Bill Text: CA SB28 | 2013-2014 | Regular Session | Chaptered
Bill Title: California Health Benefit Exchange.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2013-10-01 - Chaptered by Secretary of State. Chapter 442, Statutes of 2013. [SB28 Detail]
Download: California-2013-SB28-Chaptered.html
BILL NUMBER: SB 28 CHAPTERED
BILL TEXT
CHAPTER 442
FILED WITH SECRETARY OF STATE OCTOBER 1, 2013
APPROVED BY GOVERNOR OCTOBER 1, 2013
PASSED THE SENATE SEPTEMBER 11, 2013
PASSED THE ASSEMBLY SEPTEMBER 10, 2013
AMENDED IN ASSEMBLY SEPTEMBER 6, 2013
AMENDED IN ASSEMBLY AUGUST 7, 2013
AMENDED IN SENATE MAY 13, 2013
AMENDED IN SENATE APRIL 16, 2013
INTRODUCED BY Senators Hernandez and Steinberg
DECEMBER 3, 2012
An act to add Section 100503.2 to the Government Code, to add
Section 12712.5 to the Insurance Code, and to amend Sections
14005.28, 14005.30, 14005.36, 14005.37, 14005.39, 14005.61, 14011.66,
14015.8, 14016.6, 14102, 14132.02, and 14154 of the Welfare and
Institutions Code, relating to health.
LEGISLATIVE COUNSEL'S DIGEST
SB 28, Hernandez. California Health Benefit Exchange.
(1) Existing law establishes the California Major Risk Medical
Insurance Program (MRMIP), which is administered by the Managed Risk
Medical Insurance Board (MRMIB), to provide major risk medical
coverage to persons who, among other things, have been rejected for
coverage by at least one private health plan.
Under the federal Patient Protection and Affordable Care Act
(PPACA), each state is required, by January 1, 2014, to establish an
American Health Benefit Exchange that makes available qualified
health plans to qualified individuals and small employers. Existing
state law establishes the California Health Benefit Exchange
(Exchange) within state government, specifies the powers and duties
of the board governing the Exchange, and requires the board to
facilitate the purchase of qualified health plans through the
Exchange by qualified individuals and small employers by January 1,
2014. Existing law also requires the board to undertake activities
necessary to market and publicize the availability of health care
coverage and federal subsidies through the Exchange and to undertake
outreach and enrollment activities.
This bill would require MRMIB to provide the Exchange, or its
designee, with specified information of subscribers and applicants of
MRMIP in order to assist the Exchange in conducting outreach to
those subscribers and applicants.
The bill would require the board governing the Exchange to provide
a specified notice informing those subscribers and applicants that
they may be eligible for reduced-cost coverage through the Exchange
or no-cost coverage through Medi-Cal.
(2) 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.
Chapters 3 and 4 of the First Extraordinary Session of 2013-14, to
be effective on the 91st day after adjournment of that session,
implement various provisions of PPACA relating to determining
eligibility for the Medi-Cal program.
This bill would authorize the department to implement some of
those provisions by, among other things, all-county letters, until
the time any necessary regulations are adopted. The bill would
require the department to adopt regulations implementing those
provisions by July 1, 2017.
(3) Existing law, to be effective on the 91st day after
adjournment of the First Extraordinary Session of 2013-14, requires
the department, commencing January 1, 2014, to develop a program to
implement provisions that would authorize individuals or their
authorized representatives to select Medi-Cal managed care plans via
the California Healthcare Eligibility, Enrollment, and Retention
System (CalHEERS), as specified. In this regard, the program is
required to include training of specialized county employees to carry
out the program.
This bill would, instead, require the program to include training
of individuals, including county human services staff, to carry out
the program.
(4) Existing law requires the department to establish and maintain
a County Administrative Cost Control Plan under which costs for
county administration for the determination of eligibility for
benefits are controlled, as specified. Existing law requires the
department to develop and implement a new budgeting methodology for
Medi-Cal county administrative costs to be used to reimburse counties
for eligibility determinations for applicants and beneficiaries, and
requires that the budgeting methodology include identification of
the costs of eligibility determinations for applicants, and the costs
of eligibility redeterminations and case maintenance activities for
recipients, for different groupings of cases.
This bill would instead provide that the budgeting methodology may
include identification of the costs of eligibility determinations
for applicants, and the costs of eligibility redeterminations and
case maintenance activities for recipients, for different groupings
of cases. The bill would authorize the development of the new
budgeting methodology to include, among other things, county survey
of costs, time and motion studies, and in-person observations by
department staff. The bill would require that the new budgeting
methodology be implemented no sooner than the 2015-16 fiscal year and
that it reflect the impact of PPACA implementation on county
administrative work. The bill would make other technical changes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 100503.2 is added to the Government Code, to
read:
100503.2. The board shall use the information received pursuant
to Section 12712.5 of the Insurance Code to provide an individual a
notice that he or she may be eligible for reduced-cost coverage
through the Exchange or no-cost coverage through Medi-Cal. The notice
shall include information on obtaining coverage pursuant to those
programs.
SEC. 2. Section 12712.5 is added to the Insurance Code, to read:
12712.5. In order to assist the California Health Benefit
Exchange, established under Title 22 (commencing with Section 100500)
of the Government Code, in conducting outreach to program
subscribers and applicants, the board shall provide the Exchange, or
its designee, with the names, addresses, email addresses, telephone
numbers, other contact information, and written and spoken languages
of program subscribers and applicants.
SEC. 3. Section 14005.28 of the Welfare and Institutions Code, as
added by Section 5 of Chapter 4 of the First Extraordinary Session of
the Statutes of 2013, 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 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 an individual who is in foster care
on his or her 18th birthday until his or her 26th birthday. In
addition, the department shall implement the federal option to
provide Medi-Cal benefits to individuals who were in foster care and
enrolled in Medicaid in any state.
(1) A foster care adolescent who is in foster care in this state
on his or her 18th birthday shall be enrolled to receive benefits
under this section without any interruption in coverage and without
requiring a new application.
(2) The department shall develop procedures to identify and enroll
individuals who meet the criteria for Medi-Cal eligibility in this
subdivision, including, but not limited to, former foster care
adolescents who were in foster care on their 18th birthday and who
lost Medi-Cal coverage as a result of attaining 21 years of age. The
department shall work with counties to identify and conduct outreach
to former foster care adolescents who lost Medi-Cal coverage during
the 2013 calendar year as a result of attaining 21 years of age, to
ensure they are aware of the ability to reenroll under the coverage
provided pursuant to this section.
(3) (A) The department shall develop and implement a simplified
redetermination form for this program. A beneficiary qualifying for
the benefits extended pursuant to this section shall fill out and
return this form only if information known to the department is no
longer accurate or is materially incomplete.
(B) The department shall seek federal approval to institute a
renewal process that allows a beneficiary receiving benefits under
this section to remain on Medi-Cal after a redetermination form is
returned as undeliverable and the county is otherwise unable to
establish contact. If federal approval is granted, the recipient
shall remain eligible for services under the Medi-Cal fee-for-service
program until the time contact is reestablished or ineligibility is
established, and to the extent federal financial participation is
available.
(C) The department shall terminate eligibility only after it
determines that the recipient is no longer eligible and all due
process requirements are met in accordance with state and federal
law.
(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 implement, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(c) This section shall be implemented only if and to the extent
that federal financial participation is available.
(d) This section shall become operative January 1, 2014.
SEC. 4. Section 14005.30 of the Welfare and Institutions Code, as
added by Section 4 of Chapter 3 of the First Extraordinary Session of
the Statutes of 2013, is amended to read:
14005.30. (a) Medi-Cal benefits under this chapter shall be
provided to individuals eligible for services under Section 1396u-1
of Title 42 of the United States Code.
(b) (1) When determining eligibility under this section, an
applicant's or beneficiary's income and resources shall be
determined, counted, and valued in accordance with the requirements
of Section 1396a(e)(14) of Title 42 of the United States Code, as
added by the ACA.
(2) When determining eligibility under this section, an applicant'
s or beneficiary's assets shall not be considered and deprivation
shall not be a requirement for eligibility.
(c) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec. 401
et seq.) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the federal
poverty level requires the department to modify the income disregard
pursuant to subdivision (c) and in which new income limits for the
program established by this section are adopted by the department.
(d) The MAGI-based income eligibility standard applied under this
section shall conform with the maintenance of effort requirements of
Sections 1396a(e)(14) and 1396a(gg) of Title 42 of the United States
Code, as added by the ACA.
(e) For purposes of this section, the following definitions shall
apply:
(1) "ACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as originally enacted and as amended
by the federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152) and any subsequent amendments.
(2) "MAGI-based income" means income calculated using the
financial methodologies described in Section 1396a(e)(14) of Title 42
of the United States Code, as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148) and as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments.
(f) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(g) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(h) This section shall become operative on January 1, 2014.
SEC. 5. Section 14005.36 of the Welfare and Institutions Code, as
amended by Section 5 of Chapter 3 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14005.36. (a) The county shall undertake outreach efforts to
beneficiaries receiving benefits under this chapter, in order to
maintain the most up-to-date home addresses, telephone numbers, and
other necessary contact information, and to encourage and assist with
timely submission of the annual reaffirmation form, and, when
applicable, transitional Medi-Cal program reporting forms and to
facilitate the Medi-Cal redetermination process when one is required
as provided in Section 14005.37. In implementing this subdivision, a
county may collaborate with community-based organizations, provided
that confidentiality is protected.
(b) The department shall encourage and facilitate efforts by
managed care plans to report updated beneficiary contact information
to counties.
(c) (1) The department and each county shall incorporate, in a
timely manner, updated contact information received from managed care
plans pursuant to subdivision (b) into the beneficiary's Medi-Cal
case file and into all systems used to inform plans of their
beneficiaries' enrollee status. Updated Medi-Cal beneficiary contact
information shall be limited to the beneficiary's telephone number,
change of address information, and change of name.
(2) When a managed care plan obtains a beneficiary's updated
contact information, the managed care plan shall ask the beneficiary
for approval to provide the beneficiary's updated contact information
to the appropriate county. If the managed care plan does not obtain
approval from the beneficiary to provide the appropriate county with
the updated contact information, the county shall attempt to verify
that the information that it receives from the plan is accurate,
which may include, but is not limited to, making contact with the
beneficiary, before updating the beneficiary's case file. The contact
shall first be attempted using the method of contact identified by
the beneficiary as the preferred method of contact, if a method has
been identified.
(d) This section shall be implemented only to the extent that
federal financial participation under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
(e) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
SEC. 6. Section 14005.37 of the Welfare and Institutions Code, as
added by Section 7 of Chapter 3 of the First Extraordinary Session of
the Statutes of 2013, is amended to read:
14005.37. (a) Except as provided in Section 14005.39, a county
shall perform redeterminations of eligibility for Medi-Cal
beneficiaries every 12 months and shall promptly redetermine
eligibility whenever the county receives information about changes in
a beneficiary's circumstances that may affect eligibility for
Medi-Cal benefits. The procedures for redetermining Medi-Cal
eligibility described in this section shall apply to all Medi-Cal
beneficiaries.
(b) Loss of eligibility for cash aid under that program shall not
result in a redetermination under this section unless the reason for
the loss of eligibility is one that would result in the need for a
redetermination for a person whose eligibility for Medi-Cal under
Section 14005.30 was determined without a concurrent determination of
eligibility for cash aid under the CalWORKs program.
(c) A loss of contact, as evidenced by the return of mail marked
in such a way as to indicate that it could not be delivered to the
intended recipient or that there was no forwarding address, shall
require a prompt redetermination according to the procedures set
forth in this section.
(d) Except as otherwise provided in this section, Medi-Cal
eligibility shall continue during the redetermination process
described in this section and a beneficiary's Medi-Cal eligibility
shall not be terminated under this section until the county makes a
specific determination based on facts clearly demonstrating that the
beneficiary is no longer eligible for Medi-Cal benefits under any
basis and due process rights guaranteed under this division have been
met. For the purposes of this subdivision, for a beneficiary who is
subject to the use of MAGI-based financial methods, the determination
of whether the beneficiary is eligible for Medi-Cal benefits under
any basis shall include, but is not limited to, a determination of
eligibility for Medi-Cal benefits on a basis that is exempt from the
use of MAGI-based financial methods only if either of the following
occurs:
(A) The county assesses the beneficiary as being potentially
eligible under a program that is exempt from the use of MAGI-based
financial methods, including, but not limited to, on the basis of
age, blindness, disability, or the need for long-term care services
and supports.
(B) The beneficiary requests that the county determine whether he
or she is eligible for Medi-Cal benefits on a basis that is exempt
from the use of MAGI-based financial methods.
(e) (1) For purposes of acquiring information necessary to conduct
the eligibility redeterminations described in this section, a county
shall gather information available to the county that is relevant to
the beneficiary's Medi-Cal eligibility prior to contacting the
beneficiary. Sources for these efforts shall include information
contained in the beneficiary's file or other information, including
more recent information available to the county, including, but not
limited to, Medi-Cal, CalWORKs, and CalFresh case files of the
beneficiary or of any of his or her immediate family members, which
are open, or were closed within the last 90 days, information
accessed through any databases accessed under Sections 435.948,
435.949, and 435.956 of Title 42 of the Code of Federal Regulations,
and wherever feasible, other sources of relevant information
reasonably available to the county or to the county via the
department.
(2) In the case of an annual redetermination, if, based upon
information obtained pursuant to paragraph (1), the county is able to
make a determination of continued eligibility, the county shall
notify the beneficiary of both of the following:
(A) The eligibility determination and the information it is based
on.
(B) That the beneficiary is required to inform the county via the
Internet, by telephone, by mail, in person, or through other commonly
available electronic means, in counties where such electronic
communication is available, if any information contained in the
notice is inaccurate but that the beneficiary is not required to sign
and return the notice if all information provided on the notice is
accurate.
(3) The county shall make all reasonable efforts not to send
multiple notices during the same time period about eligibility. The
notice of eligibility renewal shall contain other related information
such as if the beneficiary is in a new Medi-Cal program.
(4) In the case of a redetermination due to a change in
circumstances, if a county determines that the change in
circumstances does not affect the beneficiary's eligibility status,
the county shall not send the beneficiary a notice unless required to
do so by federal law.
(f) (1) In the case of an annual eligibility redetermination, if
the county is unable to determine continued eligibility based on the
information obtained pursuant to paragraph (1) of subdivision (e),
the beneficiary shall be so informed and shall be provided with an
annual renewal form, at least 60 days before the beneficiary's annual
redetermination date, that is prepopulated with information that the
county has obtained and that identifies any additional information
needed by the county to determine eligibility. The form shall include
all of the following:
(A) The requirement that he or she provide any necessary
information to the county within 60 days of the date that the form is
sent to the beneficiary.
(B) That the beneficiary may respond to the county via the
Internet, by mail, by telephone, in person, or through other commonly
available electronic means if those means are available in that
county.
(C) That if the beneficiary chooses to return the form to the
county in person or via mail, the beneficiary shall sign the form in
order for it to be considered complete.
(D) The telephone number to call in order to obtain more
information.
(2) The county shall attempt to contact the beneficiary via the
Internet, by telephone, or through other commonly available
electronic means, if those means are available in that county, during
the 60-day period after the prepopulated form is mailed to the
beneficiary to collect the necessary information if the beneficiary
has not responded to the request for additional information or has
provided an incomplete response.
(3) If the beneficiary has not provided any response to the
written request for information sent pursuant to paragraph (1) within
60 days from the date the form is sent, the county shall terminate
his or her eligibility for Medi-Cal benefits following the provision
of timely notice.
(4) If the beneficiary responds to the written request for
information during the 60-day period pursuant to paragraph (1) but
the information provided is not complete, the county shall follow the
procedures set forth in paragraph (3) of subdivision (g) to work
with the beneficiary to complete the information.
(5) (A) The form required by this subdivision shall be developed
by the department in consultation with the counties and
representatives of eligibility workers and consumers.
(B) For beneficiaries whose eligibility is not determined using
MAGI-based financial methods, the county may use existing renewal
forms until the state develops prepopulated renewal forms to provide
to beneficiaries. The department shall develop prepopulated renewal
forms for use with beneficiaries whose eligibility is not determined
using MAGI-based financial methods by January 1, 2015.
(g) (1) In the case of a redetermination due to change in
circumstances, if a county cannot obtain sufficient information to
redetermine eligibility pursuant to subdivision (e), the county shall
send to the beneficiary a form that is prepopulated with the
information that the county has obtained and that states the
information needed to renew eligibility. The county shall only
request information related to the change in circumstances. The
county shall not request information or documentation that has been
previously provided by the beneficiary, that is not absolutely
necessary to complete the eligibility determination, or that is not
subject to change. The county shall only request information for
nonapplicants necessary to make an eligibility determination or for a
purpose directly related to the administration of the state Medicaid
plan. The form shall advise the individual to provide any necessary
information to the county via the Internet, by telephone, by mail, in
person, or through other commonly available electronic means and, if
the individual will provide the form by mail or in person, to sign
the form. The form shall include a telephone number to call in order
to obtain more information. The form shall be developed by the
department in consultation with the counties, representatives of
consumers, and eligibility workers. A Medi-Cal beneficiary shall have
30 days from the date the form is mailed pursuant to this
subdivision to respond. Except as provided in paragraph (2), failure
to respond prior to the end of this 30-day period shall not impact
his or her Medi-Cal eligibility.
(2) If the purpose for a redetermination under this section is a
loss of contact with the Medi-Cal beneficiary, as evidenced by the
return of mail marked in such a way as to indicate that it could not
be delivered to the intended recipient or that there was no
forwarding address, a return of the form described in this
subdivision marked as undeliverable shall result in an immediate
notice of action terminating Medi-Cal eligibility.
(3) During the 30-day period after the date of mailing of a form
to the Medi-Cal beneficiary pursuant to this subdivision, the county
shall attempt to contact the beneficiary by telephone, in writing, or
other commonly available electronic means, in counties where such
electronic communication is available, to request the necessary
information if the beneficiary has not responded to the request for
additional information or has provided an incomplete response. If the
beneficiary does not supply the necessary information to the county
within the 30-day limit, a 10-day notice of termination of Medi-Cal
eligibility shall be sent.
(h) Beneficiaries shall be required to report any change in
circumstances that may affect their eligibility within 10 calendar
days following the date the change occurred.
(i) If within 90 days of termination of a Medi-Cal beneficiary's
eligibility or a change in eligibility status pursuant to this
section, the beneficiary submits to the county a signed and completed
form or otherwise provides the needed information to the county,
eligibility shall be redetermined by the county and if the
beneficiary is found eligible, or the beneficiary's eligibility
status has not changed, whichever applies, the termination shall be
rescinded as though the form were submitted in a timely manner.
(j) If the information available to the county pursuant to the
redetermination procedures of this section does not indicate a basis
of eligibility, Medi-Cal benefits may be terminated so long as due
process requirements have otherwise been met.
(k) The department shall, with the counties and representatives of
consumers, including those with disabilities, and Medi-Cal
eligibility workers, develop a timeframe for redetermination of
Medi-Cal eligibility based upon disability, including ex parte
review, the redetermination forms described in subdivisions (f) and
(g), timeframes for responding to county or state requests for
additional information, and the forms and procedures to be used. The
forms and procedures shall be as consumer-friendly as possible for
people with disabilities. The timeframe shall provide a reasonable
and adequate opportunity for the Medi-Cal beneficiary to obtain and
submit medical records and other information needed to establish
eligibility for Medi-Cal based upon disability.
(l) The county shall consider blindness as continuing until the
reviewing physician determines that a beneficiary's vision has
improved beyond the applicable definition of blindness contained in
the plan.
(m) The county shall consider disability as continuing until the
review team determines that a beneficiary's disability no longer
meets the applicable definition of disability contained in the plan.
(n) In the case of a redetermination due to a change in
circumstances, if a county determines that the beneficiary remains
eligible for Medi-Cal benefits, the county shall begin a new 12-month
eligibility period.
(o) For individuals determined ineligible for Medi-Cal by a county
following the redetermination procedures set forth in this section,
the county shall determine eligibility for other insurance
affordability programs and if the individual is found to be eligible,
the county shall, as appropriate, transfer the individual's
electronic account to other insurance affordability programs via a
secure electronic interface.
(p) Any renewal form or notice shall be accessible to persons who
are limited-English proficient and persons with disabilities
consistent with all federal and state requirements.
(q) The requirements to provide information in subdivisions (e)
and (g), and to report changes in circumstances in subdivision (h),
may be provided through any of the modes of submission allowed in
Section 435.907(a) of Title 42 of the Code of Federal Regulations,
including an Internet Web site identified by the department,
telephone, mail, in person, and other commonly available electronic
means as authorized by the department.
(r) Forms required to be signed by a beneficiary pursuant to this
section shall be signed under penalty of perjury. Electronic
signatures, telephonic signatures, and handwritten signatures
transmitted by electronic transmission shall be accepted.
(s) For purposes of this section, "MAGI-based financial methods"
means income calculated using the financial methodologies described
in Section 1396a(e)(14) of Title 42 of the United States Code, and as
added by the federal Patient Protection and Affordable Care Act
(Public Law 111-148), as amended by the federal Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), and any
subsequent amendments.
(t) When contacting a beneficiary under paragraphs (2) and (4) of
subdivision (f), and paragraph (3) of subdivision (g), a county shall
first attempt to use the method of contact identified by the
beneficiary as the preferred method of contact, if a method has been
identified.
(u) The department shall seek federal approval to extend the
annual redetermination date under this section for a three-month
period for those Medi-Cal beneficiaries whose annual redeterminations
are scheduled to occur between January 1, 2014, and March 31, 2014.
(v) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, in accordance
with the requirements of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10231.5 of the Government
Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted.
(w) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(x) This section shall become operative on January 1, 2014.
SEC. 7. Section 14005.39 of the Welfare and Institutions Code, as
amended by Section 10 of Chapter 4 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14005.39. (a) If a county has facts clearly demonstrating that a
Medi-Cal beneficiary cannot be eligible for Medi-Cal due to an event,
such as death or change of state residency, Medi-Cal benefits shall
be terminated without a redetermination under Section 14005.37.
(b) Whenever Medi-Cal eligibility is terminated without a
redetermination, as provided in subdivision (a), the Medi-Cal
eligibility worker shall record that fact or event causing the
eligibility termination in the beneficiary's file, along with a
certification that a full redetermination could not result in a
finding of Medi-Cal eligibility. Following this certification, a
notice of action specifying the basis for termination of Medi-Cal
eligibility shall be sent to the beneficiary.
(c) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(d) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available and
necessary federal approvals have been obtained.
SEC. 8. Section 14005.61 of the Welfare and Institutions Code, as
added by Section 10 of Chapter 3 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14005.61. (a) Except as provided in subdivision (e), individuals
who are enrolled in a Low Income Health Program (LIHP) as of December
31, 2013, under California's Bridge to Reform Section 1115(a)
Medicaid Demonstration who are at or below 133 percent of the federal
poverty level shall be transitioned directly to the Medi-Cal program
in accordance with the requirements of this section and pursuant to
federal approval.
(b) Except as provided in paragraph (8) of subdivision (c),
individuals who are eligible under subdivision (a) shall be required
to enroll into Medi-Cal managed care health plans.
(c) Except as provided in subdivision (d), with respect to managed
care health plan enrollment, a LIHP enrollee shall be notified by
the department at least 60 days prior to January 1, 2014, in
accordance with the department's LIHP transition plan of all of the
following:
(1) Which Medi-Cal managed care health plan or plans contain his
or her existing primary care provider, if the department has this
information and the primary care provider is contracted with a
Medi-Cal managed care health plan.
(2) That the LIHP enrollee, subject to his or her ability to
change as described in paragraph (3), will be assigned to a health
plan that includes his or her primary care provider and enrolled
effective January 1, 2014. If the enrollee wants to keep his or her
primary care provider, no additional action will be required if the
primary care provider is contracted with a Medi-Cal managed care
health plan.
(3) That the LIHP enrollee may choose any available Medi-Cal
managed care health plan and primary care provider in his or her
county of residence prior to January 1, 2014, if more than one such
plan is available in the county where he or she resides, and he or
she will receive all provider and health plan information required to
be sent to new enrollees and instructions on how to choose or change
his or her health plan and primary care provider.
(4) That in counties with more than one Medi-Cal managed care
health plan, if the LIHP enrollee does not affirmatively choose a
plan within 30 days of receipt of the notice, he or she shall be
enrolled into the Medi-Cal managed care health plan that contains his
or her LIHP primary care provider as part of the Medi-Cal managed
care contracted primary care network, if the department has this
information about the primary care provider, and the primary care
provider is contracted with a Medi-Cal managed care health plan. If
the primary care provider is contracted with more than one Medi-Cal
managed care health plan, then the LIHP enrollee will be assigned to
one of the health plans containing his or her primary care provider
in accordance with an assignment process established to ensure the
linkage.
(5) That if the LIHP enrollee's existing primary care provider is
not contracted with any Medi-Cal managed care health plan, then he or
she will receive all provider and health plan information required
to be sent to new enrollees. If the LIHP enrollee does not
affirmatively select one of the available Medi-Cal managed care plans
within 30 days of receipt of the notice, he or she will
automatically be assigned a plan through the department-prescribed
auto-assignment process.
(6) That the LIHP enrollee does not need to take any action to be
transitioned to the Medi-Cal program or to retain his or her primary
care provider, if the primary care provider is available pursuant to
paragraph (2).
(7) That the LIHP enrollee may choose not to transition to the
Medi-Cal program, and what this choice will mean for his or her
health care coverage and access to health care services.
(8) That in counties where no Medi-Cal managed care health plans
are available, the LIHP enrollee will be transitioned into
fee-for-service Medi-Cal, and provided with all information that is
required to be sent to new Medi-Cal enrollees including the
assistance telephone number for fee-for-service beneficiaries, and
that, if a Medi-Cal managed care health plan becomes available in the
residence county, he or she will be enrolled in a Medi-Cal managed
care health plan according to the enrollment procedures in place at
that time.
(d) Individuals who qualify under subdivision (a) who apply and
are determined eligible for LIHP after the date identified by the
department that is not later than October 1, 2013, will be considered
late enrollees. Late enrollees shall be notified in accordance with
subdivision (c), except according to a different timeframe, but will
transition to Medi-Cal coverage on January 1, 2014. Late enrollees
after the date identified in this subdivision shall be transitioned
pursuant to the department's LIHP transition plan process.
(e) Individuals who qualify under subdivision (a) and are not
denoted as active LIHP enrollees according to the Medi-Cal
Eligibility Data System at any point within the date range identified
by the department that will start not sooner than December 20, 2013,
and continue through December 31, 2013, will not be included in the
LIHP transition to the Medi-Cal program. These individuals may apply
for Medi-Cal eligibility separately from the LIHP transition process.
(f) In conformity with the department's transition plan,
individuals who are enrolled in a LIHP at any point from September
2013 through December 2013, under California's Bridge to Reform
Section 1115(a) Medicaid Demonstration and are above 133 percent of
the federal poverty level will be provided information regarding how
to apply for an eligibility determination for an insurance
affordability program, including submission of an application by
telephone, by mail, online, or in person.
(g) A Medi-Cal managed care health plan that receives a LIHP
enrollee during this transition shall assign the LIHP primary care
provider of the enrollee as the Medi-Cal managed care health plan
primary care provider of the enrollee, to the extent possible, if the
Medi-Cal managed care health plan contracts with that primary care
provider, unless the beneficiary has chosen another primary care
provider on his or her choice form. A LIHP enrollee who is enrolled
into a Medi-Cal managed care plan may work through the Medi-Cal
managed care plan to change his or her assigned primary care provider
or other provider, after enrollment and subject to provider
availability, according to the standard processes that are currently
available in Medi-Cal managed care for selecting providers.
(h) The director may, with federal approval, suspend, delay, or
otherwise modify the requirement for LIHP program eligibility
redeterminations in 2013 to facilitate the process of transitioning
LIHP enrollees to other health coverage in 2014.
(i) The county LIHPs and their designees shall work with the
department and its designees during the 2013 and 2014 calendar years
to facilitate continuity of care and data sharing for the purposes of
delivering Medi-Cal services in the 2014 calendar year.
(j) This section shall be implemented only if and to the extent
that federal financial participation under Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available and
all necessary federal approvals have been obtained.
SEC. 9. Section 14011.66 of the Welfare and Institutions Code, as
added by Section 22 of Chapter 4 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14011.66. (a) Effective January 1, 2014, the department shall
provide Medi-Cal benefits during a presumptive eligibility period to
individuals who have been determined eligible on the basis of
preliminary information by a qualified hospital in accordance with
Section 1396a(a)(47)(B) of Title 42 of the United States Code and as
set forth in this section.
(b) A hospital may only make presumptive eligibility
determinations under this section if it complies with all of
following:
(1) It is a participating provider under the state plan or under a
federal waiver under Section 1315 of Title 42 of the United States
Code.
(2) It has notified the department in writing that it has elected
to be a qualified entity for the purpose of making presumptive
eligibility determinations.
(3) It agrees to make presumptive eligibility determinations
consistent with all applicable policies and procedures.
(4) It has not been disqualified to make presumptive eligibility
determinations by the department.
(c) Qualified hospitals may only make presumptive eligibility
determinations based upon income for children, pregnant women,
parents and other caretaker relatives, and other adults, whose income
is calculated using the applicable MAGI-based income standard.
(d) The department shall establish a process for determining
whether a hospital should be disqualified from being able to make
presumptive eligibility determinations under this section.
(e) For purposes of this section, "MAGI-based income" means income
calculated using the financial methodologies described in Section
1396a(e)(14) of Title 42 of the United States Code, as added by the
federal Patient Protection and Affordable Care Act (Public Law
111-148) and as amended by the federal Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152) and any subsequent
amendments.
(f) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(g) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 10. Section 14015.8 of the Welfare and Institutions Code, as
added by Section 18 of Chapter 3 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14015.8. (a) The department, any other government agency that is
determining eligibility for, or enrollment in, the Medi-Cal program
or any other program administered by the department, or collecting
protected health information for those purposes, and the California
Health Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code, shall share information
with each other as necessary to enable them to perform their
respective statutory and regulatory duties under state and federal
law. This information shall include, but not be limited to, personal
information, as defined in subdivision (a) of Section 1798.3 of the
Civil Code, and protected health information, as defined in Parts 160
and 164 of Title 45 of the Code of Federal Regulations, regarding
individual beneficiaries and applicants.
(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 implement, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
SEC. 11. Section 14016.6 of the Welfare and Institutions Code, as
added by Section 22 of Chapter 3 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14016.6. The State Department of Health Care Services shall
develop a program to implement subdivision (p) of Section 14016.5 and
to provide information and assistance to enable Medi-Cal
beneficiaries to understand and successfully use the services of the
Medi-Cal managed care plans in which they enroll. The program shall
include, but not be limited to, the following components:
(a) (1) Development of a method to inform beneficiaries and
applicants of all of the following:
(A) Their choices for receiving Medi-Cal benefits including the
use of fee-for-service sector managed health care plans, or pilot
programs.
(B) The availability of staff and information resources to
Medi-Cal managed health care plan enrollees described in subdivision
(f).
(2) (A) Marketing and informational materials, including printed
materials, films, and exhibits, to be provided to Medi-Cal
beneficiaries and applicants when choosing methods of receiving
health care benefits.
(B) The department shall not be responsible for the costs of
developing material required by subparagraph (A).
(C) (i) The department may prescribe the format and edit the
informational materials for factual accuracy, objectivity, and
comprehensibility.
(ii) The department, the California Health Benefit Exchange
(Exchange), the California Healthcare Eligibility, Enrollment, and
Retention System (CalHEERS), and entities or persons designated
pursuant to subdivision (g) shall use the edited materials in
informing beneficiaries and applicants of their choices for receiving
Medi-Cal benefits.
(b) Provision of information that is necessary to implement this
program in a manner that fairly and objectively explains to
beneficiaries and applicants their choices for methods of receiving
Medi-Cal benefits, including information prepared by the department.
(c) Provision of information about providers who will provide
services to Medi-Cal beneficiaries. This may be information about
provider referral services of a local provider professional
organization. The information shall be made available to Medi-Cal
beneficiaries and applicants at the same time the beneficiary or
applicant is being informed of the options available for receiving
care.
(d) Training of individuals, including county human services
staff, to carry out the program.
(e) Monitoring the implementation of the program at any location,
including online at the Exchange or at counties, where choices are
made available in order to assure that beneficiaries and applicants
may make a well-informed choice, without duress.
(f) Staff and information resources dedicated to directly assist
Medi-Cal managed health care plan enrollees to understand how to
effectively use the services of, and resolve problems or complaints
involving, their managed health care plans.
(g) Notwithstanding any other law, the department, in consultation
with the Exchange, may authorize specific persons or entities,
including counties, to provide information to beneficiaries
concerning their health care options for receiving Medi-Cal benefits
and assistance with enrollment. This subdivision shall apply in all
geographic areas designated by the director. This subdivision shall
be implemented in a manner consistent with federal law.
(h) To the extent otherwise required by Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall adopt emergency regulations
implementing this section no later than July 1, 2015. The department
may thereafter readopt the emergency regulations pursuant to that
chapter. The adoption and readoption, by the department, of
regulations implementing this section shall be deemed to be an
emergency and necessary to avoid serious harm to the public peace,
health, safety, or general welfare for purposes of Sections 11346.1
and 11349.6 of the Government Code, and the department is hereby
exempted from the requirement that it describe facts showing the need
for immediate action and from review by the Office of Administrative
Law.
(i) This section shall become operative on January 1, 2014.
SEC. 12. Section 14102 of the Welfare and Institutions Code, as
added by Section 25 of Chapter 4 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14102. (a) Notwithstanding any other law and except as otherwise
provided in this section, any individual who is 21 years of age or
older, who does not have minor children eligible for Medi-Cal
benefits and would be eligible for Medi-Cal benefits pursuant to
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)) but for the
five-year eligibility limitation under Section 1613 of Title 8 of the
United States Code, and who is enrolled in coverage through the
Exchange with an advanced premium tax credit shall be eligible for
the following:
(1) Those Medi-Cal benefits for which he or she would have been
eligible but for the five-year eligibility limitation only to the
extent that they are not available through his or her individual
health plan.
(2) The department shall pay on behalf of the beneficiary:
(A) The beneficiary's insurance premium costs for an individual
health plan, minus the beneficiary's premium tax credit authorized by
Section 36B of Title 26 of the United States Code and its
implementing regulations.
(B) The beneficiary's cost-sharing charges so that the individual
has the same cost-sharing charges as he or she would have in the
Medi-Cal program.
(b) (1) If an individual is eligible for benefits under
subdivision (a) and he or she is otherwise eligible for state-only
funded full-scope benefits, but (A) he or she is barred from
enrolling in an Exchange qualified health plan because he or she is
outside of an available enrollment period for coverage or (B) the
Exchange and the department do not have the operational capability to
implement the benefits under subdivision (a), he or she shall remain
eligible for those state-only funded benefits subject to paragraph
(2).
(2) On the first date that an individual referenced in paragraph
(1) is eligible for and can enroll in coverage under a qualified
health plan offered through the Exchange, he or she shall be
ineligible for the state-only funded full-scope benefits referenced
in paragraph (1) unless the Exchange and the department do not have
the operational capability to implement the benefits under
subdivision (a).
(c) The department shall inform and assist individuals eligible
under this section on enrolling in coverage through the Exchange with
the premium assistance, cost sharing, and benefits described in
subdivision (a), including, but not limited to, developing processes
to coordinate with the county entities that administer eligibility
for coverage in Medi-Cal and the Exchange.
(d) For purposes of this section, the following definitions shall
apply:
(1) "Cost-sharing charges" means any expenditure required by or on
behalf of an enrollee by his or her individual health plan with
respect to essential health benefits and includes deductibles,
coinsurance, copayments, or similar charges, but excludes premiums,
and spending for noncovered services.
(2) "Exchange" means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.
(e) Benefits for services under this section shall be provided
with state-only funds only if federal financial participation is not
available for those services. The department shall maximize federal
financial participation in implementing this section to the extent
allowable.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, in accordance
with the requirements of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code. Beginning
six months after the effective date of this section, and
notwithstanding Section 10321.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
(g) This section shall become operative on January 1, 2014.
SEC. 13. Section 14132.02 of the Welfare and Institutions Code, as
added by Section 28 of Chapter 4 of the First Extraordinary Session
of the Statutes of 2013, is amended to read:
14132.02. (a) The department shall seek approval from the United
States Secretary of Health and Human Services to provide individuals
made eligible pursuant to Section 14005.60 with the alternative
benefit package option authorized by Section 1396u-7(b)(1)(D) of
Title 42 of the United States Code. Effective January 1, 2014, the
alternative benefit package shall provide the same schedule of
benefits provided to full-scope Medi-Cal beneficiaries qualifying
under the modified adjusted gross income standard pursuant to Section
1396a(e)(14) of Title 42 of the United States Code, except coverage
of long-term services and supports shall be excluded unless otherwise
required by Section 1396u-7(a)(2) of Title 42 of the United States
Code or made available pursuant to subdivision (b). The alternative
benefit package shall also include any benefits otherwise required by
Section 1396u-7 of Title 42 of the United States Code and any
regulations or guidance issued pursuant to that section.
(b) Notwithstanding Section 14005.64, and only to the extent
federal approval is obtained, the department shall provide coverage
for long-term services and supports to only those individuals who
meet the asset requirements imposed under the Medi-Cal program for
receipt of the services.
(c) For purposes of this section, long-term services and supports
include nursing facility services, a level of care in any institution
equivalent to nursing facility services, home- and community-based
services furnished under the state plan or a waiver under Section
1315 or 1396n of Title 42 of the United States Code, home health
services as described in Section 1396d(a)(7) of Title 42 of the
United States Code, and personal care services described in Section
1396d(a)(24) of Title 42 of the United States Code.
(d) The department may seek approval of any necessary state plan
amendments or waivers to implement this section.
(e) 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, interpret, or make specific this section by
means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the effective date
of this section, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature on a semiannual basis, in compliance with Section 9795 of
the Government Code, until regulations have been adopted.
(f) This section shall be implemented only to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 14. Section
14154 of the Welfare and Institutions Code is amended to read:
14154. (a) (1) The department shall establish and maintain a plan
whereby costs for county administration of the determination of
eligibility for benefits under this chapter will be effectively
controlled within the amounts annually appropriated for that
administration. The plan, to be known as the County Administrative
Cost Control Plan, shall establish standards and performance
criteria, including workload, productivity, and support services
standards, to which counties shall adhere. The plan shall include
standards for controlling eligibility determination costs that are
incurred by performing eligibility determinations at county
hospitals, or that are incurred due to the outstationing of any other
eligibility function. Except as provided in Section 14154.15,
reimbursement to a county for outstationed eligibility functions
shall be based solely on productivity standards applied to that
county's welfare department office.
(2) (A) The plan shall delineate both of the following:
(i) The process for determining county administration base costs,
which include salaries and benefits, support costs, and staff
development.
(ii) The process for determining funding for caseload changes,
cost-of-living adjustments, and program and other changes.
(B) The annual county budget survey document utilized under the
plan shall be constructed to enable the counties to provide
sufficient detail to the department to support their budget requests.
(3) The plan shall be part of a single state plan, jointly
developed by the department and the State Department of Social
Services, in conjunction with the counties, for administrative cost
control for the California Work Opportunity and Responsibility to
Kids (CalWORKs), CalFresh, and Medical Assistance (Medi-Cal)
programs. Allocations shall be made to each county and shall be
limited by and determined based upon the County Administrative Cost
Control Plan. In administering the plan to control county
administrative costs, the department shall not allocate state funds
to cover county cost overruns that result from county failure to meet
requirements of the plan. The department and the State Department of
Social Services shall budget, administer, and allocate state funds
for county administration in a uniform and consistent manner.
(4) The department and county welfare departments shall develop
procedures to ensure the data clarity, consistency, and reliability
of information contained in the county budget survey document
submitted by counties to the department. These procedures shall
include the format of the county budget survey document and process,
data submittal and its documentation, and the use of the county
budget survey documents for the development of determining county
administration costs. Communication between the department and the
county welfare departments shall be ongoing as needed regarding the
content of the county budget surveys and any potential issues to
ensure the information is complete and well understood by involved
parties. Any changes developed pursuant to this section shall be
incorporated within the state's annual budget process by no later
than the 2011-12 fiscal year.
(5) The department shall provide a clear narrative description
along with fiscal detail in the Medi-Cal estimate package, submitted
to the Legislature in January and May of each year, of each component
of the county administrative funding for the Medi-Cal program. This
shall describe how the information obtained from the county budget
survey documents was utilized and, where applicable, modified and the
rationale for the changes.
(6) Notwithstanding any other law, the department shall develop
and implement, in consultation with county program and fiscal
representatives, a new budgeting methodology for Medi-Cal county
administrative costs that reflects the impact of PPACA implementation
on county administrative work. The new budgeting methodology shall
be used to reimburse counties for eligibility processing and case
maintenance for applicants and beneficiaries.
(A) The budgeting methodology may include, but is not limited to,
identification of the costs of eligibility determinations for
applicants, and the costs of eligibility redeterminations and case
maintenance activities for recipients, for different groupings of
cases, based on variations in time and resources needed to conduct
eligibility determinations. The calculation of time and resources
shall be based on the following factors: complexity of eligibility
rules, ongoing eligibility requirements, and other factors as
determined appropriate by the department. The development of the new
budgeting methodology may include, but is not limited to, county
survey of costs, time and motion studies, in-person observations by
department staff, data reporting, and other factors deemed
appropriate by the department.
(B) The new budgeting methodology shall be clearly described,
state the necessary data elements to be collected from the counties,
and establish the timeframes for counties to provide the data to the
state.
(C) The new budgeting methodology developed pursuant to this
paragraph shall be implemented no sooner than the 2015-16 fiscal
year. The department may develop a process for counties to phase in
the requirements of the new budgeting methodology.
(D) The department shall provide the new budgeting methodology to
the legislative fiscal committees by March 1 of the fiscal year
immediately preceding the first fiscal year of implementation of the
new budgeting methodology.
(E) To the extent that the funding for the county budgets
developed pursuant to the new budget methodology is not fully
appropriated in any given fiscal year, the department, with input
from the counties, shall identify and consider options to align
funding and workload responsibilities.
(F) For purposes of this paragraph, "PPACA" means the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments.
(G) 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, interpret, or make specific this paragraph
by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code. Beginning six months after the implementation
of the new budgeting methodology pursuant to this paragraph, and
notwithstanding Section 10231.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
(b) Nothing in this section, Section 15204.5, or Section 18906
shall be construed so as to limit the administrative or budgetary
responsibilities of the department in a manner that would violate
Section 14100.1, and thereby jeopardize federal financial
participation under the Medi-Cal program.
(c) (1) The Legislature finds and declares that in order for
counties to do the work that is expected of them, it is necessary
that they receive adequate funding, including adjustments for
reasonable annual cost-of-doing-business increases. The Legislature
further finds and declares that linking appropriate funding for
county Medi-Cal administrative operations, including annual
cost-of-doing-business adjustments, with performance standards will
give counties the incentive to meet the performance standards and
enable them to continue to do the work they do on behalf of the
state. It is therefore the Legislature's intent to provide
appropriate funding to the counties for the effective administration
of the Medi-Cal program at the local level to ensure that counties
can reasonably meet the purposes of the performance measures as
contained in this section.
(2) It is the intent of the Legislature to not appropriate funds
for the cost-of-doing-business adjustment for the 2008-09, 2009-10,
2010-11, 2011-12, and 2012-13 fiscal years.
(d) The department is responsible for the Medi-Cal program in
accordance with state and federal law. A county shall determine
Medi-Cal eligibility in accordance with state and federal law. If in
the course of its duties the department becomes aware of accuracy
problems in any county, the department shall, within available
resources, provide training and technical assistance as appropriate.
Nothing in this section shall be interpreted to eliminate any remedy
otherwise available to the department to enforce accurate county
administration of the program. In administering the Medi-Cal
eligibility process, each county shall meet the following performance
standards each fiscal year:
(1) Complete eligibility determinations as follows:
(A) Ninety percent of the general applications without applicant
errors and are complete shall be completed within 45 days.
(B) Ninety percent of the applications for Medi-Cal based on
disability shall be completed within 90 days, excluding delays by the
state.
(2) (A) The department shall establish best-practice guidelines
for expedited enrollment of newborns into the Medi-Cal program,
preferably with the goal of enrolling newborns within 10 days after
the county is informed of the birth. The department, in consultation
with counties and other stakeholders, shall work to develop a process
for expediting enrollment for all newborns, including those born to
mothers receiving CalWORKs assistance.
(B) Upon the development and implementation of the best-practice
guidelines and expedited processes, the department and the counties
may develop an expedited enrollment timeframe for newborns that is
separate from the standards for all other applications, to the extent
that the timeframe is consistent with these guidelines and
processes.
(3) Perform timely annual redeterminations, as follows:
(A) Ninety percent of the annual redetermination forms shall be
mailed to the recipient by the anniversary date.
(B) Ninety percent of the annual redeterminations shall be
completed within 60 days of the recipient's annual redetermination
date for those redeterminations based on forms that are complete and
have been returned to the county by the recipient in a timely manner.
(C) Ninety percent of those annual redeterminations where the
redetermination form has not been returned to the county by the
recipient shall be completed by sending a notice of action to the
recipient within 45 days after the date the form was due to the
county.
(D) When a child is determined by the county to change from no
share of cost to a share of cost and the child meets the eligibility
criteria for the Healthy Families Program established under Section
12693.98 of the Insurance Code, the child shall be placed in the
Medi-Cal-to-Healthy Families Bridge Benefits Program, and these cases
shall be processed as follows:
(i) Ninety percent of the families of these children shall be sent
a notice informing them of the Healthy Families Program within five
working days from the determination of a share of cost.
(ii) Ninety percent of all annual redetermination forms for these
children shall be sent to the Healthy Families Program within five
working days from the determination of a share of cost if the parent
has given consent to send this information to the Healthy Families
Program.
(iii) Ninety percent of the families of these children placed in
the Medi-Cal-to-Healthy Families Bridge Benefits Program who have not
consented to sending the child's annual redetermination form to the
Healthy Families Program shall be sent a request, within five working
days of the determination of a share of cost, to consent to send the
information to the Healthy Families Program.
(E) Subparagraph (D) shall not be implemented until 60 days after
the Medi-Cal and Joint Medi-Cal and Healthy Families applications and
the Medi-Cal redetermination forms are revised to allow the parent
of a child to consent to forward the child's information to the
Healthy Families Program.
(e) The department shall develop procedures in collaboration with
the counties and stakeholder groups for determining county review
cycles, sampling methodology and procedures, and data reporting.
(f) On January 1 of each year, each applicable county, as
determined by the department, shall report to the department on the
county's results in meeting the performance standards specified in
this section. The report shall be subject to verification by the
department. County reports shall be provided to the public upon
written request.
(g) If the department finds that a county is not in compliance
with one or more of the standards set forth in this section, the
county shall, within 60 days, submit a corrective action plan to the
department for approval. The corrective action plan shall, at a
minimum, include steps that the county shall take to improve its
performance on the standard or standards with which the county is out
of compliance. The plan shall establish interim benchmarks for
improvement that shall be expected to be met by the county in order
to avoid a sanction.
(h) (1) If a county does not meet the performance standards for
completing eligibility determinations and redeterminations as
specified in this section, the department may, at its sole
discretion, reduce the allocation of funds to that county in the
following year by 2 percent. Any funds so reduced may be restored by
the department if, in the determination of the department, sufficient
improvement has been made by the county in meeting the performance
standards during the year for which the funds were reduced. If the
county continues not to meet the performance standards, the
department may reduce the allocation by an additional 2 percent for
each year thereafter in which sufficient improvement has not been
made to meet the performance standards.
(2) No reduction of the allocation of funds to a county shall be
imposed pursuant to this subdivision for failure to meet performance
standards during any period of time in which the
cost-of-doing-business increase is suspended.
(i) The department shall develop procedures, in collaboration with
the counties and stakeholders, for developing instructions for the
performance standards established under subparagraph (D) of paragraph
(3) of subdivision (d), no later than September 1, 2005.
(j) No later than September 1, 2005, the department shall issue a
revised annual redetermination form to allow a parent to indicate
parental consent to forward the annual redetermination form to the
Healthy Families Program if the child is determined to have a share
of cost.
(k) The department, in coordination with the Managed Risk Medical
Insurance Board, shall streamline the method of providing the Healthy
Families Program with information necessary to determine Healthy
Families eligibility for a child who is receiving services under the
Medi-Cal-to-Healthy Families Bridge Benefits Program.
(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and except
as provided in subparagraph (G) of paragraph (6) of subdivision (a),
the department shall, without taking any further regulatory action,
implement, interpret, or make specific this section and any
applicable federal waivers and state plan amendments by means of
all-county letters or similar instructions.
