BILL NUMBER: ABX1 1 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY NOVEMBER 8, 2007
INTRODUCED BY Assembly Member Nunez
(Principal coauthor: Senator Perata)
SEPTEMBER 11, 2007
An act relating to health care. An act to
amend Sections 2069, 2836.1, and 3516 of, and to add Sections 2838,
4040.1, 4071.2, 4071.3, and 4071.4 to, the Business and Professions
Code, to add Section 49452.9 to the Education Code, to add Sections
12803.1, 12803.2, 22830.5, and 22830.6 to, and to add Chapter 15
(commencing with Section 8899.50) to Division 1 of Title of, the
Government Code, to amend Sections 1363 and 1378 of, to add Sections
1262.9, 1342.9, 1347, 1367.205, 1367.38, 1368.025, 1395.2, 104376,
128745.1, and 130545 to, to add Article 3.11 (commencing with Section
1357.20) and Article 4.1 (commencing with Section 1366.10) to
Chapter 2.2 of Division 2 of, to add Article 1 (commencing with
Section 104250) to Chapter 4 of Part 1 of Division 103 of, to add
Article 3 (commencing with Section 104705) to Chapter 2 of
Part 3 of Division 103 of, and to add Chapter 4 (commencing with
Section 128850) to Part 5 of Division 107 of, the Health and Safety
Code, to amend Sections 10607, 12693.43, 12693.70, 12693.73, and
12693.76 of, to add Sections 10113.11, 10123.56, 10293.5, 12693.56,
12693.57, 12693.58, 12693.59, 12886, and 12887 to, to add Chapter 1.6
(commencing with Section 10199.10) and Chapter 8.1 (commencing with
Section 10760) to Part 2 of Division 2 of, and to add Part 6.45
(commencing with Section 12699.201) to Division 2 of, the Insurance
Code, to add Sections 96.8 and 96.81 to the Labor Code, and to amend
Sections 14005.30, 14005.31, 14005.32, and 14008.85 of, to amend and
repeal Section 14011.16 of, to add Sections 14005.301, 14005.305,
14005.306, 14005.307, 14005.310, 14005.311, 14005.331, 14005.333,
14005.334, 14011.16.1, 14132.105, and 14137.10 to, and to add Article
5.22 (commencing with Section 14167.22) and Article 7 (commencing
with Section 14199.10) to Chapter 7 of Part 3 of Division
9 of, the Welfare and Institutions Code, relating to health care
coverage, and making an appropriation therefor.
LEGISLATIVE COUNSEL'S DIGEST
AB 1, as amended, Nunez. Health care reform.
(1) Existing law creates the California Health and Human Services
Agency.
This bill would require the agency, in consultation with the Board
of Administration of the Public Employees' Retirement System (PERS),
to assume lead agency responsibility for professional review and
development of best practice standards for high-cost chronic diseases
that state health care programs would be required to implement upon
their adoption. The bill would additionally require the agency, in
consultation with PERS and health provider groups, to develop health
care provider performance measurement benchmarks, as specified.
The bill, effective July 1, 2008, would create the California
Health Care Cost and Quality Transparency Commission in the Health
and Human Services Agency, with various powers and duties, including
the development of a health care cost and quality transparency plan.
The bill would authorize the commission to impose fees on data
sources and data users, as specified, and to impose penalties on data
sources that fail to file any report required by the commission. The
bill would transfer certain data collection responsibilities from
the Office of Statewide Health Planning and Development to the
commission on July 1, 2009. The bill would also create the California
Health Benefits Service within the California Health and Human
Services Agency, with various powers and duties relative to creation
of joint ventures between certain county-organized health plans and
various other entities. The bill would require these joint ventures
to be licensed as health care service plans.
(2) Existing law does not provide a system of health care coverage
for all California residents. Existing law does not require
employers to provide health care coverage for employees and
dependents, other than coverage provided as part of the workers'
compensation system for work-related employee injuries, and does not
require individuals to maintain health care coverage. Existing law
provides for the creation of various programs to provide health care
coverage to persons who have limited incomes and meet various
eligibility requirements. These programs include the Healthy Families
Program, administered by the Managed Risk Medical Insurance Board,
and the Medi-Cal program, administered by the State Department of
Health Care Services and county welfare departments.
This bill would require California residents, subject to certain
exceptions, to maintain a minimum policy of health care coverage for
themselves and their dependents, as defined. The bill would require
the Managed Risk Medical Insurance Board to determine the minimum
policy of health care coverage and would require the board to
facilitate enrollment in public or private coverage and to establish
an education and awareness program, on or before January 1, 2010,
relating to the requirement to obtain a minimum policy of health care
coverage. The bill would make implementation of these requirements
subject to an appropriation of funds therefor in the annual Budget
Act or other statute. The bill would make related changes, including
authorizing a school district, on and after January 1, 2010, to
provide parents and guardians information explaining these health
care coverage requirements.
The bill would, as of January 1, 2009, create the California
Cooperative Health Insurance Purchasing Program (Cal-CHIPP), which
would function as a statewide purchasing pool for health care
coverage and be administered by the Managed Risk Medical Insurance
Board. The bill would require, on and after January 1, 2010, certain
health care service plans and health insurers to submit a good faith
bid to the board to be a participating plan in Cal-CHIPP. The bill
would specify eligibility for Cal-CHIPP and would require the board
to develop and offer a variety of benefit plan designs, including the
Cal-CHIPP Healthy Families plan where enrollment would be restricted
to specified low-income persons. The bill would authorize an
employer to pay all or a part of the premium payment required of its
employees enrolled in Cal-CHIPP. The bill would make it an unfair
labor practice for an employer to refer an employee, or his or her
dependent, to Cal-CHIPP or to arrange for their application to that
program to separate them from group coverage provided through the
employment relationship, and for an employer to change the
share-of-cost ratio or modify coverage in order for an employee or
his or her dependents to enroll in that program. Because an unfair
labor practice may be punishable as a crime, the bill would impose a
state-mandated local program. The bill would create the California
Health Trust Fund as part of Cal-CHIPP, and moneys in the fund would
be continuously appropriated to the board for the purposes of
Cal-CHIPP. The bill would require the State Department of Health Care
Services to seek any necessary federal approval to enable the state
to receive federal Medicaid funds for specified persons who could
otherwise be made eligible for Medi-Cal benefits, with the state
share of funds to be provided from the California Health Trust Fund.
The bill would expand eligibility under the Medi-Cal program,
commencing July 1, 2010, to certain populations subject to federal
financial participation and would additionally expand eligibility
under the Medi-Cal program to a population 19 years of age or older
with a family income greater than 100% of the federal poverty level
but less than or equal to 250% of the federal poverty level, subject
to establishment of a county share of cost. The bill would require
certain of these individuals to receive their benefits in the form of
a benchmark package, which would be the subsidized benefit package
or packages established under Cal-CHIPP. The bill would provide for
the benchmark benefits to be administered by the Managed Risk Medical
Insurance Board, pursuant to an interagency agreement with the
department. The bill would make these provisions subject to federal
financial participation and approval, as specified.
The bill, subject to future appropriation of funds, would expand
the number of children eligible for coverage under the Healthy
Families Program on and after July 1, 2010. The bill would, on and
after July 1, 2010, delete as an eligibility requirement for a child
under the Healthy Families Program and the Medi-Cal program that the
child satisfy citizen and immigration status requirements applicable
to the program under federal law, thereby creating a state-only
element of the programs. The bill would additionally, on and after
July 1, 2010, disregard all income over 250% but less than or equal
to 300% of the federal poverty level and would apply Medi-Cal program
income deductions to a family income greater than 300% of the
federal poverty level in determining eligibility for the Healthy
Families Program. The bill would authorize the board to provide, or
arrange for the provision of, an electronic personal health record
under the Healthy Families Program, to the extent funds are
appropriated for that purpose, and would provide for the
confidentiality of information obtained pursuant to the program.
The bill would require the department to exercise its federal
option as necessary to simplify Medi-Cal eligibility by exempting all
resources for applicants and recipients, commencing July 1, 2010,
and it would revise the semiannual status reports required of
Medi-Cal beneficiaries on and after July 1, 2010.
The bill would require the State Department of Health Care
Services to establish a Healthy Action Incentives and Rewards Program
to be provided as a covered benefit under the Medi-Cal program,
subject to federal financial participation and approval. The bill
would also require the Director of Health Care Services to establish
a local coverage option program that would be the exclusive Medi-Cal
coverage for a 5-year period beginning with the program's
commencement, for county residents 21 years of age or older who,
among other requirements, have a family income at or below 100
percent of the federal poverty level and are not otherwise eligible
for the Medi-Cal program. The bill would specify that the program
would become operational for services rendered on or after July 1,
2010. The bill would specify that coverage under the program would be
provided at a county's option and only by a county that operates a
designated public hospital. The bill would require the State
Department of Health Care Services, by January 1, 2010, to contract
with an independent 3rd party to develop an assessment tool to
measure the care provided under the program. The bill would require
the department after 3 years of the program's operation, to evaluate
the program using the assessment tool and would extend the program
for an additional 2 years if the program substantially met certain
criteria and would terminate the program if it did not. The bill
would enact other related provisions.
The bill would provide for the Medi-Cal Physician Rate Increase
Act, which would establish, with respect to services rendered to
Medi-Cal beneficiaries on and after July 1, 2010, increased
reimbursements for physicians and physician groups, as defined, that
are enrolled Medi-Cal providers eligible to receive payments for
Medi-Cal services. The bill would permit some of these rate increases
to be linked to specified performance measures and would provide
that these rate increases would be implemented only to the extent
that state funds are appropriated for the nonfederal share of these
increases. The bill would require the Director of Health Care
Services to seek federal approval of the rate methodology set forth
in the act and would prohibit the methodology from being implemented
if federal approval is not obtained.
Because each county is required to determine eligibility for the
Medi-Cal program, expansion of program eligibility would impose a
state-mandated local program.
(3) Existing law, the Knox-Keene Health Care Service Plan Act of
1975, provides for the licensure and regulation of health care
service plans by the Department of Managed Health Care and makes a
willful violation of the act a crime. Existing law also provides for
the regulation of health insurers by the Department of Insurance.
This bill would enact various health insurance market reforms, to
be operative on specified dates, including requirements for guarantee
issue of individual health care service plan contracts and health
insurance policies, modified small employer coverage, modified
disclosures, and other related changes. The bill would require the
Director of the Department of Managed Health Care and the Insurance
Commissioner to adopt regulations by July 1, 2008, to require at
least 85% of full-service health care service plan dues, fees, and
other periodic payments and health insurance premiums to be spent on
health care services and not on administrative costs. The bill would
allow a health care service plan and a health insurer to provide
notices by electronic transmission using specified procedures.
The bill would require a health care service plan providing
prescription drug benefits and maintaining a drug formulary to,
commencing on or before January 1, 2010, make the most current
formularies available electronically to prescribers and pharmacies
and would require health care service plans that provide services to
certain beneficiaries under a Medi-Cal managed care program comply to
filing, reporting, monitoring, and survey requirements established
by the State Department of Health Care Services for the Medi-Cal
managed care program.
The bill would also require specified group health care service
plan contracts and group health insurance policies offered, amended,
or renewed on or after January 1, 2009, to offer at least one benefit
design that includes a Healthy Action Incentives and Rewards
Program, as specified. The bill would also authorize an employer to
provide health coverage that includes a Healthy Action Incentives and
Reward program to his or her employees.
Because a willful violation of the bill's requirements relative to
health care service plans would be a crime, the bill would impose a
state-mandated local program.
(4) Existing law authorizes the Board of Administration of the
Public Employees' Retirement System to contract with carriers
offering health benefit plans for coverage for eligible employees and
annuitants.
This bill would require the board, on or before January 1, 2009,
to provide or arrange for the provision of an electronic personal
health record for enrollees receiving health care benefits.
(5) Existing law establishes the State Department of Public
Health, which licenses and regulates health facilities and also
administers funds for programs relating to smoking cessation. Under
existing law, a noncontracting hospital is required to contact an
enrollee's health care service plan to obtain the enrollee's medical
record information prior to admitting the enrollee for inpatient
poststabilization care, as defined, or prior to transferring the
enrollee, if certain conditions apply. Existing law prohibits the
hospital from billing the enrollee for poststabilization care if it
is required to, and fails to, contact the enrollee's health care
service plan. Under existing law, a violation of any of these
provisions is punishable as a misdemeanor.
This bill would prohibit a noncontracting hospital, as defined,
from billing a covered patient for emergency health care services and
poststabilizing care except for applicable copayments and cost
shares. By changing the definition of an existing crime, this bill
would impose a state-mandated local program.
The bill would also require the department to maintain the
California Diabetes Program to provide information and assistance
pertaining to the prevention and treatment of diabetes. The bill
would also establish the Comprehensive Diabetes Services Program in
the State Department of Health Care Services to provide diabetes
prevention and management services to certain beneficiaries in the
Medi-Cal program, to the extent funding is available for this
purpose. The bill would also require the department, in consultation
with the Department of Managed Health Care, the State Department of
Health Care Services, the Managed Risk Medical Insurance Board, and
the Department of Insurance, to annually identify the 10 largest
providers of health care coverage in the state, to ascertain and
summarize the smoking cessation benefits provided by those coverage
providers, to publish the benefit summary on the department's
Internet Web site, to include the benefit summary as part of its
preventive health education against tobacco use campaign, and to
evaluate any changes in connection with the smoking cessation
benefits provided by the coverage providers, as provided. The bill
would also require the department, to the extent that funds are
available and appropriated for this purpose, to increase the capacity
of effective smoking cessation services available from, and expand
the awareness of, services available through, the California Smokers'
Helpline, as prescribed.
The bill would also create the Community Makeover Grant program
that would be administered by the department and would require it to
award grants to local health departments in cities and counties,
which would serve as the local lead agencies in administering the
program, for the purpose of developing new programs or improving
existing programs that promote active living and healthy eating. The
bill would require the department to issue guidelines and to specify
data reporting requirements for local lead agencies to comply with
various requirements relating to the administration of the program.
The bill would also require the department to develop a sustained
media campaign to educate the public about the importance of obesity
prevention.
(6) Existing law provides for the Office of Statewide Health
Planning and Development, which has specified powers and duties.
Existing law requires the office to publish specified reports.
This bill would require the office to publish risk-adjusted
outcome reports for percutaneous coronary interventions, commencing
January 1, 2010, and would require the office to establish a clinical
data collection program to collect data on percutaneous coronary
interventions and establish by regulation the data to be reported by
each hospital.
(7) Existing law provides for the certification and regulation of
nurses, including nurse practitioners and nurse-midwives, by the
Board of Registered Nursing and for the licensure and regulation of
physician assistants by the Physician Assistant Committee of the
Medical Board of California. Existing law provides that a medical
assistant may administer medication upon the specific authorization
and supervision of a licensed physician and surgeon or licensed
podiatrist or, in specified clinic settings, upon the specific
authorization and supervision of a nurse practitioner, nurse-midwife,
or physician assistant.
This bill would remove the requirement that a medical assistant's
administration of medication upon the specific authorization and
supervision of a nurse practitioner, nurse-midwife, or physician
assistant occur in specified clinic settings, and would make related
changes.
(8) Existing law, the Nursing Practice Act, provides for the
licensure and regulation of nurse practitioners by the Board of
Registered Nursing which is within the Department of Consumer
Affairs. Under existing law, a physician and surgeon is prohibited
from supervising more than 4 nurse practitioners at one time.
This bill would instead prohibit a physician and surgeon from
supervising more than 6 nurse practitioners at one time. The bill
would create the Task Force on Nurse Practitioner Scope of Practice
that would consist of specified members appointed by the Governor,
the Speaker of the Assembly, and the Senate Committee on Rules. The
bill would make the task force responsible for developing a
recommended scope of practice for nurse practitioners and would
require the task force to report the recommended scope of practice to
the Governor and the Legislature on or before June 30, 2009. The
bill would require the Director of Consumer Affairs, on or before
July 1, 2010, to promulgate regulations that adopt the recommended
scope of practice. The bill would require the aforementioned boards
to pay the state administrative costs of implementing these
provisions.
(9) Existing law, the Physician Assistant Practice Act, provides
for the licensure and regulation of physician assistants by the
Physician Assistant Committee of the Medical Board of California and
limits the number of physician assistants supervised by a physician.
This bill would prohibit a physician and surgeon from supervising
more than 6 physician assistants at one time.
(10) Existing law, the Pharmacy Law, defines an electronic
transmission prescription and sets forth the requirements for those
types of prescriptions.
This bill would require electronic prescribing systems to meet
specified standards and requirements and would require a prescriber
or prescriber's authorized agent to offer patients a written receipt
of information transmitted electronically, including the patient's
name and the drug prescribed, and would require the State Department
of Health Care Services to develop a pilot program to foster the
adoption and use of electronic prescribing by health care providers
that contract with the Medi-Cal program, as specified. The bill would
require every licensed prescriber, or prescriber's authorized agent,
or pharmacy operating in California, on or before January 1, 2010,
to have the ability to transmit and receive prescriptions by
electronic data transmission.
(11) This bill would give the State Department of Health Care
Services, in consultation with the Department of Finance, authority
to take various actions as necessary to implement the bill, including
promoting flexibility of implementation and maximizing federal
financial participation. The bill would require the Director of
Health Care Services to notify the Chair of the Joint Legislative
Budget Committee prior to exercising this flexibility. The bill would
declare the intent of the Legislature to implement the bill to
harmonize and best effectuate the purposes and intent of the bill.
(12) This bill would declare the Legislature's intent that the act'
s provisions be financed by contributions from various sources,
including payments by acute care hospitals and employers, and by
increasing the taxes on cigarettes and other tobacco products. The
bill would also declare the Legislature's intent to increase the
rates paid under the Medi-Cal program for inpatient and outpatient
hospital services.
(13) 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 with regard to certain mandates no
reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that,
if the Commission on State Mandates determines that the bill contains
costs so mandated by the state, reimbursement for those costs shall
be made pursuant to the statutory provisions noted above.
Existing law does not provide for a health care system for all
California residents. Existing law provides for the creation of
various programs to provide health care services to persons who have
limited incomes and meet various eligibility requirements. These
programs include the Healthy Families Program administered by the
Managed Risk Medical Insurance Board and the Medi-Cal program
administered by the State Department of Health Care Services.
Existing law provides for the regulation of health care service plans
by the Department of Managed Health Care and health insurers by the
Department of Insurance.
This bill would state that it is the intent of the Legislature to
enact comprehensive health care reform.
Vote: majority. 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. It is the intent of the Legislature
to enact comprehensive health care reform.
SECTION 1. This act shall be known and may be
cited as the California Health Care Reform and Cost Control Act.
SEC. 2. It is the intent of the Legislature to
accomplish the goal of universal health care for all California
residents. To accomplish this goal, the Legislature proposes to take
all of the following steps:
(a) Ensure that all Californians have access to affordable,
comprehensive health care.
(b) Leverage available federal funds to the greatest extent
possible through existing federal programs.
(c) Maintain and strengthen the health insurance system and
improve availability and affordability of private health care
coverage for all purchasers through (1) insurance market reforms; (2)
enhanced access to effective primary and preventive services,
including management of chronic illnesses; (3) promotion of
cost-effective health technologies; and (4) implementation of
meaningful, systemwide cost containment strategies.
(d) Engage in early and systematic evaluation at each step of the
implementation process to identify the impacts on state costs, the
costs of coverage, employment and insurance markets, health delivery
systems, quality of care, and overall progress in moving toward
universal coverage.
SEC. 3. Section 2069 of the Business and
Professions Code is amended to read:
2069. (a) (1) Notwithstanding any other provision of law, a
medical assistant may administer medication only by intradermal,
subcutaneous, or intramuscular injections and perform skin tests and
additional technical supportive services upon the specific
authorization and supervision of a licensed physician and surgeon
, nurse practitioner, nurse-midwife, physician
assistant, or a licensed podiatrist.
A medical assistant may also perform all these tasks and
services in a clinic licensed pursuant to subdivision (a) of Section
1204 of the Health and Safety Code upon the specific authorization of
a physician assistant, a nurse practitioner, or a nurse-midwife.
(2) The supervising physician and surgeon at a clinic
described in paragraph (1) licensed physician and
surgeon, nurse practitioner, nurse-midwife, physician assistant, or
licensed podiatrist may, at his or her discretion, in
consultation with the nurse practitioner, nurse-midwife, or physician
assistant provide written instructions to be followed by a
medical assistant in the performance of tasks or supportive
services. These written instructions may provide that the
supervisory function for the medical assistant for these tasks or
supportive services may be delegated to the nurse practitioner,
nurse-midwife, or physician assistant within the standardized
procedures or protocol, and that tasks may be performed
when the supervising physician and surgeon
licensed physician and surgeon, nurse practitioner, nurse-midwife,
physician assistant, or licensed podiatrist is not onsite, so
long as the following apply:
(A) The nurse practitioner or nurse-midwife is functioning
pursuant to standardized procedures, as defined by Section 2725, or
protocol. The standardized procedures or protocol shall be developed
and approved by the supervising physician and surgeon, the nurse
practitioner or nurse-midwife, and the facility administrator or his
or her designee.
(B) The physician assistant is functioning pursuant to regulated
services defined in Section 3502 and is approved to do so by the
supervising physician or surgeon.
(b) As used in this section and Sections 2070 and 2071, the
following definitions shall apply:
(1) "Medical assistant" means a person who may be unlicensed, who
performs basic administrative, clerical, and technical supportive
services in compliance with this section and Section 2070 for a
licensed physician and surgeon or a licensed podiatrist, or group
thereof, for a medical , nursing, or podiatry corporation,
for a physician assistant, a nurse practitioner, or a nurse-midwife
as provided in subdivision (a), or for a health care service plan,
who is at least 18 years of age, and who has had at least the minimum
amount of hours of appropriate training pursuant to standards
established by the Division of Licensing. The medical assistant shall
be issued a certificate by the training institution or instructor
indicating satisfactory completion of the required training. A copy
of the certificate shall be retained as a record by each employer of
the medical assistant.
(2) "Specific authorization" means a specific written order
prepared by the supervising physician and surgeon or the
supervising podiatrist, or the physician assistant, the nurse
practitioner, or the nurse-midwife as provided in subdivision (a),
licensed physician and surgeon, nurse practitioner,
nurs e-midwife, physician assistant, or licensed
podiatrist authorizing the procedures to be performed on a
patient, which shall be placed in the patient's medical record, or a
standing order prepared by the supervising physician and
surgeon or the supervising podiatrist, or the physician assistant,
the nurse practitioner, or the nurse-midwife as provided in
subdivision (a), licensed physician and surgeon, nurse
practitioner, nurse-midwife, physician assistant, or licensed
podiatrist, authorizing the procedures to be performed, the
duration of which shall be consistent with accepted medical practice.
A notation of the standing order shall be placed on the patient's
medical record.
(3) "Supervision" means the supervision of procedures authorized
by this section by the following practitioners, within the scope of
their respective practices, who shall be physically present in the
treatment facility during the performance of those procedures:
(A) A licensed physician and surgeon.
(B) A licensed podiatrist.
(C) A physician assistant, nurse practitioner, or nurse-midwife
as provided in subdivision (a) .
(4) "Technical supportive services" means simple routine medical
tasks and procedures that may be safely performed by a medical
assistant who has limited training and who functions under the
supervision of a licensed physician and surgeon or
, a licensed podiatrist, or a
physician assistant, a nurse practitioner, or a nurse-midwife
as provided in subdivision (a) .
(c) Nothing in this section shall be construed as authorizing the
licensure of medical assistants. Nothing in this section shall be
construed as authorizing the administration of local anesthetic
agents by a medical assistant. Nothing in this section shall be
construed as authorizing the division to adopt any regulations that
violate the prohibitions on diagnosis or treatment in Section 2052.
(d) Notwithstanding any other provision of law, a medical
assistant may not be employed for inpatient care in a licensed
general acute care hospital as defined in subdivision (a) of Section
1250 of the Health and Safety Code.
(e) Nothing in this section shall be construed as authorizing a
medical assistant to perform any clinical laboratory test or
examination for which he or she is not authorized by Chapter 3
(commencing with Section 1200). Nothing in this section shall be
construed as authorizing a nurse practitioner, nurse-midwife, or
physician assistant to be a laboratory director of a clinical
laboratory, as those terms are defined in paragraph (7) of
subdivision (a) of Section 1206 and subdivision (a) of Section 1209.
SEC. 4. Section 2836.1 of the Business
and Professions Code is amended to read:
2836.1. Neither this chapter nor any other provision of law shall
be construed to prohibit a nurse practitioner from furnishing or
ordering drugs or devices when all of the following apply:
(a) The drugs or devices are furnished or ordered by a nurse
practitioner in accordance with standardized procedures or protocols
developed by the nurse practitioner and the supervising physician and
surgeon when the drugs or devices furnished or ordered are
consistent with the practitioner's educational preparation or for
which clinical competency has been established and maintained.
(b) The nurse practitioner is functioning pursuant to standardized
procedure, as defined by Section 2725, or protocol. The standardized
procedure or protocol shall be developed and approved by the
supervising physician and surgeon, the nurse practitioner, and the
facility administrator or the designee.
(c) (1) The standardized procedure or protocol covering the
furnishing of drugs or devices shall specify which nurse
practitioners may furnish or order drugs or devices, which drugs or
devices may be furnished or ordered, under what circumstances, the
extent of physician and surgeon supervision, the method of periodic
review of the nurse practitioner's competence, including peer review,
and review of the provisions of the standardized procedure.
(2) In addition to the requirements in paragraph (1), for Schedule
II controlled substance protocols, the provision for furnishing
Schedule II controlled substances shall address the diagnosis of the
illness, injury, or condition for which the Schedule II controlled
substance is to be furnished.
(d) The furnishing or ordering of drugs or devices by a nurse
practitioner occurs under physician and surgeon supervision.
Physician and surgeon supervision shall not be construed to require
the physical presence of the physician, but does include (1)
collaboration on the development of the standardized procedure, (2)
approval of the standardized procedure, and (3) availability by
telephonic contact at the time of patient examination by the nurse
practitioner.
(e) For purposes of this section, no physician and surgeon shall
supervise more than four six nurse
practitioners at one time.
(f) (1) Drugs or devices furnished or ordered by a nurse
practitioner may include Schedule II through Schedule V controlled
substances under the California Uniform Controlled Substances Act
(Division 10 (commencing with Section 11000) of the Health and Safety
Code) and shall be further limited to those drugs agreed upon by the
nurse practitioner and physician and surgeon and specified in the
standardized procedure.
(2) When Schedule II or III controlled substances, as defined in
Sections 11055 and 11056, respectively, of the Health and Safety
Code, are furnished or ordered by a nurse practitioner, the
controlled substances shall be furnished or ordered in accordance
with a patient-specific protocol approved by the treating or
supervising physician. A copy of the section of the nurse
practitioner's standardized procedure relating to controlled
substances shall be provided, upon request, to any licensed
pharmacist who dispenses drugs or devices, when there is uncertainty
about the nurse practitioner furnishing the order.
(g) (1) The board has certified in accordance with Section 2836.3
that the nurse practitioner has satisfactorily completed (1) at least
six month's physician and surgeon-supervised experience in the
furnishing or ordering of drugs or devices and (2) a course in
pharmacology covering the drugs or devices to be furnished or ordered
under this section.
(2) Nurse practitioners who are certified by the board and hold an
active furnishing number, who are authorized through standardized
procedures or protocols to furnish Schedule II controlled substances,
and who are registered with the United States Drug Enforcement
Administration, shall complete, as part of their continuing education
requirements, a course including Schedule II controlled substances
based on the standards developed by the board. The board shall
establish the requirements for satisfactory completion of this
subdivision.
(h) Use of the term "furnishing" in this section, in health
facilities defined in Section 1250 of the Health and Safety Code,
shall include (1) the ordering of a drug or device in accordance with
the standardized procedure and (2) transmitting an order of a
supervising physician and surgeon.
(i) "Drug order" or "order" for purposes of this section means an
order for medication which is dispensed to or for an ultimate user,
issued by a nurse practitioner as an individual practitioner, within
the meaning of Section 1306.02 of Title 21 of the Code of Federal
Regulations. Notwithstanding any other provision of law, (1) a drug
order issued pursuant to this section shall be treated in the same
manner as a prescription of the supervising physician; (2) all
references to "prescription" in this code and the Health and Safety
Code shall include drug orders issued by nurse practitioners; and (3)
the signature of a nurse practitioner on a drug order issued in
accordance with this section shall be deemed to be the signature of a
prescriber for purposes of this code and the Health and Safety Code.
SEC. 5. Section 2838 is added to the
Business and Professions Code , to read:
2838. (a) The Task Force on Nurse Practitioner Scope of Practice
is hereby created and shall consist of the following members:
(1) The Director of Consumer Affairs, who shall serve as an ex
officio member of the task force and shall cast the deciding vote in
any matter voted upon by the task force that results in a tie vote.
(2) Three members of the Medical Board of California, two of whom
shall be appointed to the task force by the Governor, and one of whom
shall be appointed to the task force by the Speaker of the Assembly.
(3) Three members of the Board of Registered Nursing, two of whom
shall be appointed to the task force by the Governor, and one of whom
shall be appointed to the task force by the Senate Committee on
Rules.
(4) Two representatives of an institution of higher education, who
shall be appointed to the task force by the Governor as nonvoting
members.
(b) The duty of the task force shall be to develop a recommended
scope of practice for nurse practitioners.
(c) The task force shall report its recommended scope of practice
for nurse practitioners to the Governor and the Legislature on or
before June 30, 2009.
(d) On or before July 1, 2010, the Director of Consumer Affairs
shall promulgate regulations that adopt the task force's recommended
scope of practice.
(e) The Medical Board of California and the Board of Registered
Nursing shall pay the state administrative costs of implementing this
section.
SEC. 6. Section 3516 of the Business
and Professions Code , as amended by Section 4 of Chapter
376 of the Statutes of 2007, is amended to read:
3516. (a) Notwithstanding any other provision of law, a physician
assistant licensed by the committee shall be eligible for employment
or supervision by any physician and surgeon who is not subject to a
disciplinary condition imposed by the board prohibiting that
employment or supervision.
(b) No physician and surgeon shall supervise more than
four six physician assistants at any one time,
except as provided in Section 3502.5.
(c) The board may restrict a physician and surgeon to supervising
specific types of physician assistants including, but not limited to,
restricting a physician and surgeon from supervising physician
assistants outside of the field of specialty of the physician and
surgeon.
SEC. 7. Section 4040.1 is added to the
Business and Professions Code , to read:
4040.1. Electronic prescribing shall not interfere with a patient'
s existing freedom to choose a pharmacy, and shall not interfere with
the prescribing decision at the point of care.
SEC. 8. Section 4071.2 is added to the
Business and Professions Code , to read:
4071.2. (a) On or before January 1, 2010, every licensed
prescriber, prescriber's authorized agent, or pharmacy operating in
California shall have the ability to transmit and receive
prescriptions by electronic data transmission.
(b) The Medical Board of California, the State Board of Optometry,
the Bureau of Naturopathic Medicine, the Dental Board of California,
the Osteopathic Medical Board of California, the Board of Registered
Nursing, and the Physician Assistant Committee shall have authority
with the California State Board of Pharmacy to ensure compliance with
this section, and those boards are specifically charged with the
enforcement of this section with respect to their respective
licensees.
(c) Nothing in this section shall be construed to diminish or
modify any requirements or protections provided for in the
prescription of controlled substances as otherwise established by
this chapter or by the California Uniform Controlled Substances Act
(Division 10 (commencing with Section 11000) of the Health and Safety
Code).
SEC. 9. Section 4071.3 is added to the
Business and Professions Code , to read:
4071.3. Every electronic prescription system shall meet all of
the following requirements:
(a) Comply with nationally recognized or certified standards for
data exchange or be accredited by a recognized accreditation
organization.
(b) Allow real-time verification of an individual's eligibility
for benefits and whether the prescribed medication is a covered
benefit.
(c) Comply with applicable state and federal confidentiality and
data security requirements.
(d) Comply with applicable state record retention and reporting
requirements.
SEC. 10. Section 4071.4 is added to the
Business and Professions Code , to read:
4071.4. A prescriber or prescriber's authorized agent using an
electronic prescription system shall offer patients a written receipt
of the information that has been transmitted electronically to the
pharmacy. The receipt shall include the patient's name, the dosage
and drug prescribed, the name of the pharmacy where the electronic
prescription was sent, and shall indicate that the receipt cannot be
used as a duplicate order for the same medicine.
SEC. 11. Section 49452.9 is added to the
Education Code , to read:
49452.9. (a) On and after January 1, 2010, the school district
may provide an information sheet regarding health insurance
requirements to the parent or guardian of all of the following:
(1) A pupil enrolled in kindergarten.
(2) A pupil enrolled in first grade if the pupil was not
previously enrolled in kindergarten.
(3) A pupil enrolled during the course of the year in the case of
children who have recently arrived, and intend to remain, in
California.
(b) The information sheet described in subdivision (a) shall
include all of the following:
(1) An explanation of the health insurance requirements under
Section 8899.50 of the Government Code.
(2) Information on the important relationship between health and
learning.
(3) A toll-free telephone number to request an application for
Healthy Families, Medi-Cal, or other government-subsidized health
insurance programs.
(4) Contact information for county public health departments.
(5) A statement of privacy applicable under state and federal laws
and regulations.
(c) By January 1, 2010, the State Department of Education shall,
in consultation with the State Department of Health Care Services and
the Managed Risk Medical Insurance Board, develop a standardized
template for the information sheet required by this section. To the
extent possible, the information provided pursuant to this section
shall be consolidated with the information listed in subdivision (c)
of Section 49452.8 into one document. The State Department of
Education shall make the template available on its Internet Web site
and shall, upon request, provide written copies of the template to a
school district.
SEC. 12. Chapter 15 (commencing with Section
8899.50) is added to Division 1 of Title 2 of the
Government Code , to read:
CHAPTER 15. MINIMUM HEALTH CARE COVERAGE
8899.50. (a) Every individual in this state shall be required to
maintain a minimum policy of health care coverage, as determined by
the Managed Risk Medical Insurance Board, for himself or herself and
his or her dependents.
(b) An individual is not subject to the requirements of
subdivision (a) if either of th following apply:
(1) The total cost for a minimum policy, including all
out-of-pocket costs, exceeds 6.5 percent of the individual's family
income.
(2) The individual has a significant financial hardship, as
determined by the Managed Risk Medical Insurance Board.
(c) For purposes of this chapter, the term "dependents" means the
spouse, domestic partner, minor child of the individual, or a child
18 years of age and over who is dependent on the individual, as
defined by the Managed Risk Medical Insurance Board.
(d) In establishing the minimum policy of health care coverage,
the board shall consider all of the following:
(1) The affordability of the minimum policy for individuals who
are subject to the requirements of subdivision (a), taking into
account premiums, deductibles, coinsurance, copayments, and total
out-of-pocket costs.
(2) The degree to which the minimum policy protects individuals
subject to the requirement of subdivision (a) from catastrophic
medical costs.
(3) The importance of encouraging periodic health evaluations and
the use of services that have been shown to be effective in detecting
or preventing serious illness.
(e) It is the intent of the Legislature that the Managed Risk
Medical Insurance Board pay the cost of health care coverage on
behalf of an individual who has been without health care coverage for
a period greater than 63 days after the date of leaving employment
where the individual had health care coverage, by enrolling him or
her in minimum health coverage though the California Cooperative
Heath Insurance Purchasing Program established pursuant to Part 6.45
(commencing with Section 12699.201) of Division 2 of the Insurance
Code and then recouping from the individual the cost of that
coverage.
(f) The Managed Risk Medical Insurance Board shall identify and
implement methods and strategies to establish multiple entry points
and opportunities for enrollment in public or private coverage, as
appropriate, for individuals subject to subdivision (a). The board
shall work with state and local agencies, health care providers,
health plans, employers, consumer groups, community organizations,
and other appropriate stakeholders to establish point-of-service
methods to facilitate enrollment of individuals who do not have or
maintain a minimum policy of health care coverage as required under
this section. The board shall identify and implement in
state-administered health care programs, to the greatest extent
practicable and permissible under federal law, best practices for
streamlined eligibility and enrollment.
(g) On or before January 1, 2010, the board shall establish and
maintain an active statewide education and awareness program to
inform all California residents of their obligation under this
section, including informing them of the options available to obtain
affordable coverage through public programs, the state purchasing
pool, and commercial coverage.
(h) The board may enter into, or authorize entities within the
agency to enter into, agreements with other state agencies or
departments, or local agencies or organizations, to develop,
implement, or participate in the educational program established
pursuant to this section.
(i) Implementation of this section shall be contingent upon an
appropriation of funds for the purpose of this section in the annual
Budget Act or another statute.
SEC. 13. Section 12803.1 is added to the
Government Code , to read:
12803.1. (a) The California Health Benefits Service is hereby
created within the California Health and Human Services Agency.
(1) The California Health Benefits Service (CHBS) shall be
governed by a nine member board appointed by the Governor, the Senate
Committee on Rules, and the Speaker of the Assembly. The Governor
shall appoint a representative of local initiatives authorized under
the Welfare and Institutions Code, a representative of county
organized health systems, and a representative of health care
purchasers. The Senate Committee on Rules shall appoint a
representative of local initiatives authorized under the Welfare and
Institutions Code, a representative of county organized health
systems, and a representative of health care consumers. The Speaker
of the Assembly shall appoint a representative of local initiatives
authorized under the Welfare and Institutions Code, a representative
of health care providers, and a representative of organized labor.
Terms of appointment shall be four years. The members of the board
shall elect a board chair from among
the nine appointed members.
(2) The board shall appoint an executive director for the board,
who shall serve at the pleasure of the board. The executive director
shall receive the salary established by the Department of Personnel
Administration for exempt officials. The executive director shall
administer the affairs of the board as directed by the board and
shall direct the staff of the board. The executive director may
appoint, with the approval of the board, staff necessary to carry out
the provisions of this section.
(b) The Health and Human Services Agency shall convene a working
group with the collaboration of the Department of Managed Health
Care, the State Department of Health Care Services, and the Managed
Risk Medical Insurance Board. This working group shall assist CHBS in
identifying statutory, regulatory, or financial barriers or
incentives that must be addressed before CHBS can facilitate the
establishment and maintenance of one or more joint ventures between
health plans that contract with, or are governed, owned, or operated
by, a county board of supervisors, a county special commission, or
county health authority authorized by Section 14018.7, 14087.31,
14087.35, 14087.36, 14087.38, or 14087.96 of the Welfare and
Institutions Code. The working group shall also assist CHBS in
identifying statutory, regulatory, or financial barriers or
incentives that must be addressed before CHBS can enter into
contracts with providers to provide health care services in counties
in which there is not a prepaid health plan that contracts with, or
is governed, owned, or operated by, a county board of supervisors, a
county special commission, or a county health authority authorized by
Section 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, or 14087.96
of the Welfare and Institutions Code. The working group shall, no
later than April 1, 2008, report its findings to the executive
director, the CHBS governing board, and the committees of
jurisdiction in the Senate and Assembly.
(c) To the extent permitted under existing law, CHBS is authorized
to solicit and assist prepaid health plans that contract with, or
are governed, owned, or operated by, a county board of supervisors, a
county special commission or county health authority authorized by
Section 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, or 14087.96
of the Welfare and Institutions Code in forming joint ventures to
create integrated networks of public health plans that pool risk and
share networks. CHBS may, upon agreement of participating health
plans, administer those joint ventures. Consistent with the
recommendations pursuant to subdivision (b), and existing law, CHBS
is authorized to develop networks to provide health care services in
counties in which there is not a prepaid health plan that contracts
with, or is governed, owned, or operated by, a county board of
supervisors, a county special commission, or a county health
authority authorized by Section 14018.7, 14087.31, 14087.35,
14087.36, 14087.38, or 14087.96 of the Welfare and Institutions Code.
(1) In forming joint ventures, CHBS and participating health plans
shall seek to contract with the 22 designated public hospitals,
county health clinics, and community clinics.
(2) All joint ventures established pursuant to this section shall
seek licensure as a health care service plan consistent with the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code). Prior to commencement of enrollment, the joint venture shall
be licensed pursuant to that act.
(d) By March 1, 2009, and annually thereafter, CHBS shall submit a
report to the committees of jurisdiction in the Senate and Assembly
on implementation of this section and make recommendations on
resources, regulatory, and legislative changes necessary to implement
this section. The report shall also include recommendations on
resources, policy, and legislative changes necessary to build and
implement a system of health coverage throughout California.
SEC. 14. Section 12803.2 is added to the
Government Code , to read:
12803.2. (a) The California Health and Human Services Agency, in
consultation with the Board of Administration of the Public Employees'
Retirement System, and after consultation with affected health care
provider groups, shall develop health care provider performance
measurement benchmarks and incorporate these benchmarks into a common
pay-for-performance model to be offered in every state-administered
health care program, including, but not limited to, the Public
Employees' Medical and Hospital Care Act, the Healthy Families
Program, the Major Risk Medical Insurance Program, the Medi-Cal
program, and the California Cooperative Health Insurance Purchasing
Program. These benchmarks shall be developed to advance a common
statewide framework for health care quality measurement and
reporting, including, but not limited to, measures that have been
approved by the National Quality Forum (NQF) such as the Health Plan
Employer Data and Information Set (HEDIS) and the Joint Commission on
Accreditation of Health Care Organizations (JCAHO), and that have
been adopted by the Hospitals Quality Alliance and other national and
statewide groups concerned with quality.
(b) The California Health and Human Services Agency, in
consultation with the Board of Administration of the Public Employees'
Retirement System, shall assume lead agency responsibility for
professional review and development of best practice standards in the
care and treatment of patients with high-cost chronic diseases, such
as asthma, diabetes, and heart disease. In developing the best
practice standards, the agency shall consider the use of an annual
health assessment for patients. Upon adoption of the standards, each
state health care program, including, but not limited to, programs
offered under the Public Employees' Medical and Hospital Care Act,
the Medi-Cal program, the Healthy Families Program, the Major Risk
Medical Insurance Program, and the California Cooperative Health
Insurance Purchasing Program, shall implement those standards.
SEC. 15. Section 22830.5 is added to the
Government Code , to read:
22830.5. (a) On or before January 1, 2009, the board shall
provide or arrange for the provision of an electronic personal health
record for enrollees receiving health care benefits. The record
shall be provided for the purpose of providing enrollees with
information to assist them in understanding their coverage benefits
and managing their health care.
(b) At a minimum, the personal health record shall provide access
to real-time, patient-specific information regarding eligibility for
covered benefits and cost sharing requirements. Such access can be
provided through the use of an Internet-based system.
(c) In addition to the data required pursuant to subdivision (b),
the board may determine that the personal health record shall also
incorporate additional data, such as laboratory results, prescription
history, claims history, and personal health information authorized
or provided by the enrollee. Inclusion of this additional data shall
be at the option of the enrollee.
(d) Systems or software that pertain to the personal health record
shall adhere to accepted national standards for interoperability,
privacy, and data exchange, or shall be certified by a nationally
recognized certification body.
(e) The personal health record shall comply with applicable state
and federal confidentiality and data security requirements.
SEC. 16. Section 22830.6 is added to the
Government Code , to read:
22830.6. On or before January 1, 2009, the board shall provide or
arrange for the provision of a Healthy Action Incentives and Rewards
Program, as described in subdivision (c) of Section 1367.38 of the
Health and Safety Code, to all enrollees.
SEC. 17. Section 1262.9 is added to the
Health and Safety Code , to read:
1262.9. (a) If a patient has coverage for emergency health care
services and poststabilizing care, a noncontracting hospital shall
not bill the patient for emergency health care services and
poststabilizing care, except for applicable copayments and cost
shares.
(b) The noncontracting hospital and the health care service plan
or health insurer shall each retain their right to pursue all
currently available legal remedies they may have against each other,
including the right to determine the final payment due.
(c) For the purposes of this section:
(1) "Noncontracting hospital" means a general acute care hospital
as defined in subdivision (a) of Section 1250 that has a special
permit to operate an emergency medical service and does not have a
contract with a health care service plan or a health insurer for the
provision of emergency health care services and poststabilizing care
to the patient, who is one of that health care service plan's or
health insurer's enrollees, members, or insureds.
(2) "Emergency health care services and poststabilizing care"
means emergency services and out-of-area urgent services provided in
an emergency department and a hospital through discharge in
compliance with Sections 1262.8 and 1317 and, in the case of health
care service plans, the services required to be covered pursuant to
paragraph (6) of subdivision (b) of Section 1345, subdivision (i) of
Section 1367, Sections 1371.4, and 1371.5, of this code, and Sections
1300.67(g) and 1300.71.4 of Title 28 of the California Code of
Regulations.
SEC. 18. Section 1342.9 is added to the
Health and Safety Code , to read:
1342.9. (a) Notwithstanding any other provision of this chapter,
a health care service plan that provides services to a beneficiary of
the Medi-Cal program pursuant to Article 2.7 (commencing with
Section 14087.3), Article 2.8 (commencing with Section 14087.5), or
Article 2.91 (commencing with Section 14089) of Chapter 7 of, or
Article 1 (commencing with Section 14200) or Article 7 (commencing
with Section 14490) of Chapter 8 of, Part 3 of Division 9 of the
Welfare and Institutions Code shall, regarding coverage for
participants in a Medi-Cal managed care program, be subject solely to
the filing, reporting, monitoring, and survey requirements
established by the State Department of Health Care Services for the
Medi-Cal managed care program as those requirements pertain to the
following subjects: advertising and marketing; member materials,
including member handbooks, evidences of coverage, and disclosure
forms; and product design, including its scope and limitations. A
health care service plan that satisfies any of the foregoing filing,
reporting, monitoring, or survey requirements shall be deemed in
compliance with corresponding provisions, if any, of this chapter.
(b) The department and the State Department of Health Care
Services shall develop a joint filing and review process for medical
quality surveys required pursuant to Section 1380 and pursuant to
Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of
the Welfare and Institutions Code.
SEC. 19. Section 1347 is added to the
Health and Safety Code , to read:
1347. The director shall provide regulatory and program
flexibilities as may be necessary to facilitate new, modified, or
combined licenses of local initiatives, county organized health
systems, or the California Health Benefits Service, created pursuant
to Section 12803.1 of the Government Code, seeking licensure for
regional or statewide networks for the purposes of contracting with
the Managed Risk Medical Insurance Board as a participating plan in
the California Cooperative Health Insurance Purchasing Program by
January 1, 2010, or for the purposes of providing coverage in the
individual and group coverage markets. In providing those
flexibilities, the director shall ensure that the health plans
established pursuant to this section meet essential financial,
capacity, and consumer protection requirements of this chapter.
SEC. 20. Article 3.11 (commencing with Section
1357.20) is added to Chapter 2.2 of Division 2 of the
Health and Safety Code , to read:
Article 3.11. Insurance Market Reform
1357.20. On and after January 1, 2010, the department, in
consultation with the Department of Insurance, shall require each
health care service plan with one million or more enrollees in
California, based on the plan's enrollment in the prior year, to
submit a good faith bid to the Managed Risk Medical Insurance Board
in order to be a participating plan through the California
Cooperative Health Insurance Purchasing Program (Cal-CHIPP) pursuant
to Part 6.45 (commencing with Section 12699.201) of Division 2 of the
Insurance Code.
1357.23. Effective July 1, 2010, all requirements in Article 3.1
(commencing with Section 1357) applicable to offering, marketing, and
selling health care service plan contracts to small employers as
defined in that article, including, but not limited to, the
obligation to fairly and affirmatively offer, market, and sell all of
the plan's contracts to all employers, guaranteed renewal of all
health care service plan contracts, use of the risk adjustment
factor, and the restriction of risk categories to age, geographic
region, and family composition as described in that article, shall be
applicable to all health care service plan contracts offered to all
employers with 100 or fewer eligible employees, except as follows:
(a) For small employers with 2 to 50, inclusive, eligible
employees, all requirements in that article shall apply.
(b) For employers with 51 to 100, inclusive, eligible employees,
all requirements in that article shall apply, except that the health
care service plan may develop health care coverage benefit plan
designs to fairly and affirmatively market only to employer groups of
51 to 100, inclusive, eligible employees.
1357.24. It is the intent of the Legislature to establish a
mechanism by which the state may defray the costs of an enrollee's
public program participation by taking advantage of other
opportunities for coverage available to that enrollee.
1357.25. The requirements of this article shall not apply to a
specialized health care service plan or a Medicare supplement
contract.
1357.26. This article shall become operative on July 1, 2008.
SEC. 21. Section 1363 of the Health and
Safety Code is amended to read:
1363. (a) The director shall require the use by each plan of
disclosure forms or materials containing information regarding the
benefits, services, and terms of the plan contract as the director
may require, so as to afford the public, subscribers, and enrollees
with a full and fair disclosure of the provisions of the plan in
readily understood language and in a clearly organized manner. The
director may require that the materials be presented in a reasonably
uniform manner so as to facilitate comparisons between plan contracts
of the same or other types of plans. Nothing contained in this
chapter shall preclude the director from permitting the disclosure
form to be included with the evidence of coverage or plan contract.
The disclosure form shall provide for at least the following
information, in concise and specific terms, relative to the plan,
together with additional information as may be required by the
director, in connection with the plan or plan contract:
(1) The principal benefits and coverage of the plan, including
coverage for acute care and subacute care.
(2) The exceptions, reductions, and limitations that apply to the
plan.
(3) The full premium cost of the plan.
(4) Any copayment, coinsurance, or deductible requirements that
may be incurred by the member or the member's family in obtaining
coverage under the plan.
(5) The terms under which the plan may be renewed by the plan
member, including any reservation by the plan of any right to change
premiums.
(6) A statement that the disclosure form is a summary only, and
that the plan contract itself should be consulted to determine
governing contractual provisions. The first page of the disclosure
form shall contain a notice that conforms with all of the following
conditions:
(A) (i) States that the evidence of coverage discloses the terms
and conditions of coverage.
(ii) States, with respect to individual plan contracts, small
group plan contracts, and any other group plan contracts for which
health care services are not negotiated, that the applicant has a
right to view the evidence of coverage prior to enrollment, and, if
the evidence of coverage is not combined with the disclosure form,
the notice shall specify where the evidence of coverage can be
obtained prior to enrollment.
(B) Includes a statement that the disclosure and the evidence of
coverage should be read completely and carefully and that individuals
with special health care needs should read carefully those sections
that apply to them.
(C) Includes the plan's telephone number or numbers that may be
used by an applicant to receive additional information about the
benefits of the plan or a statement where the telephone number or
numbers are located in the disclosure form.
(D) For individual contracts, and small group plan contracts as
defined in Article 3.1 (commencing with Section 1357), the disclosure
form shall state where the health plan benefits and coverage matrix
is located.
(E) Is printed in type no smaller than that used for the remainder
of the disclosure form and is displayed prominently on the page.
(7) A statement as to when benefits shall cease in the event of
nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon an enrollee who is hospitalized or undergoing
treatment for an ongoing condition.
(8) To the extent that the plan permits a free choice of provider
to its subscribers and enrollees, the statement shall disclose the
nature and extent of choice permitted and the financial liability
that is, or may be, incurred by the subscriber, enrollee, or a third
party by reason of the exercise of that choice.
(9) A summary of the provisions required by subdivision (g) of
Section 1373, if applicable.
(10) If the plan utilizes arbitration to settle disputes, a
statement of that fact.
(11) A summary of, and a notice of the availability of, the
process the plan uses to authorize, modify, or deny health care
services under the benefits provided by the plan, pursuant to
Sections 1363.5 and 1367.01.
(12) A description of any limitations on the patient's choice of
primary care physician, specialty care physician, or nonphysician
health care practitioner, based on service area and limitations on
the patient's choice of acute care hospital care, subacute or
transitional inpatient care, or skilled nursing facility.
(13) General authorization requirements for referral by a primary
care physician to a specialty care physician or a nonphysician health
care practitioner.
(14) Conditions and procedures for disenrollment.
(15) A description as to how an enrollee may request continuity of
care as required by Section 1373.96 and request a second opinion
pursuant to Section 1383.15.
(16) Information concerning the right of an enrollee to request an
independent review in accordance with Article 5.55 (commencing with
Section 1374.30).
(17) A notice as required by Section 1364.5.
(b) (1) As of July 1, 1999, the director shall require each plan
offering a contract to an individual or small group to provide with
the disclosure form for individual and small group plan contracts a
uniform health plan benefits and coverage matrix containing the plan'
s major provisions in order to facilitate comparisons between plan
contracts. The uniform matrix shall include the following category
descriptions together with the corresponding copayments and
limitations in the following sequence:
(A) Deductibles.
(B) Lifetime maximums.
(C) Professional services.
(D) Outpatient services.
(E) Hospitalization services.
(F) Emergency health coverage.
(G) Ambulance services.
(H) Prescription drug coverage.
(I) Durable medical equipment.
(J) Mental health services.
(K) Chemical dependency services.
(L) Home health services.
(M) Other.
(2) The following statement shall be placed at the top of the
matrix in all capital letters in at least 10-point boldface type:
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN
CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE
BENEFITS AND LIMITATIONS.
(c) Nothing in this section shall prevent a plan from using
appropriate footnotes or disclaimers to reasonably and fairly
describe coverage arrangements in order to clarify any part of the
matrix that may be unclear.
(d) All plans, solicitors, and representatives of a plan shall,
when presenting any plan contract for examination or sale to an
individual prospective plan member, provide the individual with a
properly completed disclosure form, as prescribed by the director
pursuant to this section for each plan so examined or sold.
(e) In the case of group contracts, the completed disclosure form
and evidence of coverage shall be presented to the contractholder
upon delivery of the completed health care service plan agreement.
(f) Group contractholders shall disseminate copies of the
completed disclosure form to all persons eligible to be a subscriber
under the group contract at the time those persons are offered the
plan. If the individual group members are offered a choice of plans,
separate disclosure forms shall be supplied for each plan available.
Each group contractholder shall also disseminate or cause to be
disseminated copies of the evidence of coverage to all applicants,
upon request, prior to enrollment and to all subscribers enrolled
under the group contract.
(g) In the case of conflicts between the group contract and the
evidence of coverage, the provisions of the evidence of coverage
shall be binding upon the plan notwithstanding any provisions in the
group contract that may be less favorable to subscribers or
enrollees.
(h) In addition to the other disclosures required by this section,
every health care service plan and any agent or employee of the plan
shall, when presenting a plan for examination or sale to any
individual purchaser or the representative of a group consisting of
25 100 or fewer individuals, disclose
in writing the ratio of premium costs to health services paid for
plan contracts with individuals and with groups of the same or
similar size for the plan's preceding fiscal year. A plan may report
that information by geographic area, provided the plan identifies the
geographic area and reports information applicable to that
geographic area.
(i) Subdivision (b) shall not apply to any coverage provided by a
plan for the Medi-Cal program or the Medicare program pursuant to
Title XVIII and Title XIX of the Social Security Act.
SEC. 22. Article 4.1 (commencing with Section
1366.10) is added to Chapter 2.2 of Division 2 of the
Health and Safety Code , to read:
Article 4.1. California Individual Coverage Guarantee Issue
1366.10. It is the intent of the Legislature to do both of the
following:
(a) Guarantee the availability and renewability of health coverage
through the private health insurance market to individuals.
(b) Require that health care service plans and health insurers
issuing coverage in the individual market compete on the basis of
price, quality, and service, and not on risk selection.
1366.104. (a) On or before September 1, 2008, the director and
the Insurance Commissioner shall jointly adopt regulations governing
five classes of individual health benefit plans that health care
service plans and health insurers shall make available.
(b) Within 90 days of the adoption of the regulations required by
subdivision (a), the director and the Insurance Commissioner shall
jointly approve five classes of individual health benefit plans for
each health care service plan and health insurer participating in the
individual market, with each class having an increased level of
benefits beginning with the lowest class. Within each class, the
director and the Insurance Commissioner shall jointly approve one
baseline HMO and one
baseline PPO, each of which is the lowest cost product to be issued
by health care service plans and health insurers in the individual
market. The classes of benefits jointly approved by the director and
the Insurance Commissioner shall reflect a reasonable continuum
between the class with the lowest level of benefits and the class
with the highest level of benefits, shall permit reasonable benefit
variation that will allow for a diverse market within each class, and
shall be enforced consistently between health care service plans and
health insurers in the same marketplace regardless of licensure.
(c) In approving the five classes of plans filed by health care
service plans and health insurers, the director and the Insurance
Commissioner shall do both of the following:
(1) Jointly determine that the plans provide reasonable benefit
variation, allowing a diverse market.
(2) Jointly require either (A) that benefits within each class are
standard and uniform across all plans and insurers, or (B) that
benefits offered in each class are actuarially equivalent across all
plans and insurers.
1366.105. On and after July 1, 2010, health care service plans
and health insurers participating in the individual market shall
guarantee issue the five classes of approved health benefit plans and
shall, at the same time, discontinue offering and selling health
benefit plans other than those within the five approved classes of
benefit plans in the individual market.
1366.106. Individuals may purchase a health benefit plan from one
of the five classes of approved plans on a guaranteed issue basis.
After selecting and purchasing a health benefit plan within a class
of benefits, an individual may change plans only as set forth in this
section. For individuals enrolled as a family, the subscriber may
change classes for himself or herself, or for all dependents:
(a) Annually in the month of the subscriber's birth, an individual
may select a different individual plan from another health care
service plan or insurer, within the same class of benefits or the
next higher class of benefits.
(b) Annually in the month of the subscriber's birth, an individual
may move up one class of benefits offered by the same health care
service plan or health insurer.
(c) At any time a subscriber may move to a lower class of
benefits.
(d) At significant life events, the enrollee may move up to a
higher class of benefits as follows:
(1) Upon marriage or entering into a domestic partnership.
(2) Upon divorce.
(3) Upon the death of a spouse or domestic partner, on whose
health coverage an individual was a dependent.
(4) Upon the birth or adoption of a child.
(e) A dependent child may terminate coverage under a parent's plan
and select coverage for his or her own account following his or her
18th birthday.
(f) If a subscriber becomes eligible for group benefits, Medicare,
or other benefits, and selects those benefits in lieu of his or her
individual coverage, the dependent spouse or domestic partner may
become the subscriber. If there is no dependent spouse or domestic
partner enrolled in the plan, the oldest child may become the
subscriber.
1366.107. At the time an individual applies for health coverage
from a health care service plan or health insurer participating in
the individual market, an individual shall provide information as
required by a standardized health status questionnaire to assist
plans and insurers in identifying persons in need of disease
management. Health care service plans and health insurers may not use
information provided on the questionnaire to decline coverage or to
limit an individual's choice of health care benefit plan.
1366.108. Health benefit plans shall become effective within 31
days of receipt of the individual's application, standardized health
status questionnaire, and premium payment.
1366.109. Health care service plans and health insurers may
reject an application for health care benefits if the individual does
not reside or work in a plan's or insurer's approved service area.
1366.110. The director or the Insurance Commissioner, as
applicable, may require a health care service plan or health insurer
to discontinue the offering of health care benefits, or acceptance of
applications from individuals, upon a determination by the director
or commissioner that the plan or insurer does not have sufficient
financial viability, or organizational and administrative capacity,
to ensure the delivery of health care benefits to its enrollees or
insureds.
1366.111. All health care benefits offered to individuals shall
be renewable with respect to all individuals and dependents at the
option of the subscriber, except:
(a) For nonpayment of the required premiums by the subscriber.
(b) When the plan or insurer withdraws from the individual health
care market, subject to rules and requirements jointly approved by
the director and the Insurance Commissioner.
1366.112. No health care service plan or health insurer shall,
directly or indirectly, enter into any contract, agreement, or
arrangement with a solicitor that provides for or results in the
compensation paid to a solicitor for the sale of a health care
service plan contract or health insurance policy to be varied because
of the health status, claims experience, occupation, or geographic
location of the individual, provided the geographic location is
within the plan's or insurer's approved service area.
1366.113. This article shall not apply to individual health plan
contracts for coverage of Medicare services pursuant to contracts
with the United States Government, Medi-Cal contracts with the State
Department of Health Care Services, Healthy Families Program
contracts with the Managed Risk Medical Insurance Board, high risk
pool contracts with the Major Risk Medical Insurance Program,
Medicare supplement policies, long-term care policies, specialized
health plan contracts, or contracts issued to individuals who secure
coverage from Cal-CHIPP.
1366.114. (a) A health care service plan or health insurer may
rate its entire portfolio of health benefit plans in accordance with
expected costs or other market considerations, but the rate for each
plan or insurer shall be set in relation to the balance of the
portfolio as certified by an actuary. Each benefit plan shall be
priced as determined by each health care service plan or health
insurer to reflect the difference in benefit variation, or the
effectiveness of a provider network, but may not adjust the rate for
a specific plan for risk selection. A health care service plan's or
health insurer's rates shall use the same rating factors for age,
family size, and geographic location for each individual health care
benefit plan it issues. Rates for health care benefits may vary from
applicant to applicant only by any of the following:
(1) Age of the subscriber, as determined by the director and the
Insurance Commissioner.
(2) Family size in categories determined by the director and the
Insurance Commissioner.
(3) Geographic rate regions as determined by the director and the
Insurance Commissioner.
(4) Health improvement discounts. A health care service plan or
health insurer may reduce copayments or offer premium discounts for
nonsmokers, individuals demonstrating weight loss through a
measurable health improvement program, or individuals actively
participating in a disease management program, provided those
discounts are approved by the director and the Insurance
Commissioner.
(b) The director and Insurance Commissioner shall take into
consideration the age, family size, and geographic region rating
categories applicable to small group coverage contracts pursuant to
Section 1357 of this code and Section 10700 of the Insurance Code in
implementing this section.
1366.115. The first term of each health benefit plan contract or
policy issued shall be from the effective date through the last day
of the month immediately preceding the subscriber's next birthday.
Contracts or policies may be renewed by the subscriber as set forth
in this article.
1366.116. This article, other than Section 1366.104, shall not
become operative until the date that the provisions of Section
8899.50 of the Government Code are implemented.
SEC. 23. Section 1367.205 is added to the
Health and Safety Code , to read:
1367.205. Commencing on or before January 1, 2010, a health care
service plan that provides prescription drug benefits and maintains
one or more drug formularies shall make the most current formularies
available electronically to prescribers and pharmacies.
SEC. 24. Section 1367.38 is added to the
Health and Safety Code , to read:
1367.38. (a) A full-service health care service plan, except for
a Medicare supplement plan, that offers, delivers, amends, or renews
a contract on or after January 1, 2009, that covers hospital,
medical, or surgical expenses on a group basis shall offer at least
one benefit design that includes a Healthy Action Incentives and
Rewards Program as described in subdivision (c). Any plan subject to
this section shall communicate the availability of the Healthy Action
Incentives and Rewards Program coverage to all group subscribers and
to all prospective group subscribers with whom they are negotiating.
(b) In addition to benefit designs offered pursuant to subdivision
(a), every health care service plan contract offered, delivered,
amended, or renewed on or after January 1, 2009, that offers coverage
on a group basis shall offer a Healthy Action Incentives and Rewards
Program, as described in subdivision (c), as a supplement to every
contract that covers hospital, medical, or surgical expenses and that
does not include a Healthy Action Incentives and Rewards Program as
part of the overall benefit design.
(c) For purposes of this section, benefits for a Healthy Action
Incentives and Rewards Program shall provide for all of the
following:
(1) Health risk appraisals to be used to assess an individual's
overall health status and to identify risk factors, including, but
not limited to, smoking and smokeless tobacco use, alcohol abuse,
drug use, and nutrition and physical activity practices.
(2) A followup appointment with a licensed health care
professional acting within his or her scope of practice to review the
results of the health risk appraisal and discuss any recommended
actions.
(3) Incentives or rewards for enrollees to become more engaged in
their health care and to make appropriate choices that support good
health, including obtaining health risk appraisals, screening
services, immunizations, or participating in healthy lifestyle
programs and practices. These programs and practices may include, but
need not be limited to, smoking cessation, physical activity, or
nutrition. Incentives may include, but need not be limited to, health
premium reductions, differential copayment or coinsurance amounts,
and cash payments. Rewards may include, but need not be limited to,
nonprescription pharmacy products or services not otherwise covered
under an enrollee's health plan contract, exercise classes, gym
memberships, and weight management programs. If a health care service
plan elects to offer an incentive in the form of a reduction in the
premium amount, the premium reduction shall be standardized and
uniform for all groups and subscribers and shall be offered only
after the successful completion of the specified program or practice
by the enrollee or subscriber.
(d) In order to demonstrate compliance with this section, a health
care service plan may file an amendment to its application for
licensure pursuant to subdivision (a) of Section 1352.
(e) This section is in addition to, and does not replace, any
other section in this chapter concerning requirements for plans to
provide health care screening services, childhood immunizations,
adult immunizations, and preventive care services.
(f) (1) Notwithstanding any other provision of law, the provision
of healthy incentives and rewards pursuant to this section by a
health care provider, or his or her agent, that meets the requirement
of this section, shall not be considered or construed as an unlawful
practice, act, kickback, bribe, rebate, remuneration, offer, coupon,
product, payment, or any other form of compensation by a provider or
his or her agent, directly or indirectly, overtly or covertly, in
exchange for another to obtain, participate, or otherwise undergo or
receive health care services.
(2) Notwithstanding any other provision of law, incentives
authorized pursuant to this section are not subject to the penalties,
discipline, limitations, or sanctions imposed under law to preclude
or prohibit, as an unlawful practice, bribe, kickback, or other act,
the offering or delivery of a rebate, remuneration, offer, coupon,
product, rebate, payment, or any other form of compensation by the
provider, or his or her agent, directly or indirectly, overtly or
covertly, in exchange for another to obtain, participate, or
otherwise undergo or receive health care services.
(3) Notwithstanding any other provision of law, the provision of
healthy incentives and rewards pursuant to this section by a health
care provider, or his or her agent, that meets the requirements of
this section shall not be considered or construed as an inducement to
enroll.
(g) This section shall only be implemented if and to the extent
allowed under federal law. If any portion of this section is held to
be invalid, as determined by a final judgment of a court of competent
jurisdiction, this section shall become inoperative.
SEC. 25. Section 1368.025 is added to the
Health and Safety Code , to read:
1368.025. In addition to the duties listed in paragraph (3) of
subdivision (c) of Section 1368.02, the duties of the Office of
Patient Advocate shall include providing access to the public to
reports and data obtained by the lead agency in a format and through
mechanisms, including, but not limited to, the Internet, that allow
the public to use the information to assist them in making informed
selections of health plans, hospitals, medical groups, nursing homes,
and other providers about whom the office has collected information.
SEC. 26. Section 1378 of the Health and
Safety Code is amended to read:
1378. No plan shall expend for administrative costs in any fiscal
year an excessive amount of the aggregate dues, fees and other
periodic payments received by the plan for providing health care
services to its subscribers or enrollees. The term "administrative
costs," as used herein, includes costs incurred in connection with
the solicitation of subscribers or enrollees for the plan. The
director shall adopt regulations no later than July 1, 2008,
requiring that at least 85 percent of aggregate dues, fees, and other
periodic payments received by a full-service plan be spent on health
care services. The regulations shall also define "health care
services." This section shall not apply to Medicare supplement
contracts.
This section shall not preclude a plan from expending additional
sums of money for administrative costs provided such money is not
derived from revenue obtained from subscribers or enrollees of the
plan.
SEC. 27. Section 1395.2 is added to the
Health and Safety Code , to read:
1395.2. (a) A health care service plan may provide notice by
electronic transmission and shall be deemed to have fully complied
with the specific statutory or regulatory requirements to provide
notice by United States mail to an applicant, enrollee, or
subscriber, if it complies with all of the following requirements:
(1) Obtains written authorization from the applicant, enrollee, or
subscriber to provide notices by electronic transmission and to
cease providing notices by United States mail. The authorization
shall be renewed by the enrollee or subscriber on an annual basis. If
the health care service plan obtains an application for coverage by
electronic transmission, it may obtain authorization by electronic
transmission from the applicant, enrollee, or subscriber to provide
notices by electronic transmission.
(2) Uses an authorization form, approved by the department, in
which the applicant, enrollee, or subscriber confirms understanding
of the type of notice that will be provided by electronic
transmission.
(3) Complies with the specific statutory or regulatory
requirements as to the content of the notices it sends by electronic
transmission.
(4) Provides for the privacy of the notice as required by state
and federal laws and regulations.
(5) Allows the applicant, enrollee, or subscriber at any time to
terminate the authorization to provide notices by electronic
transmission and receive the notices through the United States mail.
(6) Sends the electronic transmission of a notice to the last
known electronic address of the applicant, enrollee, or subscriber.
If the electronic transmission fails to reach its intended recipient
twice, the health care service plan shall resume sending all notices
to the last known United States mail address of the applicant,
enrollee, or subscriber.
(7) Maintains an Internet Web site where the applicant, enrollee,
or subscriber may access the notices sent by electronic transmission.
(b) A health care service plan shall not use the electronic mail
address of an applicant, enrollee, or subscriber that it obtained for
the purposes of providing notice pursuant to subdivision (a) for any
purpose other than sending a notice as described in subdivision (a).
(c) No person other than the applicant, enrollee, or subscriber to
whom the medical information in the notice pertains or a
representative lawfully authorized to act on behalf of the applicant,
enrollee, or subscriber, may authorize the transmission of medical
information by electronic transmission. "Medical information" for
these purposes shall have the meaning set forth in subdivision (g) of
Section 56.05 of the Civil Code.
(d) A notice transmitted electronically pursuant to this section
is a private and confidential communication, and it shall constitute
a violation of this chapter for a person, other than the applicant,
enrollee, or subscriber to whom the notice is addressed, to read or
otherwise gain access to the notice without the express, specific
permission of the notice's addressee. This subdivision shall not
apply to a provider of an applicant, enrollee, or subscriber if the
provider is authorized to have access to the medical information
pursuant to the Confidentiality of Medical Information Act (Part 2.6
(commencing with Section 56) of Division 1 of the Civil Code).
(e) A health care service plan shall not impose additional fees or
a differential if an applicant, enrollee, or subscriber elects not
to receive notices by electronic transmission.
(f) "Notice" for purposes of this section includes an explanation
of benefits; responses to inquiries from an applicant, enrollee, or
subscriber; underwriting decisions; distribution of plan contracts,
including evidence of coverage and disclosure forms pursuant to
Sections 1300.63.1 and 1300.63.2 of Title 28 of the California Code
of Regulations; a list of contracting providers pursuant to Section
1367.26; and changes in rates or coverage pursuant to Sections
1374.21, 1374.22, and 1374.23.
SEC. 28. Article 1 (commencing with Section
104250) is added to Chapter 4 of Part 1 of Division 103 of the
Health and Safety Code , to read:
Article 1. California Diabetes Program
104250. The State Department of Public Health shall maintain the
California Diabetes Program, including, but not limited to, the
following:
(a) Provide information on diabetes prevention and management to
the public, including health care providers.
(b) Provide technical assistance to the Medi-Cal program,
including participating providers and Medi-Cal managed care plans,
regarding the proper scope of benefits to be provided to eligible
individuals under Section 14132.23 of the Welfare and Institutions
Code. The assistance may include, but shall not be limited to, all of
the following:
(1) Provide information on evidence-based screening guidelines,
tools, and protocols, including the distribution of these guidelines,
tools, and protocols.
(2) Develop, with assistance from the State Department of Health
Care Services, the Comprehensive Diabetes Services Program
operational screening guidelines and protocols, utilizing the most
current American Diabetes Association screening criteria for diabetes
testing in adults.
(3) Provide the Comprehensive Diabetes Services Program
operational screening guidelines, tools, and protocols, including the
distribution of those guidelines, tools, and protocols.
(4) Provide screening service criteria for diabetes and
prediabetes in accordance with the guidelines developed for the
Comprehensive Diabetes Services Program.
(5) Provide information regarding culturally and linguistically
appropriate lifestyle coaching and self-management training for
eligible adults with prediabetes and diabetes, in accordance with
evidence-based interventions to avoid unhealthy blood sugar levels
that contribute to the progression of diabetes and its complications.
(c) Provide technical assistance to the State Department of Health
Care Services, including assistance on data collection and
evaluation of the Medi-Cal program's Comprehensive Diabetes Services
Program, established pursuant to Section 14132.23 of the Welfare and
Institutions Code.
(d) This section shall be implemented only to the extent funds are
appropriated for purposes of this section in the annual Budget Act
or in another statute.
SEC. 29. Section 104376 is added to the
Health and Safety Code , to read:
104376. (a) (1) The department, in consultation with the
Department of Managed Health Care, the State Department of Health
Care Services, the Managed Risk Medical Insurance Board, and the
Department of Insurance, shall annually identify, on the basis of the
number of persons insured, the 10 largest providers of health care
coverage, including both public and private entities, and ascertain
the smoking cessation benefits provided by each of these coverage
providers.
(2) The department shall summarize the smoking cessation benefit
information gathered under this subdivision and make the benefit
summary available on the Internet, including the department's Web
site.
(b) The department shall, where appropriate, include the smoking
cessation benefit information as part of its educational efforts to
prevent tobacco use that it renders to the public and to health care
providers.
(c) The department shall conduct an evaluation, commencing one
year following the publication of the smoking cessation benefit
information on the department's Web site as provided in this section,
to assess all of the following:
(1) Any changes in the awareness of the beneficiaries of the 10
largest providers of health care coverage as to the availability of
smoking cessation benefits.
(2) Any changes in the awareness of health care providers as to
the availability of smoking cessation benefits.
(3) The extent to which
smoking cessation benefits are utilized by beneficiaries of the 10
largest providers of health care coverage, and any changes in the
utilization rate of these benefits as determined by a comparison with
any available preexisting information.
(4) Smoking-related indicators available through the Health Plan
Employer Data and Information Set.
(5) Any changes to the smoking cessation benefit coverage of the
10 largest providers of health care coverage.
(6) The impact on smoking rates based on the expansion of
counseling services and the direct provision of tobacco cessation
pharmacotherapy by the California Smokers' Helpline.
(d) To the extent funds are appropriated for these purposes, the
department shall increase its efforts to do all of the following:
(1) Reduce smoking by increasing the capacity of effective
cessation services available from the California Smokers' Helpline,
including tobacco cessation pharmacotherapy.
(2) Expand public awareness about the services that are available
through the California Smokers' Helpline.
(3) Expand public awareness and use of existing cessation benefits
that are available to California smokers through their public and
private providers of health care coverage.
SEC. 30. Article 3 (commencing with Section
104705) is added to Chapter 2 of Part 3 of Division 103 of the
Health and Safety Code , to read:
Article 3. Community Makeover Grants
104705. (a) The Community Makeover Grant program is hereby
created and shall be administered by the department. The department
shall award grants to local health departments to serve as local lead
agencies in accordance with this article.
(b) For purposes of determining the amount of each grant awarded
under this article, local health departments shall be allocated, at a
minimum, base funding in proportion to total available funding.
(c) Except as provided in subdivision (b), local health
departments shall receive an allocation based on each county's or
city's proportion of the statewide population, to be expended for
purposes that include, but need not be limited to:
(1) Creating a community infrastructure that promotes active
living and healthy eating.
(2) Coordinating with, at minimum, city, county, and school
partners to facilitate community level, multisector collaboration for
the development and implementation of strategies to facilitate
active living and healthy eating.
(3) Conducting competitive grant application processes to support
local grants. These local grants may be used to develop new programs
and improve existing programs to promote physical activity for
children, improve access to healthy foods, and better utilize
community recreation facilities.
(4) Preparing program interventions and materials that will be
available in accessible, and culturally and linguistically
appropriate, formats.
(d) The department shall issue guidelines for local lead agencies
on how to prepare a local plan for a comprehensive community
intervention program that includes changes to promote active living
and healthy eating, and to prevent obesity and other related chronic
diseases.
(e) The department shall specify data reporting requirements for
local lead agencies and their subcontractors.
(f) (1) The department shall conduct a fiscal and program review
on a regular basis.
(2) If the department determines that any local lead agency is not
in compliance with any provision of this article, the local lead
agency shall submit to the department, within 60 days, a plan for
complying with this article.
(3) The department may withhold funds allocated under this section
from local lead agencies that are not in compliance with this
article.
(g) For purposes of this article, "department" means the State
Department of Public Health.
104710. (a) The department may provide a variety of training,
consultation, and technical assistance to support local programs.
(b) Notwithstanding any other provision of law, the department may
use a request for proposal process or may directly award contracts
to provide the assistance described in subdivision (a) to another
state, federal, or auxiliary organization.
(c) Any organization awarded a contract under this section shall
demonstrate the ability to provide statewide assistance to accelerate
progress, and to ensure the long-term impact of local obesity
prevention programs.
104715. (a) The department shall track and evaluate obesity
related measures, including, but not limited to, active living,
healthy eating, and community environment indicators. These tracking
and evaluation activities shall utilize scientifically appropriate
methods, and may include, but need not be limited to, the following:
(1) Track statewide health indicators.
(2) Evaluate funded projects, determining baseline measures and
progress toward goals, as well as capturing successes and emerging
models.
(3) Compare the effectiveness of individual programs to inform
funding decisions and program modifications.
(4) Incorporate other aspects into the evaluation that have been
identified by the department in consultation with state and local
advisory groups, local health departments, and other interested
parties.
(5) Forecast health and economic cost consequences associated with
obesity.
(6) Funds permitting, utilize a sample size that is adequate to
produce county-, ethnic-, and disability-specific estimates.
(b) The purpose of the evaluation shall be to direct the most
efficient allocation of resources appropriated under this article to
accomplish the maximum reduction of obesity rates. The comprehensive
evaluation shall be designed to measure the extent to which programs
funded pursuant to this article promote the goals identified in the
California Obesity Prevention Plan.
104720. The department shall develop a campaign to educate the
public about the importance of obesity prevention that frames active
living and healthy eating as "California living." The
campaign-centered efforts shall be closely linked with
community-level program change efforts and shall be available in
accessible and culturally and linguistically appropriate formats.
104721. The department shall provide assistance and other support
for schools to promote the availability and consumption of fresh
fruits and vegetables and foods with whole grains.
104725. The department shall provide technical assistance to help
employers integrate wellness policies and programs into employee
benefit plans and worksites.
104726. Notwithstanding any other provision of law, this article
shall be implemented only to the extent funds are appropriated for
purposes of this article in the annual Budget Act or in another
statute.
SEC. 31. Section 128745.1 is added to the
Health and Safety Code , to read:
128745.1. (a) In addition to any other established and pending
reports, commencing January 1, 2010, and every year thereafter, the
office shall publish risk-adjusted outcome reports for percutaneous
coronary interventions, including, but not limited to, the use of
angioplasty or stents. In each year, the reports shall compare
risk-adjusted outcomes by hospital, and in at least every other year,
by hospital and physician. Upon the recommendation of the technical
advisory committee based on statistical and technical considerations,
information on individual hospitals and surgeons may be excluded
from the reports.
(b) The office shall establish a clinical data collection program
to collect data on percutaneous coronary interventions, including,
but not limited to, the use of angioplasty or stents, performed in
hospitals. The office shall establish by regulation the data to be
reported by each hospital at which percutaneous coronary
interventions are performed. In establishing the data to be reported,
the office shall consult with the clinical panel established
pursuant to Section 128748.
SEC. 32. Chapter 4 (commencing with Section
128850) is added to Part 5 of Division 107 of the Health
and Safety Code , to read:
CHAPTER 4. HEALTH CARE COST AND QUALITY TRANSPARENCY
Article 1. General Provisions
128850. The Legislature hereby finds and declares that:
(a) The steady rise in health costs is eroding health access,
undermining wages and pensions, straining public health and finance
systems, and placing an undue burden on the state's economy. Health
care that costs more is not necessarily health care that improves
life expectancy, reduces death rates, improves health or minimizes
illness and chronic conditions.
(b) Although there are existing voluntary efforts to report on
health care quality at various levels of the health care system in
California, the collection of performance data on a voluntary basis
is inconsistent and incomplete and does not meet the needs of
policymakers, purchasers, consumers, or the health industry for
reliable comparisons of provider cost and quality.
(c) Data that is collected through existing state programs is not
collected or analyzed with the goal of reducing health care costs in
the system, monitoring performance, or ensuring quality patient
outcomes.
(d) The present day overall lack of transparency of health
outcomes and the factors affecting health care costs limits the
ability of consumers, purchasers, and policymakers to seek out and
reward high quality providers, or to make quality improvements where
they are needed.
(e) The effective use and distribution of health care data and
meaningful analysis of that data will lead to greater transparency in
the health care system resulting in improved health care quality and
outcomes, more cost-effective care and improvements in life
expectancy, reduced death rates, and improved overall public health.
(f) Hospitals, physicians, health care providers, and health
insurers who have access to systemwide performance data can use the
information to improve patient safety, efficiency of health care
delivery, and quality of care, leading to quality improvement and
costs savings throughout the health care system.
(g) Without comprehensive, systemwide data that is adequately
analyzed and reported widely, the Legislature cannot effectively
evaluate the health care system, establish appropriate regulatory
standards, or identify the most effective use and value for state
health care dollars. Moreover, consumers and purchasers cannot
exercise informed choice in the market or identify the most
cost-effective quality providers and services.
(h) The State of California is uniquely positioned to collect,
analyze, and report all payer data on health care utilization,
quality, and costs in the state in order to facilitate value-based
purchasing of health care and to support and promote continuous
quality improvement among health care plans and providers.
(i) It is therefore the intent of the Legislature to assume a
leadership role in measuring performance and value in the health care
system. By establishing statewide data and common measurement and
analyses of health care costs, quality, and outcomes, and by
establishing a statewide leadership organization with sufficient
revenues to adequately analyze and report meaningful performance
measures related to health care costs and quality, the Legislature
intends to promote competition, identify appropriate health care
utilization, and ensure the highest quality of health care services
for all Californians.
(j) The Legislature further intends to reduce duplication and
inconsistency in the collection, analysis, and dissemination of
health care performance information within state government and among
both public and private entities by establishing one state-level
commission with primary responsibility for coordinating health care
data development, collection, analysis, evaluation, and
dissemination.
(k) The Legislature intends for the commission to ensure the
availability of reliable data to measure and compare performance
within the health care system along each of the domains identified by
the Institute of Medicine: safety, timeliness, effectiveness,
efficiency, equity, and patient-centeredness.
(l) It is further the intent of the Legislature that the data
collected be used for the transparent public reporting of quality and
cost efficiency information regarding all levels of the health care
system, including health care service plans and health insurers,
hospitals and other health facilities, and medical groups and
physicians, so that health care plans and providers can improve their
performance and deliver safer, better health care more affordably;
so that purchasers can know which health care services reduce
morbidity, mortality, and other adverse health outcomes; so that
consumers can choose whether and where to have health care provided;
and so that the Legislature can effectively regulate and monitor the
health care delivery system to ensure quality and value for all
purchasers and consumers.
128851. As used in this chapter, the following terms have the
following meanings:
(a) "Administrative claims data" means data that is submitted
electronically or otherwise to, or collected by, health insurers,
health care service plans, administrators, or other payers of health
care services, and which are submitted to, or collected for, the
purposes of payment to any physician, physician group, laboratory,
pharmacy, hospital of any type, imaging center, or any other facility
or person that is requesting payment for the provision of medical
care.
(b) "Ambulatory surgery center" means a facility where procedures
are performed on an outpatient basis in general operating rooms,
ambulatory surgery rooms, endoscopy units, or cardiac catheterization
laboratories of a hospital or a freestanding ambulatory surgery
clinic.
(c) "Commission" means the California Health Care Cost and Quality
Transparency Commission.
(d) "Data source" means any physician, physician group, health
facility, health care service plan, health insurer, any state agency
providing or paying for health care or collecting health care data or
information, or any other payer for health care services in
California.
(e) "Encounter data" means data relating to treatment or services
rendered by providers to patients which may be reimbursed on a
fee-for-service or capitation basis.
(f) "Group" or "physician group" means an affiliation of
physicians and other health care professionals, whether a
partnership, corporation, or other legal form, with the primary
purpose of providing medical care.
(g) "Healthcare-associated infection" means a localized or
systemic condition that (1) results from adverse reaction to the
presence of an infectious agent or its toxin and (2) was not present
or incubating at the time of admission to the hospital.
(h) "Health care provider" means a physician, physician group, or
health facility.
(i) "Health facility" or "health facilities" means health
facilities required to be licensed pursuant to Chapter 2 (commencing
with Section 1250) of Division 2.
(j) "Office" means the Office of Statewide Health Planning and
Development.
(k) "Risk-adjusted outcomes" means the clinical outcomes of
patients grouped by diagnoses or procedures that have been adjusted
for demographic and clinical factors.
128852. Notwithstanding the provisions of Chapter 1 (commencing
with Section 128675), commencing July 1, 2009, the responsibilities
of the office with respect to determining the data to be collected
and the analysis and reporting of the data collected pursuant to
Chapter 1 (commencing with Section 128675) shall be transferred to
the commission, as determined by the commission and as reported to
the Secretary of Health and Welfare and the Legislature no later than
January 1, 2009. Any limitations on the collection, analysis, and
use of data in that chapter shall be inapplicable to the extent
determined necessary by the commission to implement its
responsibilities under this chapter. All data collected by the office
shall be available to the commission for the purposes of carrying
out its responsibilities under this chapter. During the initial
development of the data plan pursuant to Section 128675, the office
shall make available to the commission any and all data files,
information, and staff resources as may be necessary to assist in and
support the plan's development.
128853. This chapter shall be operative on July 1, 2008.
Article 2. Health Care Cost and Quality Transparency
Commission
128855. There is hereby created in the California Health and
Human Services Agency, the California Health Care Cost and Quality
Transparency Commission composed of 13 members, each of whom shall
have demonstrated knowledge and experience in the measurement and
analysis of health care quality or cost data, in deploying that data
on behalf of consumers and purchasers, or in health care or other
issues relevant to the commission's responsibilities. The
appointments shall be made as follows:
(a) The Governor shall appoint seven members as follows:
(1) One academic with experience in health care data and cost
efficiency research.
(2) One representative of hospitals.
(3) One representative of an integrated multispecialty medical
group.
(4) One representative of physician and surgeons.
(5) One representative of large employers that purchase group
health care coverage for employees and that is not also a supplier or
broker in health care coverage.
(6) One representative of a labor union.
(7) One representative of employers that purchase group health
care coverage for their employees or a representative of a nonprofit
organization that demonstrates experience working with employers to
enhance value and affordability of health care coverage.
(b) The Senate Committee on Rules shall appoint three members as
follows:
(1) One representative of a labor union.
(2) One representative of consumers with a demonstrated record of
advocating health care issues on behalf of consumers.
(3) One representative of health insurers or health care service
plans.
(c) The Assembly Speaker shall appoint three members as follows:
(1) One representative of consumers with a demonstrated record of
advocating health care issues on behalf of consumers.
(2) One representative of small employers that purchase group
health care coverage for employees that is not also a supplier or
broker in health care coverage.
(3) One representative of a nonprofit labor-management purchaser
coalition that has a demonstrated record of working with employers
and employee associations to enhance value and affordability in
health care.
(d) The following members shall serve in an ex officio, nonvoting
capacity:
(1) The Secretary of California Health and Human Services or a
designee.
(2) A designee of the California Public Employees' Retirement
System.
(3) The Director of the Department of Managed Health Care or a
designee.
(4) The executive director of the Managed Risk Medical Insurance
Board or a designee.
(5) The Insurance Commissioner or a designee.
(e) The Governor shall designate a member to serve as chairperson
for a two-year term. No member may serve more than two, two-year
terms as chairperson. All appointments shall be for four-year terms;
provided, however, that the initial term shall be two years for
members initially filling the positions set forth in paragraphs 1, 2,
4, and 6 of subdivision (a), paragraph 2 of subdivision (b), and
paragraph 2 of subdivision (c).
128856. The commission shall meet at least once every two months,
or more often if necessary to fulfill its duties.
128857. The members of the commission shall receive a per diem of
one hundred dollars ($100) for each day actually spent in the
discharge of official duties and shall be reimbursed for any actual
and necessary expenses incurred in connection with their duties as
members of the commission.
128858. The commission shall appoint an executive director, who
shall serve at the pleasure of the commission. The executive director
shall receive the salary established by the Department of Personnel
Administration for exempt officials. The executive director shall
administer the affairs of the commission as directed by the
commission and shall direct the staff of the commission. The
executive director may appoint, with the approval of the commission,
staff necessary to carry out the functions and duties of the
commission.
128859. The commission shall be authorized to do the following:
(a) Enter into contracts.
(b) Sue and be sued.
(c) Employ necessary staff.
(d) Authorize expenditures from the fund or from other moneys
appropriated in the annual Budget Act or other public or private
revenues as necessary to carry out its responsibilities under this
chapter.
(e) Adopt, amend, and rescind such regulations, forms, and orders
as are necessary to carry out its responsibilities under this
chapter.
(f) Require any data source to submit data necessary to implement
the health care cost and quality transparency plan, provided the
health care cost and quality transparency plan is adopted by
regulation, pursuant to Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code.
(g) Determine the data elements to be collected, the reporting
formats for data submitted, and the use and reporting by the
commission of any data submitted.
(h) Audit the accuracy of all data submitted and require entities
submitting financial data for the purposes of this part to submit
proof that financial data submitted has been audited in accordance
with generally accepted auditing principles.
(i) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon it
under this chapter.
128860. The commission shall have no authority to disclose any
confidential information concerning contracted rates between health
care providers and any data source, but nothing in this section shall
prevent the commission from publicly disclosing information on the
relative or comparative cost to payers or purchasers of health care
or the costs for a specific course of treatment or episode, as
applicable for the reporting.
128861. (a) No later than January 1, 2009, the commission shall
determine the functions currently performed by the office that are
necessary to the commission's activities and report to the Secretary
of Health and Welfare and the Legislature those functions that shall
be transferred to the commission effective July 1, 2009.
(b) All regulations adopted by the office that relate to functions
vested in the commission and that are in effect immediately
preceding July 1, 2009, shall remain in effect and shall be fully
enforceable unless and until readopted, amended, or repealed by the
commission.
(c) The commission may use the unexpended balance of funds
available for use in connection with the performance of the functions
of the office transferred to the commission.
(d) All officers and employees of the office who, on July 1, 2009,
are serving in the state civil service, other than as temporary
employees, and engaged in the performance
of a function vested in the commission shall be
transferred to the commission. The status, positions, and rights of
these persons shall not be affected by the transfer except as to
positions exempted from civil service.
(e) The commission shall have possession and control of all
records, papers, offices, equipment, supplies, moneys, funds,
appropriations, land or other property, real or personal, held for
the benefit or use of the office for the performance of functions
transferred to the commission.
128862. The functions and duties of the commission shall include
the following:
(a) Develop, implement, and periodically update a health care
quality and cost containment plan, including data collection,
performance measurement, and reporting methods, that provides for
effective measurement of the safety and quality of an array of health
care services provided to Californians.
(b) Determine the data to be collected, and method of collection,
to implement the data collection and reporting requirements set forth
in this chapter.
(c) Determine the measures necessary to implement the reporting
requirements in the plan developed pursuant to 128864 in a manner
that is cost-effective and reasonable for data sources and timely,
relevant, and reliable for consumers and purchasers.
(d) Determine the reports and data to be made available to the
public in order to accomplish the purposes of this chapter, including
conducting studies and reporting the results of the studies.
(e) Seek to establish agreements for voluntary reporting of health
care claims and data from any and all health care payers who are not
subject to mandatory reporting to the commission pursuant to this
chapter, and its subsequent regulations, in order to ensure
availability of the most comprehensive, systemwide data on health
care costs and quality.
(f) Collect, aggregate, and timely distribute performance data on
quality, health outcomes, cost, utilization, and pricing in a manner
accessible for purchasers, consumers, and policymakers.
(g) Fully protect patient privacy, in compliance with state and
federal medical privacy laws, while preserving the ability to analyze
data using date of birth, ethnicity, and sex where the disclosure of
this information will not identify an individual.
(h) Create technical advisory committees and clinical advisory
committees, as necessary, to advise the commission on technical or
clinical issues.
(i) Annually report to the Governor and the Legislature, on or
before March 1, on the status of implementing this chapter, the
resources necessary to fully implement this chapter, and any
recommendations for statutory changes that would advance the purposes
of this chapter.
(j) Provide state leadership and coordination of public and
private health care quality and performance measurements to ensure
efficiency, cost-effectiveness, transparency, and informed choice by
purchasers and consumers.
128863. (a) The commission shall appoint at least one technical
advisory committee, and may appoint additional technical advisory
committees as the commission deems appropriate, and shall include on
each such committee academic and professional experts with expertise
related to the activities of the commission.
(b) The commission shall appoint at least one clinical advisory
committee and may appoint additional advisory committees specific to
issues that require additional or different clinical expertise. Each
clinical advisory committee shall include clinicians and others with
expertise related to the activities of the commission and any issue
under consideration.
(c) The commission shall, as appropriate, refer technical and
clinical issues, including issues related to risk adjustment
methodology, to an advisory committee for recommendation. The
advisory committee shall, within the time period specified by the
commission, issue to the commission a written recommendation
concerning the issue referred to the advisory committee. The
commission shall consider the recommendation of the advisory
committee. If the commission rejects the recommendation, it shall
issue a written finding and rationale for rejecting the
recommendation. If the advisory committee fails to issue a
recommendation within the time period prescribed by the commission,
the commission may appoint another advisory committee or take such
other action it deems necessary to obtain the needed technical or
clinical information required to carry out its responsibilities.
(d) The members of the technical and clinical advisory committees
appointed by the commission shall receive no compensation, but shall
be reimbursed for any actual and necessary expenses incurred in
connection with their duties as members of the advisory committee.
(e) The commission shall provide opportunities for participation
from consumers, purchasers, and providers at all advisory committee
meetings.
128864. The commission shall develop and implement a
conflict-of-interest policy applicable to all employees, contractors,
and advisory committee members that will ensure, at a minimum, that
persons advising the commission disclose any material financial
interest in the outcome of the work performed on behalf of the
commission.
Article 3. Health Care Cost and Quality Transparency Plan
128865. (a) The Commission shall, by December 1, 2009, develop
and, by regulation adopt, a health care cost and quality transparency
plan that will, when implemented, result in the transparent public
reporting of safety, quality, and cost efficiency information at all
levels of the health care system. The plan shall:
(1) Include specific strategies to measure and collect data
related to health care safety and quality, utilization, cost to
payers, and health outcomes and shall focus on data elements that
foster quality improvement and peer group comparisons.
(2) Facilitate value-based, cost-effective purchasing of health
care services by public and private purchasers.
(3) Result in useable information that allows health care
purchasers, consumers, and data sources to identify and compare
health plans and insurers as well as individual health facilities,
physicians, and other health care providers, on the extent to which
they provide safe, cost-effective, high quality health care services.
(4) Be designed to measure each of the performance domains
identified by the Institute of Medicine: safety, timeliness,
effectiveness, efficiency, equity and patient-centeredness.
(5) Use and build on existing data collection standards and
methods to the greatest extent possible to accomplish the goals of
the commission in a cost-effective manner, which may include, but not
be limited to, collecting and disseminating one or more nationally
recognized methodologies for measuring and quantifying provider
quality, cost and service effectiveness, and implementing systemwide
mandatory collection of data elements otherwise being collected in
existing voluntary public and private reporting programs in
California.
(6) Incorporate and utilize administrative claims data to the
extent it is the most cost-efficient method of collecting data in
order to minimize the cost and administrative burden on data sources.
The commission may incorporate and utilize data other than
administrative claims data, provided it is necessary to measure and
analyze a significant health care quality, safety, or cost issue that
cannot be adequately measured with the use of administrative claims
data.
(b) The plan shall include all of the following:
(1) The reports, analyses, and data that will be made available to
data sources, purchasers, and consumers on the performance of health
plans and insurers, medical groups, health facilities, and
physicians, the format in which the reports and data will be made
available, and the planned implementation dates.
(2) The data elements necessary to produce the reports and data to
be made available. The plan shall address the extent to which
standardized electronic reporting of administrative claims data can
provide the information necessary for the purposes of this chapter,
and the most efficient, least burdensome method of collecting other
necessary data, including systemwide encounter data.
(3) The data elements to be collected and how they will be
collected.
(4) A unique patient identifier to permit analysis of health care
utilization patterns that indicate inadequate quality of care, such
as hospital readmissions and repetitive service utilization.
(5) The manner in which patient confidentiality will be maintained
in compliance with state and federal medical and patient privacy
laws.
(6) The administration of data collection, quality assurance, and
reporting functions.
(7) The funding necessary to implement the plan and
recommendations for revenue sources to provide that funding.
(8) A review of existing public and private health performance
data collection and reporting standards and practices, at the state
and federal level, and strategies for incorporating or coordinating
with existing mandatory and voluntary measurement and reporting
activities as the commission determines necessary to accomplish the
goal of this chapter in a cost-effective manner. The review of state
programs shall include, at a minimum, review of data collection
programs administered by the office and the Office of the Patient
Advocate.
(9) The timeline for implementation of the plan and a specific
timeline and process for updating the plan on a regular basis.
128866. The commission may contract with a qualified public or
private agency or academic institution to assist in the review of
existing data collection programs or to conduct other research or
analysis the commission deems necessary to complete and implement the
plan required pursuant to Section 128865 or to meet any of its
obligations under this chapter.
128867. The commission shall review and, where appropriate,
incorporate into the plan required by Section 128865 health care data
collection and reporting required under other state laws, including,
but not limited to, Chapter 1 (commencing with Section 128675),
Article 3.5 (commencing with Section 1288.10) of Chapter 2 of
Division 2, and Sections 1279.1, 1279.3, and 1368.02, and shall
recommend any modification of these statutes necessary to be
consistent with the plan developed pursuant to Section 128865. Data
collection and reporting required by these provisions shall not be
delayed pending the development and implementation of the plan.
128868. (a) No later than December 1, 2008, and annually
thereafter, the commission shall publicly report the federal Agency
for Healthcare Research and Quality Patient Safety Indicators and
Inpatient Quality Indicators for each acute care hospital licensed in
California using administrative discharge data that hospitals report
pursuant to this part.
(b) No later than July 1, 2010, the commission shall publish an
initial report of health care associated infection rates in general
acute care hospitals. The types of infection to be included and the
methods to be used shall be determined by the commission, in
consultation with the state Department of Public Health and the
committee established pursuant to Section 1288.5. The report shall be
based on data collected for a period of 12 months, and thereafter
shall be updated quarterly.
Article 4. Fees
128870. (a) The commission shall, to the extent possible, recover
the cost of implementing this chapter from fees charged to data
sources and data users. As part of the plan adopted pursuant to
Article 3 (commencing with Section 128865), the commission shall
promulgate a schedule of fees that will, to the extent possible,
recover the cost of implementing centralized data collection,
effective analysis, and reporting activities under this chapter. The
schedule of fees shall be based on the relative need to collect and
analyze information from various data sources, and the relative value
to data sources and users, in order to correct the adverse health
effects that have resulted from the lack of transparency of health
care cost and quality information. The fee schedule shall ensure
appropriate access to data at a reasonable cost for academic
researchers. Notwithstanding this section, the commission shall not
fail to publish reports for the public consistent with the plan and
shall not otherwise charge members of the public for access to the
reports generated and published by the commission.
(b) The commission may seek and accept contributions to support
the work of the commission from any foundation or other public or
private entity that does not have a financial interest in the outcome
of the work of the commission, as defined in the
conflict-of-interest policy adopted pursuant to Section 128864.
128871. There is hereby established in the State Treasury, the
Health Care Cost and Quality Transparency Fund to support the work of
the commission. All fees and contributions collected by the
commission pursuant to Section 128870 shall be deposited in this fund
and, upon appropriation by the Legislature, used to support the work
of the commission.
Article 5. Penalties
128875. (a) Any data source that fails to file any report as
required by this chapter or by the health care cost and quality
transparency plan adopted pursuant to this chapter, shall be liable
for a civil penalty of one hundred dollars ($100) to one thousand
dollars ($1,000) per day. The commission shall, as part of the plan
developed pursuant to section 128865, promulgate a schedule of civil
penalties that will be assessed for reporting violations that varies
from one hundred dollars ($100) per day for the least serious
violation, up to one thousand dollars ($1,000) for the most serious
violation.
(b) Civil penalties shall be assessed and recovered in a civil
action brought by the commission in the name of the people of the
State of California. Assessment of a civil penalty may, at the
request of a health care provider, be reviewed on appeal and the
penalty may be reduced or waived by the commission for good cause.
(c) Any money received by the commission pursuant to this section
shall be paid into the General Fund.
SEC. 33. Section 130545 is added to the
Health and Safety Code , to read:
130545. (a) The State Department of Health Care Services shall
identify best practices related to e-prescribing modalities and
standards and shall make recommendations for statewide adoption of
e-prescribing on or before January 1, 2009.
(b) The State Department of Health Care Services shall develop a
pilot program to foster the adoption and use of electronic
prescribing by health care providers that contract with Medi-Cal. The
implementation of this Medi-Cal pilot is contingent upon the
availability of FFP or federal grant funds. The department may
provide electronic prescribing technology, including equipment and
software, to participating Medi-Cal prescribers.
SEC. 34. Section 10113.11 is added to the
Insurance Code , to read:
10113.11. (a) A health insurer may provide notice by electronic
transmission and shall be deemed to have fully complied with the
specific statutory or regulatory requirements to provide notice by
United States mail to an applicant or insured if it complies with all
of the following requirements:
(1) Obtains written authorization from the applicant or insured to
provide notices by electronic transmission and to cease providing
notices by United States mail. The authorization shall be renewed by
the insured on an annual basis. If the health insurer obtains an
application for coverage by electronic transmission, it may obtain
authorization by electronic transmission from the applicant or
insured to provide notices by electronic transmission.
(2) Uses an authorization form, approved by the department, in
which the applicant or insured confirms understanding of the type of
notice that will be provided by electronic transmission.
(3) Complies with the specific statutory or regulatory
requirements as to the content of the notices it sends by electronic
transmission.
(4) Provides for the privacy of the notice as required by state
and federal laws and regulations.
(5) Allows the applicant or insured at any time to terminate the
authorization to provide notices by electronic transmission and
receive the notices through the United States mail.
(6) Sends the electronic transmission of a notice to the last
known electronic address of the applicant or insured. If the
electronic transmission of the notice fails to reach its intended
recipient twice, the health insurer shall resume sending all notices
to the last known United States mail address of the applicant or
insured.
(7) Maintains an Internet Web site where the applicant or insured
may access the notices sent by electronic transmission.
(b) A health insurer shall not use the electronic mail address of
an applicant or insured that it obtained for the purposes of
providing notice pursuant to subdivision (a) for any purpose other
than sending a notice as described in subdivision (a).
(c) No person other than the applicant or insured to whom the
medical information in the notice pertains or a representative
lawfully authorized to act on behalf of the applicant or insured, may
authorize the transmission of medical information by electronic
transmission. "Medical information" for these purposes shall have the
meaning set forth in subdivision (g) of Section 56.05 of the Civil
Code.
(d) A notice transmitted electronically pursuant to this section
is a private and confidential communication, and it shall be unlawful
for a person, other than the applicant or insured to whom the notice
is addressed, to read or otherwise gain access to the notice without
the express, specific permission of the notice's addressee. This
subdivision shall not apply to a provider of an applicant or insured
if the provider is authorized to have access to the medical
information pursuant to the Confidentiality of Medical Information
Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil
Code).
(e) A health insurer may not impose additional fees or a
differential if an applicant or insured elects not to receive notices
by electronic transmissions.
(f) "Notice" for purposes of this section includes explanation of
benefits; distribution of the insurer's policies and certificates of
coverage; a list of contracting providers; responses to inquiries
from insureds; changes in rates pursuant to Sections 10113.7 and
10901.3; and notices related to underwriting decisions pursuant to
Section 791.10.
SEC. 35. Section 10123.56 is added to the
Insurance Code , to read:
10123.56. (a) Every policy of group health insurance that is
offered, delivered, amended, or renewed on or after January 1, 2009,
that covers hospital, medical, or surgical expenses shall offer
coverage that includes a Healthy Action Incentives and Rewards
Program as described in subdivision (c). Every insurer shall
communicate the availability of this coverage to all group
policyholders and to all prospective group policyholders with whom
they are negotiating.
(b) Every policy of insurance that is offered, delivered, amended,
or renewed on or after January 1, 2009, that covers hospital,
medical, or surgical expenses on an individual basis shall offer
individuals at least one coverage choice that includes a Healthy
Action Incentives and Rewards Program that meets the requirements
described in subdivision (c).
(c) For purposes of this section, benefits for a Healthy Action
Incentives and Rewards Program shall provide for all of the
following:
(1) Health risk appraisals that collect information from
individuals to assess overall health status and to identify risk
factors, including, but not limited to, smoking and smokeless tobacco
use, alcohol abuse, drug use, and nutrition and physical activity
practices.
(2) A followup appointment with a licensed health care
professional acting within his or her scope of practice to review the
results of the health risk appraisal and discuss any recommended
actions.
(3) Incentives or rewards for policyholders to became more engaged
in their health care and to make appropriate choices that support
good health, including obtaining health risk appraisals, screening
services, immunizations, or participating in healthy lifestyle
programs or practices. These programs or practices may include, but
need not be limited to, smoking cessation, physical activity, or
nutrition. Incentives may include, but need not be limited to, health
premium reductions, differential copayment or coinsurance amounts,
and cash payments. Rewards may include, but need not be limited to,
nonmedical pharmacy products or services not otherwise covered under
a policyholder's health insurance contract, gym memberships, and
weight management programs. If an insurer elects to offer an
incentive in the form of a reduction in the premium amount, the
premium reduction shall be standardized and uniform for all groups
and policyholders and shall be offered only after the successful
completion of the specified program or practice by the insured or
policyholder.
(d) This section is in addition to, and does not replace, any
other section in this code concerning requirements for insurers to
provide health care screening services, childhood immunizations,
adult immunizations, and preventive care services.
(e) (1) Notwithstanding any other provision of law, the provision
of healthy incentives and rewards pursuant to this section by a
health care provider, or his or her agent, that meets the
requirements of this section, Section 1367.38 of the Health and
Safety Code, or Section 14132.105 of the Welfare and Institutions
Code shall not be considered or construed as an unlawful practice,
act, kickback, bribe, rebate, remuneration, offer, coupon, product,
payment, or any other form of compensation by a provider or his or
her agent, directly or indirectly, overtly or covertly, in exchange
for another to obtain, participate, or otherwise undergo or receive
health care services.
(2) Notwithstanding any other provision of law, incentives
authorized pursuant to this section are not subject to the penalties,
discipline, limitations, or sanctions imposed under law to preclude
or prohibit, as an unlawful practice, bribe, kickback or other act,
the offering or delivery of a rebate, remuneration, offer, coupon,
product, rebate, payment, or any other form of compensation by the
provider, or his or her agent, directly or indirectly, overtly or
covertly, in exchange for another to obtain, participate, or
otherwise undergo or receive health care services.
(3) Notwithstanding any other provision of law, the provision of
healthy incentives and rewards pursuant to this section by a health
care provider, or his or her agent, that meets the requirements of
this section shall not be considered or construed as an inducement to
enroll.
(f) This section shall only be implemented if and to the extent
allowed under federal law. If any portion of this section is held to
be invalid, as determined by a final judgment of a court of competent
jurisdiction, this
section shall become inoperative.
SEC. 36. Chapter 1.6 (commencing with Section
10199.10) is added to Part 2 of Division 2 of the
Insurance Code , to read:
CHAPTER 1.6. CALIFORNIA INDIVIDUAL COVERAGE GUARANTEE ISSUE
10199.10. It is the intent of the Legislature to do both of the
following:
(a) Guarantee the availability and renewability of health coverage
through the private health insurance market to individuals.
(b) Require that health care service plans and health insurers
issuing coverage in the individual market compete on the basis of
price, quality, and service, and not on risk selection.
10199.104. (a) On or before September 1, 2008, the commissioner
and the Director of the Department of Managed Health Care shall
jointly adopt regulations governing five classes of individual health
benefit plans that health care service plans and health insurers
shall make available.
(b) Within 90 days of the adoption of the regulations required by
subdivision (a), the commissioner and the Director of the Department
of Managed Health Care shall jointly approve five classes of
individual health benefit plans for each health care service plan and
health insurer participating in the individual market, with each
class having an increased level of benefits beginning with the lowest
class. Within each class, the commissioner and the Director of the
Department of Managed Health Care shall jointly approve one baseline
HMO and one baseline PPO, each of which is the lowest cost product to
be issued by health care service plans and health insurers in the
individual market. The classes of benefits jointly approved by the
commissioner and the Director of the Department of Managed Health
Care shall reflect a reasonable continuum between the class with the
lowest level of benefits and the class with the highest level of
benefits, shall permit reasonable benefit variation that will allow
for a diverse market within each class, and shall be enforced
consistently between health care service plans and health insurers in
the same marketplace regardless of licensure.
(c) In approving the five classes of plans filed by health care
service plans and health insurers, the commissioner and the Director
of the Department of Managed Health Care shall do both of the
following:
(1) Jointly determine that the plans provide reasonable benefit
variation, allowing a diverse market.
(2) Jointly require either (A) that benefits within each class are
standard and uniform across all plans and insurers, or (B) that
benefits offered in each class are actuarially equivalent across all
plans and insurers.
10199.105. On and after July 1, 2010, health care service plans
and health insurers participating in the individual market shall
guarantee issue the five classes of approved health benefit plans and
shall, at the same time, discontinue offering and selling health
benefit plans other than those within the five approved classes of
benefit plans in the individual market.
10199.106. Individuals may purchase a health benefit plan from
one of the five classes of approved plans on a guaranteed issue
basis. After selecting and purchasing a health benefit plan within a
class of benefits, an individual may change plans only as set forth
in this section. For individuals enrolled as a family, the subscriber
may change classes for himself or herself, or for all dependents:
(a) Annually in the month of the subscriber's birth, an individual
may select a different individual plan from another health care
service plan or insurer, within the same class of benefits or the
next higher level of benefits.
(b) Annually in the month of the subscriber's birth, an individual
may move up one class of benefits offered by the same health care
service plan or health insurer.
(c) At any time a subscriber may move to a lower class of
benefits.
(d) At significant life events, the insured may move up to a
higher class of benefits as follows:
(1) Upon marriage or entering into a domestic partnership.
(2) Upon divorce.
(3) Upon the death of a spouse or domestic partner, on whose
health coverage an individual was a dependent.
(4) Upon the birth or adoption of a child.
(e) A dependent child may terminate coverage under a parent's plan
and select coverage for his or her own account following his or her
18th birthday.
(f) If a subscriber becomes eligible for group benefits, Medicare,
or other benefits, and selects those benefits in lieu of his or her
individual coverage, the dependent spouse or domestic partner may
become the subscriber. If there is no dependent spouse or domestic
partner enrolled in the plan, the oldest child may become the
subscriber.
10199.107. At the time an individual applies for health coverage
from a health care service plan or health insurer participating in
the individual market, an individual shall provide information as
required by a standardized health status questionnaire to assist
plans and insurers in identifying persons in need of disease
management. Health care service plans and health insurers may not use
information provided on the questionnaire to decline coverage, or to
limit an individual's choice of health care benefit plan.
10199.108. Health benefit plans shall become effective within 31
days of receipt of the individual's application, standardized health
status questionnaire, and premium payment.
10199.109. Health care service plans and health insurers may
reject an application for health care benefits if the individual does
not reside or work in a plan's or insurer's approved service area.
10199.110. The commissioner or the Director of the Department of
Managed Health Care, as applicable, may require a health care service
plan or health insurer to discontinue the offering of health care
benefits, or acceptance of applications from individuals, upon a
determination by the director or commissioner that the plan or
insurer does not have sufficient financial viability, or
organizational and administrative capacity, to ensure the delivery of
health care benefits to its enrollees or insureds.
10199.111. All health care benefits offered to individuals shall
be renewable with respect to all individuals and dependents at the
option of the subscriber, except:
(a) For nonpayment of the required premiums by the subscriber.
(b) When the plan or insurer withdraws from the individual health
care market, subject to rules and requirements jointly adopted by the
director and the Insurance Commissioner.
10199.112. No health care service plan or health insurer shall,
directly or indirectly, enter into any contract, agreement, or
arrangement with a solicitor that provides for or results in the
compensation paid to a solicitor for the sale of a health care
service plan contract or health insurance policy to be varied because
of the health status, claims experience, occupation, or geographic
location of the individual, provided the geographic location is
within the plan's or insurer's approved service area.
10199.113. This chapter shall not apply to individual health plan
contracts for coverage of Medicare services pursuant to contracts
with the United States Government, Medi-Cal contracts with the State
Department of Health Care Services, Healthy Families Program
contracts with the Managed Risk Medical Insurance Board, high-risk
pool contracts with the Major Risk Medical Insurance Program,
Medicare supplement policies, long-term care policies, specialized
health plan contracts, or contracts issued to individuals who secure
coverage from Cal-CHIPP.
10199.114. (a) A health care service plan or health insurer may
rate its entire portfolio of health benefit plans in accordance with
expected costs or other market considerations, but the rate for each
plan or insurer shall be set in relation to the balance of the
portfolio as certified by an actuary. Each benefit plan shall be
priced as determined by each health care service plan or health
insurer to reflect the difference in benefit variation, or the
effectiveness of a provider network, but may not adjust the rate for
a specific plan for risk selection. A health care service plan's or
health insurer's rates shall use the same rating factors for age,
family size, and geographic location for each individual health care
benefit plan it issues. Rates for health care benefits may vary from
applicant to applicant only by any of the following:
(1) Age of the subscriber, as determined by the commissioner and
the Director of the Department of Managed Health Care.
(2) Family size in categories determined by the commissioner and
the Director of the Department of Managed Health Care.
(3) Geographic rate regions as determined by the commissioner and
the Director of the Department of Managed Health Care.
(4) Health improvement discounts. A health care service plan or
health insurer may reduce copayments or offer premium discounts for
nonsmokers, individuals demonstrating weight loss through a
measurable health improvement program, or individuals actively
participating in a disease management program, provided discounts are
approved by the commissioner and the Director of the Department of
Managed Health Care.
(b) The commissioner and the Director of the Department of Managed
Health Care shall take into consideration the age, family size, and
geographic region rating categories applicable to small group
coverage contracts pursuant to Section 1357 of the Health and Safety
Code and Section 10700 of this code in implementing this section.
10199.115. The first term of each health benefit plan contract or
policy issued shall be from the effective date through the last day
of the month immediately preceding the subscriber's next birthday.
Contracts or policies may be renewed by the subscriber as set forth
in this chapter.
10199.116 This chapter, other than Section 10199.104, shall not
become operative until the date that the provisions of Section
8899.50 of the Government Code are implemented.
SEC. 37. Section 10293.5 is added to the
Insurance Code , to read:
10293.5. (a) The commissioner shall adopt regulations no later
than July 1, 2008, requiring that at least 85 percent of health
insurance premium revenue received by a health insurer be spent on
health care services. The regulations shall also define "health care
services."
(b) As used in this section, health insurance shall have the same
meaning as in subdivision (b) of Section 106.
(c) The requirements of this chapter shall not apply to a Medicare
supplement, vision-only, dental-only, or CHAMPUS-supplement
insurance or to hospital indemnity, hospital-only, accident-only, or
specified disease insurance that does not pay benefits on a fixed
benefit, cash payment only basis.
SEC. 38. Section 10607 of the Insurance
Code is amended to read:
10607. In addition to the other disclosures required by this
chapter, every insurer and their employees or agents shall, when
presenting a plan for examination or sale to any individual or the
representative of a group consisting of 25
100 or fewer individuals, disclose in writing the ratio of
incurred claims to earned premiums (loss-ratio) for the insurer's
preceding calendar year. This section shall become operative
on March 1, 1991, in order to allow insurers time to comply
year for policies with its provisions.
individuals and with groups of the same or similar size for the
insurer's preceding fiscal year.
SEC. 39. Chapter 8.1 (commencing with Section
10760) is added to Part 2 of Division 2 of the Insurance
Code , to read:
CHAPTER 8.1. INSURANCE MARKET REFORM
10760. On and after January 1, 2010, the department, in
consultation with the Department of Managed Health Care, shall
require each health insurer with one million or more insureds in
California, based on the insurer's enrollment in the prior year, to
submit a good faith bid to the Managed Risk Medical Insurance Board
in order to be a participating plan through the California
Cooperative Health Insurance Purchasing Program (Cal-CHIPP) pursuant
to Part 6.45 (commencing with Section 12699.201).
10763. On and after July 1, 2010, all requirements in Chapter 8
(commencing with Section 10700) applicable to offering, marketing,
and selling health benefit plans to small employers as defined in
that chapter, including, but not limited to, the obligation to fairly
and affirmatively offer, market, and sell all of the carrier's
health benefit plan designs to all employers, guaranteed renewal of
all health benefit plan designs, use of the risk adjustment factor,
and the restriction of risk categories to age, geographic region, and
family composition as described in that chapter, shall be applicable
to all health benefit plan designs offered to all employers with 100
or fewer eligible employees, except as follows:
(a) For small employers with 2 to 50, inclusive, eligible
employees, all requirements in that chapter shall apply.
(b) For employers with 51 to 100, inclusive, eligible employees,
all requirements in that chapter shall apply, except that the carrier
may develop health care coverage benefit plan designs to fairly and
affirmatively market only to employer groups of 51 to 100 eligible
employees.
10764. It is the intent of the Legislature to establish a
mechanism by which the state may defray the costs of an insured's
public program participation by taking advantage of other
opportunities for coverage available to that insured.
10765. (a) As used in this chapter, "health insurance" shall have
the same meaning as in subdivision (b) of Section 106.
(b) The requirements of this chapter shall not apply to a Medicare
supplement, vision-only, dental-only, or CHAMPUS-supplement
insurance or to hospital indemnity, hospital-only, accident-only, or
specified disease insurance that does not pay benefits on a fixed
benefit, cash payment only basis.
10766. This chapter shall become operative on July 1, 2008.
SEC. 40. Section 12693.43 of the
Insurance Code is amended to read:
12693.43. (a) Applicants applying to the purchasing pool shall
agree to pay family contributions, unless the applicant has a family
contribution sponsor. Family contribution amounts consist of the
following two components:
(1) The flat fees described in subdivision (b) or (d).
(2) Any amounts that are charged to the program by participating
health, dental, and vision plans selected by the applicant that
exceed the cost to the program of the highest cost Family
Value Package family value package in a given
geographic area.
(b) In each geographic area, the board shall designate one or more
Family Value Packages family value packages
for which the required total family contribution is:
(1) Seven dollars ($7) per child with a maximum required
contribution of fourteen dollars ($14) per month per family for
applicants with annual household incomes up to and including 150
percent of the federal poverty level.
(2) Nine dollars ($9) per child with a maximum required
contribution of twenty-seven dollars ($27) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, fifteen dollars ($15) per child
with a maximum required contribution of forty-five dollars ($45) per
month per family for applicants with annual household income to which
subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph paragraph shall
be applicable to the applicant on July 1, 2005, unless subparagraph
(B) of paragraph (6) of subdivision (a) of Section 12693.70 is no
longer applicable to the relevant family income. The program shall
provide prior notice to any applicant for currently enrolled
subscribers whose premium will increase on July 1, 2005, pursuant to
this subparagraph paragraph and, prior
to the date the premium increase takes effect, shall provide that
applicant with an opportunity to demonstrate that subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is no longer
applicable to the relevant family income.
(4) On and after July 1, 2010, twenty-five dollars ($25) per child
with a maximum required contribution of seventy-five dollars ($75)
per month per family for applicants with annual household incomes
greater than 250 percent and up to and including 300 percent of the
federal poverty level.
(c) Combinations of health, dental, and vision plans that are more
expensive to the program than the highest cost Family Value
Package family value package may be offered to
and selected by applicants. However, the cost to the program of those
combinations that exceeds the price to the program of the highest
cost Family Value Package family value
package shall be paid by the applicant as part of the family
contribution.
(d) The board shall provide a family contribution discount to
those applicants who select the health plan in a geographic area that
has been designated as the Community Provider Plan. The discount
shall reduce the portion of the family contribution described in
subdivision (b) to the following:
(1) A family contribution of four dollars ($4) per child with a
maximum required contribution of eight dollars ($8) per month per
family for applicants with annual household incomes up to and
including 150 percent of the federal poverty level.
(2) Six dollars ($6) per child with a maximum required
contribution of eighteen dollars ($18) per month per family for
applicants with annual household incomes greater than 150 percent and
up to and including 200 percent of the federal poverty level and for
applicants on behalf of children described in clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70.
(3) On and after July 1, 2005, twelve dollars ($12) per child with
a maximum required contribution of thirty-six dollars ($36) per
month per family for applicants with annual household income to which
subparagraph (B) of paragraph (6) of subdivision (a) of Section
12693.70 is applicable. Notwithstanding any other provision of law,
if an application with an effective date prior to July 1, 2005, was
based on annual household income to which subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is applicable,
then this subparagraph paragraph shall
be applicable to the applicant on July 1, 2005, unless subparagraph
(B) of paragraph (6) of subdivision (a) of Section 12693.70 is no
longer applicable to the relevant family income. The program shall
provide prior notice to any applicant for currently enrolled
subscribers whose premium will increase on July 1, 2005, pursuant to
this subparagraph paragraph and, prior
to the date the premium increase takes effect, shall provide that
applicant with an opportunity to demonstrate that subparagraph (B) of
paragraph (6) of subdivision (a) of Section 12693.70 is no longer
applicable to the relevant family income.
(4) On and after July 1, 2010, twenty-two dollars ($22) per child
with a maximum required contribution of sixty-six dollars ($66) per
month per family for applicants with annual household incomes greater
than 250 percent and up to and including 300 percent of the federal
poverty level.
(e) Applicants, but not family contribution sponsors, who pay
three months of required family contributions in advance shall
receive the fourth consecutive month of coverage with no family
contribution required.
(f) Applicants, but not family contribution sponsors, who pay the
required family contributions by an approved means of electronic fund
transfer shall receive a 25-percent discount from the required
family contributions.
(g) It is the intent of the Legislature that the family
contribution amounts described in this section comply with the
premium cost sharing limits contained in Section 2103 of Title XXI of
the Social Security Act. If the amounts described in subdivision (a)
are not approved by the federal government, the board may adjust
these amounts to the extent required to achieve approval of the state
plan.
(h) The adoption and one readoption of regulations to implement
paragraph (3) of subdivision (b) and paragraph (3) of subdivision (d)
shall be deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or general welfare
for purposes of Sections 11346.1 and 11349.6 of the Government Code,
and the board is hereby exempted from the requirement that it
describe specific facts showing the need for immediate action and
from review by the Office of Administrative Law. For purpose
purposes of subdivision (e) of Section 11346.1
of the Government code, Code, the
120-day period, as applicable to the effective period of an emergency
regulatory action and submission of specified materials to the
Office of Administrative law, Law, is
hereby extended to 180 days.
SEC. 41. Section 12693.56 is added to the
Insurance Code , to read:
12693.56. (a) The board may provide or arrange for the provision
of an electronic personal health record for enrollees receiving
health care benefits, to the extent funds are appropriated for this
purpose. The record shall be provided for the purpose of providing
enrollees with information to assist them in understanding their
coverage benefits and managing their health care.
(b) At a minimum, the personal health record shall provide access
to real-time, patient-specific information regarding eligibility for
covered benefits and cost sharing requirements. The access may be
provided through the use of an Internet-based system.
(c) In addition to the data required pursuant to subdivision (b),
the board may determine that the personal health record shall also
incorporate additional data, including, but not limited to,
laboratory results, prescription history, claims history, and
personal health information authorized or provided by the enrollee.
Inclusion of this additional data shall be at the option of the
enrollee.
(d) Systems or software that pertain to the personal health record
shall adhere to accepted national standards for interoperability,
privacy, and data exchange, or shall be certified by a nationally
recognized certification body.
(e) The personal health record shall comply with applicable state
and federal confidentiality and data security requirements.
SEC. 42. Section 12693.57 is added to the
Insurance Code , to read:
12693.57. Every person administering or providing benefits under
the program shall perform his or her duties in such a manner as to
secure for every subscriber the amount of assistance to which the
subscriber is entitled, without attempting to elicit any information
that is not required to carry out the provisions of law applicable to
the program.
SEC. 43. Section 12693.58 is added to the
Insurance Code , to read:
12693.58. (a) All types of information, whether written or oral,
concerning an applicant, subscriber, or household member, made or
kept by any public officer or agency in connection with the
administration of any provision of this part shall be confidential,
and shall not be open to examination other than for purposes directly
connected with the administration of the Healthy Families Program or
the Medi-Cal program.
(b) Except as provided in this section and to the extent permitted
by federal law or regulation, all information about applicants,
subscribers, and household members to be safeguarded as provided for
in subdivision (a) includes, but is not limited to, names and
addresses, medical services
provided, social and economic conditions or circumstances, agency
evaluation of personal information, and medical data, including
diagnosis and past history of disease or disability.
(c) Purposes directly connected with the administration of the
Healthy Families Program or the Medi-Cal program encompass all
activities and responsibilities in which the Managed Risk Medical
Insurance Board or State Department of Health Care Services and their
agents, officers, trustees, employees, consultants, and contractors
engage to conduct program operations.
(d) Nothing in this section shall be construed to prohibit the
disclosure of information about the applicant, subscriber, or
household member when the applicant, subscriber, or household member
to whom the information pertains or the parent or adult with legal
custody provides express written authorization.
(e) Nothing in this part shall prohibit the disclosure of
protected health information as provided in 45 C.F.R. 164.512.
SEC. 44. Section 12693.59 is added to the
Insurance Code , to read:
12693.59. Nothing in this part shall preclude the board from
soliciting voluntary participation by applicants and subscribers in
communicating with the board, or with any other party, concerning
their needs as well as the needs of others who are not adequately
covered by existing private and public health care delivery systems
or concerning means of ensuring the availability of adequate health
care services. The board shall inform applicants and subscribers that
their participation is voluntary and shall inform them of the uses
for which the information is intended.
SEC. 45. Section 12693.70 of the
Insurance Code is amended to read:
12693.70. To be eligible to participate in the program, an
applicant shall meet all of the following requirements:
(a) Be an applicant applying on behalf of an eligible child, which
means a child who is all of the following:
(1) Less than 19 years of age. An application may be made on
behalf of a child not yet born up to three months prior to the
expected date of delivery. Coverage shall begin as soon as
administratively feasible, as determined by the board, after the
board receives notification of the birth. However, no child less than
12 months of age shall be eligible for coverage until 90 days after
the enactment of the Budget Act of 1999.
(2) Not eligible for no-cost full-scope Medi-Cal or Medicare
coverage at the time of application.
(3) In compliance with Sections 12693.71 and 12693.72.
(4) A child who meets citizenship and immigration status
requirements that are applicable to persons participating in the
program established by Title XXI of the Social Security Act, except
as specified in Section 12693.76. This paragraph shall become
inoperative on July 1, 2010 .
(5) A resident of the State of California pursuant to Section 244
of the Government Code; or, if not a resident pursuant to Section 244
of the Government Code, is physically present in California and
entered the state with a job commitment or to seek employment,
whether or not employed at the time of application to or after
acceptance in, the program.
(6) (A) In either of the following:
(i) In a family with an annual or monthly household income equal
to or less than 200 percent of the federal poverty level.
(ii) When implemented by the board, subject to subdivision (b) of
Section 12693.765 and pursuant to this section, a child under the age
of two years who was delivered by a mother enrolled in the Access
for Infants and Mothers Program as described in Part 6.3 (commencing
with Section 12695). Commencing July 1, 2007, eligibility under this
subparagraph shall not include infants during any time they are
enrolled in employer-sponsored health insurance or are subject to an
exclusion pursuant to Section 12693.71 or 12693.72, or are enrolled
in the full scope of benefits under the Medi-Cal program at no share
of cost. For purposes of this clause, any infant born to a woman
whose enrollment in the Access for Infants and Mothers Program begins
after June 30, 2004, shall be automatically enrolled in the Healthy
Families Program, except during any time on or after July 1, 2007,
that the infant is enrolled in employer-sponsored health insurance or
is subject to an exclusion pursuant to Section 12693.71 or 12693.72,
or is enrolled in the full scope of benefits under the Medi-Cal
program at no share of cost. Except as otherwise specified in this
section, this enrollment shall cover the first 12 months of the
infant's life. At the end of the 12 months, as a condition of
continued eligibility, the applicant shall provide income
information. The infant shall be disenrolled if the gross annual
household income exceeds the income eligibility standard that was in
effect in the Access for Infants and Mothers Program at the time the
infant's mother became eligible, or following the two-month period
established in Section 12693.981 if the infant is eligible for
Medi-Cal with no share of cost. At the end of the second year,
infants shall again be screened for program eligibility pursuant to
this section, with income eligibility evaluated pursuant to clause
(i), subparagraphs (B) and (C), and paragraph (2) of subdivision (a).
(B) All income over 200 percent of the federal poverty level but
less than or equal to 250 percent of the federal poverty level shall
be disregarded in calculating annual or monthly household income.
On and after July 1, 20 10 , all
income over 250 percent of the federal poverty level but less than
or equal to 300 percent of the federal poverty level shall be
disregarded in calculating annual or monthly household income.
(C) In a family with an annual or monthly household income greater
than 250 percent of the federal poverty level, any income deduction
that is applicable to a child under Medi-Cal shall be applied in
determining the annual or monthly household income. If the income
deductions reduce the annual or monthly household income to 250
percent or less of the federal poverty level, subparagraph (B) shall
be applied.
(D) On and after July 1, 2010, in a family with an annual or
monthly household income greater than 300 percent of the federal
poverty level, any income deduction that is applicable to a child
under the Medi-Cal program shall be applied in determining the annual
or monthly household income. If the income deductions reduce the
annual or monthly household income to 300 percent or less of the
federal poverty level, subparagraph (B) shall apply.
(b) The applicant shall agree to remain in the program for six
months, unless other coverage is obtained and proof of the coverage
is provided to the program.
(c) An applicant shall enroll all of the applicant's eligible
children in the program.
(d) In filing documentation to meet program eligibility
requirements, if the applicant's income documentation cannot be
provided, as defined in regulations promulgated by the board, the
applicant's signed statement as to the value or amount of income
shall be deemed to constitute verification.
(e) An applicant shall pay in full any family contributions owed
in arrears for any health, dental, or vision coverage provided by the
program within the prior 12 months.
(f) By January 2008, the board, in consultation with stakeholders,
shall implement processes by which applicants for subscribers may
certify income at the time of annual eligibility review, including
rules concerning which applicants shall be permitted to certify
income and the circumstances in which supplemental information or
documentation may be required. The board may terminate using these
processes not sooner than 90 days after providing notification to the
Chair of the Joint Legislative Budget Committee. This notification
shall articulate the specific reasons for the termination and shall
include all relevant data elements that are applicable to document
the reasons for the termination. Upon the request of the Chair of the
Joint Legislative Budget Committee, the board shall promptly provide
any additional clarifying information regarding implementation of
the processes required by this subdivision.
SEC. 46. Section 12693.73 of the
Insurance Code is amended to read:
12693.73. Notwithstanding any other provision of law, children
excluded from coverage under Title XXI of the Social Security Act are
not eligible for coverage under the program, except as specified in
clause (ii) of subparagraph (A) of paragraph (6) of subdivision (a)
of Section 12693.70 and Section 12693.76. On and after July 1,
2010, children who otherwise meet eligibility requirements
for the program but for their immigration status are
eligible for the program .
SEC. 47. Section 12693.76 of the
Insurance Code is amended to read:
12693.76. (a) Notwithstanding any other provision of law, a child
who is a qualified alien as defined in Section 1641 of Title 8 of
the United States Code Annotated shall not be determined ineligible
solely on the basis of his or her date of entry into the United
States.
(b) Notwithstanding any other provision of law, subdivision (a)
may only be implemented to the extent provided in the annual Budget
Act.
(c) Notwithstanding any other provision of law, any uninsured
parent or responsible adult who is a qualified alien, as defined in
Section 1641 of Title 8 of the United States Code, shall not be
determined to be ineligible solely on the basis of his or her date of
entry into the United States.
(d) Notwithstanding any other provision of law, subdivision (c)
may only be implemented to the extent of funding provided in the
annual Budget Act.
(e) Notwithstanding any other provision of law, on and after July
1, 2010, a child who is otherwise eligible to participate in the
program shall not be determined ineligible solely on the basis of his
or her immigration status.
SEC. 48. Part 6.45 (commencing with Section
12699.201) is added to Division 2 of the Insurance Code
, to read:
PART 6.45. THE CALIFORNIA COOPERATIVE HEALTH INSURANCE
PURCHASING PROGRAM
CHAPTER 1. GENERAL PROVISIONS
12699.201. For the purposes of this part, the following terms
have the following meanings:
(a) "Benefit plan design" means a specific health coverage product
offered for sale and includes services covered and the levels of
copayments, deductibles, and annual out-of-pocket expenses, and may
include the professional providers who are to provide those services
and the sites where those services are to be provided. A benefit plan
design may also be an integrated system for the financing and
delivery of quality health care services that has significant
incentives for the covered individuals to use the system.
(b) "Board" means the Managed Risk Medical Insurance Board.
(c) "California Cooperative Health Insurance Purchasing Program"
or "Cal-CHIPP" means the statewide purchasing pool established
pursuant to this part and administered by the board.
(d) "Dependent" means the spouse, domestic partner, minor child of
an enrollee, and a child 18 years of age or older of the enrollee
who is dependent on the enrollee, as defined by the board.
(e) "Enrollee" means an individual who is eligible for, and
participates in, Cal-CHIPP.
(f) "Fund" means the California Health Trust Fund established
pursuant to Section 12699.212.
(g) "Cal-CHIPP Healthy Families plan" shall mean health care
coverage provided through a health care service plan or a health
insurer that provides for individuals eligible pursuant to Section
14005.301 or 14005.307 of the Welfare and Institutions Code, coverage
that meets the requirements of federal law and that, at a minimum,
provides the same covered services and benefits required under the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code) plus prescription drug benefits.
(h) "Participating dental plan" means either a dental insurer
holding a valid certificate of authority from the commissioner or a
specialized health care service plan, as defined by subdivision (o)
of Section 1345 of the Health and Safety Code, that contracts with
the board to provide dental coverage to enrollees.
(i) "Participating health plan" means either a private health
insurer holding a valid outstanding certificate of authority from the
commissioner or a health care service plan as defined under
subdivision (f) of Section 1345 of the Health and Safety Code that
contracts with the board to provide or to sell coverage in Cal-CHIPP
and, pursuant to its contract with the board, provides, arranges,
pays for, or reimburses the costs of health services for Cal-CHIPP
enrollees.
(j) "Participating vision care plan" means either an insurer
holding a valid certificate of authority from the commissioner that
issues vision-only coverage or a specialized health care service
plan, as defined by subdivision (o) of Section 1345 of the Health and
Safety Code, that contracts with the board to provide vision
coverage to enrollees.
CHAPTER 2. ADMINISTRATION
12699.202. (a) The board shall be responsible for establishing
Cal-CHIPP and administering this part.
(b) The board may do all of the following consistent with the
standards of this part:
(1) Determine eligibility and enrollment criteria and processes
for Cal-CHIPP consistent with the eligibility standards in Chapter 3
(commencing with Section 12699.211).
(2) Determine the participation requirements for enrollees.
(3) Determine the participation requirements and the standards and
selection criteria for participating health, dental, and vision care
plans, including reasonable limits on a plan's administrative costs.
(4) Determine when an enrollee's coverage commences and the extent
and scope of coverage.
(5) Determine premium schedules, collect the premiums, and
administer subsidies to eligible enrollees.
(6) Determine rates paid to participating health, dental, and
vision care plans.
(7) Provide, or make available, coverage through participating
health plans in Cal-CHIPP.
(8) Provide, or make available, coverage through participating
dental and vision care plans in Cal-CHIPP.
(9) Provide for the processing of applications and the enrollment
of enrollees.
(10) Determine and approve the benefit designs and cost-sharing
provisions for participating health, dental, and vision care plans.
(11) Enter into contracts.
(12) Sue and be sued.
(13) Employ necessary staff.
(14) Authorize expenditures, as necessary, from the fund to pay
program expenses that exceed enrollee contributions and to administer
Cal-CHIPP.
(15) Issue rules and regulations, as necessary.
(16) Maintain enrollment and expenditures to ensure that
expenditures do not exceed the amount of revenue available in the
fund, and if sufficient revenue is not available to pay the estimated
expenditures, the board shall institute appropriate measures to
ensure fiscal solvency. This paragraph shall not be construed to
allow the board to deny enrollment of a person who otherwise meets
the eligibility requirements of Chapter 3 (commencing with Section
12699.211) in order to ensure the fiscal solvency of the fund.
(17) Establish the criteria and procedures through which employers
direct employees' premium dollars, withheld under the terms of a
cafeteria plan, to Cal-CHIPP to be credited against the employees'
premium obligations.
(18) Share information obtained pursuant to this part with the
Employment Development Department solely for the purpose of the
administration and enforcement of this part.
(19) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
part.
12699.203. The board shall develop and offer a variety of benefit
plan designs, including, but not limited to the following:
(a) A Cal-CHIPP Healthy Families plan for parents and caretaker
relatives pursuant to Section 14005.301 of the Welfare and
Institutions Code and for adults eligible for coverage pursuant to
Section 14005.307 of the Welfare and Institutions Code with incomes
greater than 100 percent of the federal poverty level.
(b) A low-cost plan for Cal-CHIPP enrollees who are adults with a
family income at or below 300 percent of the federal poverty level
who are ineligible for coverage through Section 14005.301 or
14005.307 of the Welfare and Institutions Code or the Medi-Cal
program.
(c) A high value plan for all Cal-CHIPP enrollees with a family
income above 300 percent of the federal poverty level.
(d) All benefit plan designs shall meet the requirements of the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code) and shall include prescription drug benefits, combined with
enrollee cost-sharing levels that promote prevention and health
maintenance, including appropriate cost sharing for physician office
visits, diagnostic laboratory services, and maintenance medications
to manage chronic diseases, such as asthma, diabetes, and heart
disease.
(e) In determining the enrollee and dependent deductibles,
coinsurance, and copayment requirements, the board shall consider
whether those costs would deter an enrollee or his or her dependents
from obtaining appropriate and timely care, including those enrollees
with a low- or moderate-family income. The board shall also consider
the impact of these costs on an enrollee's ability to afford health
care services.
(f) The board shall consult with the Insurance Commissioner, the
Director of the Department of Managed Health Care, and the Director
of Health Care Services.
12699.204. (a) The board may adjust premiums at a public meeting
of the board after providing, at minimum, 30 days' public notice of
the adjustment. In making the adjustment, the board shall take into
account the costs of health care typically paid for by employers and
employees in California.
(b) Notwithstanding subdivision (a), the amount of the premium
paid by an employee with a household income at or below 300 percent
of the federal poverty level shall not exceed 0 to 5 percent of the
household income, depending on the income, after taking into account
the tax savings the employee is able to realize by using the
cafeteria plan made available by his or her employer.
(c) The following premiums shall apply to coverage under this part
for the population eligible for coverage pursuant to Section
14005.301 of the Welfare and Institutions Code.
(1) For individuals with a family income less than or equal to 150
percent of the federal poverty level, no premiums or out-of-pocket
costs shall be allowed.
(2) For individuals with a family income above 150 percent but
less than or equal to 300 percent of the federal poverty level
premiums shall not exceed 5 percent of the family income net of
applicable deductions.
(d) The following premiums shall apply to coverage under this part
for the population eligible for coverage pursuant to Sections
14005.305 and 14005.307 of the Welfare and Institutions Code:
(1) For individuals with a family income less than or equal to 150
percent of the federal poverty level, no premiums or out-of-pocket
costs shall be allowed.
(2) For individuals with a family income above 150 percent but
less than or equal to 250 percent of the federal poverty level,
premiums shall not exceed 5 percent of the family income net of
applicable deductions.
(e) An employer may pay all, or a portion of, the premium payment
required of its employees enrolled in Cal-CHIPP.
12699.204.1. The board shall limit enrollment in the Cal-CHIPP
Heathy Families plan to individuals who are eligible under Sections
14005.301 and 14005.305 of the Welfare and Institutions Code and to
individuals eligible under Section 14005.307 of the Welfare and
Institutions Code with a family income greater than 100 percent of
the federal poverty level.
12699.205. The board, in its contract with a participating health
plan, shall require that the plan utilize efficient practices to
improve and control costs. These practices may include, but are not
limited to, the following:
(a) Preventive care.
(b) Care management for chronic diseases.
(c) Promotion of health information technology.
(d) Standardized billing practices.
(e) Reduction of medical errors.
(f) Incentives for healthy lifestyles.
(g) Patient cost-sharing to encourage the use of preventive and
appropriate care.
(h) Evidence-based use of new technology.
12699.206. (a) The board shall negotiate with Medi-Cal managed
care plans to obtain affordable coverage for eligible enrollees.
(b) The board, in consultation with the State Department of Health
Care Services, shall take all reasonable steps necessary to maximize
federal funding and support federal claiming in the administration
of the purchasing pool created pursuant to this part.
12699.206.1. (a) To provide prescription drug coverage for
Cal-CHIPP enrollees, the board may take any of the following actions:
(1) Contract directly with health care service plans or health
insurers for prescription drug coverage as a component of a health
care service plan contract or a health insurance policy.
(2) Contract with a pharmacy benefits manager (PBM) if the PBM
meets transparency and disclosure requirements established by the
board.
(3) Procure products directly through the prescription drug
purchasing program established pursuant to Chapter 12 (commencing
with Section 14977) of Part 5.5 of Division 3 of Title 2 of the
Government Code.
(b) The board may engage in any of the activities described in
subdivision (a), or in any cost-effective combination of those
activities.
(c) If the board enters into a prescription drug purchasing
arrangement pursuant to paragraph (2) or (3) of subdivision (a), the
board may allow any of the following entities to participate in that
arrangement:
(1) Any state, district, county, city, municipal, or other public
agency or governmental entity.
(2) A board or administrator responsible for providing or
delivering health care coverage pursuant to a collective bargaining
agreement, memorandum of understanding, or other similar agreement
with a labor organization.
12699.206.2. (a) All information, whether written or oral,
concerning an applicant to Cal-CHIPP, an enrollee in Cal-CHIPP, or a
household member of the applicant or enrollee, created or maintained
by a public officer or agency in connection with the administration
of this part shall be confidential and shall not be open to
examination other than for purposes directly connected with the
administration of this part. "Purposes directly connected with the
administration of this part" includes all activities and
responsibilities in which the board or the State Department of Health
Care Services and their agents, officers, trustees, employees,
consultants, and contractors engage to conduct program operations.
(b) Information subject to the provisions of this section
includes, but is not limited to, names and addresses, medical
services provided to an enrollee, social and economic conditions or
circumstances, agency evaluation of personal information, and medical
data, such as diagnosis and health history.
(c) Nothing in this section shall be construed to prohibit the
disclosure of information about applicants and enrollees, or their
household members, if express written authorization for the
disclosure has been provided by the person to whom the information
pertains or, if that person is a minor, authorization has been
provided by the minor's parent or other adult with legal custody of
the minor.
(d) The use and disclosure of information concerning an applicant
or enrollee in the program who is a beneficiary in the Medi-Cal
program or an applicant to the Medi-Cal program shall be strictly
limited to the circumstances described in Section 14100.2 of the
Welfare and Institutions Code.
(e) Except as provided in subdivision (d), nothing
in this part shall prohibit the disclosure of protected health
information as provided in Section 164.152 of Title 45 of the Code of
Federal Regulations.
12699.207. (a) Notwithstanding any other provision of law, the
board shall not be subject to licensure or regulation by the
Department of Insurance or the Department of Managed Health Care.
(b) Participating health, dental, and vision care plans that
contract with the board shall be regulated by either the Department
of Insurance or the Department of Managed Health Care and shall be
licensed and in good standing with their respective licensing agency.
In their application to Cal-CHIPP and upon request by the board, the
participating health, dental, and vision care plans shall provide
assurance of their licensure and standing with the appropriate
licensing agency.
12699.208. The board shall collect and disseminate, as
appropriate and to the extent possible, information on the quality of
participating health, dental, and vision care plans and each plan's
cost-effectiveness to assist enrollees in selecting a plan.
12699.209. The board, in consultation with the State Department
of Health Care Services, shall take all reasonable steps necessary to
maximize federal funding and support federal claiming in the
administration of the purchasing pool created pursuant to this part.
In addition, the board shall consult and coordinate with the State
Department of Health Care Services in seeking federal financial
support pursuant to Article 7 (commencing with Section 14199.10) of
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code. To the extent the state obtains federal financial support for
the populations described in Section 14199.10 of the Welfare and
Institutions Code, the coverage shall be subject to the terms,
conditions, and duration of any applicable state plan amendment or
waiver. To the extent required to obtain federal financial support,
the board shall apply citizenship, immigration, and identity
documentation standards required in Title XIX of the federal Social
Security Act.
12699.210. The provisions of Section 12693.54 shall apply to a
contract entered into pursuant to this part.
CHAPTER 3. ELIGIBILITY
12699.211. To be eligible to enroll in Cal-CHIPP, an individual
must be a resident of the state pursuant to Section 244 of the
Government Code or physically present in the state, having entered
the state with an employment commitment or to obtain employment,
whether or not employed at the time of application to Cal-CHIPP or
after enrollment in Cal-CHIPP. In addition, to be eligible to enroll
in Cal-CHIPP, an individual must meet any of the following
requirements:
(a) Be an employee or a dependent of an employee of an employer
who elected to pay into the California Health Trust Fund. To the
extent an employer elects to pay into the California Health Trust
Fund, only employees and dependents in the category of employees for
which the employer has elected to pay shall be eligible to enroll in
Cal-CHIPP.
(b) Be an individual eligible for coverage pursuant to Section
14005.301, 14005.305, or 14005.307 of the Welfare and Institutions
Code.
(c) Be an individual eligible for a state tax credit for purposes
of purchasing affordable health care coverage.
12699.211.01. Notwithstanding any other provision of law, an
adult otherwise eligible for coverage under Section 14005.307 of the
Welfare and Institutions Code is not eligible to enroll in Cal-CHIPP
if he or she is offered health care coverage through his or her
employment.
12699.211.02. (a) The following program decisions may be appealed
to the board:
(1) A decision that an individual is not qualified to participate
or continue to participate in the program.
(2) A decision that an individual is not eligible for enrollment
or continuing enrollment in the program.
(3) A decision as to the effective date of coverage.
(b) An applicant or subscriber who appeals one of the decisions
listed in subdivision (a) shall be accorded an opportunity for an
administrative hearing. The hearing shall be conducted, insofar as
practicable, pursuant to Chapter 5 (commencing with Section 11500) of
Part 1 of Division 3 of the Government Code.
(c) To the extent required by law, the board shall implement this
section consistent with applicable federal law.
CHAPTER 4. FISCAL
12699.212. (a) The California Health Trust Fund is hereby created
in the State Treasury. Notwithstanding Section 13340 of the
Government Code, the moneys in the fund shall be continuously
appropriated to the board, without regard to fiscal year, for the
purposes of providing health care coverage pursuant to this part. Any
moneys in the fund that are unexpended or unencumbered at the end of
a fiscal year, may be carried forward to the next succeeding fiscal
year.
(b) The board shall establish a prudent reserve in the fund.
(c) Notwithstanding Section 16305.7 of the Government Code, all
interest earned on the moneys that have been deposited into the fund
shall be retained in the fund.
12699.213. The board, subject to the approval of the Department
of Finance, may obtain loans from the General Fund for all necessary
and reasonable expenses related to the administration of the fund.
12699.214. The board shall authorize, for the purposes of this
part, the expenditure from the fund of any state or federal revenue
or other revenue received from any source.
12699.215. The board may solicit and accept gifts, contributions,
and grants from any source, public or private, to administer the
program and shall deposit all revenue from those sources into the
fund.
12699.216. The board, subject to federal approval pursuant to
Section 14199.10 of the Welfare and Institutions Code, shall pay the
nonfederal share of cost from the fund for employees and dependents
eligible under that federal approval.
12699.217. This part shall become operative on January 1, 2009.
The board shall provide health coverage pursuant to this part on and
after July 1, 2010.
SEC. 49. Section 12886 is added to the
Insurance Code , to read:
12886. It shall constitute an unfair labor practice contrary to
public policy, and enforceable under Section 95 of the Labor Code,
for an employer to refer an individual employee or employee's
dependent to the program established pursuant to Part 6.45
(commencing with Section 12699.201), or to arrange for an individual
employee or employee's dependent to apply to that program, for the
purpose of separating that employee or employee's dependent from
group health coverage provided in connection with the employee's
employment. An employer who pays the premium for the employee in the
program established pursuant to Part 6.45 (commencing with Section
12699.201) shall not, on the basis of that action, be deemed to be in
violation of this section.
SEC. 50. Section 12887 is added to the
Insurance Code , to read:
12887. It shall constitute an unfair labor practice contrary to
public policy and enforceable under Section 95 of the Labor Code for
an employer to change the employee-employer share-of-cost ratio based
upon the employee's wage base or job classification or to make any
modification of coverage for employees and employees' dependents in
order that the employees or employees' dependents enroll in the
program established pursuant to Part 6.45 (commencing with Section
12699.201).
SEC. 51. Section 96.8 is added to the
Labor Code , to read:
96.8. (a) Notwithstanding any other provision in this chapter, an
employer may provide health coverage that includes a Healthy Action
Incentives and Rewards Program that meets the requirements of Section
1367.38 of the Health and Safety Code, or Section 10123.56 of the
Insurance Code, to the employer's employees.
(b) A Healthy Action Incentives and Rewards Program offered
pursuant to this section may include, but need not be limited to,
monetary incentives and health coverage premium cost reductions for
employees for nonsmokers and smoking cessation.
SEC. 52. Section 96.81 is added to the
Labor Code , to read:
96.81. (a) (1) Notwithstanding any other provision of law, the
delivery or provision of Healthy Action Incentives and Rewards
Program benefits or coverage by the employer or the employer's agents
to employees for the purposes of and in accordance with the criteria
and requirements established under Section 96.8 shall not be
considered or construed as an unlawful practice, act, kickback,
bribe, rebate, remuneration, offer, payment, or any other form of
compensation made directly or indirectly, overtly or covertly, in
exchange for another to obtain, participate, or otherwise undergo or
receive health care services.
(2) Notwithstanding any other provision of law, the delivery or
provision of Healthy Action Incentives and Rewards Program benefits
or coverage by the employer or the employer's agents to employees for
the purposes of and in accordance with the criteria and requirements
established under Section 96.8 is not subject to the penalties,
discipline, limitations, or sanctions imposed under state law to
preclude or prohibit, as an unlawful practice, bribe, kickback, or
other act, the offering or delivery of a rebate, remuneration, offer,
coupon, product, rebate, payment, or any other form of compensation
made directly or indirectly, overtly or covertly, in exchange for
another to obtain, participate, or otherwise undergo or receive
health care services.
(b) This section shall only be implemented if and to the extent
allowed under federal law. If any portion of this section is held to
be invalid, as determined by a final judgment of a court of competent
jurisdiction, this section shall become inoperative.
SEC. 53. Section 14005.30 of the Welfare
and Institutions Code is amended to read:
14005.30. (a) (1) To the extent that federal financial
participation is available, Medi-Cal benefits under this chapter
shall be provided to individuals eligible for services under Section
1396u-1 of Title 42 of the United States Code, including any options
under Section 1396u-1(b)(2)(C) made available to and exercised by the
state.
(2) The department shall exercise its option under Section 1396u-1
(b)(2)(C) of Title 42 of the United States Code to adopt less
restrictive income and resource eligibility standards and
methodologies to the extent necessary to allow all recipients of
benefits under Chapter 2 (commencing with Section 11200) to be
eligible for Medi-Cal under paragraph (1).
(3) To the extent federal financial participation is available,
the department shall exercise its option under Section 1396u-1(b)(2)
(C) of Title 42 of the United States Code authorizing the state to
disregard all changes in income or assets of a beneficiary until the
next annual redetermination under Section 14012. The department shall
implement this paragraph only if, and to the extent that the State
Child Health Insurance Program waiver described in Section 12693.755
of the Insurance Code extending Healthy Families Program eligibility
to parents and certain other adults is approved and implemented.
(b) (1) To the extent that federal financial
participation is available, the department shall exercise its option
under Section 1396u-1(b)(2)(C) of Title 42 of the United States Code
as necessary to expand eligibility for Medi-Cal under subdivision
(a) by establishing the amount of countable resources individuals or
families are allowed to retain at the same amount medically needy
individuals and families are allowed to retain, except that a family
of one shall be allowed to retain countable resources in the amount
of three thousand dollars ($3,000). This paragraph shall not be
operative during implementation of paragraph (2).
(2) To the extent that federal financial participation is
available, the department shall exercise its option under Section
1396u-1(b)(2)(C) of Title 42 of the United States Code as necessary
to simplify eligibility for Medi-Cal under subdivision (a) by
exempting all resources for applicants and recipients, commencing
July 1, 2010.
(c) To the extent federal financial participation is available,
the department shall, commencing March 1, 2000, adopt an income
disregard for applicants equal to the difference between the income
standard under the program adopted pursuant to Section 1931(b) of the
federal Social Security Act (42 U.S.C. Sec. 1396u-1) and the amount
equal to 100 percent of the federal poverty level applicable to the
size of the family. A recipient shall be entitled to the same
disregard, but only to the extent it is more beneficial than, and is
substituted for, the earned income disregard available to recipients.
(d) For purposes of calculating income under this section during
any calendar year, increases in social security benefit payments
under Title II of the federal Social Security Act (42 U.S.C. Sec. 401
and following) arising from cost-of-living adjustments shall be
disregarded commencing in the month that these social security
benefit payments are increased by the cost-of-living adjustment
through the month before the month in which a change in the federal
poverty level requires the department to modify the income disregard
pursuant to subdivision (c) and in which new income limits for the
program established by this section are adopted by the department.
(e) Subdivision (b) shall be applied retroactively to January 1,
1998.
(f)
(e) Notwithstanding Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code, the department shall implement, without taking regulatory
action, subdivisions (a) and (b) of this section by means of an all
county letter or similar instruction. Thereafter, the department
shall adopt regulations 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, the department shall provide a status
report to the Legislature on a semiannual basis until regulations
have been adopted.
SEC. 54. Section 14005.301 is added to the
Welfare and Institutions Code , to read:
14005.301. (a) Notwithstanding Section 14005.30, to the extent
that federal financial participation is available, and as permitted
under Section 6044 of the federal Deficit Reduction Act of 2005 (42
U.S.C. Sec. 1396u-7) the department shall provide benefits under a
Cal-CHIPP Healthy Families plan to a population composed of parents
and other caretaker relatives with a household income at or below 300
percent of the federal poverty level who are not otherwise eligible
for full scope benefits with no share of cost.
(b) The eligibility determination under this section shall not
include an asset test. A redetermination for eligibility under this
section shall be completed annually.
(c) To the extent necessary to implement this section, the
department shall seek federal approval to modify the definition of
"unemployed parent" in Section 14008.85.
(d) The department shall implement this section by means of a
state plan amendment. If this section cannot be implemented by a
state plan amendment, the department shall seek a waiver or a waiver
and a state plan amendment necessary to accomplish the intent of this
section.
(e) This section shall become operative on July 1, 2010.
SEC. 55. Section 14005.305 is added to the
Welfare and Institutions Code , to read:
14005.305. (a) The department shall provide benefits to a
population composed of individuals who are either 19 or 20 years of
age and who meet all of the following requirements:
(1) Net family income is at or below 250 percent of the federal
poverty level.
(2) The individual is not otherwise eligible for full-scope
benefits in one of the federal poverty level programs for children,
but would be eligible for those benefits if he or she were under 19
years of age with income at or below 100 percent of the federal
poverty level.
(3) The individual is a citizen, national, or qualified alien
without regard to date of entry.
(b) The eligibility determination under this section shall not
include an asset test. A redetermination for eligibility under this
section shall be completed annually.
(c) The department shall implement this section by means of a
state plan amendment under Section 1902(a)(10)(A)(ii)(I) of the
federal Social Security Act (Title 42 U.S.C. Sec. 1396a(a)(10)(A)(ii)
(I)), or by any other state plan amendment or waiver, or combination
thereof, as is necessary to accomplish the intent of this section.
(d) The department shall seek federal approval to utilize the same
premiums and copayments for the population to whom this section
applies as are applied to the population established pursuant to
Section 14005.307.
(e) This section shall be implemented only if, and to the extent
that federal approval has been obtained to provide benchmark benefits
for individuals made eligible under this section with net income
over 100 percent of the federal poverty level in a manner consistent
with Section 14005.306.
(f) The income methodology for eligibility determinations under
this section shall be the methodology used for the federal poverty
level programs, but shall not include any income disregards available
under those programs.
(g) This section shall become operative on July 1, 2010, but only
to the extent federal financial participation is available.
SEC. 56. Section 14005.306 is added to the
Welfare and Institutions Code , to read:
14005.306. (a) Subject to the limitations provided in
subdivisions (b) and (c), a Medi-Cal beneficiary with a net family
income above 100 percent of the federal poverty level whose
eligibility is based on Section 14005.301 or Section 14005.305 and
who is otherwise eligible for full-scope benefits, shall receive his
or her benefits by means of a benchmark package pursuant to Section
1937 of the federal Social Security Act. This package shall be the
Cal-CHIPP Healthy Families benefit package established for the
program established pursuant to Part 6.45 (commencing with Section
12699.201) of Division 2 of the Insurance Code.
(b) To the extent required by federal law, the categories of
beneficiaries listed in Section 1937(a)(2)(B) of the federal Social
Security Act (Title 42 U.S.C. Sec. 1396u-7(a)(2)(B)), are exempt from
mandatory enrollment in the benchmark package described in
subdivision (a).
(c) The department, with the concurrence of the Managed Risk
Medical Insurance Board, may identify groups of otherwise exempt
individuals that will be allowed a choice, at the beneficiary's
option, to participate in a benchmark package.
(d) The department, with concurrence of the Managed Risk Medical
Insurance Board, may exempt other groups or categories of
beneficiaries from the requirements provided in subdivision (a).
(e) To the extent federal approval is obtained, the appeals
process for issues relating to receipt of benefits through the
benchmark package shall be the process prescribed by the Managed Risk
Medical Insurance Board for the program established pursuant to Part
6.45 (commencing with Section 12699.201) of Division 2 of the
Insurance Code.
(f) This section shall be implemented only if and to the extent
that federal financial participation is available and all necessary
federal approvals have been obtained.
(g) The department shall accomplish the intent of this section by
means of a state plan amendment or by a waiver. If this section is
implemented in whole or in part by means of a state plan amendment,
all applicable federal requirements not otherwise waived, including,
but not limited to, requirements related to cost sharing, shall
apply.
SEC. 57. Section 14005.307 is added to the
Welfare and Institutions Code , to read:
14005.307. (a) The department shall provide benefits under a
Cal-CHIPP Healthy Families plan to a population composed of
individuals who meet all of the following requirements:
(1) Is a resident of the state pursuant to Section 244 of the
Government Code or is physically present in the state, having entered
the state with an employment commitment or to obtain employment,
whether or not employed at the time of application to the program.
(2) Is a citizen or national of the United States or a qualified
alien without regard to date of entry.
(3) Is 19 years of age or older and is ineligible for Medicare
Parts A and B.
(4) Has family income, less applicable deductions, greater than
100 percent of the federal poverty level but less than or equal to
250 percent of the federal poverty level.
(5) Is either ineligible for the Medi-Cal program or eligible to
participate in benchmark package pursuant to Section 14005.306.
(6) Does not have access to employer-sponsored health care
coverage. However, this provision does not apply to a person with
coverage under Section 14005.301 or 14005.305.
(b) Implementation of this section with respect to individuals
with coverage under Section 14005.332 is contingent on establishment
of a county share of cost.
SEC. 58. Section 14005.31 of the
Welfare and Institutions Code is amended to read:
14005.31. (a) (1) Subject to paragraph (2), for any person whose
eligibility for benefits under Section 14005.30 has been determined
with a concurrent determination of eligibility for cash aid under
Chapter 2 (commencing with Section 11200), loss of eligibility or
termination of cash aid under Chapter 2 (commencing with Section
11200) shall not result in a loss of eligibility or termination of
benefits under Section 14005.30 absent the existence of a factor that
would result in loss of eligibility for benefits under Section
14005.30 for a person whose eligibility under Section 14005.30 was
determined without a concurrent determination of eligibility for
benefits under Chapter 2 (commencing with Section 11200).
(2) Notwithstanding paragraph (1), a person whose eligibility
would otherwise be terminated pursuant to that paragraph shall not
have his or her eligibility terminated until the transfer procedures
set forth in Section 14005.32 or the redetermination procedures set
forth in Section 14005.37 and all due process requirements have been
met.
(b) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform Medi-Cal beneficiaries whose
eligibility for cash aid under Chapter 2 (commencing with Section
11200) has ended, but whose eligibility for benefits under Section
14005.30 continues pursuant to subdivision (a), that their benefits
will continue. To the extent feasible, the notice shall be sent out
at the same time as the notice of discontinuation of cash aid, and
shall include all of the following:
(1) A statement that Medi-Cal benefits will continue even though
cash aid under the CalWORKs program has been terminated.
(2) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(3) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but shall be required to submit a semiannual status report
and annual reaffirmation forms. forms, except
that the semiannual status report shall no longer be required on and
after July 1, 20 10 . The notice shall
remind individuals whose cash aid ended under the CalWORKs program as
a result of not submitting a status report that he or she should
review his or her circumstances to determine if changes have occurred
that should be reported to the Medi-Cal eligibility worker.
(4) A statement describing the responsibility of the
Medi-Cal beneficiary to report to the county, within 10 days,
significant changes that may affect eligibility.
(5) A telephone number to call for more information.
(6) A statement that the Medi-Cal beneficiary's eligibility worker
will not change, or, if the case has been reassigned, the new worker'
s name, address, and telephone number, and the hours during which the
county's eligibility workers can be contacted.
(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act (Title 42 U.S.C. Sec.
1396 and following) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall, without taking any regulatory action, implement
this section by means of all county letters or similar instructions.
Thereafter, the department shall adopt regulations 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. Comprehensive
implementing instructions shall be issued to the counties no later
than March 1, 2001.
SEC. 59. Section 14005.310 is added to the
Welfare and Institutions Code , to read:
14005.310. The department shall seek federal approval to utilize
an interval of one year in determining the cost amounts specified in
Section 12699.204 of the Insurance Code for persons receiving
benchmark benefits pursuant to Sections 14005.301 and 14005.305.
SEC. 60. Section 14005.311 is added to the
Welfare and Institutions Code , to read:
14005.311. (a) The department and the Managed Risk Medical
Insurance Board shall enter into an interagency agreement under which
the board shall have authority and responsibility for administering
benchmark benefits under Sections 14005.301, 14005.305, and 14005.307
and for prescribing all rules and procedures necessary for
administering these benefits subject to the single state agency
oversight responsibilities of the department.
(b) This section shall be implemented only to the extent that
federal financial participation is not jeopardized.
SEC. 61. Section 14005.32 of the
Welfare and Institutions Code is amended to read:
14005.32. (a) (1) If the county has evidence clearly
demonstrating that a beneficiary is not eligible for benefits under
this chapter pursuant to Section 14005.30, but is eligible for
benefits under this chapter pursuant to other provisions of law, the
county shall transfer the individual to the corresponding Medi-Cal
program. Eligibility under Section 14005.30 shall continue until the
transfer is complete.
(2) The department, in consultation with the counties and
representatives of consumers, managed care plans, and Medi-Cal
providers, shall prepare a simple, clear, consumer-friendly notice to
be used by the counties, to inform beneficiaries that their Medi-Cal
benefits have been transferred pursuant to paragraph (1) and to
inform them about the program to which they have been transferred. To
the extent feasible, the notice shall be issued with the notice of
discontinuance from cash aid, and shall include all of the following:
(A) A statement that Medi-Cal benefits will continue under another
program, even though aid under Chapter 2 (commencing with Section
11200) has been terminated.
(B) The name of the program under which benefits will continue,
and an explanation of that program.
(C) A statement that continued receipt of Medi-Cal benefits will
not be counted against any time limits in existence for receipt of
cash aid under the CalWORKs program.
(D) A statement that the Medi-Cal beneficiary does not need to
fill out monthly status reports in order to remain eligible for
Medi-Cal, but shall be required to submit a semiannual status report
and annual reaffirmation forms. forms, except
that the semiannual status report shall no longer be required on and
after July 1, 20 10 . In addition, if
the person or persons to whom the notice is directed has been found
eligible for transitional Medi-Cal as described in Section 14005.8,
14005.81, or 14005.85, the statement shall explain the reporting
requirements and duration of benefits under those programs, and shall
further explain that, at the end of the duration of these benefits,
a redetermination, as provided for in Section 14005.37 shall be
conducted to determine whether benefits are available under any other
provision of law.
(E) A statement describing the beneficiary's responsibility to
report to the county, within 10 days, significant changes that may
affect eligibility or share of cost.
(F) A telephone number to call for more information.
(G) A statement that the beneficiary's eligibility worker will not
change, or, if the case has been reassigned, the new worker's name,
address, and telephone number, and the hours during which the county'
s Medi-Cal eligibility workers can be contacted.
(b) No later than September 1, 2001, the department shall submit a
federal waiver application seeking authority to eliminate the
reporting requirements imposed by transitional medicaid under Section
1925 of the federal Social Security Act (Title 42 U.S.C. Sec.
1396r-6).
(c) This section shall be implemented on or before July 1, 2001,
but only to the extent that federal financial participation under
Title XIX of the federal Social Security Act (Title 42 U.S.C. Sec.
1396 and following) is available.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall, without taking any regulatory action, implement
this section by means of all county letters or similar instructions.
Thereafter, the department shall adopt regulations 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. Comprehensive
implementing instructions shall be issued to the counties no later
than March 1, 2001.
SEC. 62. Section 14005.331 is added to the Welfare
and Institutions Code, to read:
14005.331. (a) All children under 19 years of age who meet the
state residency requirements of the Medi-Cal program or the Healthy
Families Program shall be eligible for health care coverage in
accordance with subdivision (b) if they either (1) live in a family
with countable household income at or below 300 percent of the
federal poverty level, or (2) meet the income and resource
requirements of Section 14005.7 or the income requirements of Section
14005.30. The children described in this section include all
children for whom federal financial participation under Title XIX of
the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) or
Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397 et
seq.) is not available due to their immigration status or date of
entry into the United States, but does not include children who are
ineligible for Title XIX and Title XXI funds based on other grounds.
Nothing in this section shall be construed to limit a child's right
to Medi-Cal eligibility under existing law.
(b) Children described in subdivision (a) in families whose
household income would render them ineligible for no-cost Medi-Cal,
and who are in compliance with Sections 12693.71 and 12693.72 of the
Insurance Code, shall be eligible for the Healthy Families Program
and shall also be eligible for Medi-Cal with a share of cost in
accordance with Section 14005.7. Other children described in this
section shall be eligible for Medi-Cal with no share of cost.
(c) This section shall become operative on July 1, 2010.
SEC. 63. Section 14005.333 is added to the
Welfare and Institutions Code , to read:
14005.333. (a) The department shall design and implement a
program to provide the benefits described in subdivision (d) to the
population described in subdivision (c).
(b) The department shall seek to maximize the availability of
federal funding for this section under the terms of any existing
waiver, through amendment of any existing waiver, or by means of a
new waiver, or any combination thereof.
(c) The population eligible to receive benefits under this section
shall consist of all residents 21 years of age or older who meet all
of the following requirements.
(1) Their family income is at or below 100 percent of the federal
poverty level.
(2) They are not otherwise eligible for the Medi-Cal program.
(3) They would be eligible for full-scope Medi-Cal without a share
of cost if they had a categorical linkage.
(4) They are citizens, nationals, or qualified aliens without
regard to date of entry.
(5) They do not have access to employer-sponsored health care
coverage.
(d) (1) Benefits available under this section shall consist of a
benefit package that is designed by the department and is equivalent
to the subsidized coverage made available in the purchasing pool
established pursuant to Part 6.45 (commencing with Section 12699.201)
of Division 2 of the Insurance Code, except as provided in
subdivision (k) of Section 14005.334. To the extent that specific
services are excluded from the subsidized package, these services are
not required to be provided under this section to the population
described under subdivision (c). These excluded services shall
include, but are not limited to, long-term care services, nursing
home care, personal care services, in-home supportive services, and
home- and community-based or other waiver services.
(2) For a five year period beginning with the first month of
operation of a local coverage option program in a county under
Section 14005.334, the local coverage option program shall be the
exclusive Medi-Cal coverage available for the individuals who reside
in the county and who are eligible Medi-Cal beneficiaries under this
section. This paragraph shall apply only if local coverage option
program services are provided by or through a health care service
plan licensed under the Knox-Keene Health Care Service Plan Act of
1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code).
(e) In determining eligibility for benefits under this section,
the department shall use the application requirements and the income
methodology of the federal poverty level programs for pregnant women
and children, including the income deductions and exemptions
applicable under those programs, but shall not include any income
disregards available under those programs.
(f) Nothing in this section is intended to affect or modify the
availability of the eligibility category described in Section 14052
or the application process, documentation requirements, methodology,
or benefits available pursuant to that section.
SEC. 64. Section 14005.334 is added to the
Welfare and Institutions Code , to read:
14005.334. (a) The director shall establish a local coverage
option program to provide Medi-Cal coverage for low income adults.
The program shall meet the requirements of this section.
(b) Coverage shall be provided, at the option of the county, only
by counties that operate designated public hospitals. Each county
shall provide coverage only for those eligible individuals who reside
in the county.
(1) All covered services shall be provided by designated public
hospitals, their affiliated public providers, and community clinics,
except with respect to those medically necessary services that are
not available or accessible through these providers. Each enrollee
shall be assigned a medical home at a public provider affiliated with
a public hospital or at a community clinic. Counties may elect to
contract with additional providers for services to enrollees, if the
county, the department, or the Department of Managed Health Care
determines that the services of a particular provider are necessary
to serve a specific need of enrollees.
(2) Counties may provide coverage directly through a county
operated health care service plan licensed under the Knox-Keene
Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code), or
through a local initiative created pursuant to Section 14087.31,
14087.35, 14087.36 or 14087.38 or a county organized health system
described in Section 14087.51 or 14087.54.
(3) A county may elect to provide coverage through the local
initiative or county organized health system only if the
administrative costs of the local initiative or county organized
health system do not exceed 15 percent, such that at least 85 percent
of aggregate dues, fees, and other periodic payments received by the
local initiative or county organized health system is spent on
health care services.
(4) If a county elects to provide coverage through a local
initiative or county organized health system, the director shall
contract with, and make the payments required under this section to,
the designated local initiative or county organized health system.
(c) A county may offer enrollment in its local coverage option
program to employers and individuals.
(d) In consultation with participating counties, the director
shall complete the following actions:
(1) Establish a uniform benefit package consistent with
subdivision (d) of Section 14005.333.
(2) Design a common identification card to be provided by the
county to each enrollee in a local coverage option program.
(e) Each county, local initiative, or county organized health
system that operates a local coverage option program shall be
entitled to periodic payments per individual who resides in the
county who is an eligible Medi-Cal beneficiary under Section
141005.333 that are actuarially determined to be adequate to meet the
full cost of services, including administrative costs and the cost
incurred in paying for out of network emergency services required in
the benefit package established under subdivision (d) of Section
14005.333 for these individuals.
(f) In consultation with participating counties, the director
shall establish payment rates that shall be accepted by Medi-Cal
participating providers that provide out of network emergency
services to local coverage option program enrollees as payment in
full for those services. The payment rates shall not exceed the
amount the provider would have received had the services been
provided on a fee for service basis to a Medi-Cal beneficiary.
(g) In consultation with the participating counties, by January 1,
2010, the department shall contract with an independent third party
to develop a local coverage option program assessment tool to measure
the extent to which the counties are providing quality, coordinated
care to eligible individuals. The local coverage option program
assessment tool shall be designed to evaluate the following for each
local coverage option program:
(1) Enrolled patient population.
(2) The use of medical services.
(3) Access and barriers to health care.
(4) Processes and quality of care for selected medical conditions,
as appropriate for the population enrolled in the program.
(5) Patient satisfaction.
(h) The following elements shall be evaluated using the local
coverage option program assessment tool developed under subdivision
(g):
(1) Designation of a medical home and assignment of eligible
individuals to a primary care provider within 60 days of enrollment.
For purposes of this paragraph, "medical home" means a single
provider or facility that maintains all of an individual's medical
information. The primary care provider shall be a provider from which
the enrollee can access primary and preventive care, or specialty
care as determined appropriate by a medical professional.
(2) An enrollment process that includes a patient identification
system to demonstrate enrollment into the program.
(3) A screening process for individuals who may qualify for
enrollment into the Healthy Families Program and the Access for
Infants and Mothers Program prior to enrollment into the local
coverage option program.
(4) Use of a medical record system, which may include electronic
medical records.
(5) Demonstrated progress in meeting industry-accepted quality
monitoring processes to assess the health care outcomes of
individuals with chronic conditions who are enrolled in the local
coverage option program, including HEDIS and NCQA standards.
(6) Promotion of the use of preventive services and early
intervention.
(7) The ability to demonstrate how the local coverage option
program will promote the viability of the existing safety net health
care system.
(8) Demonstration of how the program will provide consumer
assistance to individuals applying to, participating in, or accessing
services in the local coverage option program. For purposes of this
paragraph, "consumer assistance" includes specific processes to
address consumer grievances and patient advocacy.
(i) After three years of operation of a local coverage option
program in a county, the department shall conduct a review using the
local coverage option program assessment tool to evaluate each county'
s performance against the benchmarks established under subdivisions
(g) and (h). If the department determines that the local coverage
option program in a particular county has substantially met the
benchmarks, the director shall extend the period of exclusive
coverage in that county for an additional two years. If the
department concludes that a county failed to substantially meet the
benchmarks, the county's local coverage option program shall cease to
be the exclusive coverage option as provided in paragraph (2) of
subdivision (d) of Section 14005.332.01. The county shall have the
opportunity for administrative and judicial review of the department'
s determination.
(j) After five years of operation of a local coverage option
program in a county, newly enrolled Medi-Cal beneficiaries described
in Section 14005.333 shall have the ability to enroll in either the
local coverage option program or the county organized health system
(COHS) or the two-plan contractor in the county.
(k) To the extent necessary to implement the local coverage option
program, the director may waive, or exempt local coverage option
programs from, the Medi-Cal managed care program requirements of
Chapters 4 and 4.1 of Title 22 of the California Code of Regulations,
and the director of the Department of Managed Health Care may waive,
or exempt local coverage option programs from, the requirements of
Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code if the director of Health Care Services and
the director of the Department of Managed Health Care find the action
to be in the public interest and not detrimental to the protection
of patients. The director shall comply with the following provisions
in implementing this subdivision:
(1) Waivers or exemptions may be granted to a program as necessary
to implement the limited network of providers authorized under this
section.
(2) Financial responsibility requirements may be waived or
adjusted to recognize the financial viability of the public entity
operating the program.
(3) Section 1342.9 of the Health and Safety Code shall apply to
local coverage option programs.
(l) The local coverage option program shall become operational for
services rendered on and after July 1, 2010.
SEC. 65. Section 14008.85 of the
Welfare and Institutions Code is amended to read:
14008.85. (a) To the extent federal financial participation is
available, a parent who is the principal wage earner shall be
considered an unemployed parent for purposes of establishing
eligibility based upon deprivation of a child where any of the
following applies:
(1) The parent works less than 100 hours per month as determined
pursuant to the rules of the Aid to Families with Dependent Children
program as it existed on July 16, 1996, including the rule allowing a
temporary excess of hours due to intermittent work.
(2) The total net nonexempt earned income for the family is not
more than 100 percent of the federal poverty level as most recently
calculated by the federal government. The department may adopt
additional deductions to be taken from a family's income.
(3) The parent is considered unemployed under the terms of an
existing federal waiver of the 100-hour rule for recipients under the
program established by Section 1931(b) of the federal Social
Security Act (42 U.S.C. Sec. 1396u-1).
(b) The department shall seek any federal approval required to
waive or to increase the income limit in paragraph (2) of subdivision
(a) to the extent necessary to implement Sections 14005.30 and
14005.301.
(b)
(c) Notwithstanding Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, the department shall implement this section by means
of an all county letter or similar instruction without taking
regulatory action. Thereafter, the department shall adopt regulations
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.
(c) This section shall become operative March 1, 2000.
SEC. 66. Section 14011.16 of the
Welfare and Institutions Code is amended to read:
14011.16. (a) Commencing August 1, 2003, the department shall
implement a requirement for beneficiaries to file semiannual status
reports as part of the department's procedures to ensure that
beneficiaries make timely and accurate reports of any change in
circumstance that may affect their eligibility. The department shall
develop a simplified form to be used for this purpose. The department
shall explore the feasibility of using a form that allows a
beneficiary who has not had any changes to so indicate by checking a
box and signing and returning the form.
(b) Beneficiaries who have been granted continuous eligibility
under Section 14005.25 shall not be required to submit semiannual
status reports. To the extent federal financial participation is
available, all children under 19 years of age shall be exempt from
the requirement to submit semiannual status reports.
(c) Beneficiaries whose eligibility is based on a determination of
disability or on their status as aged or blind shall be exempt from
the semiannual status report requirement described in subdivision
(a). The department may exempt other groups from the semiannual
status report requirement as necessary for simplicity of
administration.
(d) When a beneficiary has completed, signed, and filed a
semiannual status report that indicated a change in circumstance,
eligibility shall be redetermined.
(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of all county
letters or similar instructions without taking regulatory action.
Thereafter, the department shall adopt regulations 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.
(f) This section shall be implemented only if and to the extent
federal financial participation is available.
(g) This section shall become inoperative on July 1, 2010, and, as
of January 1, 2011, is repealed, unless a later enacted statute that
is enacted before January 1, 2011, deletes or extends the dates on
which it becomes inoperative and is repealed.
SEC. 67. Section 14011.16.1 is added to the
Welfare and Institutions Code , to read:
14011.16.1. (a) Commencing July 1, 2010, the department shall
implement a requirement for any beneficiary who is not required to
make premium payments to file a semiannual address verification
report. The department shall develop a simplified form to be used for
this purpose so that a beneficiary who has not had a change of
address can so indicate by checking a box and returning the form.
(b) When a beneficiary who is required to complete and return the
form described in subdivision (a) fails to do so, the county shall
follow up by attempting to
contact the individual using the last known phone number or
numbers. If the attempted phone contact fails to resolve the issue by
providing confirmation of the current address, the county shall
search available files to determine if an alternate or new address
has been used by the beneficiary and shall send a form to that
address that is required to be returned. In the absence of a new or
alternate address, a form shall be sent to the last known address. If
the form is not returned, or if it is returned under circumstances
indicating that the individual no longer resides at the address last
provided by the individual and no forwarding address is provided,
eligibility shall be terminated for loss of contact.
(c) Whenever Medi-Cal eligibility is terminated based on a loss of
contact as described in this section, the entity responsible for
redeterminations of eligibility for the affected beneficiary shall
document the facts causing the eligibility termination in the
beneficiary's file. Following this written certification, a notice of
action specifying that Medi-Cal eligibility was terminated based on
loss of contact shall be sent to the beneficiary.
(d) A beneficiary whose eligibility is based on a determination of
disability or on his or her status as aged or blind shall be exempt
from the requirements of subdivision (a).
(e) Children under 19 years of age and pregnant women shall be
exempt from the requirements of this section.
(f) The department may exempt categories or groups of individuals
from the requirement to file an address verification as necessary for
simplicity of administration.
(g) This section shall be implemented only if and to the extent
that its implementation does not jeopardize federal financial
participation.
SEC. 68. Section 14132.105 is added to the
Welfare and Institutions Code , to read:
14132.105. (a) (1) The department shall establish a Healthy
Action Incentives and Rewards Program to be provided as a covered
benefit under the Medi-Cal program.
(2) The benefits described in this section shall only be provided
under the terms and conditions determined by the department, and
shall meet all the requirements described in subdivision (b).
(b) For purposes of this section, the Healthy Action Incentives
and Rewards Program shall include, but need not be limited to, all of
the following:
(1) Health risk appraisals that collect information from eligible
beneficiaries to assess overall health status and identify risk
factors, including, but not limited to, smoking and smokeless tobacco
use, alcohol abuse, drug use, nutrition, and physical activity
practices.
(2) A followup appointment with a licensed health care
professional acting within his or her scope of practice to review the
results of the health risk appraisal and discuss any recommended
actions.
(3) Incentives or rewards or both for eligible beneficiaries to
become more engaged in their health care and to make appropriate
choices that support good health, including obtaining health risk
appraisals, screening services, immunizations, or participating in
health lifestyle programs or practices. These programs or practices
may include, but need not be limited to, smoking cessation, physical
activity, or nutrition. Incentives may include, but need not be
limited to, nonmedical pharmacy products or services not otherwise
covered under this chapter, gym memberships, and weight management
programs.
(c) The department shall seek and obtain federal financial
participation and secure all federal approvals, including all
required state plan amendments or waivers, necessary to implement and
fund the services authorized under this section.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and has been
obtained.
(e) (1) Notwithstanding any other provision of law, the provision
of healthy incentives and rewards pursuant to this section by a
health care provider, or his or her agent, that meets the
requirements of this section, Section 1367.38 of the Health and
Safety Code, or Section 10123.56 of the Insurance Code shall not be
considered or construed as an unlawful practice, act, kickback,
bribe, rebate, remuneration, offer, coupon, product, payment, or any
other form of compensation by a provider or his or her agent,
directly or indirectly, overtly or covertly, in exchange for another
to obtain, participate, or otherwise undergo or receive health care
services.
(2) Notwithstanding any other provision of law, incentives
authorized pursuant to this section are not subject to the penalties,
discipline, limitations, or sanctions imposed under law to preclude
or prohibit, as an unlawful practice, bribe, kickback or other act,
the offering or delivery of a rebate, remuneration, offer, coupon,
product, rebate, payment, or any other form of compensation by the
provider, or his or her agent, directly or indirectly, overtly or
covertly, in exchange for another to obtain, participate, or
otherwise undergo or receive health care services.
(3) Notwithstanding any other provision of law, the provision of
healthy incentives and rewards pursuant to this section by a health
care provider, or his or her agent, that meets the requirements of
this section shall not be considered or construed as an inducement to
enroll.
(f) This section shall only be implemented if, and to the extent,
allowed under federal law. If any portion of this section is found to
be invalid, as determined by a final judgment of a court of
complaint jurisdiction, this section shall become inoperative.
SEC. 69. Section 14137.10 is added to the
Welfare and Institutions Code , to read:
14137.10. (a) (1) There is hereby established in the department
the Comprehensive Diabetes Services Program to provide comprehensive
diabetes prevention and management services to any individual who
meets the requirements set forth in paragraph (2). For purposes of
this subdivision, "comprehensive diabetes prevention and management
services" shall be defined by the department based on consultation
pursuant to subdivision (b). Services may include, but need not be
limited to, all of the following:
(A) Screening for diabetes and prediabetes in accordance with the
operational screening guidelines and protocols developed for the
Comprehensive Diabetes Services Program utilizing the most current
American Diabetes Association criteria for diabetes in adults.
(B) Providing visits by certified practitioners in accordance with
the operational protocols developed for the Comprehensive Diabetes
Service Program for eligible beneficiaries who have been diagnosed
with prediabetes.
(C) Providing culturally and linguistically appropriate life-style
coaching and self-management training for eligible adult
beneficiaries with prediabetes and diabetes, in accordance with
evidence-based interventions, to avoid unhealthy blood sugar levels
that contribute to the progression of diabetes and its complications.
(D) Conducting regular and timely laboratory evaluations, by the
primary care physician of the eligible beneficiary, in conjunction
with a program of blood sugar level self-management education and
training for eligible adult beneficiaries who have been diagnosed
with prediabetes and diabetes.
(2) A beneficiary is eligible for services pursuant to this
section if he or she is all of the following:
(A) Between 18 and 64 years of age.
(B) Not dually enrolled in the Medi-Cal program and the federal
Medicare program.
(C) Diagnosed with prediabetes or diabetes.
(D) Otherwise eligible for full scope of benefits under this
chapter but not enrolled in a Medi-Cal managed care plan.
(b) The department shall seek and obtain federal financial
participation and secure all federal approvals, including all
required state plan amendments or waivers, necessary to implement and
fund the services authorized under this section.
(c) For the purposes of implementation of this section, the
director may enter into contracts for the purposes of providing the
benefits offered under the Comprehensive Diabetes Services Program.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and has been
obtained.
(e) The Comprehensive Diabetes Services Program shall be developed
and implemented only to the extent that state funds are appropriated
annually for the services provided under this section.
(f) The department shall develop and implement incentives for
Medi-Cal fee-for-service eligible beneficiaries who participate in
the Comprehensive Diabetes Services Program and are compliant with
program requirements for screening and self-management activities.
(g) The department shall develop and implement financial
incentives for Medi-Cal fee-for-service providers who participate in
the Comprehensive Diabetes Services Program and are compliant with
program requirements in the screening and management of eligible
beneficiaries who have been diagnosed with prediabetes and diabetes.
(h) The department shall collect data including, but not be
limited to, laboratory values from screening and diagnostic tests for
the individual beneficiaries participating in the Comprehensive
Diabetes Services Program and monitor the health outcomes of the
participating individual beneficiaries.
(i) The department shall, in consultation with the California
Diabetes Program in the State Department of Public Health, contract
with an independent organization to:
(1) Evaluate and report the health outcomes and cost savings of
the Comprehensive Diabetes Services program.
(2) Estimate the short- and long-term cost savings of expanding
the strategies of the Comprehensive Diabetes Services Program
statewide through the private or commercial insurance markets.
SEC. 70. Article 5.22 (commencing with Section
14167.22) is added to Chapter 7 of Part 3 of Division 9 of the
Welfare and Institutions Code , to read:
Article 5.22. Medi-Cal Physician Rate Increase Act
14167.22. (a) The director shall seek federal approval of the
rate methodology set forth in this article. The director may alter
any methodology specified in this article, to the extent necessary to
meet the requirements of federal law or regulations or to obtain
federal approval. If, after seeking federal approval, federal
approval is not obtained, that methodology shall not be implemented.
(b) Payments made pursuant to this article are contingent on the
receipt of federal reimbursement. Unless otherwise expressly provided
in this article, nothing in this article shall create an obligation
on the part of the department to fund any payment from state funds in
the absence of, or on account of a shortfall in, federal funding.
(c) It is the intent of the Legislature that, to the extent
practicable, the director increase reimbursement rates to managed
health care plans by the actuarial equivalent amount necessary to
ensure that managed health care plans make payments to the classes of
providers whose rates are governed by this article at the same level
as are made pursuant to this article.
14167.23. For purposes of this article, the following definitions
shall apply:
(a) "Physician" means a practitioner meeting the requirements of
Section 51228 of Title 22 of the California Code of Regulations.
(b) "Physician group" means two or more physicians legally
organized as a partnership, professional corporation, foundation,
not-for-profit corporation, or similar association, and that meets
the requirements of Section 51000.16 of Title 22 of the California
Code of Regulations.
14167.24. (a) A physician or physician group, as described in
subdivision (b), shall receive Medi-Cal reimbursement to the extent
provided in this section.
(b) A physician or physician group shall be eligible for
reimbursement if the particular physician or physician group has all
of the following characteristics:
(1) Is an enrolled Medi-Cal provider eligible to receive Medi-Cal
payments and provides services to Medi-Cal beneficiaries.
(2) Is a physician or physician group as defined in Section
14167.23.
(c) An eligible physician's reimbursement pursuant to this section
shall be calculated and paid as follows:
(1) Except as provided under Section 14167.25, commencing on July
1, 2010, reimbursement to an eligible physician or physician group,
as described in subdivisions (a) and (b), shall not be less than ____
percent of the amount that the federal Medicare program would pay
the physician or physician group for the same service, rendered on
the same date. In determining the amounts to be paid pursuant to this
paragraph, the department shall ensure that the equivalent Medicare
rate to be used takes into account all of the factors, supplemental
payments, and other variables that are used to determine the Medicare
rate. The supplemental rate augmentation paid for physician services
in California Children Services, as established in the annual Budget
Act, shall continue.
(2) The department shall establish a rate for services for which
Medicare does not provide a comparable service, or for which the
Medicare payment for the service cannot be separately determined,
which shall be the department's best estimate of a rate that is not
less than ____ percent of what Medicare would pay for that service.
(d) As a condition of receiving reimbursement under this section,
a physician or physician group shall keep, maintain, and have readily
retrievable, any records specified by the department to fully
disclose reimbursement amounts to which the physician or physician
group is entitled, and any other records required by the federal
Centers for Medicare and Medicaid Services.
(e) This section shall apply to services rendered to Medi-Cal
beneficiaries on and after July 1, 2010. With respect to services
that are paid under this section, any other provider rate methodology
that is inconsistent or duplicative of the rates paid pursuant to
this section shall become inoperative for those services to the
extent that the rates are inconsistent or duplicative.
14167.25. (a) (1) Notwithstanding Section 14105 or any other
provision of law, on or after July 1, 2010, the director may
designate a percentage of the rate increase paid to Medi-Cal
fee-for-service providers pursuant to paragraph (1) of subdivision
(c) of Section 14167.24, to be directly linked to performance
measures developed pursuant to subdivisions (c) and (d), including a
demonstrated showing of continued performance improvement.
(2) For purposes of paragraph (1), the percentage of the rate that
is linked to performance measures shall be established by the
director such that physicians and physician groups will be
sufficiently reimbursed for implementing performance measures,
including continued performance improvement.
(b) The performance measures shall be developed by the department
in consultation with stakeholders, including, but not limited to,
representatives of patients, physicians, managed care plans, payers,
and other appropriate stakeholders.
(c) The department, in consultation with the stakeholders
identified in subdivision (b), shall develop a comprehensive list of
performance measures relying, in part, on existing quality and
performance measures endorsed by national organizations, such as the
Ambulatory Quality Alliance, the Hospital Quality Alliance, and the
National Quality Forum (NQF).
(d) At a minimum, all of the following performance measures shall
be used in determining the appropriate percentage rate increases:
(1) Reporting of health care outcomes, including the cost of that
health care.
(2) Improvements in health care efficiency.
(3) Improvements in health care safety.
(4) The efficient exchange of health information data through
technology.
(5) The quality assurance requirements set forth in Section
1300.70 of Title 28 of the California Code of Regulations.
(6) Efforts to promote healthy behaviors among Medi-Cal
beneficiaries pursuant to the Healthy Incentives and Rewards Program
described in Section 14132.105.
(7) The extent to which purchasers, payers, providers, and
consumers are able to monitor the quality and cost of health care
utilizing public reporting information published by the Office of the
Patient Advocate.
(8) The extent to which physicians and physician groups that
provide services to Medi-Cal beneficiaries on a fee-for-service basis
implement activities, such as telemedicine, electronic prescribing
and the electronic exchange of health information among various
payers and providers for the purpose of attaining health care safety
and quality improvements, informed clinical care decisions, the
increased use of interoperable platforms for the exchange of relevant
health care data, and more accurate and timely diagnosis and
treatment.
(9) Compliance with the federal Health Insurance Portability and
Accountability Act (HIPAA) (42 U.S.C. Sec. 300gg).
(e) The department shall consult with stakeholders, including, but
not limited to, representatives of patients, managed care plans, and
payers, to determine the means to measure and document
implementation by each physician and physician group of the
performance measures developed pursuant to subdivisions (c) and (d).
(f) The department may exempt classes of physician and physician
groups and services from this section, if necessary to comply with
the requirements of federal law or regulations.
(g) The department may file one or more state plan amendments to
implement this section.
(h) The department shall seek necessary federal approvals for
implementation of this section. The department shall implement this
section only in a manner that is consistent with federal Medicaid law
and regulations. This section shall be implemented only to the
extent that federal approval is obtained and federal financial
participation is available.
(i) The department shall implement this section only to the extent
that state funds are appropriated for the nonfederal share of the
rate increases provided under this section.
SEC. 71. Article 7 (commencing with Section
14199.10) is added to Chapter 7 of Part 3 of Division 9 of
the Welfare and Institutions Code , to read:
Article 7. Coordination with the California Health Trust Fund
14199.10. The department shall seek any necessary federal
approval to enable the state to receive federal funds for coverage
provided through the California Cooperative Health Insurance
Purchasing Program (Cal-CHIPP) to persons who would be eligible for
the Medi-Cal program if the state expanded eligibility to a
population composed of parents and other caretaker relatives with a
household income at or below 300 percent of the federal poverty level
who are not otherwise eligible for full scope benefits with no share
of cost. Revenues in the California Health Trust Fund created
pursuant to Section 12699.212 of the Insurance Code shall be used as
state matching funds for receipt of federal funds resulting from the
implementation of this section. All federal funds received pursuant
to that federal approval shall be deposited in the California Health
Trust Fund.
SEC. 72. The State Department of Health Care
Services, in consultation with the Managed Risk Medical Insurance
Board, shall take all reasonable steps that are required to obtain
the maximum amount of federal funds and to support federal claiming
procedures in the administration of this act.
SEC. 73. Notwithstanding Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code, during the period January 1, 2008, to December 31,
2011, inclusive, the State Department of Health Care Services may
implement this act by means of all county letters or similar
instructions without taking regulatory action. After December 31,
2011, the department shall adopt all necessary regulations 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. 74. Notwithstanding any other provision of
law, the Managed Risk Medical Insurance Board may implement the
provisions of this act expanding the Healthy Families Program only to
the extent that funds are appropriated for those purposes in the
annual Budget Act or in another statute.
SEC. 75. During the period from January 1, 2008 to
December 31, 2011, inclusive, the adoption of regulations pursuant
to this act by the Managed Risk Medical Insurance Board shall be
deemed to be an emergency and necessary for the immediate
preservation of public peace, health, and safety, or the general
welfare.
SEC. 76. (a) In order to achieve the purposes of
this act, the State Department of Health Care Services, after
consultation with the Department of Finance, may utilize either state
plan amendments or waivers, or combination thereof, as necessary to
implement this act, to maximize the availability of federal financial
participation, and to maximize the number of persons for whom that
federal financial participation is available to cover the cost of
health care services.
(b) The flexibility authorized by this act shall include
modification of the requirements, standards, and methodologies for
expansion categories or populations created by this act in order to
maximize the availability of federal financial participation. When
exercising this flexibility, the State Department of Health Care
Services shall not make changes that would do any of the following:
(1) Make otherwise eligible individuals ineligible for health
coverage under the Medi-Cal program and the Healthy Families Program.
(2) Increase cost-sharing amounts beyond levels established in
this act.
(3) Reduce benefits below those provided for in this act.
(4) Otherwise disadvantage applicants or recipients in a way not
contemplated by this act.
(c) The department shall take all reasonable steps necessary to
maximize federal financial participation and to support federal
claiming in the implementation of this act.
(d) It is the intent of the Legislature that the provisions of
this act shall be implemented simultaneously to the extent possible
in order to harmonize and best effectuate the purposes and intent of
this act.
(e) The Director of Health Care Services shall notify the Chair of
the Joint Legislative Budget Committee in any case when it is
necessary to exercise the flexibility provided under this section.
This notification shall be provided 30 days prior to exercising that
flexibility.
SEC. 77. It is the intent of the Legislature that
provisions of this act shall be financed by contributions from
employers; individuals; federal, state, and local governments; and
health care providers. Specifically financial support shall include:
(a) Federal financial participation through the federal Medicaid
and S-CHIP programs.
(b) Revenue from counties to support the cost of enrolling persons
otherwise entitled to county-funded care.
(c) Fees paid by acute care hospitals at a rate of 4 percent of
patient revenues.
(d) Fees paid by employers not expending an equivalent amount
for health care
expenditures at a rate ranging from 2 to 6.5 percent of total
payroll, based on social security wages.
(e) Premium contributions from currently offering employers when
employees, eligible for employer-based coverage, choose to enroll in
public programs.
(f) Premium payments for individuals enrolled in publicly
subsidized coverage and coverage purchased in the individual market.
(g) Additional public funds obtained through increasing the taxes
by two dollars ($2) on the sale of each package of cigarettes and by
an equivalent amount on other tobacco products.
(h) Other state funds made available through savings generated
through reduced demand for existing health care programs.
SEC. 78. It is the intent of the Legislature that
the rates paid pursuant to the Medi-Cal program for inpatient and
outpatient hospital services be increased.
SEC. 79. No reimbursement is required by this act
pursuant to Section 6 of Article XIII B of the California
Constitution for certain costs that may be incurred by a local agency
or school district because, in that regard, 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.
However, if the Commission on State Mandates determines that this
act contains other costs mandated by the state, reimbursement to
local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division 4 of
Title 2 of the Government Code.
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