Bill Text: CA AB2956 | 2023-2024 | Regular Session | Amended
Bill Title: Medi-Cal eligibility: redetermination.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced) 2024-05-16 - In committee: Held under submission. [AB2956 Detail]
Download: California-2023-AB2956-Amended.html
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Amended
IN
Assembly
April 18, 2024 |
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Amended
IN
Assembly
March 13, 2024 |
CALIFORNIA LEGISLATURE—
2023–2024 REGULAR SESSION
Assembly Bill
No. 2956
| Introduced by Assembly Member Boerner (Coauthor: Assembly Member Bonta) |
February 16, 2024 |
An act to amend Sections 14005.18 and 14005.37 of, and to add Section 14005.251 to, the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2956, as amended, Boerner.
Medi-Cal eligibility: redetermination.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law generally requires a county to redetermine a Medi-Cal beneficiary’s eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiary’s circumstances that may affect their Medi-Cal eligibility. Existing law conditions implementation of the redetermination provisions on the availability of federal financial participation and receipt of any necessary federal approvals. Under existing law, 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 are terminated without a redetermination.
Existing law requires the department, subject to federal funding, to extend continuous eligibility to children 19 years of age or younger for a 12-month period, as specified. Under existing law, operative on January 1, 2025, or the date that the department certifies that certain conditions have been met, a child is continuously eligible for Medi-Cal up to 5 years of age. Under those provisions, a redetermination is prohibited during this time, unless certain circumstances apply, including, voluntary disenrollment, death, or change of state residency.
This bill would require the department to seek federal approval to extend continuous eligibility to individuals over 19 years of age. Under the bill, subject to federal funding, and except as described above with regard to death, change of state
residency, or other events, an individual would remain eligible from the date of a Medi-Cal eligibility determination until the end of a 12-month period, as specified.
The bill would make various changes to the above-described redetermination procedures. The bill would, among other things, require the county, in the event of a loss of contact, to attempt communication with the intended recipient through all additionally available channels before completing a prompt redetermination. The bill would require the county to make another review of certain obtained information in an attempt to renew eligibility without needing a response from a beneficiary.
The bill would require the county to complete a determination at renewal without requesting additional information or documentation if specified conditions are met, relating to, among other things, prior income verification and no contradictory information on file.
When income is found not reasonably compatible from electronically available sources, the bill would require the county to first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiary’s self-attestation and information received through electronic data sources on required eligibility factors. For purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, the bill would require a county to accept self-attested information, as specified.
Under the bill, for a beneficiary whose eligibility was discontinued due to failure to provide needed information and who submits to the county that information, as specified, the beneficiary would be entitled to a Medi-Cal eligibility determination for the 3 months immediately prior to the month in which the beneficiary
provided the information, unless the beneficiary opts out. The bill would make conforming changes to related provisions.
In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population, as defined, makes contact with the county, the bill would require the county to begin a new 12-month eligibility period if certain conditions are met.
The bill would require the department to set a goal, in the form of a target rate of at least 50%, for successful ex parte renewals, and to post a related report. The bill would require counties to collect and submit to the department call-center data metrics.
The bill would require the department to seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described above, that were originally
implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
By creating new duties for counties relating to the redetermination of 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 the statutory provisions noted above.
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
SECTION 1.
Section 14005.18 of the Welfare and Institutions Code is amended to read:14005.18.
(a) (1) An individual is eligible, to the extent required by federal law, as though the individual was pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.(2) For purposes of paragraph (1), “postpartum services” means those services provided after childbirth, child delivery, or miscarriage.
(b) (1) Notwithstanding subdivision (a), Section 15840, the income eligibility requirements specified in Section 15832, and the annual redetermination requirements described in Section 14005.37, a pregnant individual who is
receiving health care coverage under a program identified in subdivision (d) and who is diagnosed with a maternal mental health condition shall remain eligible for the Medi-Cal program under their current eligibility category for a period of one year following the last day of the individual’s pregnancy if the individual complies with the requirements specified in subdivision (c) and is otherwise eligible for the Medi-Cal program.
(2) For purposes of this section, “maternal mental health condition” means a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.
(c) (1) An individual, or a designee of the individual, who seeks to extend Medi-Cal program coverage pursuant to
this section shall submit to a county eligibility worker a note from that individual’s treating health care provider stating that the health care provider has diagnosed the individual with a maternal mental health condition within 60 days following the last day of the individual’s pregnancy.
(2) Notwithstanding paragraph (1), an individual who has had Medi-Cal coverage discontinued within the 60-day period beginning on the last day of pregnancy, but who is diagnosed with a maternal mental health condition more than 60 days following the last day of pregnancy and within the time limit described in subdivision (j) of Section 14005.37, may be reinstated to their previous Medi-Cal eligibility pursuant to subdivision (j) of Section 14005.37 by submitting a note, as described in paragraph (1), from the individual’s treating health care
provider within the timeframe described in that subdivision.
(d) For purposes of this section, “Medi-Cal program” refers to any of the following programs:
(1) The Medi-Cal Access Program, as described in Chapter 2 (commencing with Section 15810) of Part 3.3.
(2) The Medi-Cal program, as described in this article.
(3) The Perinatal Services Program, as described in Article 4.7 (commencing with Section 14148).
(e) This section does not limit the ability of a qualified individual to apply for and purchase a qualified health plan in Covered California pursuant to Title 22 (commencing with Section 100500) of
the Government Code if the qualified individual is otherwise eligible for coverage pursuant to that title.
(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, provider bulletins, or similar instructions, without taking regulatory action.
(g) Implementation of this section is subject to an appropriation in the annual Budget Act for these purposes.
(h) This section shall become inoperative commencing on the date that Section 14005.185 is implemented. If made inoperative, this section shall become operative again if, and upon the date that, Section 14005.185
is no longer implemented. The department shall determine the implementation status of Section 14005.185 and shall post, on the department’s internet website, notice of its determination.
SEC. 2.
Section 14005.251 is added to the Welfare and Institutions Code, immediately following Section 14005.25, to read:14005.251.
(a) The department shall seek federal approval(1) For existing Medi-Cal beneficiaries, the end of a 12-month period following the Medi-Cal eligibility determination at renewal.
(2) For new Medi-Cal applicants, the end of the 12-month period starting with the first month of Medi-Cal eligibility.
(b) This section shall be implemented only if, and to the extent that, federal financial participation is available.
(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, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar public and statewide instructions, until the time any necessary regulations are adopted. The department shall adopt regulations by January 1,
2027, 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.
SEC. 3.
Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.
(a) 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, except as provided in Sections 14005.18, 14005.185, 14005.25, 14005.251, 14005.255, and 14005.39. 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 the county to attempt communication with the intended recipient through all additionally available channels prior to completing 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 completes processing of a beneficiary’s redetermination following the procedures in this section, 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 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:
(1) 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.
(2) The beneficiary requests that the county determine whether the beneficiary 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 their 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 on 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 on which it is based.
(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 that 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.
(5) In the case of an annual redetermination, the county shall complete an eligibility determination at renewal without requesting additional information or documentation if either of the following sets of conditions is met:
(A) The following set of conditions:
(i) The most recent income determination was based on a previously verified attestation of income at or below 100
percent of the federal poverty level, including ex parte, electronic, or administrative verification, during either of the following:
(I) At the initial application.
(II) At the most recent renewal within the last 12 months.
(ii) The county has checked financial data sources and no information is received, but all other eligibility criteria are verified.
(iii) No contradictory information is on file.
(B) The following set of conditions:
(i) The most recent income determination, at either initial application or most recent renewal
renewal, was within the last 12 months.
(ii) The beneficiary receives benefits under Title II of the federal Social Security Act or other sources of stable income at the most recent determination.
(iii) No contradictory information is on file.
(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 the beneficiary 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) The telephone number to call in order to obtain more information.
(2) The county shall attempt to contact the beneficiary twice 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
again review all information described in paragraph (1) of subdivision (e) in an attempt to renew eligibility without needing a response from a beneficiary. Only after completing these two steps may the county terminate the beneficiary’s eligibility for Medi-Cal benefits following the provision of timely notice. The county shall not terminate eligibility until after it has processed all submitted renewal information.
(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 incomplete, the county shall follow the procedures set forth in paragraph (4) 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
states the information needed to redetermine 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. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions
to 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.
(2) For applicants or beneficiaries, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods, when income is found not reasonably compatible from electronically available sources, the county shall first attempt to obtain a reasonable explanation through a verbal or written explanation, in an attempt to resolve a discrepancy between the beneficiary’s self-attestation and information received through electronic data sources on required eligibility factors. If that information is unavailable, the county shall obtain any other needed
verification in order to complete the financial eligibility determination.
(3) 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 require the county to attempt communication with the intended recipient through all additionally available channels prior to completing a redetermination. 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.
(4) 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 twice by telephone, in writing, or other commonly available electronic means, in counties where that 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) In the case of a redetermination, for purposes of the income verification process only, when a renewal is received without a reasonable explanation or other income verification, a county shall accept self-attested information. For
purposes of the income verification process only, the Medi-Cal beneficiary may provide verification through a verbal or written explanation.
(i) 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.
(j) If, within 90 days of a Medi-Cal beneficiary’s eligibility termination date or a change in eligibility status due to the beneficiary’s failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. Unless the beneficiary opts out, the beneficiary shall be
entitled to a Medi-Cal eligibility determination for the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(k) 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.
(l) 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 on 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 on disability.
(m) 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.
(n) 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.
(o) 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.
(p) (1) In the case of a redetermination due to a change in circumstances, each time a Medi-Cal beneficiary who is considered a member of a vulnerable or difficult-to-reach population makes contact with the county, the county shall begin a new 12-month eligibility period if all of the following conditions are met:
(A) The county determines that the beneficiary remains eligible for Medi-Cal benefits.
(B) Utilization of change-in-circumstances data will not lead to a negative action.
(C) The
individual has not reported, and the county has not obtained from external data sources, any information indicating a change in circumstances that results in a determination of ineligibility or an increase in share of cost.
(2) For purposes of this subdivision, “vulnerable or difficult-to-reach population” includes, but is not limited to, any of the following:
(A) Medi-Cal beneficiaries who are unsheltered or without a fixed address.
(B) Aged, blind, or disabled individuals.
(C) Victims of a natural disaster.
(D) Medi-Cal beneficiaries who live in a remote area.
(E) Incarcerated Medi-Cal beneficiaries.
(F) Migrant workers.
(G) Individuals in foster care.
(H) Unaccompanied immigrant minors.
(I) Any other population that the county determines is appropriate for designation as a vulnerable or difficult-to-reach population.
(q) 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.
(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) (1) The department shall set a goal, in the form of a target rate of at least 50 percent, for successful ex parte renewals for populations, regardless of whether eligibility is determined using MAGI-based or non-MAGI-based financial methods.
(2) The department shall prepare a report, excluding any personally identifiable information, on the causes of missing the target
described in paragraph (1), if applicable, and action steps to increase ex parte renewal rates in months involving a failure to meet the target. The department shall post the report on the department’s internet website.
(t) Counties shall collect and submit to the department call-center data metrics, including, but not limited to, call volume, average wait times, disconnects, callbacks, high-volume message recipients, and staff readiness.
(u) The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (i), 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 website identified by the department, telephone, mail, in
person, and other commonly available electronic means as authorized by the department.
(v) 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.
(w) 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.
(x) When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (4) 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. After the first attempt, the second attempt shall be through a different modality when the beneficiary’s file includes a phone number or email address.
(y) 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.
(z) 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.
(aa) The department shall seek any necessary federal approvals to make permanent all temporary eligibility rules, not already described in this section, that were originally implemented for Medi-Cal renewals that were due between June 2023 and May 2024, inclusive, as part of the COVID-19 Unwinding Period.
(ab) 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.
