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Summary of Medicaid Expansion: SB X 1 1 and AB X 1 1

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Summary of SB X 1 1 & AB X 1 1 Summary of SB X 1 1 & AB X 1 1.pdf

Executive Summary

Eligibility

  • Coverage of Parents and MIAs up to 133% of FPL (MAGI, Modified Adjusted Gross Income eligibles)
    • MAGI applies to all individuals and families, except the aged and disabled.
  • Consolidation of all income disregards to a 5% uniform disregard for all MAGI eligibles, essentially all but the aged and disabled.
  • Elimination of the assets test for all MAGI eligibles
  • Converts all existing eligibility groups, other than the aged and disabled, to the MAGI rules.
  • Eliminates the deprivation requirement for families
  • Expands the definition of caretaker relative to include a variety of different relatives or a domestic parent – i.e. if the children are living with a grandparent, aunt, uncle, older sibling, step-parents
  • Covers children in foster care at age 18 through age 26
  • Provides premium assistance to new legal immigrant MIAs so they can qualify for Covered California
  • Income eligibility can be computed based on annual projected income, so that income fluctuations do not result in individuals being ping ponged back and forth between Medi-Cal and Covered California
  • Extends post partum coverage under AIM and Medi-Cal to the last day of the month – i.e. if 60 days post partum ends on the 20th, it would be extended to the 30th or 31st
  • Changes residency rules to comply with the ACA – intent to reside plus presence with computer cross checks to verify residency, and if not, by paper verifications

Services

  • Upgrades the Medi-Cal benefit package for new and existing eligibles to meet the essential health benefits and parity requirements
    • Substance abuse treatment upgraded to meet the Kaiser small group standard
    • Managed care mental health services for individuals with moderate levels of mental illness
  • Upgrades the coverage for pregnant women from pregnancy related to full scope
  • Covers long term care, if individuals meet the asset test requirements for the aged and disabled

Eligibility Processing and Simplification

  • Seamless transition of LIHP eligibles into Medi-Cal managed care
    • Continuity of care with existing provider and right to change to a different provider
    • Beneficiary choice of plan and provider
    • Default to existing provider if no selection is made
  • Repeals semi-annual redeterminations and moves to annual renewals
  • Moves to electronic applications with option to apply by phone, fax, mail, e-mail or in person
  • Moves to computer cross checks of eligibility criteria instead of paper verifications wherever feasible, assuming accuracy
  • Moves to self-attestations and to timely reporting of eligibility changes
  • Moves to renewals through electronic cross-checks
  • Specifies the interactions among CalHEERS and the counties
    • CalHEERS determines Medi-Cal eligibility for MAGI eligibles when application is submitted to CalHEERS (on line or with paper applications) if no additional information is required, otherwise the county does it
    • CalHEERS provides information on health plan choices for those it determines eligible for Medi-Cal
    • Counties determine eligibility in all other cases and ongoing case management for all Medi-Cal
  • Sets performance standards for call centers operated by Covered California and the counties
  • Sets standards and privacy safeguards for authorized representatives
  • Authorizes presumptive eligibility in hospital settings
  • Requires full or partial Express lane eligibility, where feasible
  • Expedited eligibility authorized for parents (and children)

Federal Matching Contingencies

  • Makes state participation contingent on federal government keeping the enhanced match
    • Any deviations below 90% match addressed through budget and legislation
    • Any reductions below a 70% federal match leads to automatic repeal, 12 months after the federal change

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