become operative on January 1, 2014.
SEC. 20. Section 14007.6 of the Welfare and Institutions Code is
amended to read:
14007.6. (a) A recipient who maintains a residence outside of
this state for a period of at least two months shall not be eligible
for services under this chapter where the county has made inquiry
of the recipient pursuant to
Section 11100, and where the recipient has not responded to this
inquiry by clearly showing that he or she has (1) not established
residence elsewhere; and (2) been prevented by illness or other good
cause from returning to this state.
(b) If a recipient whose services are terminated pursuant to
subdivision (a) reapplies for services, services shall be restored
provided all other eligibility criteria are met if this individual
can prove both of the following:
(1) His or her permanent residence is in this state.
(2) That residence has not been established in any other state
which can be considered to be of a permanent nature.
(c) 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. 21. Section 14007.6 is added to the Welfare and Institutions
Code, to read:
14007.6. (a) A recipient who maintains a residence outside of
this state for a period of at least two months shall not be eligible
for services under this chapter where the county has made inquiry of
the recipient pursuant to Section 11100, and where the recipient has
not responded to this inquiry by clearly showing that he or she has
(1) not established residence elsewhere; or (2) been prevented by
illness or other good cause from returning to this state.
(b) If a recipient whose services are terminated pursuant to
subdivision (a) reapplies for services, services shall be restored
provided all other eligibility criteria are met if this individual
can prove both of the following:
(1) His or her residence is in this state.
(2) That residence has not been established in any other state
which can be considered to be of a permanent nature.
(c) This section shall become operative on January 1, 2014.
SEC. 22. Section 14008.85 of the Welfare and Institutions Code is
amended to read:
14008.85. (a) To the extent federal financial participation is
available, a parent who is the principal wage earner shall be
considered an unemployed parent for purposes of establishing
eligibility based upon deprivation of a child where any of the
following applies:
(1) The parent works less than 100 hours per month as determined
pursuant to the rules of the Aid to Families with Dependent Children
program as it existed on July 16, 1996, including the rule allowing a
temporary excess of hours due to intermittent work.
(2) The total net nonexempt earned income for the family is not
more than 100 percent of the federal poverty level as most recently
calculated by the federal government. The department may adopt
additional deductions to be taken from a family's income.
(3) The parent is considered unemployed under the terms of an
existing federal waiver of the 100-hour rule for recipients under the
program established by Section 1931(b) of the federal Social
Security Act (42 U.S.C. Sec. 1396u-1).
(b) 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 an all county
letter or similar instruction 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.
(c) This section shall become operative March 1, 2000.
(c) 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. 23. 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. 24. 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. 25. 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. 26. Section 14012 is added to the Welfare and Institutions
Code, to read:
14012. (a) This section implements Section 435.916(a)(1) of Title
42 of the Code of Federal Regulations, which applies to the
eligibility of Medi-Cal beneficiaries whose financial eligibility is
determined using modified adjusted gross income (MAGI) based income.
(b) To the extent required by federal law or regulations, the
eligibility of Medi-Cal beneficiaries whose financial eligibility is
determined using a MAGI-based income shall be renewed once every 12
months, and no more frequently than every 12 months.
(c) This section shall become operative on January 1, 2014.
SEC. 27. Section 14132 of the Welfare and Institutions Code is
amended to read:
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) (1) Inpatient hospital services, including, but not limited
to, physician and podiatric services, physical therapy and
occupational therapy, are covered subject to utilization controls.
(2) For Medi-Cal fee-for-service beneficiaries, emergency services
and care that are necessary for the treatment of an emergency
medical condition and medical care directly related to the emergency
medical condition. This paragraph shall not be construed to change
the obligation of Medi-Cal managed care plans to provide emergency
services and care. For the purposes of this paragraph, "emergency
services and care" and "emergency medical condition" shall have the
same meanings as those terms are defined in Section 1317.1 of the
Health and Safety Code.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) (i) For the purposes of this paragraph, nonlegend has the
same meaning as defined in subdivision (a) of Section 14105.45.
(ii) Nonlegend acetaminophen-containing products, with the
exception of children's acetaminophen-containing products, selected
by the department are not covered benefits.
(iii) Nonlegend cough and cold products selected by the department
are not covered benefits. This clause shall be implemented on the
first day of the first calendar month following 90 days after the
effective date of the act that added this clause, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(iv) Beneficiaries under the Early and Periodic Screening,
Diagnosis, and Treatment Program shall be exempt from clauses (ii)
and (iii).
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to
a waiver obtained from the Secretary of the United States Department
of Health and Human Services pursuant to this subdivision, and which
are not otherwise included in the Medi-Cal schedule of benefits,
shall be available only to the extent that federal financial
participation for these services is available in accordance with the
waiver, and subject to the terms, conditions, and duration of the
waiver. These services shall be provided to individual beneficiaries
in accordance with the client's needs as identified in the plan of
care, and subject to medical necessity and applicable utilization
control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI)
(ii)(2) 1396a(a)(10)(A)(ii)(XXI) of Title 42 of
the United States Code, which was added to Section 1396a of Title 42
of the United States Code by Section 2303(a)(2) of the federal
Patient Protection and Affordable Care Act (PPACA) (Public Law
111-148), for a program to provide comprehensive clinical family
planning services as described in paragraph (8). Under the waiver,
the program shall be operated only in accordance with the waiver and
the statutes and regulations in paragraph (4) and subject to the
terms, conditions, and duration of the waiver. Under the state plan
amendment, which shall replace the waiver and shall be known as the
Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section
1396a(a)(10)(A)(ii)(XXI)(ii)(2) 1396a(a)(10)
(A)(ii)(XXI) of Title 42 of the United States Code. To the
extent that federal financial participation is available, the program
shall continue to conduct education, outreach, enrollment, service
delivery, and evaluation services as specified under the waiver. The
services shall be provided under the program only if the waiver and,
when applicable, the successor state plan amendment are approved by
the federal Centers for Medicare and Medicaid Services and only to
the extent that federal financial participation is available for the
services. Nothing in this section shall prohibit the department from
seeking the Family PACT successor state plan amendment during the
operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other provision of law,
the collection and use of an individual's social security number
shall be necessary only to the extent required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver 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 the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) (1) Purchase of prescribed enteral nutrition products is
covered, subject to the Medi-Cal list of enteral nutrition products
and utilization controls.
(2) Purchase of enteral nutrition products is limited to those
products to be administered through a feeding tube, including, but
not limited to, a gastric, nasogastric, or jejunostomy tube.
Beneficiaries under the Early and Periodic Screening, Diagnosis, and
Treatment Program shall be exempt from this paragraph.
(3) Notwithstanding paragraph (2), the department may deem an
enteral nutrition product, not administered through a feeding tube,
including, but not limited to, a gastric, nasogastric, or jejunostomy
tube, a benefit for patients with diagnoses, including, but not
limited to, malabsorption and inborn errors of metabolism, if the
product has been shown to be neither investigational nor experimental
when used as part of a therapeutic regimen to prevent serious
disability or death.
(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the amendments to this subdivision made by
the act that added this paragraph by means of all-county letters,
provider bulletins, or similar instructions, without taking
regulatory action.
(5) The amendments made to this subdivision by the act that added
this paragraph shall be implemented June 1, 2011, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
(ad) Commencing January 1, 2014, any benefits, services, and
coverage not otherwise described in this section that are included in
the essential health benefits package adopted by the state and
approved by the United States Secretary of Health and Human Services
under Section 18022 of Title 42 of the United States Code.
SEC. 28. Section 14132.02 is added to the Welfare and Institutions
Code, to read:
14132.02. (a) Pursuant to Sections 1902(k)(1) and 1937(b)(1)(D)
of the federal Social Security Act (42 U.S.C. Sec. 1396a(k)(1); 42
U.S.C. Sec. 1396u-7(b)(1)(D)), the department shall seek approval
from the United States Secretary of Health and Human Services to
establish a benchmark benefit package that includes the same
benefits, services, and coverage as is provided to all other
full-scope Medi-Cal enrollees, supplemented by any benefits,
services, and coverage included in the essential health benefits
package adopted by the state and approved by the secretary under
Section 18022 of Title 42 of the United States Code.
(b) This section shall become operative January 1, 2014.
SEC. 29. 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) "State health subsidy programs" means the programs described
in Section 1413(e) of the PPACA.
(b) An individual shall have the option to apply for state health
subsidy 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 state health subsidy 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 state health subsidy programs and by their agents.
(2) The application shall be tested and operational by the date as
required by the federal Secretary of Health and Human Services.
(3) 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 state health subsidy
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 a state health subsidy 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.
(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for state
health subsidy programs or other health programs that differs from
the application form described in subdivision (c), and related
enrollment procedures.
(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
state health subsidy 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 renewal form or, if available,
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 state health subsidy programs may
shall accept self-attestation, instead of requiring an
individual to produce a document, with respect to all
information 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.
(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 or denied
for any state health subsidy 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 state health subsidy 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 a state health subsidy program in person, over the
telephone, and online, 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 a state health subsidy program shall
ensure that an eligible applicant and recipient of state health
subsidy 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 a state health
subsidy 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, and online renewal.
(4) An applicant who is not eligible for a state health subsidy
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 state health subsidy 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 and after January 1, 2014.
SEC. 30. If the Commission on State Mandates determines that this
act contains costs mandated by the state, reimbursement to local
agencies and school districts for those costs shall be made pursuant
to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of
the Government Code.
