Bill Text: CA SB1300 | 2015-2016 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: emergency medical transport providers: quality assurance fee.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Vetoed) 2016-11-30 - Last day to consider Governor's veto pursuant to Joint Rule 58.5. [SB1300 Detail]

Download: California-2015-SB1300-Amended.html

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BILL NUMBER: SB 1300	AMENDED
	BILL TEXT

	AMENDED IN SENATE  APRIL 5, 2016

INTRODUCED BY   Senator Hernandez

                        FEBRUARY 19, 2016

   An act to  amend Section 15926   add Article
3.91 (commencing with Section 14129) to Chapter 7 of Part 3 of
Division 9  of the Welfare and Institutions Code, relating to
 health care.   Medi-Cal, making an
appropriation therefor, and declaring the urgency thereof, to take
effect immediately. 


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1300, as amended, Hernandez.  Health care: eligibility
and enrollment.   Medi-Cal: emergency medical transport
providers: quality assurance fee.  
   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. Existing law establishes a quality
assurance fee program for skilled nursing and intermediate care
facilities, as prescribed. 
   This bill, commencing July 1, 2017, and subject to federal
approval, would impose a quality assurance fee for each transport
provided by an emergency medical transport provider, as defined,
subject to the quality assurance fee in accordance with a prescribed
methodology. The bill would authorize the director to exempt
categories of emergency medical transport providers from the quality
assurance fee if necessary to obtain federal approval. The bill would
require the Director of Health Care Services to deposit the
collected quality assurance fee into the Medi-Cal Emergency Medical
Transport Fund, which the bill would create in the State Treasury, to
be continuously appropriated, thereby making an appropriation, to
the department to be used exclusively in a specified order of
priority to enhance federal financial participation for ambulance
services under the Medi-Cal program, and to provide additional
reimbursement to, and to support quality improvement efforts of,
emergency medical transport providers, to pay for state
administrative costs, and to provide funding for health care coverage
for Californians. The bill, on or before August 15, 2016, would
require each emergency medical transport provider to report to the
department specified data, including data on gross receipts, as
defined, from the provision of emergency medical transports, as
specified, in a manner and form prescribed by the department and,
commencing on October 1, 2016, and each fiscal quarter thereafter,
would require each emergency medical transport provider to report
this data to the department. The bill would authorize the department
to establish an Internet Web site for the submission of these data
reports. The bill would authorize the department to require a
certification by each emergency medical transport provider, under
penalty of perjury, of the truth of these data reports. By expanding
the scope of the crime of perjury, the bill would impose a
state-mandated local program. The bill would authorize the
department, upon written notice to the emergency medical transport
provider, to impose a $100 per day penalty against the provider for
each day that the provider fails to make a report within 5 business
days of the date upon which the data report was due. The bill would
provide that the failure to make a report under these provisions
within 90 days of the date upon which the report was due shall be
considered a violation that relates to his or her licensed activities
for purposes of a specified section of the Vehicle Code, which
authorizes the Commissioner of the California Highway Patrol to
suspend, revoke, or take other disciplinary action against a license
if the licensee violates any section of the Vehicle Code that relates
to his or her licensed activities.  
   The bill, commencing July 1, 2017, and subject to federal
approval, would increase the Medi-Cal reimbursement to private
emergency medical transport providers for emergency medical
transports, including both fee-for-service transports paid by the
department and managed care transports paid by Medi-Cal managed care
health plans, as specified.  
   The bill would authorize the department to adopt regulations as
necessary to implement these provisions, as specified.  
   The bill would provide that the provisions of the bill shall cease
to be implemented if any of certain conditions, including continued
federal approval, are no longer satisfied.  
   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 no reimbursement is required by this
act for a specified reason.  
   This bill would declare that it is to take effect immediately as
an urgency statute.  
   Existing law establishes various programs to provide health care
coverage to persons with limited financial resources, including the
Medi-Cal program and the State's Children's Health Insurance Program.
Existing law establishes the California Health Benefit Exchange
(Exchange), pursuant to the federal Patient Protection and Affordable
Care Act (PPACA), and specifies the duties and powers of the board
governing the Exchange relative to determining eligibility for
enrollment in the Exchange and arranging for coverage under qualified
health plans, and facilitating the purchase of qualified health
plans through the Exchange. Existing law, the Health Care Reform
Eligibility, Enrollment, and Retention Planning Act, requires the
State Department of Social Services in consultation with specified
entities, to establish standardized single, accessible, application
forms and related renewal procedures for insurance affordability
programs, as defined, in accordance with specified requirements
relating to the forms and notices developed for these purposes.
 
   This bill would make technical, nonsubstantive changes to those
provisions. 
   Vote:  majority   2/3  . Appropriation:
 no   yes  . Fiscal committee:  no
  yes  . State-mandated local program:  no
  yes  .


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

   SECTION 1.    Article 3.91 (commencing with Section
14129) is added to Chapter 7 of Part 3 of Division 9 of the 
 Welfare and Institutions Code   , to read:  

      Article 3.91.  Medi-Cal Emergency Medical Transportation
Reimbursement Act


   14129.  The Legislature finds and declares all of the following:
   (a) The Legislature recognizes the essential role that emergency
medical transport providers play in serving the state's Medi-Cal
beneficiaries. To that end, it has been and remains the intent of the
Legislature to improve funding for emergency medical transport
providers and obtain all available federal funds to make supplemental
Medi-Cal payments to emergency medical transport providers.
   (b) It is the intent of the Legislature to impose a quality
assurance fee to be paid by emergency medical transport providers,
which will be used to increase federal financial participation in
order to increase Medi-Cal payments to emergency medical transport
providers.
   (c) It is the intent of the Legislature to increase the Medi-Cal
emergency medical transport reimbursement by increasing the
fee-for-service payment schedule for emergency medical transports to
support quality improvement efforts by emergency medical transport
providers, including, but not limited to, the provision of advanced
life support services, as defined in Section 1797.52 of the Health
and Safety Code.
   (d) It is the further intent of the Legislature that the increased
fee-for-service payment schedule amounts pursuant to this article
shall not result in any expenditure from the General Fund.
   14129.1.  For purposes of this article, the following definitions
shall apply:
   (a) "Annual quality assurance fee rate" means the quality
assurance fee assessed on each emergency medical transport applicable
to each state fiscal year.
   (b) "Aggregate fee schedule increase amount" means the product of
the quotient described in paragraph (2) of subdivision (a) of Section
14129.4 and the Medi-Cal emergency medical transports, including
both fee-for-service transports paid by the department and managed
care transports paid by Medi-Cal managed care health plans, utilizing
the billing codes for emergency medical transport for the state
fiscal year.
   (c) "Available fee amount" shall be calculated as the sum of the
following:
    (1) The amount deposited in the Medi-Cal Emergency Transportation
Fund established under Section 14129.3 during the applicable state
fiscal year, less the amounts described in subparagraphs (A) and (B)
of paragraph (2) of subdivision (f) of Section 14129.3.
   (2) Any federal financial participation obtained as a result of
the deposit of the amount described in paragraph (1) in the Medi-Cal
Emergency Transportation Fund for the applicable fiscal year.
   (d) "Department" means the State Department of Health Care
Services.
   (e) "Director" means the Director of Health Care Services.
   (f) "Effective state medical assistance percentage" means a ratio
of the aggregate expenditures from state-only sources for the
Medi-Cal program divided by the aggregate expenditures from state and
federal sources for the Medi-Cal program for a state fiscal year.
   (g) "Emergency medical transport" means the act of transporting an
individual from any point of origin to the nearest medical facility
capable of meeting the emergency medical needs of the patient by an
ambulance licensed, operated, and equipped in accordance with
applicable state or local statutes, ordinances, or regulations that
are billed with billing codes A0429 BLS Emergency, A0427 ALS
Emergency, and A0433 ALS2, and any equivalent, predecessor, or
successor billing codes as may be determined by the director.
"Emergency medical transports" shall not include transportation of
beneficiaries by passenger car, taxicabs, litter vans, wheelchair
vans, or other forms of public or private conveyances, nor shall it
include transportation by an air ambulance provider. An "emergency
medical transport" does not occur when, following evaluation of a
patient, a transport is not provided.
   (h) "Gross receipts" means gross payments received as patient care
revenue for emergency medical transports, determined on a cash basis
of accounting.
   (i) "Emergency medical transport provider" means any provider of
emergency medical transports.
   (j) "Emergency medical transport provider subject to the fee"
means all emergency medical transport providers that bill and receive
patient care revenue from the provision of emergency medical
transports, except emergency medical transport providers that are
exempt pursuant to subdivision (c) of Section 14129.8.
   (k) "Medi-Cal managed care health plan" means a "managed health
care plan" as that term is defined in subdivision (ab) of Section
14169.51.
   14129.2.  (a) On or before August 15, 2016, each emergency medical
transport provider shall report to the department data on the number
of actual emergency medical transports by payor type, including,
without limitation, Medi-Cal fee-for-service emergency medical
transports and Medi-Cal managed care emergency medical transports,
and gross receipts from the provision of emergency medical transports
provided in each quarter from July 1, 2015, through June 30, 2016,
inclusive, in a manner and format prescribed by the department.
   (b) Commencing with the fiscal quarter beginning on October 1,
2016, and each fiscal quarter thereafter, on or before the 45th day
of the quarter, each emergency medical transport provider shall
report to the department data on the number of actual emergency
medical transports by payor type, including, without limitation,
Medi-Cal fee-for-service emergency medical transports and Medi-Cal
managed care emergency medical transports, and gross receipts from
the provision of emergency medical transports provided in the quarter
preceding the quarter in which the report is due, in a manner and
format prescribed by the department.
   (c) The department may establish an Internet Web site for the
submission of reports required by this section.
   (d) The department may require a certification by each emergency
medical transport under penalty of perjury of the truth of the
reports required under this section. Upon written notice to an
emergency medical transport provider, the department may impose a
penalty of one hundred dollars ($100) per day against an emergency
medical transport provider for every day that an emergency medical
transport provider fails to make a report required by this section
within five days of the date upon which the report was due. If an
emergency medical transport provider has not made a report as
required by this section within 90 days of the date upon which the
report was due, the failure to make the report shall be considered a
violation of a section of the Vehicle Code that relates to the
emergency medical transport provider's licensed activities for the
purposes of Section 2542 of the Vehicle Code.
   14129.3.  (a) Commencing with the state fiscal quarter beginning
on July 1, 2017, and continuing each fiscal quarter thereafter, there
shall be imposed a quality assurance fee for each transport provided
by each emergency medical transport provider subject to the fee in
accordance with this section.
   (b) (1) On or before June 15, 2017, and each June 15 thereafter,
the director shall calculate the annual quality assurance fee rate
applicable to the following state fiscal year based on the most
recently collected data collected from emergency medical transport
providers pursuant to Section 14129.2, and publish the annual quality
assurance fee rate on its Internet Web site. In no case shall the
fees calculated pursuant to this subdivision and collected pursuant
to this article exceed the amounts allowable under federal law.
   (A) For state fiscal year 2017-18, the annual quality assurance
fee rate shall be calculated by multiplying the projected total
annual gross receipts for all emergency medical transport providers
subject to the fee by 5.5 percent, which resulting product shall be
divided by the projected total annual emergency medical transports by
all emergency medical transport providers subject to the fee for the
state fiscal year.
   (B) For state fiscal years 2018-19 and thereafter, the annual
quality assurance fee rate shall be calculated by a ratio, the
numerator of which shall be the sum of the product of the projected
aggregate fee schedule amount and the effective state medical
assistance percentage, and the amount described in subparagraph (A)
of paragraph (2) of subdivision (f), and the denominator of which
shall be 95 percent of the projected total annual emergency medical
transports by all emergency medical transport providers subject to
the fee for the state fiscal year.
   (2) On or before June 15, 2017, and each June 15 thereafter, the
director shall publish the annual quality assurance fee rate on its
Internet Web site.
   (3) In no case shall the fees calculated pursuant to this
subdivision and collected pursuant to this article exceed the amounts
allowable under federal law.
   (4) If, during a state fiscal year, the actual or projected
available fee amount exceeds or is less than the actual or projected
aggregate fee schedule amount by more than 1 percent, the director
shall adjust the annual quality assurance fee rate so that the
available fee amount for the state fiscal year will approximately
equal the aggregate fee schedule amount for the state fiscal year.
The available fee amount for a state fiscal year will be considered
to equal the aggregate fee schedule amount for the state fiscal year
if the difference between the available fee amount for the state
fiscal year and the aggregate fee schedule amount for the state
fiscal year constitutes less than 1 percent of the aggregate fee
schedule amount for the state fiscal year.
   (c) (1) Each emergency medical transport provider subject to the
fee shall remit to the department an amount equal to the annual
quality assurance fee rate for the 2017-18 state fiscal year
multiplied by the number of transports reported or that should have
been reported by the emergency medical transport provider pursuant to
subdivision (b) of Section 14129.2 in the quarter commencing April
1, 2017, based on a schedule established by the director. The
schedule established by the director for the fee payment described in
this paragraph shall not require payment of any of the fee payment
prior to July 1, 2017, and shall not require payment of more than 50
percent of the fee payment prior to August 1, 2017.
   (2) Commencing with the state fiscal quarter beginning on October
1, 2017, and each fiscal quarter thereafter, on or before the first
day of each state fiscal quarter, each emergency medical transport
provider subject to the fee shall remit to the department an amount
equal to the annual quality assurance fee rate for the applicable
state fiscal year multiplied by the number of transports reported or
that should have been reported by the emergency medical transport
provider pursuant to subdivision (b) of Section 14129.2 in the
immediately preceding quarter.
   (d) (1) Interest shall be assessed on quality assurance fees not
paid on the date due at the greater of 10 percent per annum or the
rate at which the department assesses interest on Medi-Cal program
overpayments to hospitals that are not repaid when due. Interest
shall begin to accrue the day after the date the payment was due and
shall be deposited in the Medi-Cal Emergency Medical Transport Fund
established in subdivision (f).
   (2) In the event that any fee payment is more than 60 days
overdue, the department may deduct the unpaid fee and interest owed
from any Medi-Cal reimbursement payments owed to the provider until
the full amount of the fee and interest are recovered. Any deduction
made pursuant to this subdivision shall be made only after the
department gives the provider written notification. Any deduction
made pursuant to this subdivision may be deducted over a period of
time that takes into account the financial condition of the provider.

   (3) In the event that any fee payment is more than 60 days
overdue, a penalty equal to the interest charge described in
paragraph (1) shall be assessed and due for each month for which the
payment is not received after 60 days.
   (e) The department shall accept an emergency medical transport
provider's payment even if the payment is submitted in a rate year
subsequent to the rate year in which the fee was assessed.
   (f) (1) The director shall deposit the quality assurance fee
collected pursuant to this section in the Medi-Cal Emergency Medical
Transport Fund, which is hereby created in the State Treasury and,
notwithstanding Section 13440 of the Government Code, is continuously
appropriated without regard to fiscal years to the department for
the purposes specified in this article. Notwithstanding Section
16305.7 of the Government Code, the fund shall also include interest
and dividends earned on moneys in the fund.
   (2) The moneys in the Medi-Cal Emergency Medical Transport Fund,
including any interest and dividends earned on money in the fund,
shall be available exclusively to enhance federal financial
participation for ambulance services under the Medi-Cal program and
to provide additional reimbursement to, and to support quality
improvement efforts of, emergency medical transport providers, as
well as to pay for the state's administrative costs and to provide
funding for health care coverage for Californians, in the following
order of priority:
   (A) To pay for the department's staffing and administrative costs
directly attributable to implementing this article, not to exceed
three hundred fifty thousand dollars ($350,000) for each fiscal year,
exclusive of any federal matching funds.
   (B) To pay for the health care coverage in each fiscal year in the
amount of 5 percent of the projected quality assurance fee revenue
for that fiscal year, as calculated by the department on or before
June 15 preceding that fiscal year, exclusive of any federal matching
funds.
   (C) To make increased payments to emergency medical transport
providers pursuant to this article.
   (D) To provide additional support for health care coverage of
Californians.
   14129.4.  (a) Effective July 1, 2017, the Medi-Cal fee-for-service
payment schedule governing reimbursement to emergency medical
transport providers for emergency medical transports shall be
increased. The resulting fee-for-service payment schedule amounts
after the application of this section shall be equal to the sum of
(1) the Medi-Cal fee-for-service payment schedule amount for the
state fiscal year 2015-16 and (2) the quotient of the projected
available fee amount for the state fiscal year 2017-18, divided by
the total projected Medi-Cal emergency medical transports, including
both fee-for-service transports paid by the department and managed
care transports paid by Medi-Cal managed care health plans, utilizing
these billing codes for the state fiscal year 2016-17. The
department shall calculate the projections required by this
subdivision based on the data submitted pursuant to Section 14129.2.
   (b) Each Medi-Cal managed care health plan shall satisfy its
obligation under Section 438.114(c) of Title 42 of the Code of
Federal Regulations for emergency medical transports by providing
payment to emergency medical transport providers that is equal to the
amount of payment described in Section 1396u-2(b)(2)(D) of Title 42
of the United States Code.
   (c) The fee-for-service payment schedule increase established
pursuant to this section shall be funded solely from the following:
   (1) The quality assurance fee set forth in Section 14129.3, along
with any interest or other investment income thereon.
   (2) Federal reimbursement and any other related federal funds.
   (d) The proceeds of the quality assurance fee set forth in Section
14129.3, the matching amount provided by the federal government, and
any interest earned on those proceeds shall be used to supplement
existing funding for emergency medical transports provided by
emergency transport providers and not supplant this funding.
   14129.5.  If there is a delay in the implementation of this
article for any reason, including a delay in any required approval of
the quality assurance fee and reimbursement methodology specified by
the federal Centers for Medicare and Medicaid Services, all of the
following shall apply:
   (a) An emergency transport provider subject to the fee may be
assessed the amount the provider would be required to pay to the
department if the fee-for-service payment schedule increases
described in Section 14129.4 were already approved, but shall not be
required to pay the fee until the fee-for-service payment schedule
increases described in Section 14129.4 are approved. The director
shall establish a schedule for payment of retroactive fees pursuant
to this subdivision in consultation with emergency medical transport
providers to minimize the disruption to the cash flow of emergency
medical transport providers.
   (b) The department may retroactively increase and make payment of
supplemental rates to emergency medical transport providers pursuant
to Section 14129.4.
   14129.6.  (a) The director shall administer this article.
   (b) The director may adopt regulations as are necessary to
implement this article. These regulations may be adopted as emergency
regulations in accordance with the rulemaking provisions of the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code).
For purposes of this article, the first adoption of regulations shall
be deemed an emergency and necessary for the immediate preservation
of the public peace, health and safety, or general welfare. The
regulations shall include, but need not be limited to, any
regulations necessary for any of the following purposes:
   (1) The administration of this article, including the proper
imposition of the quality assurance fee and process for its
collection, reporting, and refunds. The costs associated with the
administration of this article are not to exceed the amounts
reasonably necessary to administer this article.
   (2) The development of any forms necessary to obtain required
information from providers subject to the quality assurance fee.
   (3) The provision of details, definitions, formulas, and other
requirements.
   (c) As an alternative to subdivision (b), and notwithstanding the
rulemaking provisions of the Administrative Procedure Act (Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code), the director may implement this article,
in whole or in part, by means of a provider bulletin, or other
similar instructions, without taking regulatory action, provided that
no such bulletin or other similar instructions shall remain in
effect after June 30, 2018. It is the intent of the Legislature that
the regulations adopted pursuant to subdivision (b) be adopted on or
before June 30, 2018.
   (d) The director shall ensure that the quality assurance fee per
transport imposed pursuant to this article is collected.
   14129.7.  The moneys in the Medi-Cal Emergency Medical Transport
Fund, and any federal matching funds, shall be continuously
appropriated, notwithstanding Section 13340 of the Government Code,
without regard to fiscal years to the department for the purpose of
the increased Medi-Cal fee-for-service payment schedule governing
reimbursement to emergency medical transport providers for emergency
medical transports described in Section 14129.4.
   14129.8.  (a) The department shall request approval from the
federal Centers for Medicare and Medicaid Services for the use of
fees collected pursuant to this article for the purpose of receiving
federal matching funds.
   (b) The director may alter the methodology specified in this
article to the extent necessary to meet the requirements of federal
law or regulations or to obtain federal approval. If the director,
after consulting with affected emergency medical transport providers,
determines that an alteration is needed, the director shall execute
a declaration stating that this determination has been made. The
director shall retain the declaration and provide a copy, within five
working days of the execution of the declaration, to the fiscal and
appropriate policy committees of the Legislature.
   (c) The director may add categories of exempt emergency medical
transport providers or apply a nonuniform fee per transport to
emergency medical transport providers that are subject to the fee in
order to meet requirements of federal law or regulations. The
director may exempt categories of emergency medical transport
providers from the fee if necessary to obtain federal approval.
   14129.9.  (a) This article shall be implemented only if, and as
long as, both of the following conditions are met:
   (1) The state receives federal approval of the quality assurance
fee from the federal Centers for Medicare and Medicaid Services.
   (2) The state receives federal approval for the increased
fee-for-service payment schedule increases described in subdivision
(a) of Section 14129.4.
   (b) This article shall cease to be implemented if one of the
following conditions is no longer met:
   (1) The federal Centers for Medicare and Medicaid Services
continues to allow the use of the provider assessment provided in
this article.
   (2) The Medi-Cal fee-for-service payment schedule increase
described in subdivision (a) of Section 14129.4 remains in effect.
   (3) The quality assurance fee assessed and collected pursuant to
this article remains available for the purposes specified in this
article.
   (c) If all of the conditions in subdivision (a) are met, this
article is implemented. If, subsequently, any one of the conditions
in subdivision (b) is not met, this article shall become inoperative
notwithstanding that the condition or conditions subsequently may be
met.
   (d) Notwithstanding subdivisions (a), (b), and (c), in the event
of a final judicial determination made by any state or federal court
that is not appealed, or by a court of appellate jurisdiction that is
not further appealed, in any action by any party, or a final
determination by the administrator of the federal Centers for
Medicare and Medicaid Services, that federal financial participation
is not available with respect to any payment made under the
methodology implemented pursuant to this article because the
methodology is invalid, unlawful, or contrary to any provision of
federal law or regulations or of state law, this article shall become
inoperative. 
   SEC. 2.    No reimbursement is required by this act
pursuant to Section 6 of Article XIII B of the California
Constitution because the only costs that may be incurred by a local
agency or school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction, or
changes the penalty for a crime or infraction, within the meaning of
Section 17556 of the Government Code, or changes the definition of a
crime within the meaning of Section 6 of Article XIII B of the
California                                             Constitution.

   SEC. 3.    This act is an urgency statute necessary
for the immediate preservation of the public peace, health, or safety
within the meaning of Article IV of the Constitution and shall go
into immediate effect. The facts constituting the necessity are:
 
   In order to make the necessary changes to increase Medi-Cal
payments to emergency ambulance providers and to improve access, at
the earliest possible time, to allow this act to be operative as soon
as approval from the federal Centers for Medicare and Medicaid
Services is obtained by the State Department of Health Care Services,
it is necessary that this act take effect immediately. 

  SECTION 1.    Section 15926 of the Welfare and
Institutions Code is amended to read:
   15926.  (a) The following definitions apply for purposes of this
part:
   (1) "Accessible" means in compliance with Section 11135 of the
Government Code, Section 1557 of the PPACA, and regulations or
guidance adopted pursuant to these statutes.
   (2) "Limited-English-proficient" means not speaking English as one'
s primary language and having a limited ability to read, speak,
write, or understand English.
   (3) "Insurance affordability program" means a program that is one
of the following:
   (A) The Medi-Cal program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.).
   (B) The state's children's health insurance program (CHIP) under
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa
et seq.).
   (C) A program that makes available to qualified individuals
coverage in a qualified health plan through the California Health
Benefit Exchange established pursuant to Title 22 (commencing with
Section 100500) of the Government Code with advance payment of the
premium tax credit established under Section 36B of the Internal
Revenue Code.
   (4) A program that makes available coverage in a qualified health
plan through the California Health Benefit Exchange established
pursuant to Title 22 (commencing with Section 100500) of the
Government Code with cost-sharing reductions established under
Section 1402 of PPACA and any subsequent amendments to that act.
   (b) An individual shall have the option to apply for insurance
affordability programs in person, by mail, online, by telephone, or
by other commonly available electronic means.
   (c) (1) A single, accessible, standardized paper, electronic, and
telephone application for insurance affordability programs shall be
developed by the department in consultation with MRMIB and the board
governing the Exchange as part of the stakeholder process described
in subdivision (b) of Section 15925. The application shall be used by
all entities authorized to make an eligibility determination for any
of the insurance affordability programs and by their agents.
   (2) The department may develop and require the use of supplemental
forms to collect additional information needed to determine
eligibility on a basis other than the financial methodologies
described in Section 1396a(e)(14) of Title 42 of the United States
Code, as added by the federal Patient Protection and Affordable Care
Act (Public Law 111-148), and as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152) and any
subsequent amendments, as provided under Section 435.907(c) of Title
42 of the Code of Federal Regulations.
   (3) The application shall be tested and operational by the date as
required by the federal Secretary of Health and Human Services.
   (4) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:
   (A) The form shall include simple, user-friendly language and
instructions.
   (B) The form may not ask for information related to a nonapplicant
that is not necessary to determine eligibility in the applicant's
particular circumstances.
   (C) The form may require only information necessary to support the
eligibility and enrollment processes for insurance affordability
programs.
   (D) The form may be used for, but shall not be limited to,
screening.
   (E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through an insurance affordability program for the infant's birth,
for the purpose of automatically enrolling the infant into the
applicable program without the family having to complete the
application process for the infant.
   (F) The form may include questions that are voluntary for
applicants to answer regarding demographic data categories, including
race, ethnicity, primary language, disability status, and other
categories recognized by the federal Secretary of Health and Human
Services under Section 4302 of the PPACA.
   (G) Until January 1, 2016, the department shall instruct counties
to not reject an application that was in existence prior to January
1, 2014, but to accept the application and request any additional
information needed from the applicant in order to complete the
eligibility determination process. The department shall work with
counties and consumer advocates to develop the supplemental
questions.
   (d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
insurance affordability programs or other health programs that
differs from the application form described in subdivision (c), and
related enrollment procedures. Nothing in this section shall preclude
the use of a joint application, developed by the department and the
State Department of Social Services, that allows for an application
to be made for multiple programs, including, but not limited to,
CalWORKs, CalFresh, and insurance affordability programs.
   (e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of the
applicant in accordance with the state and federal rules governing
insurance affordability programs.
   (f) (1) If the eligibility, enrollment, and retention system has
the ability to prepopulate an application form for insurance
affordability programs with personal information from available
electronic databases, an applicant shall be given the option, with
his or her informed consent, to have the application form
prepopulated. Before a prepopulated application is submitted to the
entity authorized to make eligibility determinations, the individual
shall be given the opportunity to provide additional eligibility
information and to correct any information retrieved from a database.

   (2) All insurance affordability programs may accept
self-attestation, instead of requiring an individual to produce a
document, for age, date of birth, family size, household income,
state residence, pregnancy, and any other applicable criteria needed
to determine the eligibility of an applicant or recipient, to the
extent permitted by state and federal law.
   (3) An applicant or recipient shall have his or her information
electronically verified in the manner required by the PPACA and
implementing federal regulations and guidance and state law.
   (4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.
   (5) The eligibility of an applicant shall not be delayed beyond
the timeliness standards as provided in Section 435.912 of Title 42
of the Code of Federal Regulations or denied for any insurance
affordability program unless the applicant is given a reasonable
opportunity, of at least the kind provided for under the Medi-Cal
program pursuant to Section 14007.5 and paragraph (7) of subdivision
(e) of Section 14011.2, to resolve discrepancies concerning any
information provided by a verifying entity.
   (6) To the extent federal financial participation is available, an
applicant shall be provided benefits in accordance with the rules of
the insurance affordability program, as implemented in federal
regulations and guidance, for which he or she otherwise qualifies
until a determination is made that he or she is not eligible and all
applicable notices have been provided. Nothing in this section shall
be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.
   (g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for an insurance affordability program in person, over the
telephone, by mail, online, or through other commonly available
electronic means and in a manner that is accessible to individuals
with disabilities and those who are limited-English proficient.
   (h) (1) During the processing of an application, renewal, or a
transition due to a change in circumstances, an entity making
eligibility determinations for an insurance affordability program
shall ensure that an eligible applicant and recipient of insurance
affordability programs that meets all of the program eligibility
requirements and complies with all of the necessary requests for
information moves between programs without any breaks in coverage and
without being required to provide any forms, documents, or other
information or undergo verification that is duplicative or otherwise
unnecessary. The individual shall be informed about how to obtain
information about the status of his or her application, renewal, or
transfer to another program at any time, and the information shall be
promptly provided when requested.
   (2) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross Income
(MAGI) household income but who may be eligible on the basis of being
65 years of age or older, or on the basis of blindness or
disability, shall be forwarded to the Medi-Cal program for an
eligibility determination. During the period the application or case
is processed for a non-MAGI Medi-Cal eligibility determination, if
the applicant or recipient is otherwise eligible for an insurance
affordability program, he or she shall be determined eligible for
that program.
   (3) Renewal procedures shall include all available methods for
reporting renewal information, including, but not limited to,
face-to-face, telephone, mail, and online renewal or renewal through
other commonly available electronic means.
   (4) An applicant who is not eligible for an insurance
affordability program for a reason other than income eligibility, or
for any reason in the case of applicants and recipients residing in a
county that offers a health coverage program for individuals with
income above the maximum allowed for the Exchange premium tax
credits, shall be referred to the county health coverage program in
his or her county of residence.
   (i) Notwithstanding subdivisions (e), (f), and (j), before an
online applicant who appears to be eligible for the Exchange with a
premium tax credit or reduction in cost sharing, or both, may be
enrolled in the Exchange, both of the following shall occur:
   (1) The applicant shall be informed of the overpayment penalties
under the federal Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011 (Public Law
112-9), if the individual's annual family income increases by a
specified amount or more, calculated on the basis of the individual's
current family size and current income, and that penalties are
avoided by prompt reporting of income increases throughout the year.
   (2) The applicant shall be informed of the penalty for failure to
have minimum essential health coverage.
   (j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among insurance affordability programs using the least
restrictive rules and requirements permitted by federal and state
law. This process shall include the consideration of methodologies
for determining income levels, assets, rules for household size,
citizenship and immigration status, and self-attestation and
verification requirements.
   (k) (1) Forms and notices developed pursuant to this section shall
be accessible and standardized, as appropriate, and shall comply
with federal and state laws, regulations, and guidance prohibiting
discrimination.
   (2) Forms and notices developed pursuant to this section shall be
developed using plain language and shall be provided in a manner that
affords meaningful access to limited-English-proficient individuals,
in accordance with applicable state and federal law, and at a
minimum, provided in the same threshold languages as required for
Medi-Cal managed care plans.
   (l) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall establish a process for
receiving and acting on stakeholder suggestions regarding the
functionality of the eligibility systems supporting the Exchange,
including the activities of all entities providing eligibility
screening to ensure the correct eligibility rules and requirements
are being used. This process shall include consumers and their
advocates, be conducted no less than quarterly, and include the
recording, review, and analysis of potential defects or enhancements
of the eligibility systems. The process shall also include regular
updates on the work to analyze, prioritize, and implement corrections
to confirmed defects and proposed enhancements, and to monitor
screening.
   (m) In designing and implementing the eligibility, enrollment, and
retention system, the department, MRMIB, and the Exchange board
shall ensure that all privacy and confidentiality rights under the
PPACA and other federal and state laws are incorporated and followed,
including responses to security breaches.
   (n) Except as otherwise specified, this section shall be operative
on January 1, 2014.