• New Documentation Requirements in Medi-Cal Reviewed at DHS
  • Comments Sought on Language Access Regulations at DMHC & DOI
  • Disability Access Issues and Reporting Debated Within OPA

Even with all the end-of-session action at the California state legislature, health and consumer advocates are also active at the important deliberations happening within the various state agencies, including the Department of Health Services, the Department of Insurance, and the Department of Managed Health Care.

Here’s an update by Elizabeth Abbott, Project Director, who managed administrative advocacy for Health Access:


On February 8, 2005, President Bush signed into law the Deficit Reduction Act (DRA) which made certain changes to Medicaid (Medi-Cal in California) law. One of those changes was the requirement for individuals declaring to be U.S. citizens or U.S. nationals to show documentary evidence of this fact as well as proof of identity.

On August 18th, 2006 the California Department of Health Services (DHS) hosted a meeting with stakeholders on the implementation of these onerous citizenship and identity requirements newly-imposed by the DRA. The principal purpose of the meeting was to provide some feedback to individuals and groups who had provided comments to the Department in the preparation of their letter to the counties to implement these provisions.

Between 50 and 60 organizations commented on the draft letter to the counties and offered many hundreds of comments, questions, and recommendations. DHS is taking the comments they have already received, together with the discussion at the meeting, and plan to issue a revision of the letter to the counties. Their intention is to hold another stakeholders’ meeting to discuss that document before final release. However, advocates are concerned that as federal implementation deadlines are fast-approaching, the consultation process may be shortened or eliminated.

DHS also sent the official California response to the Centers for Medicare and Medicaid Services (CMS) interim final federal regulation on August 11, 2006. They said that many of their comments to federal officials mirrored comments raised by the advocacy community. They would not speculate on how long it would take for the final implementing regulation to be released by CMS, but they did not anticipate that it would be soon.

FEEDBACK: DHS identified 23 major issues raised by a significant number of advocates regarding their letter to the counties. The issues fell into four major categories:

  1. Major legal/conceptual concerns. Perhaps the most fundamental concern is that many advocates believe that proving citizenship and identity is not a prerequisite for an individual’s eligibility to Medi-Cal, but merely a requirement for the state to be able to receive federal matching funds. If this is a correct interpretation of the DRA, it does permit the possibility that the state could establish a limited state-only funded program for certain Medi-Cal sub-categories as a last resort. There also were many recommendations regarding providing temporary eligibility, less than full-scope Medi-Cal benefits, retroactive eligibility, and presumptive eligibility while people are making efforts to secure the proper documents.
  2. Maximizing Data Match Opportunities. Many advocates urged the greatest possible use of data matches, within the state of CA (with Vital Statistics, DMV), among states (to check availability of birth records for people born outside CA), with other federal agencies (SSA). All these efforts would be aimed at eliminating the need for the applicants and beneficiaries to secure expensive and hard-to-obtain proofs.
  3. Outreach. There were many suggestions about how to make outreach efforts more effective including translating into threshold languages, being conscious of literacy limitations, correcting the misunderstanding that this applies to non-citizens, and enlisting the help of advocates and health plans to assist applicants in securing proofs.
  4. Technical Clarifications . There were several ideas about how to make this law actually work better. These suggestions included expanding the role of the counties in assistance to applicants, tapping state resources to pay for the cost of obtaining proofs, giving guidance on how counties should collect, maintain, and return proofs. There also was a discussion of whether or not to establish a separate aid category on their system to identify Medi-Cal recipients affected by this law in case there is a federal statutory or policy change.

DOCUMENTS AVAILABLE: DHS said they planned to put the following documents on their website:

  • Their formal response to CMS on the interim regulation.
  • The full text of the 23 broad comments discussed at the stakeholders’ meeting.
  • The entire text of letters from advocates on this issue.

The website is at:


The Department of Managed Health Care (DMHC) is in the process of finalizing its regulations on SB 853, Language Assistance Programs # 2004-0015. DMHC held public hearings on the proposed regulation in Los Angeles and Oakland earlier this year and incorporated almost all of what was requested by consumer and health advocates, despite some contrary testimony by some plans and providers.

This regulation establishes requirements that health plans provide free interpretation and translation services in threshold languages to Limited English Proficiency (LEP) enrollees in their plan. This requirement extends to the plan’s contracted providers, and includes clinical encounters, administrative services, appeals and grievances, and billing and financial notices.

Interested groups can still submit comments in support of this regulation by 5:00 PM on September 25, 2006 by email to or by mail to Emilie Alvarez, Regulations Coordinator, Department of Managed Health Care, Office of Legal Services, 980 9th Street, Suite 500 , Sacramento , CA 95814.

The full text of the modified regulation can be viewed at the DMHC website at

In addition, the Department of Insurance (DOI) has been working with the advocacy community to “match” their Health Care Language Assistance regulation governing insurers to the DMHC model that regulates health plans (described above.)

Interested groups can give testimony in support of the draft regulation at the public hearing scheduled for 9:00 AM on September 26 at the Employment Development Department, Conference Room A, 750 N Street, Sacramento, CA 95814. Written comments may also be submitted via email no later than 5:00 PM on September 26, 2006 to the attention of Elena Fishman at The Department of Insurance at The full text of the draft regulation can be viewed at the DOI website at


The Office of the Patient Advocate (OPA) convened a meeting on August 23, 2006 for health plans, advocates, and researchers to report on the findings and recommendations from the Survey of Disability Access Services Provided by California Health Plans. The survey was conducted in January and February 2006. The full text of the survey report and the Executive Summary may be found on OPA’s website (

There were 13 formal recommendations that came out of the survey and the discussion at the meeting also touched on methodology, standards, and the purpose of the survey. Although the survey was solicited from 28 health plans in California , only 10 plans returned the voluntary survey. Many plans admitted to the surveyors that they had not completed the survey because:

  • They had other priorities with their limited staff.
  • The timing of the survey coincided with several other mandated governmental submissions
  • The survey was cumbersome to complete.
  • Most significantly, by completing the survey the plans were opening themselves up to increased liability and requests for public records access.
  • And, in some cases, the plans acknowledged they were not doing much in this area and they were reluctant to furnish the information.

OPA conceded the response was disappointing and, as a result, they were cautious about drawing broad conclusions and looking for ways to increase plan participation.

There was acknowledgement of the plans’ concerns about the confidentiality of data provided in the survey. However, advocates stated emphatically that if real differences exist between plans, the ultimate purpose of a survey of disability access is to publish the information to help people with disabilities make informed health care choices. California Association of Health Plans (CAHP) responded that if the disability access services offered by plans were made public, it would result in adverse selection of the most generous plans by the most disabled (and expensive) members of that community. Several advocates acknowledged there could be higher initial costs, but the greater access to care and better coordination of care, would pay long-term health (and cost) dividends.

OPA agreed that it would be worthwhile to establish a Disability Advisory Committee to provide input on policy issues and a Technical Advisory Group to assist OPA to operationalize those broad objectives. These two groups would be composed of members representing plans, providers, advocates, consumers, governmental agencies, and legal experts. They envisioned that these groups would replace the large, loosely-constituted, and somewhat unwieldy ad hoc advisory structure that currently exists.

There was a spirited discussion about the plans’ responsibility to undertake changes to actually improve disability access. The CAHP expressed frustration that as an association they did not want to be in the position of “certifying” that each of their contracted providers met all of the requirements for disability access (e.g. ramps to all providers’ offices for wheelchair access, or all plan materials produced in Braille). Advocates responded that the plans had to provide program access within the network of providers (in essence, that equivalent services must be available within the geographic area), but not necessarily ensure compliance by every facility. The enforcement responsibility remained a governmental function.

OPA plans to conduct this survey again and have as their ultimate objective to incorporate the results into the Health Plan Report Card. They will explore combining this disability access survey with their survey on cultural and linguistic access (where they get almost a 100% return rate from the plans,) and rethink the timing of the survey to ensure greater plan participation.
OPA intends to offer training on the legal standards for disability access with examples of innovative services provided by plans to persons with disabilities. The training would be conducted by staff from DMHC, DHS, the health plans, providers, advocates, contractors, and academics.

For more information on any of these agency updates, or to get involved with the coalitions working on any of these issues, contact Elizabeth Abbott, Project Director, at (916) 497-0923, ext. 201 or at

For more information, contact Health Access:
Sacramento · (916) 442-2308 · 1127 11th Street Suite 234 · Sacramento · CA · 95814
Los Angeles · (213) 748-5287 · 3655 South Grand Avenue Suite 220 · Los Angeles · CA · 90007
Oakland · (510) 873-8787 · 414 13th Street Suite 450 · Oakland · CA · 94612
Health Access California promotes quality, affordable health care for all Californians.
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