California Health Benefit Exchange Holds Historic First Meeting

The California Health Benefit Exchange Board held its first meeting on April 20, 2011. The federal Affordable Care Act requires the establishment of health benefit exchanges that allow individuals and small businesses to purchase coverage. For more information about the health benefit exchange provision in federal law, see the CSAC Fact Sheet. Please recall that Speaker John Pérez’s AB 1602 (Chapter 655, Statutes of 2010) and Senator Elaine Alquist’s SB 900 (Chapter 659, Statutes of 2010) created the first-in-the-nation health benefit exchange. These pieces of legislation establish California’s Exchange Board, its governance, and clarify the board’s powers and duties. Yesterday’s meeting was the Exchange board meeting in the country. The meeting was primarily ministerial; however a number of actions were taken. 

The board has five members, and four of those seats have been filled; the Senate has yet to appoint. Members include California Health and Human Services Agency Secretary Diana Dooley; S. Kimberly Belshé, former Health and Human Agency Secretary to Governor Schwarzenegger; Susan Kennedy, former chief of staff to Governor Schwarzenegger; and Paul Fearer, Senior Executive Vice President and Director of Human Resources at Union Bank as well as Board Chair of the Pacific Business Group on Health.

The Exchange Board voted to make Secretary Dooley the interim chair of the body. In addition, the board voted to pursue a Level II federal planning grant to support the establishment of the exchange and to submit the grant on September 30, 2011. The board also voted to establish a subcommittee of its members to direct grant development and to establish a second subcommittee for purposes of search/recruitment of the Executive Officer, Chief Counsel and other key positions. The board appointed Pat Powers as Acting Administrative Officer until a permanent Executive Officer is hired.

The Exchange board has set an aggressive to schedule in order to develop a federal grant by September 30, 2011. Several policy decisions will have to be made in the coming months in order for the board to develop the grant. The board will meet next on May 11 and will discuss health insurance markets, program integration of public health care programs, public health and social services programs, the Basic Health Plan option, and the Small Business Health Options Program (SHOP) Exchange requirements. The board will meet at least monthly, and possibly more frequently than that, through 2011.

Adult and Senior Issues

AB 518 (Wagner) – Support
As Amended on March 23, 2011

AB 518, a bill by Assembly Member Donald Wagner, would continue to protect elder and dependent adults from financial abuse by eliminating the sunset date on the reporting of suspected abuse by financial institutions.

Counties support AB 518, which will be heard by the Assembly Public Safety Committee on April 26. 

AB 1288 (Gordon) – Support
As Amended March 25, 2011 

AB 1288, by Assembly Member Rich Gordon, would protect the assets of vulnerable seniors or dependent adults from misuse and fraud while a conservatorship petition is pending in court. 

Assembly Bill 1288 specifically would extend the period of time in which a public guardian or conservator may petition to protect the assets of seniors and dependent adults from 15 to 30 days. The bill also would expand the scope of the possession or control of property by the guardian to include assets held in the name of a proposed conservatee’s trust.

Counties often encounter these issues during Adult Protective Services investigations, and it is challenging to complete a petition for conservatorship within 15 days. AB 1288 is a common sense, simple measure to provide appointed guardians a suitable amount of time and authority to protect the assets of vulnerable seniors and dependent adults. It is for these reasons that CSAC, Urban Counties Caucus, Regional Council of Rural Counties, and County Welfare Directors Association support AB 1288. The Assembly Judiciary Committee will hear the bill on May 10. 

SB 718 (Vargas) – Support
As Amended on March 29, 2011

SB 718, by Senator Juan Vargas, would make it easier to report suspected elder abuse.

Senate Bill 718 would allow a county or long-term care ombudsman program to implement a confidential Internet reporting tool that mandated reporters may use to report suspected elder abuse. Senate Bill 718 also would allow the state, in conjunction with counties and other stakeholders, to develop a form for written reports, as well. The bill also specifies the information to be gathered by both methods, which will speed efficiency in both making and processing reports of suspected elder abuse. 

Counties are responsible for investigating reports of suspected elder abuse, and have a vested interest in ensuring the safety and financial security of elder Californians living in our communities. Senate Bill 718 would serve this interest by giving counties the option to implement a new Internet-based system with the goal of increasing the ease by which a mandated reporter may submit a report of suspected elder abuse. The Assembly Human Services Committee will hear SB 718 on April 26.

In-Home Supportive Services

SB 930 (Evans) – Support
As Introduced on February 18, 2011

Senate Bill 930, by Senator Noreen Evans, would eliminate the requirements for counties to collect the fingerprints of each IHSS consumer and have both providers and consumers to submit fingerprints on each IHSS timesheet (a provision of current law that is scheduled to go into effect on July 1 of this year). The bill would also repeal statute that prohibits providers from using a Post Office Box (P.O. Box) for IHSS forms, including for paychecks. 

The above provisions in SB 930 represent some of the components of Governor Schwarzenegger’s “IHSS Anti-Fraud” initiative in 2009. Many of the provisions of this package were designed to prevent fraud and duplicative aid within the program, but few were evaluated on their cost-effectiveness to deploy and implement. In fact, the requirement to fingerprint all consumers in their homes requires specialized and costly equipment that has not yet been purchased by the state. The state has estimated that it would need $8.2 million this year alone, as well as a total of $41.6 million over the next seven years, to implement this provision. Clearly, in these difficult fiscal times, the expenditure of millions to implement an anti-fraud initiative in the absence of demonstrated or widespread fraud would be imprudent at best. 

Counties are also perplexed by the prohibition on using P.O. Boxes for providers. In many of our rural areas, P.O. Boxes are often the only option for residents to receive mail. Limiting the use of P.O. Boxes does will not have a significant effect on fraudulent activities, and in fact, may harm the ability of counties and consumers to recruit and retain providers. 

The IHSS Program has numerous safeguards against fraud, including a state and county-level IHSS Quality Assurance (QA) Initiative. Counties have dedicated QA staff performing desk reviews and home visits of recipients and providers, according to state-established guidelines, looking specifically for potential fraudulent activity and adequacy and quality of care issues. In addition to these reviews, the counties perform more in-depth or “targeted” case reviews that focus on specific issues or cases which may be problematic or signal potential fraud.

Additionally, the incidence of IHSS fraud is overstated. According to 2006-07 results of state/county Quality Assurance efforts, of the nearly 24,000 total cases reviewed, only 523 were referred for further investigation for potential fraud – just 2 percent. County data of actual fraud referrals shows even fewer potentially fraudulent cases, including Los Angeles County with less than 1 percent of cases over a three-year period referred for fraud. 

For these reasons, CSAC supports SB 930. The Senate Human Services Committee will hear the bill on April 26.

Foster Youth

AB 846 (Bonilla) – Support
As Amended on March 31, 2011

AB 846, by Assembly Member Susan Bonilla, would provide assistance to foster youth who may have been victims of identity theft.

AB 846 is clean up to AB 2985 by Assembly Member Bill Maze (Statutes of 2006), which required county child welfare and probation agencies to request consumer credit disclosures on all foster youth turning 16 and to refer a foster youth to a credit counseling organization upon any indication of negative credit or evidence of identity theft. Specifically, AB 846 clarified that the request may be made by the state or a county and authorizes the requesting entity to refer the youth directly to a governmental or nonprofit organization that provides information and assistance with identify theft and other credit problems.

CSAC supports the bill, which will be heard in the Assembly Human Services Committee on April 26.

Health and Public Health

AB 824 (Chesbro) – Support
As Amended on March 31, 2011

AB 824, by Assembly Member Wesley Chesbro, will help increase physicians and health care access in rural communities throughout California. 

Assembly Bill 824 would establish a demonstration project to allow specific hospitals in rural or underserved areas to employ up to 10 physicians and surgeons. The bill also preserves the independent medical judgment of physicians and surgeons by requiring participating hospitals to implement a policy to this effect. The bill also includes a sunset date of January 1, 2022 for the demonstration project and requires a report to the Legislature by 2019, both of which are included to allow for legislative oversight of this new model. 

The scarcity of qualified medical personnel in parts of California continues to hamper the ability of rural and underserved health systems to provide quality health care. AB 824 will assist in attracting and retaining physicians in these communities, and CSAC supports Assembly Member Chesbro’s measure for this reason. The Assembly Health Committee will hear AB 824 on April 26.

Medi-Cal

AB 43 (Monning) – Support
As Introduced on December 6, 2010

AB 43, by Assembly Member William Monning, would require the state Department of Health Care Services to begin planning for the transition of individuals into Medi-Cal as required in 2014 by the federal Affordable Care Act. 

Specifically, AB 43 requires state planning to transition adults from county-run Low Income Health Plans (LIHP), established under California’s Bridge to Reform Section 1115 Medicaid Demonstration waiver approved in 2010, into Medi-Cal. The Department would be required to submit the plan to the federal government.

Counties are supportive of developing a plan to transition the LIHP enrollees into Medi-Cal. CSAC has been working with Assembly Member Monning’s staff to develop language that broadens the transition plan. This language ensures that individuals served in counties that may ultimately choose not to develop an LIHP, as well as individuals who might not be eligible for a county’s LIHP, for example, due to income slightly above the set limits, be included in transition planning. We understand this language will be amended into the bill and appreciate the author’s willingness to work with us.

Counties also support the bill’s ambitious timeline, i.e. erecting an eligibility process for transitioning LIHP participants to Medi-Cal by July 1, 2013, but recognize the technical realities associated with achieving it may be challenging. Counties will be critical partners in providing Medi-Cal eligibility determinations and enrolling individuals in the Medi-Cal program. It will be important for counties to have a role in this process, along with other key stakeholders. We have requested that the author consider adding language to this effect into the bill.

Counties look forward to working with the Legislature to achieve the goal of developing a realistic and robust transition plan for expanding Medi-Cal under the Affordable Care Act in 2014. CSAC, along with the Urban Counties Caucus, County Welfare Directors Association, and County Health Executives Association of California support AB 43. The Assembly Health Committee will hear the bill on April 26. 

SB 677 (Hernandez) – Support in Concept
As Amended on March 22, 2011

SB 677, by Senator Edward Hernandez, would implement two provisions of the federal Affordable Care Act (ACA) related to determining eligibility for the Medicaid program. The measure would implement the new federal income standards – the modified adjusted gross income (MAGI) – for determining Medi-Cal eligibility. Additionally, the measure would eliminate the asset test for determining Medi-Cal eligibility. Both of these eligibility changes would become effective January 1, 2014, in conjunction with the effective date of the ACA.

Counties have long supported efforts to simplify the Medi-Cal program, such as elimination of the asset test. We believe that program simplification increases program efficiency. Reducing complicated eligibility tests at the time when over a million Californians will become newly eligible for Medi-Cal will assist with easing enrollment.

However, states do not yet know how the federal government will change underlying Medicaid rules to implement the ACA. Counties anticipate that more direction will be forthcoming from the federal government that will clarify how to structure the eligibility changes within California. Pending this federal guidance, counties have taken a support in concept position on Senator Hernandez’s SB 677. The Senate Health Committee will hear SB 677 on April 27.

CalWORKs

AB 373 (Garrick) – Oppose
As Amended on March 31, 2011 

AB 373, a bill by Assembly Member Martin Garrick, would reduce eligibility for the California Work Opportunity and Responsibility to Kids (CalWORKs) program from the current 48 month limit to 24 months. 

Counties believe that reducing the time on aid to 24 months – especially in light of the continuing economic downturn – will severely limit recipients’ chances to move into stable employment, and effectively gut the core CalWORKs concept of “welfare to work.” 

CSAC, along with the County Welfare Directors Association, are opposing the bill. The Assembly Human Services Committee will hear the bill on April 26. 

AB 493 (Perea) – Oppose
As Amended on March 21, 2011

AB 493, a bill by Assembly Member Henry Perea, would prohibit CalWORKs recipients from accessing their cash aid via an Electronic Benefit Transaction (EBT) card in out-of-state establishments or for the purchase of alcohol and tobacco products.

We understand that the prohibition on out-of-state use of EBT cards is slated to be removed from the bill in proposed amendments. Residents in border counties often travel to a neighboring state to shop at less-expensive stores. In rural northern California, for example, CalWORKs recipients might make a monthly trip to Reno to shop at a store like Costco, where their limited dollars can stretch farther. 

While it may seem logical to ban the purchase of alcohol or tobacco products with CalWORKs funds, given that these items are not essential to one’s well-being, starting the state down this path raises thorny questions about what would be banned next and where the list would end. Additionally, the EBT system cannot currently stop the purchase certain specified items, and would have to be significantly reprogrammed to operate in this way. 

CSAC, along with the County Welfare Directors Association, are opposing the bill. The Assembly Human Services Committee will hear AB 493 on April 26. 

AB 924 (Logue) – Oppose
As Amended on April 11, 2011

AB 924, by Assembly Member Dan Logue, would jeopardize counties’ successful efforts to provide subsidized employment programs for unemployed CalWORKs parents. It also goes beyond the agreement recently enacted as part of the budget trailer bill, SB 72, which made substantial changes to the CalWORKs program rules, time limits on aid, and substantially cut counties’ welfare-to-work service allocations. The counties are currently working with state officials to implement these changes. 

Currently, counties have the option to place parents who have reached their CalWORKs time limits (reduced from 60 months to 48 months in the trailer bill) into subsidized employment in order to help them (the counties) meet welfare-to-work requirements. Many counties who offer this work participation option to their timed-out clients will also make use of existing law, Welfare and Institutions Code Section 11320.15, to provide supportive welfare-to-work services to these participants. Unfortunately, AB 924 would eliminate this section altogether, precluding the ability of counties to provide supportive services to these participants even if they wish to do so.

At the same time, the bill provides that any parent or caretaker relative who has reached the time limit, and would not otherwise be exempt from welfare-to-work participation requirements under current law, would have to meet those participation requirements or the family would lose its entire grant, essentially creating a full-family sanction in CalWORKs. 

At a time when families are struggling to get back into the workforce and CalWORKs benefits and services have already been cut substantially, further reductions to these services will likely do more harm – and cost society more in the long run – than good. For these reasons, CSAC, along with the County Welfare Directors Association, oppose AB 924. The Assembly Human Services Committee will hear the measure on April 26. 

AB 1140 (Donnelly) – Oppose
As Introduced on February 18, 2011

AB 1140, by Assembly Member Tim Donnelly, would reduce eligibility for the California Work Opportunity and Responsibility to Kids (CalWORKs) program from the current 48 month limit to 6 months. 

Like AB 373 (Garrick) above, Counties believe that reducing the time on aid to 6 months – especially in light of the continuing economic downturn – will severely limit recipients’ chances to move into stable employment, and effectively gut the core CalWORKs concept of “welfare to work.” 

CSAC, along with the County Welfare Directors Association, are opposing the bill. The Assembly Human Services Committee will hear the bill on April 26. 

AB 1182 (Hernández) – Support
As Introduced on February 18, 2011

AB 1182, by Assembly Member Roger Hernández, would allow CalWORKs applicants and recipients to own reliable cars. 

AB 1182 would specifically delete the requirement that counties assess the value of a motor vehicle when determining or redetermining CalWORKs eligibility. 

AB 1182 would increase the opportunities for recipients to find and maintain stable employment, while also increasing the state’s work participation rate, reducing grant costs in the long run and helping to avoid federal penalties. It is for these reasons that CSAC supports AB 1182, which will be heard by the Assembly Human Services Committee on April 26. 

Mental Health

AB 1297 (Chesbro) – Support
As Introduced on February 18, 2011

AB 1297, a bill by Assembly Member Wesley Chesbro, would ensure timely federal reimbursement to counties for providing Specialty Mental Health Managed Care services. 

Specifically, AB 1297 would align the state’s requirements for the Specialty Medi-Cal Mental Health Managed Care program with existing federal requirements by utilizing federal Medicaid Upper Payment Limits instead of the state’s current Statewide Maximum Allowances (SMAs) system. The SMAs system has been frozen since Fiscal Year 2006-07, and counties have incurred significant costs for serving eligible populations during this time. AB 1297 would allow counties to recover these costs from the federal government, all without impacting the state’s General Fund. 

AB 1297 also eliminates the state’s current 15 percent limit on reimbursement for administrative costs. Counties already certify the full public expenditure of funds in order to draw down federal matching funds, and, under AB 1297, counties would be fully reimbursed by the federal government for the cost of providing services. 

Lastly, AB 1297 would expand the timeframe for submitting Specialty Medi-Cal Mental Health Managed Care claims from the state’s six months to the federal standard of 12 months. We believe that this provision will give counties the flexibility in submitting claims that complex health care scenarios demand. 

AB 1297 will both streamline and enhance counties’ ability to draw down federal reimbursements for Specialty Medi-Cal Mental Health Managed Care services – all at no cost to the state’s General Fund. The bill is sponsored by the California Mental Health Directors Association and will be heard by the Assembly Health Committee on April 26.