BILL NUMBER: SB 857 ENROLLED
BILL TEXT
PASSED THE SENATE JUNE 15, 2014
PASSED THE ASSEMBLY JUNE 15, 2014
AMENDED IN ASSEMBLY JUNE 12, 2014
INTRODUCED BY Committee on Budget and Fiscal Review
JANUARY 9, 2014
An act to amend Section 56.36 of the Civil Code, to amend Sections
6254 and 100504 of the Government Code, to amend Sections 1280.15,
1341.45, 1399.861, 11833.02, 11833.04, 120955, 128200, 128205,
128210, 128215, 128225, 128230, 128235, 130200, and 136030 of, to
amend and renumber Sections 130201, 130202, 130203, 130204, and
130205 of, to add Sections 1347.5, 1368.05, 1374.76, 120962, 121451,
121452, and 131058 to, and to repeal and add Section 136000 of, the
Health and Safety Code, to amend Sections 10965.15, 12693.70,
12739.61, and 12739.78 of, to add Sections 10112.35, 12699.15,
12699.64, 12701, 12710.2, and 12739.79 to, and to repeal Part 6.3
(commencing with Section 12695), Part 6.4 (commencing with Section
12699.50), and Part 6.5 (commencing with Section 12700) of Division 2
of, the Insurance Code, to add Section 19548.2 to the Revenue and
Taxation Code, and to amend Sections 4061, 5897, 14043.38, 14132.275,
14132.277, 14154, 14165.50, 15800, 15801, 15803, 15804, and 15805
of, to amend the heading of Chapter 2 (commencing with Section 15810)
of Part 3.3 of Division 9 of, to amend, repeal, and add Sections
15810, 15811, 15826, 15832, and 15840 of, to add Sections 14005.22,
14005.225, 14104.35, 14131.11, 14132.915, 14148.65, 14148.67,
15802.5, 15806, 15814, 15818, 15827, 15833, 15835, 15839, 15841,
15847, 15847.3, 15847.5, 15847.7, 15848, and 15848.5 to, and to add
Chapter 3 (commencing with Section 15850) and Chapter 4 (commencing
with Section 15870) to Part 3.3 of Division 9 of, the Welfare and
Institutions Code, relating to health, and making an appropriation
therefor, to take effect immediately, bill related to the budget.
LEGISLATIVE COUNSEL'S DIGEST
SB 857, Committee on Budget and Fiscal Review. Health.
(1) Existing law establishes the Office of Health Information
Integrity within the California Health and Human Services Agency to
ensure the enforcement of state law mandating the confidentiality of
medical information, as defined, and to impose administrative fines
on providers of health care for the unauthorized use of medical
information.
This bill would transfer the duty to impose administrative fines
on providers of health care for the unauthorized use of medical
information to the State Department of Public Health, and would make
other conforming changes.
(2) Existing law establishes the California Health Benefit
Exchange for the purpose of facilitating the enrollment of qualified
individuals and small employers in qualified health plans. Existing
law authorizes the board of the California Health Benefit Exchange to
adopt emergency regulations until January 1, 2016. Under existing
law, emergency regulations remain in effect for no more than 180
days, except as specified, and may be readopted for 2 additional
90-day periods.
This bill would allow more than 2 readoptions of those emergency
regulations until January 1, 2017, and would allow the emergency
regulations adopted by the board to remain in effect for 2 years, as
specified.
(3) Existing law, as of July 1, 2012, transferred the Office of
Patient Advocate from the Department of Managed Health Care to the
California Health and Human Services Agency, to provide assistance
to, and advocate on behalf of, individuals served by health care
service plans regulated by the Department of Managed Health Care,
insureds covered by health insurers regulated by the Department of
Insurance, and individuals who receive or are eligible for other
health care coverage in California, including coverage available
through the Medi-Cal program, the California Health Benefit Exchange,
the Healthy Families Program, or any other county or state health
care program. The duties of the office, include, but are not limited
to, compiling an annual publication, to be made available on the
office's Internet Web site, of a quality of care report card,
rendering assistance to consumers regarding procedures, rights, and
responsibilities related to the filing of complaints, grievances, and
appeals, and coordinating and working with other government and
nongovernment patient assistance programs and health care
ombudsperson programs.
This bill would revise and recast those provisions by transferring
the direct consumer assistance activities that had previously been
conferred on the office to the Department of Managed Health Care to
be carried out in partnership with community-based consumer
assistance organizations for the purposes of serving health care
consumers, as provided. The bill would instead require the office,
among other things, to provide assistance to, and advocate on behalf
of, health care consumers, and would instead make the goal of the
office to coordinate amongst, provide assistance to, and collect data
from, all of the state agency consumer assistance or patient
assistance programs and call centers, to better enable health care
consumers to access the health care services to which they are
eligible under the law. The duties of the office would include, but
not be limited to, producing a baseline review and annual report to
be made publically available on the office's Internet Web site by
July 1, 2015, and annually thereafter, of health care consumer or
patient assistance help centers, call centers, ombudsperson, or other
assistance centers operated by the Department of Managed Health
Care, the State Department of Health Care Services (DHCS), the
Department of Insurance, and the Exchange, and including certain
minimum information, and collecting, tracking, and analyzing data on
problems and complaints by, and questions from, consumers about
health care coverage for the purpose of providing public information
about problems faced and information needed by consumers in obtaining
coverage and care. This bill would also make conforming changes.
(4) Existing federal law requires a health insurance issuer that
offers group or individual health insurance coverage that provides
both medical and surgical benefits and mental health or substance use
disorder benefits to establish parity in the terms and conditions
applicable to medical and mental health benefits, as specified.
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 requires a health care
service plan contract that provides hospital, medical, or surgical
coverage to provide coverage for the diagnosis and medically
necessary treatment of severe mental illnesses under the same terms
and conditions applied to other medical conditions, as specified.
This bill would require large group, small group, and individual
health care service plan contracts to provide covered mental health
and substance use disorder benefits in compliance with the provisions
of federal law governing mental health parity no later than January
1, 2015. Because a willful violation of that requirement would be a
crime, the bill would impose a state-mandated local program.
(5) Under existing law, DHCS is responsible for licensing and
certifying alcoholism and drug abuse recovery and treatment programs
and facilities, including both residential and nonresidential
programs. Existing law requires the department to charge a fee for
the licensure or certification of these facilities and to establish
fee scales using different capacity levels, categories based on
measures other than program capacity, or any other category or
classification that the department deems necessary or convenient to
maintain an effective and equitable fee structure. Existing law
requires the department to submit proposed new fees or fee changes to
the Legislature for approval, as specified, and prohibits new fees
or fee changes without legislative approval.
This bill would require the department to issue a provider
bulletin setting forth the approved fee structure and, on an annual
basis, to publish the fee structure on the department's Internet Web
site.
Existing law authorizes the department to implement the licensing
and certification provisions for alcoholism and drug abuse recovery
and treatment programs and facilities through emergency regulations.
This bill would remove the authorization for emergency regulations
and would require the department to adopt regulations through the
Administrative Procedure Act. The bill would authorize the department
to implement new fees or fee changes by means of provider bulletins
or similar action and to supersede the existing licensing and
certification fees until the department amends the regulations. The
bill would also require the department to notify and consult with
interested parties and appropriate stakeholders regarding new fees or
fee changes.
(6) Existing law requires the State Public Health Officer to
establish, and authorizes him or her to administer, a program to
provide drug treatments to persons infected with HIV, to the extent
that state and federal funds are appropriated. Existing law requires
the State Department of Public Health to determine a person whose
adjusted gross income does not exceed $50,000 per year to be
financially eligible to receive services under this program, as
specified. Existing law authorizes the State Department of Public
Health to subsidize certain cost-sharing requirements for persons
otherwise eligible for the AIDS Drug Assistance Program (ADAP) with
non-ADAP drug coverage by paying for prescription drugs included on
the ADAP formulary, as specified.
This bill would additionally authorize the department, if the
director determines that it would result in a cost savings to the
state, to subsidize costs associated with a health care service plan
or health insurance policy, including medical copayments and
deductibles for outpatient care, and premiums to purchase or maintain
health insurance coverage. The bill would authorize federal funds
and moneys in the AIDS Drug Assistance Program Rebate Fund to be used
for these purposes. By expanding the purposes for which moneys from
the continuously appropriated AIDS Drug Assistance Program Rebate
Fund may be expended, the bill would make an appropriation.
The bill would also, for purposes of determining financial
eligibility for the ADAP program, require information sharing between
the Franchise Tax Board and the State Department of Public Health to
verify the amount of a person's adjusted gross income.
(7) Existing law establishes a program for the control of
tuberculosis and requires the State Department of Public Health to
maintain the program and administer funds made available by the state
for the care of tuberculosis patients. Existing law authorizes the
department to establish standards and procedures for the operation of
local tuberculosis control programs and to distribute for the
purpose of tuberculosis control an annual subvention to any local
health department that maintains a tuberculosis control program
consistent with the standards and procedures established by the
department.
This bill would require a local entity that receives funding from
the state for the purposes of tuberculosis control to first allocate
the moneys received for specified purposes and activities, including
submitting the written treatment plan to the local health officer and
for cities, counties, and cities and counties to provide counsel to
nonindigent tuberculosis patients who are subject to a civil order of
detention issued by a local health officer, as specified.
(8) Existing law, the Song-Brown Health Care Workforce Training
Act, establishes a state medical contract program with accredited
medical schools, programs that train primary care physician's
assistants, programs that train primary care nurse practitioners and
registered nurses, hospitals, and other health care delivery systems.
Existing law establishes the California Healthcare Workforce
Policy Commission, consisting of 15 members, to administer the state
medical contract program, except as specified. Existing law requires
the commission to identify specific areas of the state where unmet
priority needs for primary care family physicians and registered
nurses exist, establish standards for, among other things, family
practice training programs, family practice residency programs,
primary care physician's assistants programs, and programs that train
primary care nurse practitioners, and to make recommendations to the
Director of the Office of Statewide Health Planning and Development
with regard to the funding of specific programs. Existing law
requires the director to select and contract on behalf of the state
with the above-described entities for the purpose of, among other
things, training medical students and residents in the specialty of
family practice, subject to criteria established by the commission.
This bill would authorize the state medical contract program to
include contracts with teaching health centers, as defined. The bill
would require a teaching health center that receives funds pursuant
to the state medical contract program to include within its
curriculum, programs or departments that recognize family medicine as
a major independent specialty.
For purposes of the provisions that implement the state medical
contract program, the bill would delete references to the specialty
of family practice and would refer instead to the specialties of
primary care or family medicine, thereby expanding the scope of the
state medical contract program to include those specialties. The bill
would also require the director to select and contract on behalf of
the state for the purpose of, among other things, training medical
students and residents in the specialties of internal medicine,
obstetrics and gynecology, pediatrics, and family medicine, subject
to criteria established by the commission.
Existing law requires the commission to review and make
recommendations to the Director of the Office of Statewide Health
Planning and Development concerning the funding of those programs
that are submitted to the Health Professions Development Program for
participation in the state medical contract program established under
these provisions. Existing law requires the Chief of the Health
Professions Development Program, or his or her designee, to serve as
executive secretary for the commission.
This bill would delete references to the Health Professions
Development Program and would refer instead to the Healthcare
Workforce Development Division. The bill would instead specify that
the Deputy Director of the Healthcare Workforce Development Division,
or his or her designee, serve as executive secretary for the
commission.
(9) Existing law authorizes the State Department of Public Health
to perform various activities relating to the protection,
preservation, and advancement of public health, including studies and
demonstrations of innovative methods, and authorizes the department
to, among other things, apply for and receive grants for the
performance of the activity.
This bill would authorize the State Department of Public Health to
investigate, apply for, and enter into agreements to secure federal
or nongovernmental funding opportunities for the purposes of
advancing public health, as specified.
(10) Existing law creates the Managed Risk Medical Insurance Board
(MRMIB) and requires MRMIB to administer various programs that
provide health care coverage to certain populations, including the
California Major Risk Medical Insurance Program, the Access for
Infants and Mothers Program, the County Health Initiative Matching
Fund, and the Federal Temporary High Risk Pool.
This bill would eliminate MRMIB as of July 1, 2014, and transfer
the powers, purposes, responsibilities, and jurisdiction of MRMIB to
DHCS. The bill would authorize DHCS to conduct transition activities
prior to July 1, 2014, to ensure the transfer of the programs
administered by MRMIB to DHCS.
Existing law establishes the California Major Risk Medical
Insurance Program (MRMIP), which is administered by MRMIB, to provide
major risk medical coverage to persons who, among other things, have
been rejected for coverage by at least one private health plan.
Existing law authorizes MRMIB to take various actions with respect to
MRMIP, including determining the eligibility of applicants. Existing
law affords dissatisfied subscribers a right to appeal and requires
hearings to be conducted pursuant to specified procedures. Existing
law creates the Major Risk Medical Insurance Fund as a continuously
appropriated fund for purposes of MRMIP and requires that specified
amounts from the Cigarette and Tobacco Products Surtax Fund (Surtax
Fund) be deposited in the fund.
This bill would authorize DHCS to establish eligibility criteria
for MRMIP and would authorize DHCS to implement that authority by
means of plan letters, plan or provider bulletins, or similar
instructions. The bill would authorize hearings regarding subscriber
grievances to be conducted pursuant to specified procedures. The bill
would continue the Major Risk Medical Insurance Fund in existence to
be administered by DHCS for purposes of MRMIP, would eliminate the
required deposits from the Surtax Fund, and instead authorize funds
to be deposited in the fund from the Surtax Fund. The bill would
require DHCS to, by August 1, 2014, establish a work group to develop
a plan to utilize available Major Risk Medical Insurance Program
Fund moneys, in order to provide subsidized health care coverage for
individuals not eligible for or receiving comprehensive health care.
Existing law establishes the Access for Infants and Mothers (AIM)
Program, administered by MRMIB. Existing law transferred the infant
element of AIM to the DHCS on October 1, 2013, and entitled this
program the AIM-Linked Infants Program. Existing law requires that an
infant be disenrolled from the program if his or her household
income exceeds 300% of the federal poverty level. In order to
participate in the mother element of AIM, existing law requires that
the person have a household income between 200% and 250% of the
federal poverty level, unless MRMIB determines that funds are
adequate to serve households above 250% of the federal poverty level.
Existing law authorizes MRMIB to determine subscriber contribution
amount schedules and requires that the contribution not exceed 2% of
the subscriber's annual gross family income.
This bill would transfer the mother element of AIM to DHCS and
would rename the program, including the AIM-Linked Infants Program,
the Medi-Cal Access Program. The bill would require a household
income between 208% and 317% of the federal poverty level in order to
be eligible for the mother element of the program and would require
that an infant be disenrolled from the program if his or her
household income exceeds 317% of the federal poverty level. The bill
would also require that the subscriber contribution for mothers
conform with the maintenance of effort requirements under the federal
Patient Protection and Affordable Care Act.
Existing law creates the County Health Initiative Matching Fund in
the State Treasury, administered by MRMIB in collaboration with
DHCS, for the purpose of providing matching state funds and local
funds received by the fund through intergovernmental transfers to a
county agency, a local initiative, or a county organized health
system in order to provide health insurance coverage to certain
children and adults in low-income households who do not qualify for
health care benefits through the Healthy Families Program or
Medi-Cal. Under existing law, a county, county agency, local
initiative, or county organized health system that will provide an
intergovernmental transfer may apply to MRMIB for funding to provide
health care coverage to eligible children whose family income is at
or below 300% or 400% of the federal poverty level, at the option of
the applicant, or to eligible adults whose family income does not
exceed 200% of the federal poverty level, provided that the children
or adults do not qualify for the Healthy Families Program or the
Medi-Cal program.
This bill would transfer the powers, purposes, responsibilities,
and jurisdiction of MRMIB with respect to this fund to DHCS and would
prohibit DHCS from approving any additional local entities for
participation in the fund. The bill would require a local entity that
was participating in the fund on March 23, 2010, to continue to
participate in the fund, maintaining eligibility standards,
methodologies, and procedures at least as favorable as those in
effect on March 23, 2010. If a county participating in the fund on
March 23, 2010, elects to cease funding the nonfederal share of
program expenditures, the bill would require DHCS to administer the
program within that county and would require the General Fund to
provide funding amounts equal to the total nonfederal share of all
expenditures incurred by DHCS in that regard. The bill would
continuously appropriate money in the fund, thereby making an
appropriation. The bill would eliminate the provisions authorizing
funding for coverage for certain low-income adults and would
authorize a county, county agency, local initiative, or county
organized health system that will provide an intergovernmental
transfer to apply to DHCS for funding to provide health care coverage
to eligible children who are not eligible for the Medi-Cal program,
the Medi-Cal Access Program, or a specified targeted low-income
program and whose family income is at or below 317% or 411% of the
federal poverty level, at the option of the applicant. The bill would
also limit the intergovernmental transfer amount to the expenditures
that would be eligible for federal financial participation. The bill
would require that the state be held harmless from any federal audit
disallowance and interest resulting from payments made to a
participating application for a disallowed claim.
The bill would authorize DHCS to implement these MRMIB transfer
provisions by means of all-county letters, plan letters, plan or
provider bulletins, or similar instructions.
(11) Existing law requires DHCS to implement mental health
services relating to the care and treatment of persons with mental
disorders. Existing law requires DHCS to utilize a joint state-county
decisionmaking process to determine the appropriate use of state and
local resources to meet the mission and goals of the state's mental
health system. Existing law requires the department to use that
process in, among other things, providing assistance to local mental
health departments.
This bill would require DHCS to also utilize this decisionmaking
process to determine the appropriate use of state and local resources
to meet the mission and goals with respect to substance use
disorders and to provide technical assistance to local behavioral
health and substance use disorder services departments.
(12) Existing law provides that contracts awarded by various state
entities, including the DHCS, for purposes of providing these
services may be awarded in accordance with, or are exempt from,
specified procedures governing the awarding of state contracts.
Existing law, the Mental Health Services Act, an initiative
measure enacted by the voters as Proposition 63 at the November 2,
2004, statewide general election, establishes the continuously
appropriated Mental Health Services Fund to fund various county
mental health programs. Existing law requires that funds be reserved,
prior to making allocations from the fund, for the costs incurred by
state entities, including the State Department of Public Health, in
implementing the programs funded by the act, as specified. The act
provides that it may be amended by the Legislature by a 2/3 vote of
each house as long as the amendment is consistent with and furthers
the intent of the act, and that the Legislature may also clarify
procedures and terms of the act by majority vote.
This bill would authorize contracts awarded by the State
Department of Public Health for purposes of providing mental health
services, as specified, to be awarded in accordance with, and exempt
those contracts from, specified procedures governing the awarding of
state contracts. The bill would also make technical changes. The bill
would state the findings and declarations of the Legislature that
these changes clarify procedures and terms of the act.
(13) Existing law provides for the Medi-Cal program, which is
administered by the DHCS, under which qualified low-income
individuals receive health care services. The Medi-Cal program is, in
part, governed and funded by federal Medicaid Program provisions.
Existing federal law provides for the federal Medicare Program, which
is a public health insurance program for persons 65 years of age and
older and specified persons with disabilities who are under 65 years
of age.
This bill would exclude from reimbursement under Medi-Cal any
increase in the amount charged to the Medi-Cal program for patient
care or treatment that is directly related to an identifiable
provider-preventable condition, as prescribed.
(14) Under existing law, commencing January 1, 2014, an individual
who is 21 years of age and older, does not have minor children
eligible for Medi-Cal benefits, would be eligible for Medi-Cal
benefits but for a specified 5-year bar, and who is enrolled in
coverage through the Exchange with an advanced premium tax credit is
eligible for Medi-Cal benefits, as prescribed. Commencing January 1,
2014, the department is also required to pay the beneficiary's
insurance premium costs and cost-sharing charges under these
provisions.
This bill would limit the premium and cost-sharing payments the
department would make under those provisions to the amount necessary
to pay for the 2nd lowest cost silver plan in the Exchange and would
require the department to consult with various entities in the
development and implementation of specified processes, procedures,
and notices for purposes of those provisions. The bill would require
the health care service plans and health insurers providing coverage
in the Exchange to cooperate with requests from the Exchange to
collaborate in the development of, and participate in the
implementation of, these premium and cost-sharing payments, and would
also prohibit those plans and insurers from charging or requiring an
enrollee or insured to make any payments for any services subject to
these payments. Because a willful violation of that requirement by a
health care service plan would be a crime, the bill would impose a
state-mandated local program.
The bill would also, under specified federal provisions applicable
to qualified pregnant women and children, provide that a woman shall
be eligible for Medi-Cal benefits if her income is less than or
equal to 109% of the federal poverty level as determined, counted,
and valued in accordance with federal law. The bill would also
require the department to seek any state plan amendments or federal
waivers necessary to provide full scope Medi-Cal benefits to pregnant
women during their pregnancy and for 60 days thereafter for women
whose income is over 109% of, and is up to and including 138% of, the
federal poverty level. The bill would require these women to enroll
in a Medi-Cal managed care plan in the counties in which one is
available, to the extent permitted by state and federal law.
The bill would, after the department determines that the
California Healthcare Eligibility, Enrollment, and Retention System
(CalHEERS) has been programmed for implementation of these
provisions, but no sooner than January 1, 2015, require the
department to implement a specified option for women eligible for
Medi-Cal pregnancy-related and postpartum services who are enrolled
or will be enrolled in individual health care coverage through the
Exchange and also opt to enroll in Medi-Cal. The bill would, except
as provided, require the department to provide specified benefits and
pay the beneficiary's insurance premium costs and the beneficiary's
cost sharing for benefits and services during the beneficiary's
period of eligibility for pregnancy-related and postpartum services
under the Medi-Cal program. The bill would require the department to
make these premium or cost-sharing payments to the beneficiary's
qualified health plan, as specified. The bill would require the
department to consult with various entities in developing specified
processes,
procedures, and notices for purposes of these provisions. The bill
would authorize the department to contract with public and private
entities to implement these provisions for purposes of these
provisions and would make those contracts exempt from specified
public contracting requirements. The bill would require health care
service plans and insurers providing individual coverage in the
Exchange to cooperate with requests from the Exchange to collaborate
in the development of, and participate in the implementation of,
these premium and cost-sharing payments for eligible Exchange
enrollees and would also prohibit those plans and insurers from
charging or requiring an enrollee or insured to make any payments for
any services subject to these payments. Because a willful violation
of that provision by a health care service plan would be a crime,
this bill would impose a state-mandated local program.
(15) Existing law authorizes the DHCS to enter into nonexclusive
contracts to arrange for the administration and disbursement of funds
to Medi-Cal providers or to their designated agents in consideration
for services rendered and supplies furnished, as prescribed.
This bill would, except as specified, exempt any contract
amendments, modifications, or change orders to a fiscal intermediary
contract entered into by the department pursuant to this
authorization from certain provisions of the Public Contract Code.
(16) Existing law requires the DHCS to screen Medi-Cal providers
and designate each provider as "limited," "moderate," or "high"
categorical risk. Existing law requires the State Department of
Health Care Services to conduct a criminal background check of all
providers designated as a "high" categorical risk.
This bill would require a provider or applicant designated as a
"high" categorical risk to submit to the Department of Justice
fingerprint images and related information for the purpose of
obtaining information as to the existence of past criminal conduct,
as specified. The bill would require the Department of Justice to
request specified information from the Federal Bureau of
Investigation with respect to a provider's past criminal conduct, and
to review and provide this information to DHCS. The bill would
require the Department of Justice to charge a fee, to be paid by the
applicant or provider, sufficient to cover the cost of processing the
criminal background check request.
(17) Existing law requires DHCS to seek federal approval pursuant
to a Medicare or a Medicaid demonstration project or waiver, or a
combination thereof, to establish a demonstration project that
enables beneficiaries dually eligible for the Medi-Cal program and
the Medicare Program to receive a continuum of services that
maximizes access to, and coordination of, benefits between the
programs. Existing law requires, with some exceptions, DHCS to enroll
dual eligible beneficiaries into a managed care plan that is
selected to participate in the demonstration project unless the
beneficiary makes an affirmative choice to opt out of enrollment or
is already enrolled in a specified managed care organization on or
before June 1, 2013. Existing law requires DHCS, for the 2013 and
2014 calendar years, to comply with certain requirements with respect
to offering contracts to Medicare Advantage Dual Special Needs Plans
(D-SNP plans) and the application of the above-mentioned enrollment
provisions to beneficiaries in Medicare Advantage and D-SNP plans.
This bill would, for the 2015 calendar year and the remainder of
the demonstration project, authorize DHCS to offer D-SNP contracts,
as defined, in non-Coordinated Care Initiative counties to D-SNP
plans. The bill would, in Coordinated Care Initiative counties,
authorize DHCS to offer the contracts to D-SNP plans approved for the
plans' service areas on January 1, 2013, and only for specified
beneficiaries. The bill would also make related changes to the
application of the above-mentioned enrollment provisions for the 2015
calendar year and the remainder of the demonstration project.
(18) Existing law requires DHCS to establish a list of performance
measures to ensure dental health plans meet quality criteria
required by DHCS. Existing law requires DHCS to post, on a quarterly
basis, the list of performance measures and each plan's performance
on the DHCS Internet Web site.
This bill would require DHCS, in consultation with stakeholders,
to establish a list of performance measures to ensure the dental
fee-for-service program meets quality and access criteria required by
DHCS. The bill would require DHCS, commencing October 1, 2014, for
the 2013 calendar year, and annually on or before October 1 for each
preceding calendar year thereafter, to post the list of performance
measures along with the data of the dental fee-for-service program
performance on the DHCS Internet Web site. The bill would also
require DHCS to annually prepare and post on its Internet Web site,
as specified, a summary report of the nature and types of complaints
and grievances regarding access to, and quality of, dental services,
including the outcome.
(19) Existing law requires DHCS to establish and maintain a plan,
known as the County Administrative Cost Control Plan, for the purpose
of effectively controlling costs related to the county
administration of the determination of eligibility for benefits under
the Medi-Cal program within the amounts annually appropriated for
that administration.
Under existing law, the Legislature finds and declares that
linking appropriate funding for county Medi-Cal administrative
operations, including annual cost-of-doing-business adjustments, with
performance standards will give counties the incentive to meet the
performance standards and enable them to continue to do the work they
do on behalf of the state. Existing law further provides that it is
the intent of the Legislature to provide appropriate funding to the
counties for the effectual administration of the Medi-Cal program,
except that it is the intent of the Legislature to not appropriate
money for a cost-of-doing-business adjustment for specified fiscal
years.
This bill would additionally provide that it is the intent of the
Legislature to not appropriate funds for the cost-of-doing-business
adjustment for the 2014-15 fiscal year.
(20) Existing law requires Medi-Cal funding to be made available
for a new hospital, as defined, that is a nonprofit entity that
serves the population of South Los Angeles formerly served by the Los
Angeles County Martin Luther King Jr.-Harbor Hospital, as
prescribed.
This bill would modify those funding provisions for the new
hospital as they relate to Medi-Cal payments for hospital services
and certain supplemental payments.
(21) Existing federal law provides for the federal Supplemental
Nutrition Assistance Program, formerly the Food Stamp Program, under
which nutrition assistance benefits are allocated to each state by
the federal government. Existing federal law also provides for the
Supplemental Nutrition Assistance Program Education (SNAP-Ed) program
for purposes of nutrition education and obesity prevention grant
programs.
Existing law requires the State Department of Public Health to
investigate and apply for federal funding opportunities regarding
promoting healthy eating and preventing obesity, including those
available under federal law, as specified. Existing law requires the
department to, upon receipt of federal funding regarding healthy
eating and preventing obesity, provide in-kind support and award
grants to support local assistance to local governments, nonprofit
organizations, and local education agencies.
Between July 1, 2014, and October 31, 2015, inclusive, this bill
would require the State Department of Public Health to convene a
quarterly meeting of stakeholders to solicit input and receive
feedback on nutrition education and obesity prevention, and to help
minimize disruption to services in the SNAP-Ed program during a
specified transition period.
(22) This bill would require DHCS to, by August 1, 2014, work with
stakeholders to develop a notice to be sent or made available to
individuals enrolled in a state health care program administered by
DHCS that does not provide minimum essential coverage who, as
determined by DHCS, may be eligible for Medi-Cal or coverage through
the California Health Benefit Exchange.
(23) This bill would require the State Department of Public Health
to report to the fiscal and appropriate policy committees of the
Legislature and post on its Internet Web site various reports,
including, among others, specified workload and performance metrics
and updates that relate to the State Department of Public Health's
Licensing and Certification Program. The bill would require the State
Department of Public Health to hold semiannual stakeholder meetings
for all interested stakeholders to provide feedback on improving the
program.
(24) This bill would also reappropriate the balance of a specified
appropriation made in the Budget Act of 2011 to the Mental Health
Services Oversight and Accountability Commission and would make those
funds available for encumbrance until June 30, 2015.
(25) Existing constitutional provisions require that a statute
that limits the right of access to the meetings of public bodies or
the writings of public officials and agencies be adopted with
findings demonstrating the interest protected by the limitation and
the need for protecting that interest.
This bill would make legislative findings to that effect.
(26) The California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
(27) This bill would declare that it is to take effect immediately
as a bill providing for appropriations related to the Budget Bill.
Appropriation: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 56.36 of the Civil Code is amended to read:
56.36. (a) Any violation of the provisions of this part that
results in economic loss or personal injury to a patient is
punishable as a misdemeanor.
(b) In addition to any other remedies available at law, any
individual may bring an action against any person or entity who has
negligently released confidential information or records concerning
him or her in violation of this part, for either or both of the
following:
(1) Except as provided in subdivision (e), nominal damages of one
thousand dollars ($1,000). In order to recover under this paragraph,
it shall not be necessary that the plaintiff suffered or was
threatened with actual damages.
(2) The amount of actual damages, if any, sustained by the
patient.
(c) (1) In addition, any person or entity that negligently
discloses medical information in violation of the provisions of this
part shall also be liable, irrespective of the amount of damages
suffered by the patient as a result of that violation, for an
administrative fine or civil penalty not to exceed two thousand five
hundred dollars ($2,500) per violation.
(2) (A) Any person or entity, other than a licensed health care
professional, who knowingly and willfully obtains, discloses, or uses
medical information in violation of this part shall be liable for an
administrative fine or civil penalty not to exceed twenty-five
thousand dollars ($25,000) per violation.
(B) Any licensed health care professional, who knowingly and
willfully obtains, discloses, or uses medical information in
violation of this part shall be liable on a first violation, for an
administrative fine or civil penalty not to exceed two thousand five
hundred dollars ($2,500) per violation, or on a second violation for
an administrative fine or civil penalty not to exceed ten thousand
dollars ($10,000) per violation, or on a third and subsequent
violation for an administrative fine or civil penalty not to exceed
twenty-five thousand dollars ($25,000) per violation. Nothing in this
subdivision shall be construed to limit the liability of a health
care service plan, a contractor, or a provider of health care that is
not a licensed health care professional for any violation of this
part.
(3) (A) Any person or entity, other than a licensed health care
professional, who knowingly or willfully obtains or uses medical
information in violation of this part for the purpose of financial
gain shall be liable for an administrative fine or civil penalty not
to exceed two hundred fifty thousand dollars ($250,000) per violation
and shall also be subject to disgorgement of any proceeds or other
consideration obtained as a result of the violation.
(B) Any licensed health care professional, who knowingly and
willfully obtains, discloses, or uses medical information in
violation of this part for financial gain shall be liable on a first
violation, for an administrative fine or civil penalty not to exceed
five thousand dollars ($5,000) per violation, or on a second
violation for an administrative fine or civil penalty not to exceed
twenty-five thousand dollars ($25,000) per violation, or on a third
and subsequent violation for an administrative fine or civil penalty
not to exceed two hundred fifty thousand dollars ($250,000) per
violation and shall also be subject to disgorgement of any proceeds
or other consideration obtained as a result of the violation. Nothing
in this subdivision shall be construed to limit the liability of a
health care service plan, a contractor, or a provider of health care
that is not a licensed health care professional for any violation of
this part.
(4) Nothing in this subdivision shall be construed as authorizing
an administrative fine or civil penalty under both paragraphs (2) and
(3) for the same violation.
(5) Any person or entity who is not permitted to receive medical
information pursuant to this part and who knowingly and willfully
obtains, discloses, or uses medical information without written
authorization from the patient shall be liable for a civil penalty
not to exceed two hundred fifty thousand dollars ($250,000) per
violation.
(d) In assessing the amount of an administrative fine or civil
penalty pursuant to subdivision (c), the State Department of Public
Health, licensing agency, or certifying board or court shall consider
any one or more of the relevant circumstances presented by any of
the parties to the case including, but not limited to, the following:
(1) Whether the defendant has made a reasonable, good faith
attempt to comply with this part.
(2) The nature and seriousness of the misconduct.
(3) The harm to the patient, enrollee, or subscriber.
(4) The number of violations.
(5) The persistence of the misconduct.
(6) The length of time over which the misconduct occurred.
(7) The willfulness of the defendant's misconduct.
(8) The defendant's assets, liabilities, and net worth.
(e) (1) In an action brought by an individual pursuant to
subdivision (b) on or after January 1, 2013, in which the defendant
establishes the affirmative defense in paragraph (2), the court shall
award any actual damages and reasonable attorney's fees and costs,
but may not award nominal damages for a violation of this part.
(2) The defendant is entitled to an affirmative defense if all of
the following are established, subject to the equitable
considerations in paragraph (3):
(A) The defendant is a covered entity or business associate, as
defined in Section 160.103 of Title 45 of the Code of Federal
Regulations, in effect as of January 1, 2012.
(B) The defendant has complied with any obligations to notify all
persons entitled to receive notice regarding the release of the
information or records.
(C) The release of confidential information or records was solely
to another covered entity or business associate.
(D) The release of confidential information or records was not an
incident of medical identity theft. For purposes of this
subparagraph, "medical identity theft" means the use of an individual'
s personal information, as defined in Section 1798.80, without the
individual's knowledge or consent, to obtain medical goods or
services, or to submit false claims for medical services.
(E) The defendant took appropriate preventive actions to protect
the confidential information or records against release consistent
with the defendant's obligations under this part or other applicable
state law and the Health Insurance Portability and Accountability Act
of 1996 (Public Law 104-191) (HIPAA) and all HIPAA Administrative
Simplification Regulations in effect on January 1, 2012, contained in
Parts 160, 162, and 164 of Title 45 of the Code of Federal
Regulations and Part 2 of Title 42 of the Code of Federal
Regulations, including, but not limited to:
(i) Developing and implementing security policies and procedures.
(ii) Designating a security official who is responsible for
developing and implementing its security policies and procedures,
including educating and training the workforce.
(iii) Encrypting the information or records, and protecting
against the release or use of the encryption key and passwords, or
transmitting the information or records in a manner designed to
provide equal or greater protections against improper disclosures.
(F) The defendant took reasonable and appropriate corrective
action after the release of the confidential information or records,
and the covered entity or business associate that received the
confidential information or records destroyed or returned the
confidential information or records in the most expedient time
possible and without unreasonable delay, consistent with any measures
necessary to determine the scope of the breach and restore the
reasonable integrity of the data system. A court may consider this
subparagraph to be established if the defendant shows in detail that
the covered entity or business associate could not destroy or return
the confidential information or records because of the technology
utilized.
(G) The covered entity or business associate that received the
confidential information or records, or any of its agents,
independent contractors, or employees, regardless of the scope of the
employee's employment, did not retain, use, or release the
information or records.
(H) After the release of the confidential information or records,
the defendant took reasonable and appropriate action to prevent a
future similar release of confidential information or records.
(I) The defendant has not previously established an affirmative
defense pursuant to this subdivision, or the court determines, in its
discretion, that application of the affirmative defense is
compelling and consistent with the purposes of this section to
promote reasonable conduct in light of all the facts.
(3) (A) In determining whether the affirmative defense may be
established pursuant to paragraph (2), the court shall consider the
equity of the situation, including, but not limited to, (i) whether
the defendant has previously violated this part, regardless of
whether an action has previously been brought, and (ii) the nature of
the prior violation.
(B) To the extent the court allows discovery to determine whether
there has been any other violation of this part that the court will
consider in balancing the equities, the defendant shall not provide
any medical information, as defined in Section 56.05. The court, in
its discretion, may enter a protective order prohibiting the further
use of any personal information, as defined in Section 1798.80, about
the individual whose medical information may have been disclosed in
a prior violation.
(4) In an action under this subdivision in which the defendant
establishes the affirmative defense pursuant to paragraph (2), a
plaintiff shall be entitled to recover reasonable attorney's fees and
costs without regard to an award of actual or nominal damages or the
imposition of administrative fines or civil penalties.
(5) In an action brought by an individual pursuant to subdivision
(b) on or after January 1, 2013, in which the defendant establishes
the affirmative defense pursuant to paragraph (2), a defendant shall
not be liable for more than one judgment on the merits under this
subdivision for releases of confidential information or records
arising out of the same event, transaction, or occurrence.
(f) (1) The civil penalty pursuant to subdivision (c) shall be
assessed and recovered in a civil action brought in the name of the
people of the State of California in any court of competent
jurisdiction by any of the following:
(A) The Attorney General.
(B) Any district attorney.
(C) Any county counsel authorized by agreement with the district
attorney in actions involving violation of a county ordinance.
(D) Any city attorney of a city.
(E) Any city attorney of a city and county having a population in
excess of 750,000, with the consent of the district attorney.
(F) A city prosecutor in any city having a full-time city
prosecutor or, with the consent of the district attorney, by a city
attorney in any city and county.
(G) The State Public Health Officer, or his or her designee, may
recommend that any person described in subparagraphs (A) to (F),
inclusive, bring a civil action under this section.
(2) If the action is brought by the Attorney General, one-half of
the penalty collected shall be paid to the treasurer of the county in
which the judgment was entered, and one-half to the General Fund. If
the action is brought by a district attorney or county counsel, the
penalty collected shall be paid to the treasurer of the county in
which the judgment was entered. Except as provided in paragraph (3),
if the action is brought by a city attorney or city prosecutor,
one-half of the penalty collected shall be paid to the treasurer of
the city in which the judgment was entered and one-half to the
treasurer of the county in which the judgment was entered.
(3) If the action is brought by a city attorney of a city and
county, the entire amount of the penalty collected shall be paid to
the treasurer of the city and county in which the judgment was
entered.
(4) Nothing in this section shall be construed as authorizing both
an administrative fine and civil penalty for the same violation.
(5) Imposition of a fine or penalty provided for in this section
shall not preclude imposition of any other sanctions or remedies
authorized by law.
(6) Administrative fines or penalties issued pursuant to Section
1280.15 of the Health and Safety Code shall offset any other
administrative fine or civil penalty imposed under this section for
the same violation.
(g) For purposes of this section, "knowing" and "willful" shall
have the same meanings as in Section 7 of the Penal Code.
(h) No person who discloses protected medical information in
accordance with the provisions of this part shall be subject to the
penalty provisions of this part.
SEC. 2. Section 6254 of the Government Code is amended to read:
6254. Except as provided in Sections 6254.7 and 6254.13, this
chapter does not require the disclosure of any of the following
records:
(a) Preliminary drafts, notes, or interagency or intra-agency
memoranda that are not retained by the public agency in the ordinary
course of business, if the public interest in withholding those
records clearly outweighs the public interest in disclosure.
(b) Records pertaining to pending litigation to which the public
agency is a party, or to claims made pursuant to Division 3.6
(commencing with Section 810), until the pending litigation or claim
has been finally adjudicated or otherwise settled.
(c) Personnel, medical, or similar files, the disclosure of which
would constitute an unwarranted invasion of personal privacy.
(d) Contained in or related to any of the following:
(1) Applications filed with any state agency responsible for the
regulation or supervision of the issuance of securities or of
financial institutions, including, but not limited to, banks, savings
and loan associations, industrial loan companies, credit unions, and
insurance companies.
(2) Examination, operating, or condition reports prepared by, on
behalf of, or for the use of, any state agency referred to in
paragraph (1).
(3) Preliminary drafts, notes, or interagency or intra-agency
communications prepared by, on behalf of, or for the use of, any
state agency referred to in paragraph (1).
(4) Information received in confidence by any state agency
referred to in paragraph (1).
(e) Geological and geophysical data, plant production data, and
similar information relating to utility systems development, or
market or crop reports, that are obtained in confidence from any
person.
(f) Records of complaints to, or investigations conducted by, or
records of intelligence information or security procedures of, the
office of the Attorney General and the Department of Justice, the
Office of Emergency Services and any state or local police agency, or
any investigatory or security files compiled by any other state or
local police agency, or any investigatory or security files compiled
by any other state or local agency for correctional, law enforcement,
or licensing purposes. However, state and local law enforcement
agencies shall disclose the names and addresses of persons involved
in, or witnesses other than confidential informants to, the incident,
the description of any property involved, the date, time, and
location of the incident, all diagrams, statements of the parties
involved in the incident, the statements of all witnesses, other than
confidential informants, to the victims of an incident, or an
authorized representative thereof, an insurance carrier against which
a claim has been or might be made, and any person suffering bodily
injury or property damage or loss, as the result of the incident
caused by arson, burglary, fire, explosion, larceny, robbery,
carjacking, vandalism, vehicle theft, or a crime as defined by
subdivision (b) of Section 13951, unless the disclosure would
endanger the safety of a witness or other person involved in the
investigation, or unless disclosure would endanger the successful
completion of the investigation or a related investigation. However,
nothing in this division shall require the disclosure of that portion
of those investigative files that reflects the analysis or
conclusions of the investigating officer.
Customer lists provided to a state or local police agency by an
alarm or security company at the request of the agency shall be
construed to be records subject to this subdivision.
Notwithstanding any other provision of this subdivision, state and
local law enforcement agencies shall make public the following
information, except to the extent that disclosure of a particular
item of information would endanger the safety of a person involved in
an investigation or would endanger the successful completion of the
investigation or a related investigation:
(1) The full name and occupation of every individual arrested by
the agency, the individual's physical description including date of
birth, color of eyes and hair, sex, height and weight, the time and
date of arrest, the time and date of booking, the location of the
arrest, the factual circumstances surrounding the arrest, the amount
of bail set, the time and manner of release or the location where the
individual is currently being held, and all charges the individual
is being held upon, including any outstanding warrants from other
jurisdictions and parole or probation holds.
(2) Subject to the restrictions imposed by Section 841.5 of the
Penal Code, the time, substance, and location of all complaints or
requests for assistance received by the agency and the time and
nature of the response thereto, including, to the extent the
information regarding crimes alleged or committed or any other
incident investigated is recorded, the time, date, and location of
occurrence, the time and date of the report, the name and age of the
victim, the factual circumstances surrounding the crime or incident,
and a general description of any injuries, property, or weapons
involved. The name of a victim of any crime defined by Section 220,
236.1, 261, 261.5, 262, 264, 264.1, 265, 266, 266a, 266b, 266c, 266e,
266f, 266j, 267, 269, 273a, 273d, 273.5, 285, 286, 288, 288a, 288.2,
288.3 (as added by Chapter 337 of the Statutes of 2006), 288.3 (as
added by Section 6 of Proposition 83 of the November 7, 2006,
statewide general election), 288.5, 288.7, 289, 422.6, 422.7, 422.75,
646.9, or 647.6 of the Penal Code may be withheld at the victim's
request, or at the request of the victim's parent or guardian if the
victim is a minor. When a person is the victim of more than one
crime, information disclosing that the person is a victim of a crime
defined in any of the sections of the Penal Code set forth in this
subdivision may be deleted at the request of the victim, or the
victim's parent or guardian if the victim is a minor, in making the
report of the crime, or of any crime or incident accompanying the
crime, available to the public in compliance with the requirements of
this paragraph.
(3) Subject to the restrictions of Section 841.5 of the Penal Code
and this subdivision, the current address of every individual
arrested by the agency and the current address of the victim of a
crime, where the requester declares under penalty of perjury that the
request is made for a scholarly, journalistic, political, or
governmental purpose, or that the request is made for investigation
purposes by a licensed private investigator as described in Chapter
11.3 (commencing with Section 7512) of Division 3 of the Business and
Professions Code. However, the address of the victim of any crime
defined by Section 220, 236.1, 261, 261.5, 262, 264, 264.1, 265, 266,
266a, 266b, 266c, 266e, 266f, 266j, 267, 269, 273a, 273d, 273.5,
285, 286, 288, 288a, 288.2, 288.3 (as added by Chapter 337 of the
Statutes of 2006), 288.3 (as added by Section 6 of Proposition 83 of
the November 7, 2006, statewide general election), 288.5, 288.7, 289,
422.6, 422.7, 422.75, 646.9, or 647.6 of the Penal Code shall remain
confidential. Address information obtained pursuant to this
paragraph may not be used directly or indirectly, or furnished to
another, to sell a product or service to any individual or group of
individuals, and the requester shall execute a declaration to that
effect under penalty of perjury. Nothing in this paragraph shall be
construed to prohibit or limit a scholarly, journalistic, political,
or government use of address information obtained pursuant to this
paragraph.
(g) Test questions, scoring keys, and other examination data used
to administer a licensing examination, examination for employment, or
academic examination, except as provided for in Chapter 3
(commencing with Section 99150) of Part 65 of Division 14 of Title 3
of the Education Code.
(h) The contents of real estate appraisals or engineering or
feasibility estimates and evaluations made for or by the state or
local agency relative to the acquisition of property, or to
prospective public supply and construction contracts, until all of
the property has been acquired or all of the contract agreement
obtained. However, the law of eminent domain shall not be affected by
this provision.
(i) Information required from any taxpayer in connection with the
collection of local taxes that is received in confidence and the
disclosure of the information to other persons would result in unfair
competitive disadvantage to the person supplying the information.
(j) Library circulation records kept for the purpose of
identifying the borrower of items available in libraries, and library
and museum materials made or acquired and presented solely for
reference or exhibition purposes. The exemption in this subdivision
shall not apply to records of fines imposed on the borrowers.
(k) Records, the disclosure of which is exempted or prohibited
pursuant to federal or state law, including, but not limited to,
provisions of the Evidence Code relating to privilege.
( l ) Correspondence of and to the Governor or
employees of the Governor's office or in the custody of or maintained
by the Governor's Legal Affairs Secretary. However, public records
shall not be transferred to the custody of the Governor's Legal
Affairs Secretary to evade the disclosure provisions of this chapter.
(m) In the custody of or maintained by the Legislative Counsel,
except those records in the public database maintained by the
Legislative Counsel that are described in Section 10248.
(n) Statements of personal worth or personal financial data
required by a licensing agency and filed by an applicant with the
licensing agency to establish his or her personal qualification for
the license, certificate, or permit applied for.
(o) Financial data contained in applications for financing under
Division 27 (commencing with Section 44500) of the Health and Safety
Code, where an authorized officer of the California Pollution Control
Financing Authority determines that disclosure of the financial data
would be competitively injurious to the applicant and the data is
required in order to obtain guarantees from the United States Small
Business Administration. The California Pollution Control Financing
Authority shall adopt rules for review of individual requests for
confidentiality under this section and for making available to the
public those portions of an application that are subject to
disclosure under this chapter.
(p) Records of state agencies related to activities governed by
Chapter 10.3 (commencing with Section 3512), Chapter 10.5 (commencing
with Section 3525), and Chapter 12 (commencing with Section 3560) of
Division 4, that reveal a state agency's deliberative processes,
impressions, evaluations, opinions, recommendations, meeting minutes,
research, work products, theories, or strategy, or that provide
instruction, advice, or training to employees who do not have full
collective bargaining and representation rights under these chapters.
Nothing in this subdivision shall be construed to limit the
disclosure duties of a state agency with respect to any other records
relating to the activities governed by the employee relations acts
referred to in this subdivision.
(q) (1) Records of state agencies related to activities governed
by Article 2.6 (commencing with Section 14081), Article 2.8
(commencing with Section 14087.5), and Article 2.91 (commencing with
Section 14089) of Chapter 7 of Part 3 of Division 9 of the Welfare
and Institutions Code, that reveal the special negotiator's
deliberative processes, discussions, communications, or any other
portion of the negotiations with providers of health care services,
impressions, opinions, recommendations, meeting minutes, research,
work product, theories, or strategy, or that provide instruction,
advice, or training to employees.
(2) Except for the portion of a contract containing the rates of
payment, contracts for inpatient services entered into pursuant to
these articles, on or after April 1, 1984, shall be open to
inspection one year after they are fully executed. If a contract for
inpatient services that is entered into prior to April 1, 1984, is
amended on or after April 1, 1984, the amendment, except for any
portion containing the rates of payment, shall be open to inspection
one year after it is fully executed. If the California Medical
Assistance Commission enters into contracts with health care
providers for other than inpatient hospital services, those contracts
shall be open to inspection one year after they are fully executed.
(3) Three years after a contract or amendment is open to
inspection under this subdivision, the portion of the contract or
amendment containing the rates of payment shall be open to
inspection.
(4) Notwithstanding any other law, the entire contract or
amendment shall be open to inspection by the Joint Legislative Audit
Committee and the Legislative Analyst's Office. The committee and
that office shall maintain the confidentiality of the contracts and
amendments until the time a contract or amendment is fully open to
inspection by the public.
(r) Records of Native American graves, cemeteries, and sacred
places and records of Native American places, features, and objects
described in Sections 5097.9 and 5097.993 of the Public Resources
Code maintained by, or in the possession of, the Native American
Heritage Commission, another state agency, or a local agency.
(s) A final accreditation report of the Joint Commission on
Accreditation of Hospitals that has been transmitted to the State
Department of Health Care
Services pursuant to subdivision (b) of Section 1282 of the Health
and Safety Code.
(t) Records of a local hospital district, formed pursuant to
Division 23 (commencing with Section 32000) of the Health and Safety
Code, or the records of a municipal hospital, formed pursuant to
Article 7 (commencing with Section 37600) or Article 8 (commencing
with Section 37650) of Chapter 5 of Part 2 of Division 3 of Title 4
of this code, that relate to any contract with an insurer or
nonprofit hospital service plan for inpatient or outpatient services
for alternative rates pursuant to Section 10133 of the Insurance
Code. However, the record shall be open to inspection within one year
after the contract is fully executed.
(u) (1) Information contained in applications for licenses to
carry firearms issued pursuant to Section 26150, 26155, 26170, or
26215 of the Penal Code by the sheriff of a county or the chief or
other head of a municipal police department that indicates when or
where the applicant is vulnerable to attack or that concerns the
applicant's medical or psychological history or that of members of
his or her family.
(2) The home address and telephone number of prosecutors, public
defenders, peace officers, judges, court commissioners, and
magistrates that are set forth in applications for licenses to carry
firearms issued pursuant to Section 26150, 26155, 26170, or 26215 of
the Penal Code by the sheriff of a county or the chief or other head
of a municipal police department.
(3) The home address and telephone number of prosecutors, public
defenders, peace officers, judges, court commissioners, and
magistrates that are set forth in licenses to carry firearms issued
pursuant to Section 26150, 26155, 26170, or 26215 of the Penal Code
by the sheriff of a county or the chief or other head of a municipal
police department.
(v) (1) Records of the Managed Risk Medical Insurance Board and
the State Department of Health Care Services related to activities
governed by Part 6.3 (commencing with Section 12695), Part 6.5
(commencing with Section 12700), Part 6.6 (commencing with Section
12739.5), or Part 6.7 (commencing with Section 12739.70) of Division
2 of the Insurance Code, or Chapter 2 (commencing with Section 15810)
or Chapter 4 (commencing with Section 15870) of Part 3.3 of Division
9 of the Welfare and Institutions Code, and that reveal any of the
following:
(A) The deliberative processes, discussions, communications, or
any other portion of the negotiations with entities contracting or
seeking to contract with the board or the department, entities with
which the board or the department is considering a contract, or
entities with which the board or department is considering or enters
into any other arrangement under which the board or the department
provides, receives, or arranges services or reimbursement.
(B) The impressions, opinions, recommendations, meeting minutes,
research, work product, theories, or strategy of the board or its
staff or the department or its staff, or records that provide
instructions, advice, or training to their employees.
(2) (A) Except for the portion of a contract that contains the
rates of payment, contracts entered into pursuant to Part 6.3
(commencing with Section 12695), Part 6.5 (commencing with Section
12700), Part 6.6 (commencing with Section 12739.5), or Part 6.7
(commencing with Section 12739.70) of Division 2 of the Insurance
Code, or Chapter 2 (commencing with Section 15810) or Chapter 4
(commencing with Section 15870) of Part 3.3 of Division 9 of the
Welfare and Institutions Code, on or after July 1, 1991, shall be
open to inspection one year after their effective dates.
(B) If a contract that is entered into prior to July 1, 1991, is
amended on or after July 1, 1991, the amendment, except for any
portion containing the rates of payment, shall be open to inspection
one year after the effective date of the amendment.
(3) Three years after a contract or amendment is open to
inspection pursuant to this subdivision, the portion of the contract
or amendment containing the rates of payment shall be open to
inspection.
(4) Notwithstanding any other law, the entire contract or
amendments to a contract shall be open to inspection by the Joint
Legislative Audit Committee. The committee shall maintain the
confidentiality of the contracts and amendments thereto, until the
contracts or amendments to the contracts are open to inspection
pursuant to paragraph (3).
(w) (1) Records of the Managed Risk Medical Insurance Board
related to activities governed by Chapter 8 (commencing with Section
10700) of Part 2 of Division 2 of the Insurance Code, and that reveal
the deliberative processes, discussions, communications, or any
other portion of the negotiations with health plans, or the
impressions, opinions, recommendations, meeting minutes, research,
work product, theories, or strategy of the board or its staff, or
records that provide instructions, advice, or training to employees.
(2) Except for the portion of a contract that contains the rates
of payment, contracts for health coverage entered into pursuant to
Chapter 8 (commencing with Section 10700) of Part 2 of Division 2 of
the Insurance Code, on or after January 1, 1993, shall be open to
inspection one year after they have been fully executed.
(3) Notwithstanding any other law, the entire contract or
amendments to a contract shall be open to inspection by the Joint
Legislative Audit Committee. The committee shall maintain the
confidentiality of the contracts and amendments thereto, until the
contracts or amendments to the contracts are open to inspection
pursuant to paragraph (2).
(x) Financial data contained in applications for registration, or
registration renewal, as a service contractor filed with the Director
of Consumer Affairs pursuant to Chapter 20 (commencing with Section
9800) of Division 3 of the Business and Professions Code, for the
purpose of establishing the service contractor's net worth, or
financial data regarding the funded accounts held in escrow for
service contracts held in force in this state by a service
contractor.
(y) (1) Records of the Managed Risk Medical Insurance Board and
the State Department of Health Care Services related to activities
governed by Part 6.2 (commencing with Section 12693) or Part 6.4
(commencing with Section 12699.50) of Division 2 of the Insurance
Code or Sections 14005.26 and 14005.27 of, or Chapter 3 (commencing
with Section 15850) of Part 3.3 of Division 9 of, the Welfare and
Institutions Code, if the records reveal any of the following:
(A) The deliberative processes, discussions, communications, or
any other portion of the negotiations with entities contracting or
seeking to contract with the board or the department, entities with
which the board or department is considering a contract, or entities
with which the board or department is considering or enters into any
other arrangement under which the board or department provides,
receives, or arranges services or reimbursement.
(B) The impressions, opinions, recommendations, meeting minutes,
research, work product, theories, or strategy of the board or its
staff, or the department or its staff, or records that provide
instructions, advice, or training to employees.
(2) (A) Except for the portion of a contract that contains the
rates of payment, contracts entered into pursuant to Part 6.2
(commencing with Section 12693) or Part 6.4 (commencing with Section
12699.50) of Division 2 of the Insurance Code, on or after January 1,
1998, or Sections 14005.26 and 14005.27 of, or Chapter 3 (commencing
with Section 15850) of Part 3.3 of Division 9 of, the Welfare and
Institutions Code shall be open to inspection one year after their
effective dates.
(B) If a contract entered into pursuant to Part 6.2 (commencing
with Section 12693) or Part 6.4 (commencing with Section 12699.50) of
Division 2 of the Insurance Code or Sections 14005.26 and 14005.27
of, or Chapter 3 (commencing with Section 15850) of Part 3.3 of
Division 9 of, the Welfare and Institutions Code, is amended, the
amendment shall be open to inspection one year after the effective
date of the amendment.
(3) Three years after a contract or amendment is open to
inspection pursuant to this subdivision, the portion of the contract
or amendment containing the rates of payment shall be open to
inspection.
(4) Notwithstanding any other law, the entire contract or
amendments to a contract shall be open to inspection by the Joint
Legislative Audit Committee. The committee shall maintain the
confidentiality of the contracts and amendments thereto until the
contract or amendments to a contract are open to inspection pursuant
to paragraph (2) or (3).
(5) The exemption from disclosure provided pursuant to this
subdivision for the contracts, deliberative processes, discussions,
communications, negotiations, impressions, opinions, recommendations,
meeting minutes, research, work product, theories, or strategy of
the board or its staff, or the department or its staff, shall also
apply to the contracts, deliberative processes, discussions,
communications, negotiations, impressions, opinions, recommendations,
meeting minutes, research, work product, theories, or strategy of
applicants pursuant to Part 6.4 (commencing with Section 12699.50) of
Division 2 of the Insurance Code or Chapter 3 (commencing with
Section 15850) of Part 3.3 of Division 9 of the Welfare and
Institutions Code.
(z) Records obtained pursuant to paragraph (2) of subdivision (f)
of Section 2891.1 of the Public Utilities Code.
(aa) A document prepared by or for a state or local agency that
assesses its vulnerability to terrorist attack or other criminal acts
intended to disrupt the public agency's operations and that is for
distribution or consideration in a closed session.
(ab) Critical infrastructure information, as defined in Section
131(3) of Title 6 of the United States Code, that is voluntarily
submitted to the California Emergency Management Agency for use by
that office, including the identity of the person who or entity that
voluntarily submitted the information. As used in this subdivision,
"voluntarily submitted" means submitted in the absence of the office
exercising any legal authority to compel access to or submission of
critical infrastructure information. This subdivision shall not
affect the status of information in the possession of any other state
or local governmental agency.
(ac) All information provided to the Secretary of State by a
person for the purpose of registration in the Advance Health Care
Directive Registry, except that those records shall be released at
the request of a health care provider, a public guardian, or the
registrant's legal representative.
(ad) The following records of the State Compensation Insurance
Fund:
(1) Records related to claims pursuant to Chapter 1 (commencing
with Section 3200) of Division 4 of the Labor Code, to the extent
that confidential medical information or other individually
identifiable information would be disclosed.
(2) Records related to the discussions, communications, or any
other portion of the negotiations with entities contracting or
seeking to contract with the fund, and any related deliberations.
(3) Records related to the impressions, opinions, recommendations,
meeting minutes of meetings or sessions that are lawfully closed to
the public, research, work product, theories, or strategy of the fund
or its staff, on the development of rates, contracting strategy,
underwriting, or competitive strategy pursuant to the powers granted
to the fund in Chapter 4 (commencing with Section 11770) of Part 3 of
Division 2 of the Insurance Code.
(4) Records obtained to provide workers' compensation insurance
under Chapter 4 (commencing with Section 11770) of Part 3 of Division
2 of the Insurance Code, including, but not limited to, any medical
claims information, policyholder information provided that nothing in
this paragraph shall be interpreted to prevent an insurance agent or
broker from obtaining proprietary information or other information
authorized by law to be obtained by the agent or broker, and
information on rates, pricing, and claims handling received from
brokers.
(5) (A) Records that are trade secrets pursuant to Section
6276.44, or Article 11 (commencing with Section 1060) of Chapter 4 of
Division 8 of the Evidence Code, including without limitation,
instructions, advice, or training provided by the State Compensation
Insurance Fund to its board members, officers, and employees
regarding the fund's special investigation unit, internal audit unit,
and informational security, marketing, rating, pricing,
underwriting, claims handling, audits, and collections.
(B) Notwithstanding subparagraph (A), the portions of records
containing trade secrets shall be available for review by the Joint
Legislative Audit Committee, the Bureau of State Audits, Division of
Workers' Compensation, and the Department of Insurance to ensure
compliance with applicable law.
(6) (A) Internal audits containing proprietary information and the
following records that are related to an internal audit:
(i) Personal papers and correspondence of any person providing
assistance to the fund when that person has requested in writing that
his or her papers and correspondence be kept private and
confidential. Those papers and correspondence shall become public
records if the written request is withdrawn, or upon order of the
fund.
(ii) Papers, correspondence, memoranda, or any substantive
information pertaining to any audit not completed or an internal
audit that contains proprietary information.
(B) Notwithstanding subparagraph (A), the portions of records
containing proprietary information, or any information specified in
subparagraph (A) shall be available for review by the Joint
Legislative Audit Committee, the Bureau of State Audits, Division of
Workers' Compensation, and the Department of Insurance to ensure
compliance with applicable law.
(7) (A) Except as provided in subparagraph (C), contracts entered
into pursuant to Chapter 4 (commencing with Section 11770) of Part 3
of Division 2 of the Insurance Code shall be open to inspection one
year after the contract has been fully executed.
(B) If a contract entered into pursuant to Chapter 4 (commencing
with Section 11770) of Part 3 of Division 2 of the Insurance Code is
amended, the amendment shall be open to inspection one year after the
amendment has been fully executed.
(C) Three years after a contract or amendment is open to
inspection pursuant to this subdivision, the portion of the contract
or amendment containing the rates of payment shall be open to
inspection.
(D) Notwithstanding any other law, the entire contract or
amendments to a contract shall be open to inspection by the Joint
Legislative Audit Committee. The committee shall maintain the
confidentiality of the contracts and amendments thereto until the
contract or amendments to a contract are open to inspection pursuant
to this paragraph.
(E) This paragraph is not intended to apply to documents related
to contracts with public entities that are not otherwise expressly
confidential as to that public entity.
(F) For purposes of this paragraph, "fully executed" means the
point in time when all of the necessary parties to the contract have
signed the contract.
This section shall not prevent any agency from opening its records
concerning the administration of the agency to public inspection,
unless disclosure is otherwise prohibited by law.
This section shall not prevent any health facility from disclosing
to a certified bargaining agent relevant financing information
pursuant to Section 8 of the National Labor Relations Act (29 U.S.C.
Sec. 158).
SEC. 3. Section 100504 of the Government Code is amended to read:
100504. (a) The board may do the following:
(1) With respect to individual coverage made available in the
Exchange, collect premiums and assist in the administration of
subsidies.
(2) Enter into contracts.
(3) Sue and be sued.
(4) Receive and accept gifts, grants, or donations of moneys from
any agency of the United States, any agency of the state, and any
municipality, county, or other political subdivision of the state.
(5) Receive and accept gifts, grants, or donations from
individuals, associations, private foundations, and corporations, in
compliance with the conflict of interest provisions to be adopted by
the board at a public meeting.
(6) Adopt rules and regulations, as necessary. Until January 1,
2016, any necessary rules and regulations may be adopted as emergency
regulations in accordance with the Administrative Procedure Act
(Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2). The adoption of these regulations shall be deemed to be
an emergency and necessary for the immediate preservation of the
public peace, health and safety, or general welfare. Notwithstanding
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2, including subdivisions (e) and (h) of Section 11346.1,
any emergency regulation adopted pursuant to this section shall not
be repealed by the Office of Administrative Law until revised or
repealed by the board, except that an emergency regulation adopted
pursuant to this section shall be repealed by operation of law unless
the adoption, amendment, or repeal of the regulation is promulgated
by the board pursuant to Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code within two
years of the initial adoption of the emergency regulation.
Notwithstanding subdivision (h) of Section 11346.1, until January 1,
2017, the Office of Administrative Law may approve more than two
readoptions of an emergency regulation adopted pursuant to this
section.
(7) Collaborate with the State Department of Health Care Services
and the Managed Risk Medical Insurance Board, to the extent possible,
to allow an individual the option to remain enrolled with his or her
carrier and provider network in the event the individual experiences
a loss of eligibility of premium tax credits and becomes eligible
for the Medi-Cal program or the Healthy Families Program, or loses
eligibility for the Medi-Cal program or the Healthy Families Program
and becomes eligible for premium tax credits through the Exchange.
(8) Share information with relevant state departments, consistent
with the confidentiality provisions in Section 1411 of the federal
act, necessary for the administration of the Exchange.
(9) Require carriers participating in the Exchange to make
available to the Exchange and regularly update an electronic
directory of contracting health care providers so that individuals
seeking coverage through the Exchange can search by health care
provider name to determine which health plans in the Exchange include
that health care provider in their network. The board may also
require a carrier to provide regularly updated information to the
Exchange as to whether a health care provider is accepting new
patients for a particular health plan. The Exchange may provide an
integrated and uniform consumer directory of health care providers
indicating which carriers the providers contract with and whether the
providers are currently accepting new patients. The Exchange may
also establish methods by which health care providers may transmit
relevant information directly to the Exchange, rather than through a
carrier.
(10) Make available supplemental coverage for enrollees of the
Exchange to the extent permitted by the federal act, provided that no
General Fund money is used to pay the cost of that coverage. Any
supplemental coverage offered in the Exchange shall be subject to the
charge imposed under subdivision (n) of Section 100503.
(b) The Exchange shall only collect information from individuals
or designees of individuals necessary to administer the Exchange and
consistent with the federal act.
(c) The board shall have the authority to standardize products to
be offered through the Exchange.
SEC. 4. Section 1280.15 of the Health and Safety Code is amended
to read:
1280.15. (a) A clinic, health facility, home health agency, or
hospice licensed pursuant to Section 1204, 1250, 1725, or 1745 shall
prevent unlawful or unauthorized access to, and use or disclosure of,
patients' medical information, as defined in Section 56.05 of the
Civil Code and consistent with Section 1280.18. For purposes of this
section, internal paper records, electronic mail, or facsimile
transmissions inadvertently misdirected within the same facility or
health care system within the course of coordinating care or
delivering services shall not constitute unauthorized access to, or
use or disclosure of, a patient's medical information. The
department, after investigation, may assess an administrative penalty
for a violation of this section of up to twenty-five thousand
dollars ($25,000) per patient whose medical information was
unlawfully or without authorization accessed, used, or disclosed, and
up to seventeen thousand five hundred dollars ($17,500) per
subsequent occurrence of unlawful or unauthorized access, use, or
disclosure of that patient's medical information. For purposes of the
investigation, the department shall consider the clinic's, health
facility's, agency's, or hospice's history of compliance with this
section and other related state and federal statutes and regulations,
the extent to which the facility detected violations and took
preventative action to immediately correct and prevent past
violations from recurring, and factors outside its control that
restricted the facility's ability to comply with this section. The
department shall have full discretion to consider all factors when
determining the amount of an administrative penalty pursuant to this
section.
(b) (1) A clinic, health facility, home health agency, or hospice
to which subdivision (a) applies shall report any unlawful or
unauthorized access to, or use or disclosure of, a patient's medical
information to the department no later than five business days after
the unlawful or unauthorized access, use, or disclosure has been
detected by the clinic, health facility, home health agency, or
hospice.
(2) Subject to subdivision (c), a clinic, health facility, home
health agency, or hospice shall also report any unlawful or
unauthorized access to, or use or disclosure of, a patient's medical
information to the affected patient or the patient's representative
at the last known address, no later than five business days after the
unlawful or unauthorized access, use, or disclosure has been
detected by the clinic, health facility, home health agency, or
hospice.
(c) (1) A clinic, health facility, home health agency, or hospice
shall delay the reporting, as required pursuant to paragraph (2) of
subdivision (b), of any unlawful or unauthorized access to, or use or
disclosure of, a patient's medical information beyond five business
days if a law enforcement agency or official provides the clinic,
health facility, home health agency, or hospice with a written or
oral statement that compliance with the reporting requirements of
paragraph (2) of subdivision (b) would likely impede the law
enforcement agency's investigation that relates to the unlawful or
unauthorized access to, and use or disclosure of, a patient's medical
information and specifies a date upon which the delay shall end, not
to exceed 60 days after a written request is made, or 30 days after
an oral request is made. A law enforcement agency or official may
request an extension of a delay based upon a written declaration that
there exists a bona fide, ongoing, significant criminal
investigation of serious wrongdoing relating to the unlawful or
unauthorized access to, and use or disclosure of, a patient's medical
information, that notification of patients will undermine the law
enforcement agency's investigation, and that specifies a date upon
which the delay shall end, not to exceed 60 days after the end of the
original delay period.
(2) If the statement of the law enforcement agency or official is
made orally, then the clinic, health facility, home health agency, or
hospice shall do both of the following:
(A) Document the oral statement, including, but not limited to,
the identity of the law enforcement agency or official making the
oral statement and the date upon which the oral statement was made.
(B) Limit the delay in reporting the unlawful or unauthorized
access to, or use or disclosure of, the patient's medical information
to the date specified in the oral statement, not to exceed 30
calendar days from the date that the oral statement is made, unless a
written statement that complies with the requirements of this
subdivision is received during that time.
(3) A clinic, health facility, home health agency, or hospice
shall submit a report that is delayed pursuant to this subdivision
not later than five business days after the date designated as the
end of the delay.
(d) If a clinic, health facility, home health agency, or hospice
to which subdivision (a) applies violates subdivision (b), the
department may assess the licensee a penalty in the amount of one
hundred dollars ($100) for each day that the unlawful or unauthorized
access, use, or disclosure is not reported to the department or the
affected patient, following the initial five-day period specified in
subdivision (b). However, the total combined penalty assessed by the
department under subdivision (a) and this subdivision shall not
exceed two hundred fifty thousand dollars ($250,000) per reported
event. For enforcement purposes, it shall be presumed that the
facility did not notify the affected patient if the notification was
not documented. This presumption may be rebutted by a licensee only
if the licensee demonstrates, by a preponderance of the evidence,
that the notification was made.
(e) In enforcing subdivisions (a) and (d), the department shall
take into consideration the special circumstances of small and rural
hospitals, as defined in Section 124840, and primary care clinics, as
defined in subdivision (a) of Section 1204, in order to protect
access to quality care in those hospitals and clinics. When assessing
a penalty on a skilled nursing facility or other facility subject to
Section 1423, 1424, 1424.1, or 1424.5, the department shall issue
only the higher of either a penalty for the violation of this section
or a penalty for violation of Section 1423, 1424, 1424.1, or 1424.5,
not both.
(f) All penalties collected by the department pursuant to
this section, Sections 1280.1, 1280.3, and 1280.4, shall be deposited
into the Internal Departmental Quality Improvement Account, which is
hereby created within the Special Deposit Fund under Section 16370
of the Government Code. Upon appropriation by the Legislature, moneys
in the account shall be expended for internal quality improvement
activities in the Licensing and Certification Program.
(g) If the licensee disputes a determination by the department
regarding a failure to prevent or failure to timely report unlawful
or unauthorized access to, or use or disclosure of, patients' medical
information, or the imposition of a penalty under this section, the
licensee may, within 10 days of receipt of the penalty assessment,
request a hearing pursuant to Section 131071. Penalties shall be paid
when appeals have been exhausted and the penalty has been upheld.
(h) In lieu of disputing the determination of the department
regarding a failure to prevent or failure to timely report unlawful
or unauthorized access to, or use or disclosure of, patients' medical
information, transmit to the department 75 percent of the total
amount of the administrative penalty, for each violation, within 30
business days of receipt of the administrative penalty.
(i) For purposes of this section, the following definitions shall
apply:
(1) "Reported event" means all breaches included in any single
report that is made pursuant to subdivision (b), regardless of the
number of breach events contained in the report.
(2) "Unauthorized" means the inappropriate access, review, or
viewing of patient medical information without a direct need for
medical diagnosis, treatment, or other lawful use as permitted by the
Confidentiality of Medical Information Act (Part 2.6 (commencing
with Section 56) of Division 1 of the Civil Code) or any other
statute or regulation governing the lawful access, use, or disclosure
of medical information.
SEC. 5. Section 1341.45 of the Health and Safety Code is amended
to read:
1341.45. (a) There is hereby created in the State Treasury the
Managed Care Administrative Fines and Penalties Fund.
(b) The fines and administrative penalties collected pursuant to
this chapter, on and after September 30, 2008, shall be deposited
into the Managed Care Administrative Fines and Penalties Fund.
(c) The fines and administrative penalties deposited into the
Managed Care Administrative Fines and Penalties Fund shall be
transferred by the department, beginning September 1, 2009, and
annually thereafter, as follows:
(1) The first one million dollars ($1,000,000) shall be
transferred to the Medically Underserved Account for Physicians
within the Health Professions Education Fund and shall, upon
appropriation by the Legislature, be used for the purposes of the
Steven M. Thompson Physician Corps Loan Repayment Program, as
specified in Article 5 (commencing with Section 128550) or Chapter 5
of Part 3 of Division 107 and, notwithstanding Section 128555, shall
not be used to provide funding for the Physician Volunteer Program.
(2) Any amount over the first one million dollars ($1,000,000),
including accrued interest, in the fund shall be transferred to the
Major Risk Medical Insurance Fund continued pursuant to Section 15893
of the Welfare and Institutions Code and shall, upon appropriation
by the Legislature, be used for the Major Risk Medical Insurance
Program for the purposes specified in Section 15894 of the Welfare
and Institutions Code.
(d) Notwithstanding subdivision (b) of Section 1356 and Section
1356.1, the fines and administrative penalties authorized pursuant to
this chapter shall not be used to reduce the assessments imposed on
health care service plans pursuant to Section 1356.
(e) The amendments made to this section by the act adding this
subdivision shall become operative on July 1, 2014.
SEC. 6. Section 1347.5 is added to the Health and Safety Code, to
read:
1347.5. (a) A health care service plan providing individual
coverage in the Exchange shall cooperate with requests from the
Exchange to collaborate in the development of, and participate in the
implementation of, the Medi-Cal program's premium and cost-sharing
payments under Sections 14102 and 14148.65 of the Welfare and
Institutions Code for eligible Exchange enrollees.
(b) A health care service plan providing individual coverage in
the Exchange shall not charge, bill, ask, or require an enrollee
receiving benefits under Section 14102 or Section 14148.65 of the
Welfare and Institutions Code to make any premium or cost-sharing
payments for any services that are subject to premium or cost-sharing
payments by the State Department of Health Care Services under
Section 14102 or Section 14148.65 of the Welfare and Institutions
Code.
(c) For purposes of this section, "Exchange" means the California
Health Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code.
SEC. 7. Section 1368.05 is added to the Health and Safety Code, to
read:
1368.05. (a) (1) By enacting this section, which was originally
enacted by Assembly Bill 922 (Chapter 552 of the Statutes of 2011),
the Legislature recognizes that, because of the enactment of federal
health care reform on March 23, 2010, and the implementation of
various provisions by January 1, 2014, and the ongoing complexities
of health care reform, it is appropriate to transfer the direct
consumer assistance activities that were newly conferred on the
Office of the Patient Advocate to the Department of Managed Health
Care, and the Legislature recognizes that these new duties are
necessary to be carried out by the department in partnership with
community-based consumer assistance organizations for the purposes of
serving California's health care consumers.
(2) In addition to maintaining the toll-free telephone number for
the purpose of receiving complaints regarding health care service
plans as required in Section 1368.02, the department and its
contractors shall carry out these new responsibilities, which include
assisting consumers in navigating private and public health care
coverage and assisting consumers in determining the regulator that
regulates the health care coverage of a particular consumer. In order
to further assist in implementing health care reform, the department
and its contractors shall also receive and respond to inquiries,
complaints, and requests for assistance and education concerning
health care coverage available in California.
(b) (1) The department shall annually contract with
community-based organizations in furtherance of providing assistance
to consumers as described in subdivision (a), as authorized by and in
accordance with Section 19130 of the Government Code.
(2) These organizations shall be community-based nonprofit
consumer assistance programs that shall include in their mission the
assistance of, and duty to, health care consumers.
(3) Contracting consumer assistance organizations shall have
experience in assisting consumers in navigating the local health care
system, advising consumers regarding their health care coverage
options, assisting consumers with problems in accessing health care
services, and serving consumers with special needs, including, but
not limited to, consumers with limited-English language proficiency,
consumers requiring culturally competent services, low-income
consumers, consumers with disabilities, consumers with low literacy
rates, and consumers with multiple health conditions, including
behavioral health. The organizations shall also have experience with,
and the capacity for, collecting and reporting data regarding the
consumers they assist, including demographic data, source of
coverage, regulator, type of problem or issue, and resolution of
complaints.
SEC. 8. Section 1374.76 is added to the Health and Safety Code,
immediately following Section 1374.74, to read:
1374.76. (a) No later than January 1, 2015, a large group health
care service plan contract shall provide all covered mental health
and substance use disorder benefits in compliance with the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 (Public Law 110-343) and all rules, regulations, and
guidance issued pursuant to Section 2726 of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg-26).
(b) No later than January 1, 2015, an individual or small group
health care service plan contract shall provide all covered mental
health and substance use disorder benefits in compliance with the
Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008 (Public Law 110-343), all rules, regulations, and
guidance issued pursuant to Section 2726 of the federal Public Health
Service Act (42 U.S.C. Sec. 300gg-26), and Section 1367.005.
(c) Until January 1, 2016, the director may issue guidance to
health care service plans regarding compliance with this section.
This guidance shall not be subject to the Administrative Procedure
Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code). Any guidance issued
pursuant to this subdivision shall be effective only until the
director adopts regulations pursuant to the Administrative Procedure
Act. The department shall consult with the Department of Insurance in
issuing guidance under this subdivision.
SEC. 9. Section 1399.861 of the Health and Safety Code is amended
to read:
1399.861. (a) On or before October 1, 2013, and annually every
October 1 thereafter, a health care service plan shall issue the
following notice to all subscribers enrolled in an individual health
benefit plan that is a grandfathered health plan:
New improved health insurance options are available in California.
You currently have health insurance that is not required to follow
many of the new laws. For example, your plan may not provide
preventive health services without you having to pay any cost sharing
(copayments or coinsurance). Also, your current plan may be allowed
to increase your rates based on your health status while new plans
and policies cannot. You have the option to remain in your current
plan or switch to a new plan. Under the new rules, a health plan
cannot deny your application based on any health conditions you may
have. For more information about your options, please contact Covered
California at ____, your plan representative or insurance agent, or
an entity paid by Covered California to assist with health coverage
enrollment such as a navigator or an assister.
(b) Commencing October 1, 2013, a health care service plan shall
include the notice described in subdivision (a) in any renewal
material of the individual grandfathered health plan and in any
application for dependent coverage under the individual grandfathered
health plan.
(c) A health care service plan shall not advertise or market an
individual health benefit plan that is a grandfathered health plan
for purposes of enrolling a dependent of a subscriber into the plan
for policy years on or after January 1, 2014. Nothing in this
subdivision shall be construed to prohibit an individual enrolled in
an individual grandfathered health plan from adding a dependent to
that plan to the extent permitted by PPACA.
SEC. 10. Section 11833.02 of the Health and Safety Code is amended
to read:
11833.02. (a) The department shall charge a fee to all programs
for licensure or certification by the department, regardless of the
form of organization or ownership of the program.
(b) The department may establish fee scales using different
capacity levels, categories based on measures other than program
capacity, or any other category or classification that the department
deems necessary or convenient to maintain an effective and equitable
fee structure.
(c) Licensing and certification fees shall be evaluated annually,
taking into consideration the overall cost of the residential and
outpatient licensing and certification activities of the department,
including initial issuance, renewals, complaints, enforcement
activity, related litigation, and any other program activity relating
to licensure and certification, plus a reasonable reserve.
(d) The department shall submit any proposed new fees or fee
changes to the Legislature for approval no later than April 1 of each
year as part of the spring finance letter process. No new fees or
fee changes shall be implemented without legislative approval.
(e) The department shall issue a provider bulletin pursuant to
subdivision (a) of Section 11833.04 setting forth the approved fee
structure. The department shall, on an annual basis, publish the
current fee structure on the department's Internet Web site.
(f) Unless funds are specifically appropriated from the General
Fund in the annual Budget Act or other legislation to support the
division, the Licensing and Certification Division, no later than the
beginning of the 2010-11 fiscal year, shall be supported entirely by
federal funds and special funds.
SEC. 11. Section 11833.04 of the Health and Safety Code is amended
to read:
11833.04. (a) Notwithstanding the rulemaking provisions of the
Administrative Procedure Act, Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement new fees or fee changes as approved by the
Legislature pursuant to subdivision (d) of Section 11833.02 by means
of provider bulletins or similar instructions from the director
without taking regulatory action. The department shall notify and
consult with interested parties and appropriate stakeholders
regarding new fees or fee changes made pursuant to this chapter.
(b) (1) The department shall adopt regulations in accordance with
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code by January 1, 2016, to amend
Section 10701 of Title 9 of Division 4 of Chapter 5.5 of the
California Code of Regulations to be consistent with this chapter.
(2) The authority to implement Section 11833.02 and this section
shall include the authority to supersede the licensing and
certification fees in effect on the operative date of the act that
adds this paragraph and shall continue until the department has
amended Section 10701 of Title 9 of Division 4 of Chapter 5.5 of the
California Code of Regulations pursuant to paragraph (1).
SEC. 12. Section 120955 of the Health and Safety Code is amended
to read:
120955. (a) (1) To the extent that state and federal funds are
appropriated in the annual Budget Act for these purposes, the
director shall establish and may administer a program to provide drug
treatments to persons infected with human immunodeficiency virus
(HIV), the etiologic agent of acquired immunodeficiency syndrome
(AIDS). If the director makes a formal determination that, in any
fiscal year, funds appropriated for the program will be insufficient
to provide all of those drug treatments to existing eligible persons
for the fiscal year and that a suspension of the implementation of
the program is necessary, the director may suspend eligibility
determinations and enrollment in the program for the period of time
necessary to meet the needs of existing eligible persons in the
program.
(2) The director, in consultation with the AIDS Drug Assistance
Program Medical Advisory Committee, shall develop, maintain, and
update as necessary a list of drugs to be provided under this
program. The list shall be exempt from the requirements of the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340), Chapter 4 (commencing with Section 11370), and Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code), and shall not be subject to the review and
approval of the Office of Administrative Law.
(b) The director may grant funds to a county public health
department through standard agreements to administer this program in
that county. To maximize the recipients' access to drugs covered by
this program, the director shall urge the county health department in
counties granted these funds to decentralize distribution of the
drugs to the recipients.
(c) The director shall establish a rate structure for
reimbursement for the cost of each drug included in the program.
Rates shall not be less than the actual cost of the drug. However,
the director may purchase a listed drug directly from the
manufacturer and negotiate the most favorable bulk price for that
drug.
(d) Manufacturers of the drugs on the list shall pay the
department a rebate equal to the rebate that would be applicable to
the drug under Section 1927(c) of the federal Social Security Act (42
U.S.C. Sec. 1396r-8(c)) plus an additional rebate to be negotiated
by each manufacturer with the department, except that no rebates
shall be paid to the department under this section on drugs for which
the department has received a rebate under Section 1927(c) of the
federal Social Security Act (42 U.S.C. Sec. 1396r-8(c)) or that have
been purchased on behalf of county health departments or other
eligible entities at discount prices made available under Section
256b of Title 42 of the United States Code.
(e) The department shall submit an invoice, not less than two
times per year, to each manufacturer for the amount of the rebate
required by subdivision (d).
(f) Drugs may be removed from the list for failure to pay the
rebate required by subdivision (d), unless the department determines
that removal of the drug from the list would cause substantial
medical hardship to beneficiaries.
(g) The department may adopt emergency regulations to implement
amendments to this chapter made during the 1997-98 Regular Session,
in accordance with the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code). The initial adoption of emergency regulations
shall be deemed to be an emergency and considered by the Office of
Administrative Law as necessary for the immediate preservation of the
public peace, health and safety, or general welfare. Emergency
regulations adopted pursuant to this section shall remain in effect
for no more than 180 days.
(h) Reimbursement under this chapter shall not be made for any
drugs that are available to the recipient under any other private,
state, or federal programs, or under any other contractual or legal
entitlements, except that the director may authorize an exemption
from this subdivision where exemption would represent a cost savings
to the state.
(i) The department may also subsidize certain cost-sharing
requirements for persons otherwise eligible for the AIDS Drug
Assistance Program (ADAP) with existing non-ADAP drug coverage by
paying for prescription drugs included on the ADAP formulary within
the existing ADAP operational structure up to, but not exceeding, the
amount of that cost-sharing obligation. This cost sharing may only
be applied in circumstances in which the other payer recognizes the
ADAP payment as counting toward the individual's cost-sharing
obligation. If the director determines that it would result in a cost
savings to the state, the department may subsidize, using available
federal funds and moneys from the AIDS Drug Assistance Program Rebate
Fund, costs associated with a health care service plan or health
insurance policy, including medical copayments and deductibles for
outpatient care, and premiums to purchase or maintain health
insurance coverage.
SEC. 13. Section 120962 is added to the Health and Safety Code, to
read:
120962. (a) (1) For the purpose of verifying financial
eligibility pursuant to Section 120960 and the federal Ryan White
HIV/AIDS Treatment Extension Act of 2009 (42 U.S.C. Sec. 201 et
seq.), the department shall verify the accuracy of the adjusted gross
income reported on an AIDS Drug Assistance Program application
submitted by an applicant or recipient with data, if available, from
the Franchise Tax Board.
(2) Notwithstanding any other law, the department shall disclose
the name and individual taxpayer identification number (ITIN) or
social security number of an applicant for, or recipient of, services
under this chapter to the Franchise Tax Board for the purpose of
verifying the adjusted gross income of an applicant or recipient
pursuant to subdivision (b) of Section 120960.
(b) The Franchise Tax Board, upon receipt of this information,
shall inform the department of the amount of the federal adjusted
gross income as reported by the taxpayer to the Franchise Tax Board,
and the California adjusted gross income as reported by the taxpayer
to the Franchise Tax Board or as adjusted by the Franchise Tax Board.
The Franchise Tax Board shall provide the information to the
department for the most recent taxable year that the Franchise Tax
Board has information available, and shall include the first and last
name, date of birth, and the ITIN or social security number of the
taxpayer.
(c) (1) Information provided by the department pursuant to this
section shall constitute confidential public health records as
defined in Section 121035, and shall remain subject to the
confidentiality protections and restrictions on further disclosure by
the recipient under subdivisions (d) and (e) of Section 121025.
(2) To the extent possible, verification of financial eligibility
shall be done in a way to eliminate or minimize, by use of computer
programs or other electronic means, Franchise Tax Board staff and
contractors' access to confidential public health records.
(3) Prior to accessing confidential HIV-related public health
records, Franchise Tax Board staff and contractors shall be required
to annually sign a confidentiality agreement developed by the
department that includes information related to the penalties under
Section 121025 for a breach of confidentiality and the procedures for
reporting a breach of confidentiality under subdivision (h) of
Section 121022. Those agreements shall be reviewed annually by the
department.
(4) The Franchise Tax Board shall return or destroy all
information received from the department after completing the
exchange of information.
SEC. 14. Section 121451 is added to the Health and Safety Code, to
read:
121451. A local entity that receives funding from the state for
the purposes of this part, including, but not limited to, funding
from the state for tuberculosis control pursuant to Item
4265-111-0001 of Section 2.00 of the annual Budget Act, shall first
allocate the moneys received for the following purposes and
activities before allocating the moneys for any other purposes or
activities described in this part:
(a) Either of the following activities if those activities are
carried out by a local detention facility:
(1) When a person who has active tuberculosis or is reasonably
believed to have active tuberculosis is discharged or released from a
detention facility, doing both of the following:
(A) Drafting and submitting notification to the local health
officer.
(B) Submitting the written treatment plan that includes the
information required by Section 121362 to the local health officer.
This activity does not include drafting the written treatment plan.
(2) When a person who has active tuberculosis or is reasonably
believed to have active tuberculosis is transferred to a local
detention facility in another jurisdiction, doing both of the
following:
(A) Drafting and submitting notification to the local health
officer and the medical officer of the local detention facility
receiving the person.
(B) Submitting the written treatment plan that includes the
information required by Section 121362 to the local health officer
and the medical officer of the local detention facility receiving the
person. This activity does not include drafting the written
treatment plan.
(b) Either of the following activities if those activities are
carried out by a local health officer or his or her designee:
(1) Receiving and reviewing for approval within 24 hours of
receipt only those treatment plans submitted by a health facility.
This activity includes all of the following:
(A) Receiving the health facility's treatment plan.
(B) Sending a request to a health facility for medical records and
information on tuberculosis medications, dosages, and diagnostic
workup and reviewing records and information.
(C) Coordinating with the health facility on any adjustments to
the treatment plan.
(D) Sending approval to the health facility.
(2) Drafting and sending a notice to the medical officer of a
parole region, or a physician or surgeon designated by the Department
of Corrections and Rehabilitation, if there are reasonable grounds
to believe that a parolee has active tuberculosis and ceases
treatment for the disease.
(c) For cities, counties, and cities and counties to provide
counsel to nonindigent tuberculosis patients who are subject to a
civil order of detention issued by a local health officer pursuant to
Section 121365 upon request of the patient. Services provided by
counsel include representation of the tuberculosis patient at any
court review of the order of detention required by Section 121366.
SEC. 15. Section 121452 is added to the Health and Safety Code, to
read:
121452. A local health department or local health officer that
receives funding from the state for tuberculosis control pursuant to
Item 4265-111-0001 of Section 2.00 of the annual Budget Act for
purposes of this part may use those funds to reimburse the actual
costs of carrying out the activities described in Section 121451.
SEC. 16. Section 128200 of the Health and Safety Code is amended
to read:
128200. (a) This article shall be known and may be cited as the
Song-Brown Health Care Workforce Training Act.
(b) (1) The Legislature hereby finds and declares that
physicians engaged in family medicine are in very short supply in
California. The current emphasis placed on specialization in medical
education has resulted in a shortage of physicians trained to provide
comprehensive primary health care to families. The Legislature
hereby declares that it regards the furtherance of a greater supply
of competent family physicians to be a public purpose of great
importance and further declares the establishment of the program
pursuant to this article to be a desirable, necessary, and economical
method of increasing the number of family physicians to provide
needed medical services to the people of California. The Legislature
further declares that it is to the benefit of the state to assist in
increasing the number
of competent family physicians graduated by colleges and
universities of this state to provide primary health care services to
families within the state.
(2) The Legislature finds that the shortage of family physicians
can be improved by the placing of a higher priority by public and
private medical schools, hospitals, and other health care delivery
systems in this state, on the recruitment and improved training of
medical students and residents to meet the need for family
physicians. To help accomplish this goal, each medical school in
California is encouraged to organize a strong family medicine program
or department. It is the intent of the Legislature that the programs
or departments be headed by a physician who possesses specialty
certification in the field of family medicine, and has broad clinical
experience in the field of family medicine.
(3) The Legislature further finds that encouraging the training of
primary care physician's assistants and primary care nurse
practitioners will assist in making primary health care services more
accessible to the citizenry, and will, in conjunction with the
training of family physicians, lead to an improved health care
delivery system in California.
(4) Community hospitals in general and rural community hospitals
in particular, as well as other health care delivery systems, are
encouraged to develop family medicine residencies in affiliation or
association with accredited medical schools, to help meet the need
for family physicians in geographical areas of the state with
recognized family primary health care needs. Utilization of expanded
resources beyond university-based teaching hospitals should be
emphasized, including facilities in rural areas wherever possible.
(5) The Legislature also finds and declares that nurses are in
very short supply in California. The Legislature hereby declares that
it regards the furtherance of a greater supply of nurses to be a
public purpose of great importance and further declares the expansion
of the program pursuant to this article to include nurses to be a
desirable, necessary, and economical method of increasing the number
of nurses to provide needed nursing services to the people of
California.
(6) It is the intent of the Legislature to provide for a program
designed primarily to increase the number of students and residents
receiving quality education and training in the primary care
specialties of family medicine, internal medicine, obstetrics and
gynecology, and pediatrics and as primary care physician's
assistants, primary care nurse practitioners, and registered nurses
and to maximize the delivery of primary care family physician
services to specific areas of California where there is a recognized
unmet priority need. This program is intended to be implemented
through contracts with accredited medical schools, teaching health
centers, programs that train primary care physician's assistants,
programs that train primary care nurse practitioners, programs that
train registered nurses, hospitals, and other health care delivery
systems based on per-student or per-resident capitation formulas. It
is further intended by the Legislature that the programs will be
professionally and administratively accountable so that the maximum
cost-effectiveness will be achieved in meeting the professional
training standards and criteria set forth in this article and Article
2 (commencing with Section 128250).
SEC. 17. Section 128205 of the Health and Safety Code is amended
to read:
128205. As used in this article, and Article 2 (commencing with
Section 128250), the following terms mean:
(a) "Family physician" means a primary care physician who is
prepared to and renders continued comprehensive and preventative
health care services to families and who has received specialized
training in an approved family medicine residency for three years
after graduation from an accredited medical school.
(b) "Primary care physician" means a physician who is prepared to
and renders continued comprehensive and preventative health care
services, and has received specialized training in the areas of
internal medicine, obstetrics and gynecology, or pediatrics.
(c) "Associated" and "affiliated" mean that relationship that
exists by virtue of a formal written agreement between a hospital or
other health care delivery system and an approved medical school that
pertains to the primary care or family medicine training program for
which state contract funds are sought.
(d) "Commission" means the California Healthcare Workforce Policy
Commission.
(e) "Programs that train primary care physician's assistants"
means a program that has been approved for the training of primary
care physician assistants pursuant to Section 3513 of the Business
and Professions Code.
(f) "Programs that train primary care nurse practitioners" means a
program that is operated by a California school of medicine or
nursing, or that is authorized by the Regents of the University of
California or by the Trustees of the California State University, or
that is approved by the Board of Registered Nursing.
(g) "Programs that train registered nurses" means a program that
is operated by a California school of nursing and approved by the
Board of Registered Nursing, or that is authorized by the Regents of
the University of California, the Trustees of the California State
University, or the Board of Governors of the California Community
Colleges, and that is approved by the Board of Registered Nursing.
(h) "Teaching health center" means a community-based ambulatory
patient care center that operates a primary care residency program.
Community-based ambulatory patient care settings include, but are not
limited to, federally qualified health centers, community mental
health centers, rural health clinics, health centers operated by the
Indian Health Service, an Indian tribe or tribal organization, or an
urban Indian organization, and entities receiving funds under Title X
of the federal Public Health Service Act (Public Law 91-572).
SEC. 18. Section 128210 of the Health and Safety Code is amended
to read:
128210. There is hereby created a state medical contract program
with accredited medical schools, teaching health centers, programs
that train primary care physician's assistants, programs that train
primary care nurse practitioners, programs that train registered
nurses, hospitals, and other health care delivery systems to increase
the number of students and residents receiving quality education and
training in the primary care specialties of family medicine,
internal medicine, obstetrics and gynecology, and pediatrics, or in
nursing and to maximize the delivery of primary care and family
physician services to specific areas of California where there is a
recognized unmet priority need for those services.
SEC. 19. Section 128215 of the Health and Safety Code is amended
to read:
128215. There is hereby created a California Healthcare Workforce
Policy Commission. The commission shall be composed of 15 members
who shall serve at the pleasure of their appointing authorities:
(a) Nine members appointed by the Governor, as follows:
(1) One representative of the University of California medical
schools, from a nominee or nominees submitted by the University of
California.
(2) One representative of the private medical or osteopathic
schools accredited in California from individuals nominated by each
of these schools.
(3) One representative of practicing family medicine physicians.
(4) One representative who is a practicing osteopathic physician
or surgeon and who is board certified in either general or family
medicine.
(5) One representative of undergraduate medical students in a
family medicine program or residence in family medicine training.
(6) One representative of trainees in a primary care physician's
assistant program or a practicing physician's assistant.
(7) One representative of trainees in a primary care nurse
practitioners program or a practicing nurse practitioner.
(8) One representative of the Office of Statewide Health Planning
and Development, from nominees submitted by the office director.
(9) One representative of practicing registered nurses.
(b) Two consumer representatives of the public who are not elected
or appointed public officials, one appointed by the Speaker of the
Assembly and one appointed by the Chairperson of the Senate Committee
on Rules.
(c) Two representatives of practicing registered nurses, one
appointed by the Speaker of the Assembly and one appointed by the
Chairperson of the Senate Committee on Rules.
(d) Two representatives of students in a registered nurse training
program, one appointed by the Speaker of the Assembly and one
appointed by the Chairperson of the Senate Committee on Rules.
(e) The Deputy Director of the Healthcare Workforce Development
Division in the Office of Statewide Health Planning and Development,
or the deputy director's designee, shall serve as executive secretary
for the commission.
SEC. 20. Section 128225 of the Health and Safety Code is amended
to read:
128225. The commission shall do all of the following:
(a) Identify specific areas of the state where unmet priority
needs for primary care family physicians and registered nurses exist.
(b) (1) Establish standards for primary care and family medicine
training programs, primary care and family medicine residency
programs, postgraduate osteopathic medical programs in primary care
or family medicine, and primary care physician assistants programs
and programs that train primary care nurse practitioners, including
appropriate provisions to encourage primary care physicians, family
physicians, osteopathic family physicians, primary care physician's
assistants, and primary care nurse practitioners who receive training
in accordance with this article and Article 2 (commencing with
Section 128250) to provide needed services in areas of unmet need
within the state. Standards for primary care and family medicine
residency programs shall provide that all of the residency programs
contracted for pursuant to this article and Article 2 (commencing
with Section 128250) shall be approved by the Accreditation Council
for Graduate Medical Education's Residency Review Committee for
Family Medicine, Internal Medicine, Pediatrics, or Obstetrics and
Gynecology. Standards for postgraduate osteopathic medical programs
in primary care and family medicine, as approved by the American
Osteopathic Association Committee on Postdoctoral Training for
interns and residents, shall be established to meet the requirements
of this subdivision in order to ensure that those programs are
comparable to the other programs specified in this subdivision. Every
program shall include a component of training designed for medically
underserved multicultural communities, lower socioeconomic
neighborhoods, or rural communities, and shall be organized to
prepare program graduates for service in those neighborhoods and
communities. Medical schools receiving funds under this article and
Article 2 (commencing with Section 128250) shall have programs or
departments that recognize family medicine as a major independent
specialty. Existence of a written agreement of affiliation or
association between a hospital and an accredited medical school shall
be regarded by the commission as a favorable factor in considering
recommendations to the director for allocation of funds appropriated
to the state medical contract program established under this article
and Article 2 (commencing with Section 128250). Teaching health
centers receiving funds under this article shall have programs or
departments that recognize family medicine as a major independent
specialty.
(2) For purposes of this subdivision, "primary care" and "family
medicine" includes the general practice of medicine by osteopathic
physicians.
(c) Establish standards for registered nurse training programs.
The commission may accept those standards established by the Board of
Registered Nursing.
(d) Review and make recommendations to the Director of the Office
of Statewide Health Planning and Development concerning the funding
of primary care and family medicine programs or departments and
primary care and family medicine residencies and programs for the
training of primary care physician assistants and primary care nurse
practitioners that are submitted to the Healthcare Workforce
Development Division for participation in the contract program
established by this article and Article 2 (commencing with Section
128250). If the commission determines that a program proposal that
has been approved for funding or that is the recipient of funds under
this article and Article 2 (commencing with Section 128250) does not
meet the standards established by the commission, it shall submit to
the Director of the Office of Statewide Health Planning and
Development and the Legislature a report detailing its objections.
The commission may request the Office of Statewide Health Planning
and Development to make advance allocations for program development
costs from amounts appropriated for the purposes of this article and
Article 2 (commencing with Section 128250).
(e) Review and make recommendations to the Director of the Office
of Statewide Health Planning and Development concerning the funding
of registered nurse training programs that are submitted to the
Healthcare Workforce Development Division for participation in the
contract program established by this article. If the commission
determines that a program proposal that has been approved for funding
or that is the recipient of funds under this article does not meet
the standards established by the commission, it shall submit to the
Director of the Office of Statewide Health Planning and Development
and the Legislature a report detailing its objections. The commission
may request the Office of Statewide Health Planning and Development
to make advance allocations for program development costs from
amounts appropriated for the purposes of this article.
(f) Establish contract criteria and single per-student and
per-resident capitation formulas that shall determine the amounts to
be transferred to institutions receiving contracts for the training
of primary care and family medicine students and residents and
primary care physician's assistants and primary care nurse
practitioners and registered nurses pursuant to this article and
Article 2 (commencing with Section 128250), except as otherwise
provided in subdivision (d). Institutions applying for or in receipt
of contracts pursuant to this article and Article 2 (commencing with
Section 128250) may appeal to the director for waiver of these single
capitation formulas. The director may grant the waiver in
exceptional cases upon a clear showing by the institution that a
waiver is essential to the institution's ability to provide a program
of a quality comparable to those provided by institutions that have
not received waivers, taking into account the public interest in
program cost-effectiveness. Recipients of funds appropriated by this
article and Article 2 (commencing with Section 128250) shall, as a
minimum, maintain the level of expenditure for family medicine or
primary care physician's assistant or family care nurse practitioner
training that was provided by the recipients during the 1973-74
fiscal year. Recipients of funds appropriated for registered nurse
training pursuant to this article shall, as a minimum, maintain the
level of expenditure for registered nurse training that was provided
by recipients during the 2004-05 fiscal year. Funds appropriated
under this article and Article 2 (commencing with Section 128250)
shall be used to develop new programs or to expand existing programs,
and shall not replace funds supporting current family medicine or
registered nurse training programs. Institutions applying for or in
receipt of contracts pursuant to this article and Article 2
(commencing with Section 128250) may appeal to the director for
waiver of this maintenance of effort provision. The director may
grant the waiver if he or she determines that there is reasonable and
proper cause to grant the waiver.
(g) (1) Review and make recommendations to the Director of the
Office of Statewide Health Planning and Development concerning the
funding of special programs that may be funded on other than a
capitation rate basis. These special programs may include the
development and funding of the training of primary health care teams
of primary care and family medicine residents or primary care or
family physicians and primary care physician assistants or primary
care nurse practitioners or registered nurses, undergraduate medical
education programs in primary care or family medicine, and programs
that link training programs and medically underserved communities in
California that appear likely to result in the location and retention
of training program graduates in those communities. These special
programs also may include the development phase of new primary care
or family medicine residency, primary care physician assistant
programs, primary care nurse practitioner programs, or registered
nurse programs.
(2) The commission shall establish standards and contract
criteria for special programs recommended under this subdivision.
(h) Review and evaluate these programs regarding compliance with
this article and Article 2 (commencing with Section 128250). One
standard for evaluation shall be the number of recipients who, after
completing the program, actually go on to serve in areas of unmet
priority for primary care or family physicians in California or
registered nurses who go on to serve in areas of unmet priority for
registered nurses.
(i) Review and make recommendations to the Director of the Office
of Statewide Health Planning and Development on the awarding of funds
for the purpose of making loan assumption payments for medical
students who contractually agree to enter a primary care specialty
and practice primary care medicine for a minimum of three consecutive
years following completion of a primary care residency training
program pursuant to Article 2 (commencing with Section 128250).
SEC. 21. Section 128230 of the Health and Safety Code is amended
to read:
128230. When making recommendations to the Director of the Office
of Statewide Health Planning and Development concerning the funding
of primary care and family medicine programs or departments, primary
care and family medicine residencies, and programs for the training
of primary care physician assistants, primary care nurse
practitioners, or registered nurses, the commission shall give
priority to programs that have demonstrated success in the following
areas:
(a) Actual placement of individuals in medically underserved
areas.
(b) Success in attracting and admitting members of minority groups
to the program.
(c) Success in attracting and admitting individuals who were
former residents of medically underserved areas.
(d) Location of the program in a medically underserved area.
(e) The degree to which the program has agreed to accept
individuals with an obligation to repay loans awarded pursuant to the
Health Professions Education Fund.
SEC. 22. Section 128235 of the Health and Safety Code is amended
to read:
128235. Pursuant to this article and Article 2 (commencing with
Section 128250), the Director of the Office of Statewide Health
Planning and Development shall do all of the following:
(a) Determine whether primary care and family medicine, primary
care physician's assistant training program proposals, primary care
nurse practitioner training program proposals, and registered nurse
training program proposals submitted to the California Healthcare
Workforce Policy Commission for participation in the state medical
contract program established by this article and Article 2
(commencing with Section 128250) meet the standards established by
the commission.
(b) Select and contract on behalf of the state with accredited
medical schools, teaching health centers, programs that train primary
care physician's assistants, programs that train primary care nurse
practitioners, hospitals, and other health care delivery systems for
the purpose of training undergraduate medical students and residents
in the specialties of internal medicine, obstetrics and gynecology,
pediatrics, and family medicine. Contracts shall be awarded to those
institutions that best demonstrate the ability to provide quality
education and training and to retain students and residents in
specific areas of California where there is a recognized unmet
priority need for primary care family physicians. Contracts shall be
based upon the recommendations of the commission and in conformity
with the contract criteria and program standards established by the
commission.
(c) Select and contract on behalf of the state with programs that
train registered nurses. Contracts shall be awarded to those
institutions that best demonstrate the ability to provide quality
education and training and to retain students and residents in
specific areas of California where there is a recognized unmet
priority need for registered nurses. Contracts shall be based upon
the recommendations of the commission and in conformity with the
contract criteria and program standards established by the
commission.
(d) Terminate, upon 30 days' written notice, the contract of any
institution whose program does not meet the standards established by
the commission or that otherwise does not maintain proper compliance
with this part, except as otherwise provided in contracts entered
into by the director pursuant to this article and Article 2
(commencing with Section 128250).
SEC. 23. Section 130200 of the Health and Safety Code is amended
to read:
130200. There is hereby established within the California Health
and Human Services Agency the Office of Health Information Integrity
to ensure the enforcement of state law mandating the confidentiality
of medical information. The Office of Health Information Integrity
shall be administered by a director who shall be appointed by the
Secretary of California Health and Human Services.
SEC. 24. Section 130201 of the Health and Safety Code is amended
and renumbered to read:
1280.16. For purposes of Sections 1280.17, 1280.18, 1280.19, and
1280.20, the following definitions apply:
(a) "Department" means the State Department of Public Health.
(b) "Director" means the State Public Health Officer.
(c) "Medical information" means the term as defined in Section
56.05 of the Civil Code.
(d) "Provider of health care" means the term as defined in
Sections 56.05 and 56.06 of the Civil Code.
(e) "Unauthorized access" means the inappropriate review or
viewing of patient medical information without a direct need for
diagnosis, treatment, or other lawful use as permitted by the
Confidentiality of Medical Information Act (Part 2.6 (commencing with
Section 56) of Division 1 of the Civil Code) or by other statutes or
regulations governing the lawful access, use, or disclosure of
medical information.
SEC. 25. Section 130202 of the Health and Safety Code is amended
and renumbered to read:
1280.17. (a) (1) The department may assess an administrative
fine against any person or any provider of health care, whether
licensed or unlicensed, for any violation of Section 1280.18 of this
code or Part 2.6 (commencing with Section 56) of Division 1 of the
Civil Code in an amount as provided in Section 56.36 of the Civil
Code. Proceedings against any person or entity for a violation of
this section shall be held in accordance with administrative
adjudication provisions of Chapter 4.5 (commencing with Section
11400) and Chapter 5 (commencing with Section 11500) of Part 1 of
Division 3 of Title 2 of the Government Code.
(2) Paragraph (1) shall not apply to a clinic, health facility,
agency, or hospice licensed pursuant to Section 1204, 1250, 1725, or
1745.
(b) The department shall adopt, amend, or repeal, in accordance
with the provisions of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, rules and
regulations as may be reasonable and proper to carry out the purposes
and intent of Sections 1280.18, 1280.19, and 1280.20, and to enable
the authority to exercise the powers and perform the duties conferred
upon it by those sections not inconsistent with any other provision
of law.
SEC. 26. Section 130203 of the Health and Safety Code is amended
and renumbered to read:
1280.18. (a) Every provider of health care shall establish and
implement appropriate administrative, technical, and physical
safeguards to protect the privacy of a patient's medical information.
Every provider of health care shall reasonably safeguard
confidential medical information from any unauthorized access or
unlawful access, use, or disclosure.
(b) In exercising its duties pursuant to Section 1280.17, the
department shall consider the provider's capability, complexity,
size, and history of compliance with this section and other related
state and federal statutes and regulations, the extent to which the
provider detected violations and took steps to immediately correct
and prevent past violations from reoccurring, and factors beyond the
provider's immediate control that restricted the facility's ability
to comply with this section.
(c) The department may conduct joint investigations of individuals
and health facilities for violations of this section and Section
1280.15, respectively.
SEC. 27. Section 130204 of the Health and Safety Code is amended
and renumbered to read:
1280.19. The Internal Health Information Integrity Quality
Improvement Account is hereby created in the State Treasury. All
administrative fines assessed by the department pursuant to Section
56.36 of the Civil Code shall be deposited in the Internal Health
Information Integrity Quality Improvement Account. Notwithstanding
Section 16305.7 of the Government Code, all interest earned on the
moneys deposited in the account shall be retained in the account.
Upon appropriation by the Legislature, money in the account shall be
used for the purpose of supporting quality improvement activities in
the department.
SEC. 28. Section 130205 of the Health and Safety Code is amended
and renumbered to read:
1280.20. Notwithstanding any other law, the director may send a
recommendation for further investigation of, or discipline for, a
potential violation of the licensee's relevant licensing authority.
The recommendation shall include all documentary evidence collected
by the director in evaluating
whether or not to make that recommendation. The
recommendation and accompanying evidence shall be deemed in the
nature of an investigative communication and be protected by Section
6254 of the Government Code. The licensing authority of the provider
of health care shall review all evidence submitted by the director
and may take action for further investigation or discipline of the
licensee.
SEC. 29. Section 131058 is added to the Health and Safety Code, to
read:
131058. The State Department of Public Health may investigate,
apply for, and enter into agreements to secure federal or
nongovernmental funding opportunities for the purposes of advancing
public health, subject to the provisions of Section 13326 of the
Government Code for federal funding or applicable administrative
review and approval for nongovernmental funding opportunities.
SEC. 30. Section 136000 of the Health and Safety Code is repealed.
SEC. 31. Section 136000 is added to the Health and Safety Code, to
read:
136000. (a) (1) The Office of Patient Advocate is hereby
established within the California Health and Human Services Agency,
to provide assistance to, and advocate on behalf of, health care
consumers. The goal of the office shall be to coordinate amongst,
provide assistance to, and collect data from, all of the state agency
consumer assistance or patient assistance programs and call centers,
to better enable health care consumers to access the health care
services to which they are eligible under the law, including, but not
limited to, commercial and Exchange coverage, Medi-Cal, Medicare,
and federal veterans health benefits. Notwithstanding any provision
of this division, each regulator and health coverage program shall
retain its respective authority, including its authority to resolve
complaints, grievances, and appeals.
(2) The office shall be headed by a patient advocate appointed by
the Governor. The patient advocate shall serve at the pleasure of the
Governor.
(b) (1) The duties of the office shall include, but not be limited
to, all of the following:
(A) Coordinate and work in consultation with state agency and
local, nongovernment health care consumer or patient assistance
programs and health care ombudsperson programs.
(B) Produce a baseline review and annual report to be made
publically available on the office's Internet Web site by July 1,
2015, and annually thereafter, of health care consumer or patient
assistance help centers, call centers, ombudsperson, or other
assistance centers operated by the Department of Managed Health Care,
the Department of Health Care Services, the Department of Insurance,
and the Exchange, that includes, at a minimum, all of the following:
(i) The types of calls received and the number of calls.
(ii) The call center's role with regard to each type of call,
question, complaint, or grievance.
(iii) The call center's protocol for responding to requests for
assistance from health care consumers, including any performance
standards.
(iv) The protocol for referring or transferring calls outside the
jurisdiction of the call center.
(v) The call center's methodology of tracking calls, complaints,
grievances, or inquiries.
(C) (i) Collect, track, and analyze data on problems and
complaints by, and questions from, consumers about health care
coverage for the purpose of providing public information about
problems faced and information needed by consumers in obtaining
coverage and care. The data collected shall include demographic data,
source of coverage, regulator, type of problem or issue or
comparable types of problems or issues, and resolution of complaints,
including timeliness of resolution. Notwithstanding Section 10231.5
of the Government Code, the office shall submit a report by July 1,
2015, and annually thereafter to the Legislature. The report shall be
submitted in compliance with Section 9795 of the Government Code.
The format may be modified annually as needed based upon comments
from the Legislature and stakeholders.
(ii) For the purpose of publically reporting information as
required in subparagraph (B) and this subparagraph about the problems
faced by consumers in obtaining care and coverage, the office shall
analyze data on consumer complaints and grievances resolved by the
agencies listed in subdivision (c), including demographic data,
source of coverage, insurer or plan, resolution of complaints, and
other information intended to improve health care and coverage for
consumers.
(D) Make recommendations, in consultation with stakeholders, for
improvement or standardization of the health consumer assistance
functions, referral process, and data collection and analysis.
(E) Develop model protocols, in consultation with consumer
assistance call centers and stakeholders, that may be used by call
centers for responding to and referring calls that are outside the
jurisdiction of the call center, program, or regulator.
(F) Compile an annual publication, to be made publically available
on the office's Internet Web site, of a quality of care report card,
including, but not limited, to health care service plans, preferred
provider organizations, and medical groups.
(G) Make referrals to the appropriate state agency, whether
further or additional actions may be appropriate, to protect the
interests of consumers or patients.
(H) Assist in the development of educational and informational
guides for consumers and patients describing their rights and
responsibilities and informing them on effective ways to exercise
their rights to secure and access health care coverage, produced by
the Department of Managed Health Care, the Department of Health Care
Services, the Exchange, and the California Department of Insurance,
and to endeavor to make those materials easy to read and understand
and available in all threshold languages, using an appropriate
literacy level and in a culturally competent manner.
(I) Coordinate with other state and federal agencies engaged in
outreach and education regarding the implementation of federal health
care reform, and to assist in these duties, may provide or assist in
the provision of grants to community-based consumer assistance
organizations for these purposes.
(J) If appropriate, refer consumers to the appropriate regulator
of their health coverage programs for filing complaints or
grievances.
(2) The office shall employ necessary staff. The office may employ
or contract with experts when necessary to carry out the functions
of the office. The patient advocate shall make an annual budget
request for the office that shall be identified in the annual Budget
Act.
(3) The patient advocate shall annually issue a public report on
the activities of the office, and shall appear before the appropriate
policy and fiscal committees of the Senate and Assembly, if
requested, to report and make recommendations on the activities of
the office.
(4) The office shall adopt standards for the organizations with
which it contracts pursuant to this section to ensure compliance with
the privacy and confidentiality laws of this state, including, but
not limited to, the Information Practices Act of 1977 (Chapter 1
(commencing with Section 1798) of Title 1.8 of Part 4 of Division 3
of the Civil Code). The office shall conduct privacy trainings as
necessary, and regularly verify that the organizations have measures
in place to ensure compliance with this provision.
(c) The Department of Managed Health Care, the Department of
Health Care Services, the Department of Insurance, the Exchange, and
any other public health coverage programs shall provide to the office
data concerning call centers to meet the reporting requirements in
subparagraph (B) of paragraph (1) of subdivision (b) and consumer
complaints and grievances to meet the reporting requirements in
clause (i) of subparagraph (C) of paragraph (1) of subdivision (b).
(d) For purposes of this section, the following definitions apply:
(1) "Consumer" or "individual" includes the individual or his or
her parent, guardian, conservator, or authorized representative.
(2) "Exchange" means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500) of
the Government Code.
(3) "Health care" includes services provided by any of the health
care coverage programs.
(4) "Health care service plan" has the same meaning as that set
forth in subdivision (f) of Section 1345. Health care service plan
includes "specialized health care service plans," including
behavioral health plans.
(5) "Health coverage program" includes the Medi-Cal program,
Healthy Families Program, tax subsidies and premium credits under the
Exchange, the Basic Health Program, if enacted, county health
coverage programs, and the Access for Infants and Mothers Program.
(6) "Health insurance" has the same meaning as set forth in
Section 106 of the Insurance Code.
(7) "Health insurer" means an insurer that issues policies of
health insurance.
(8) "Office" means the Office of Patient Advocate.
(9) "Threshold languages" has the same meaning as for Medi-Cal
managed care.
SEC. 32. Section 136030 of the Health and Safety Code is amended
to read:
136030. (a) In addition to the moneys received pursuant to
subdivision (d), funding for the actual and necessary expenses of the
office in implementing this division shall be provided, subject to
appropriation by the Legislature, from transfers of moneys from the
Managed Care Fund and the Insurance Fund.
(b) The share of funding from the Managed Care Fund shall be based
on the number of covered lives in the state that are covered under
plans regulated by the Department of Managed Health Care, including
covered lives under Medi-Cal managed care, as determined by the
Department of Managed Health Care, in proportion to the total number
of all covered lives in the state.
(c) The share of funding to be provided from the Insurance Fund
shall be based on the number of covered lives in the state that are
covered under health insurance policies and benefit plans regulated
by the Department of Insurance, including covered lives under
Medicare supplement plans, as determined by the Department of
Insurance, in proportion to the total number of all covered lives in
the state.
(d) In addition to moneys received pursuant to subdivision (a),
the office may receive funding as follows:
(1) The office may apply to the United States Secretary of Health
and Human Services for federal grants.
(2) The office may seek private grant funding from foundations or
other sources.
(3) To the extent permitted by federal law, the office may seek
federal financial participation for assisting beneficiaries of the
Medi-Cal program.
(e) All moneys received by the Office of Patient Advocate shall be
deposited into the fund specified in Section 136020.
SEC. 33. Section 10112.35 is added to the Insurance Code, to read:
10112.35. (a) An insurer providing individual coverage in the
Exchange shall cooperate with requests from the Exchange to
collaborate in the development of, and participate in the
implementation of, the Medi-Cal program's premium and cost-sharing
payments under Sections 14102 and 14148.65 of the Welfare and
Institutions Code for eligible Exchange insureds.
(b) An insurer providing individual coverage in the Exchange shall
not charge, bill, ask, or require an insured receiving benefits
under Section 14102 or Section 14148.65 of the Welfare and
Institutions Code to make any premium or cost-sharing payments for
any services that are subject to premium or cost-sharing payments by
the State Department of Health Care Services under Section 14102 or
Section 14148.65 of the Welfare and Institutions Code.
(c) For purposes of this section, "Exchange" means the California
Health Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code.
SEC. 34. Section 10965.15 of the Insurance Code is amended to
read:
10965.15. (a) On or before October 1, 2013, and annually every
October 1 thereafter, a health insurer shall issue the following
notice to all policyholders enrolled in an individual health benefit
plan that is a grandfathered health plan:
New improved health insurance options are available in California.
You currently have health insurance that is not required to follow
many of the new laws. For example, your policy may not provide
preventive health services without you having to pay any cost sharing
(copayments or coinsurance). Also your current policy may be allowed
to increase your rates based on your health status while new
policies cannot. You have the option to remain in your current policy
or switch to a new policy. Under the new rules, a health insurance
company cannot deny your application based on any health conditions
you may have. For more information about your options, please contact
Covered California at ____, your policy representative or insurance
agent, or an entity paid by Covered California to assist with health
coverage enrollment, such as a navigator or an assister.
(b) Commencing October 1, 2013, a health insurer shall include the
notice described in subdivision (a) in any renewal material of the
individual grandfathered health plan and in any application for
dependent coverage under the individual grandfathered health plan.
(c) A health insurer shall not advertise or market an individual
health benefit plan that is a grandfathered health plan for purposes
of enrolling a dependent of a policyholder into the plan for policy
years on or after January 1, 2014. Nothing in this subdivision shall
be construed to prohibit an individual enrolled in an individual
grandfathered health plan from adding a dependent to that plan to the
extent permitted by PPACA.
SEC. 35. 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.
(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) (I) 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).
(II) Effective on October 1, 2013, or when the State Department of
Health Care Services has implemented Chapter 2 (commencing with
Section 15810) of Part 3.3 of Division 9 of the Welfare and
Institutions Code, whichever is later, eligibility for coverage in
the program pursuant to this clause shall terminate. The board shall
coordinate with the State Department of Health Care Services to
implement Chapter 2 (commencing with Section 15810) of Part 3.3 of
Division 9 of the Welfare and Institutions Code, including transition
of subscribers to the AIM-Linked Infants Program. The State
Department of Health Care Services shall administer the AIM-Linked
Infants Program, pursuant to Chapter 2 (commencing with Section
15810) of Part 3.3 of Division 9 of the Welfare and Institutions
Code, to address the health care needs of children formerly covered
pursuant to this clause.
(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.
(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.
(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. 36. Section 12699.15 is added to the Insurance Code,
immediately following Section 12699.05, to read:
12699.15. This part shall become inoperative on July 1, 2014,
except to the extent its operation is necessary to allow the State
Department of Health Care Services and other affected parties to
complete all transactions started under this part, and, as of January
1, 2016, is repealed, unless a later enacted statute, that becomes
operative on or before January 1, 2016, deletes or extends the dates
on which it becomes inoperative and is repealed.
SEC. 37. Section 12699.64 is added to the Insurance Code,
immediately following Section 12699.63, to read:
12699.64. This part shall become inoperative on July 1, 2014,
except to the extent its operation is necessary to allow the State
Department of Health Care Services and other affected parties to
complete all transactions started under this part, and, as of January
1, 2016, is repealed, unless a later enacted statute, that becomes
operative on or before January 1, 2016, deletes or extends the dates
on which it becomes inoperative and is repealed.
SEC. 38. Section 12701 is added to the Insurance Code, to read:
12701. This part shall become inoperative on July 1, 2014,
except to the extent its operation is necessary to allow the State
Department of Health Care Services and other affected parties to
complete all transactions started under this part, and, as of January
1, 2016, is repealed, unless a later enacted statute, that becomes
operative on or before January 1, 2016, deletes or extends the dates
on which it becomes inoperative and is repealed.
SEC. 39. Section 12710.2 is added to the Insurance Code, to read:
12710.2. Notwithstanding any other law, the board created
pursuant to Section 12710 and renamed pursuant to Section 12710.1
shall continue until July 1, 2014, on which date it is dissolved and
the term of any board member serving at that time ends.
SEC. 40. Section 12739.61 of the Insurance Code is amended to
read:
12739.61. (a) Subject to subdivision (c), the board shall cease
to provide coverage through the program on July 1, 2013, except as
required by the contract between the board and the United States
Department of Health and Human Services, and at that time shall cease
to operate the program except as required to complete payments to,
or payment reconciliations with, participating health plans or other
contractors, process appeals, or conduct other necessary termination
activities.
(b) Any permanent or probationary civil service employee who is
employed by the board and assigned to the program and whose function
ceases due to this section shall immediately be transferred to the
California Health Benefit Exchange and shall retain his or her
status, position, and rights pursuant to Section 19050.9 of the
Government Code and the State Civil Service Act (Part 2 (commencing
with Section 18500) and Part 2.6 (commencing with Section 19815) of
Division 5 of Title 2 of the Government Code).
(c) Commencing on July 1, 2014, the State Department of Health
Care Services shall complete payments to, or payment reconciliations
with, participating health plans or other contractors, process
appeals, or conduct other necessary program termination activities.
SEC. 41. Section 12739.78 of the Insurance Code is amended to
read:
12739.78. (a) (1) If any statute dissolves or terminates the
board, any employee of the board who, immediately prior to the
effective date of the dissolution or termination of the board, was
assigned to the Healthy Families Program (Part 6.2 (commencing with
Section 12693)), the Access for Infants and Mothers Program (Part 6.3
(commencing with Section 12695)), the County Health Initiative
Matching Fund (Part 6.4 (commencing with Section 12699.50)), or the
Major Risk Medical Insurance Program (Part 6.5 (commencing with
Section 12700)) shall be transferred to the State Department of
Health Care Services and shall retain his or her status, position,
and rights pursuant to Section 19050.9 of the Government Code and the
State Civil Service Act (Part 2 (commencing with Section 18500) and
Part 2.6 (commencing with Section 19815) of Division 5 of Title 2 of
the Government Code).
(2) If employees are transferred to the State Department of Health
Care Services pursuant to this subdivision, the department shall
prepare a report on the transfer of employees, and, if applicable,
any functions transferred to the department upon dissolution or
termination of the board. The report shall, at a minimum, describe
any assignment of new activities to transferred employees and provide
workload justification for the position authority transferred
pursuant to this subdivision. The department shall submit the report
to the fiscal and relevant policy committees of the Legislature by
February 1 of the year following the year in which employees are
transferred, and shall update the report, if necessary, by February 1
of each of the two years following submission of the report. The
report may be included with any budget information submitted by the
department to those committees.
(b) (1) If any statute dissolves or terminates the board, any
employee of the board who, immediately prior to the effective date of
the dissolution or termination of the board, was assigned to the
Federal Temporary High Risk Pool (Part 6.6 (commencing with Section
12739.5) and Part 6.7 (commencing with Section 12739.70)) shall be
transferred to the California Health Benefit Exchange and shall
retain his or her status, position, and rights pursuant to Section
19050.9 of the Government Code and the State Civil Service Act (Part
2 (commencing with Section 18500) and Part 2.6 (commencing with
Section 19815) of Division 5 of Title 2 of the Government Code).
(2) This subdivision shall not apply to any employee who has
transferred to the California Health Benefit Exchange pursuant to
subdivision (b) of Section 12739.61 or Section 12739.79.
(c) If any statute dissolves or terminates the board, an employee'
s applicable reinstatement rights that would have applied to the
board shall instead apply to the State Department of Health Care
Services.
SEC. 42. Section 12739.79 is added to the Insurance Code, to
read:
12739.79. Any permanent or probationary civil service employee
who is employed by the board and assigned to the Federal Temporary
High Risk Pool (Part 6.6 (commencing with Section 12739.5) and Part
6.7 (commencing with Section 12739.70)) and whose function ceases due
to Section 12739.61 shall immediately be transferred to the
California Health Benefit Exchange and shall retain his or her
status, position, and rights pursuant to Section 19050.9 of the
Government Code and the State Civil Service Act (Part 2 (commencing
with Section 18500) and Part 2.6 (commencing with Section 19815) of
Division 5 of Title 2 of the Government Code).
SEC. 43. Section 19548.2 is added to the Revenue and Taxation
Code, to read:
19548.2. (a) Notwithstanding any other law and in accordance with
Section 120962 of the Health and Safety Code, the State Department
of Public Health shall disclose the name and individual taxpayer
identification number (ITIN) or social security number of an
applicant for, or recipient of services pursuant to Chapter 6
(commencing with Section 120950) of Part 4 of Division 105 of the
Health and Safety Code to the Franchise Tax Board for the purpose of
verifying the adjusted gross income of an applicant or recipient.
(b) The Franchise Tax Board, upon receipt of this information,
shall inform the State Department of Public Health of the amounts of
the federal adjusted gross income as reported by the taxpayer to the
Franchise Tax Board, and the California adjusted gross income as
reported by the taxpayer to the Franchise Tax Board or as adjusted by
the Franchise Tax Board. The Franchise Tax Board shall provide the
information to the State Department of Public Health for the most
recent taxable year that the Franchise Tax Board has information
available, and shall include the first and last name, date of birth,
and the ITIN or social security number of the taxpayer.
(c) (1) Information provided by the State Department of Public
Health pursuant to this section shall constitute confidential public
health records as defined in Section 121035 of the Health and Safety
Code, and shall remain subject to the confidentiality protections and
restrictions on further disclosure by the recipient under
subdivisions (d) and (e) of Section 121025.
(2) Prior to accessing confidential HIV-related public health
records, Franchise Tax Board staff and contractors shall be required
to annually sign a confidentiality agreement developed by the State
Department of Public Health that includes information related to the
penalties under Section 121025 of the Health and Safety Code for a
breach of confidentiality and the procedures for reporting a breach
of confidentiality under subdivision (h) of Section 121022 of the
Health and Safety Code. Those agreements shall be reviewed annually
by the State Department of Public Health.
(3) The Franchise Tax Board shall return or destroy all
information received from the State Department of Public Health after
completing the exchange of information.
SEC. 44. Section 4061 of the Welfare and Institutions Code is
amended to read:
4061. (a) The State Department of Health Care Services shall
utilize a joint state-county decisionmaking process to determine the
appropriate use of state and local training, technical assistance,
and regulatory resources to meet the mission and goals of the state's
mental health and substance use disorder services system. The
department shall use the decisionmaking collaborative process
required by this section in all of the following areas:
(1) Providing technical assistance to personnel of the State
Department of Health Care Services and local behavioral health,
mental health, and substance use disorder services departments
through direction of existing state and local mental health and
substance use disorder services staff and other resources.
(2) Analyzing mental health and substance use disorder programs,
policies, and procedures.
(3) Providing forums on specific topics as they relate to the
following:
(A) Identifying current level of services.
(B) Evaluating existing needs and gaps in current services.
(C) Developing strategies for achieving statewide goals and
objectives in the provision of services for the specific area.
(D) Developing plans to accomplish the identified goals and
objectives.
(4) Providing forums on policy development and direction with
respect to mental health and substance use disorder program
operations and clinical issues.
(5) Identifying and funding a statewide training and technical
assistance entity jointly governed by local behavioral health, mental
health, and substance use disorder services directors and mental
health and substance use disorder constituency representation, which
can do all of the following:
(A) Coordinate state and local resources to support training and
technical assistance to promote quality mental health and substance
use disorder programs.
(B) Coordinate training and technical assistance to ensure
efficient and effective program development.
(C) Provide essential training and technical assistance, as
determined by the state-county decisionmaking process.
(b) Local behavioral health, mental health, and substance use
disorder services board members shall be included in discussions
pursuant to Section 4060 when the following areas are discussed:
(1) Training and education program recommendations.
(2) Establishment of statewide forums for all organizations and
individuals involved in mental health and substance use disorder
matters to meet and discuss program and policy issues.
(3) Distribution of information between the state, local mental
health and substance use disorder programs, local mental health and
substance use disorder services boards, and other organizations as
appropriate.
(c) The State Department of Health Care Services and local mental
health and substance use disorder services departments may provide
staff or other resources, including travel reimbursement, for
consultant and advisory services; for the training of personnel,
board members, or consumers and families in state and local programs
and in educational institutions and field training centers approved
by the department; and for the establishment and maintenance of field
training centers.
SEC. 45. Section 5897 of the Welfare and Institutions Code is
amended to read:
5897. (a) Notwithstanding any other provision of state law, the
State Department of Health Care Services shall implement the mental
health services provided by Part 3 (commencing with Section 5800),
Part 3.6 (commencing with Section 5840), and Part 4 (commencing with
Section 5850) through contracts with county mental health programs or
counties acting jointly. A contract may be exclusive and may be
awarded on a geographic basis. For purposes of this section, a county
mental health program includes a city receiving funds pursuant to
Section 5701.5.
(b) Two or more counties acting jointly may agree to deliver or
subcontract for the delivery of those mental health services. The
agreement may encompass all or any part of the mental health services
provided pursuant to these parts. Any agreement between counties
shall delineate each county's responsibilities and fiscal liability.
(c) The department shall implement the provisions of Part 3
(commencing with Section 5800), Part 3.2 (commencing with Section
5830), Part 3.6 (commencing with Section 5840), and Part 4
(commencing with Section 5850) through the annual county mental
health services performance contract, as specified in Chapter 2
(commencing with Section 5650) of Part 2.
(d) When a county mental health program is not in compliance with
its performance contract, the department may request a plan of
correction with a specific timeline to achieve improvements.
(e) Contracts awarded by the State Department of Health Care
Services, the State Department of Public Health, the California
Mental Health Planning Council, the Office of Statewide Health
Planning and Development, and the Mental Health Services Oversight
and Accountability Commission pursuant to Part 3 (commencing with
Section 5800), Part 3.1 (commencing with Section 5820), Part 3.2
(commencing with Section 5830), Part 3.6 (commencing with Section
5840), Part 3.7 (commencing with Section 5845), Part 4 (commencing
with Section 5850), and Part 4.5 (commencing with Section 5890), may
be awarded in the same manner in which contracts are awarded pursuant
to Section 5814 and the provisions of subdivisions (g) and (h) of
Section 5814 shall apply to those contracts.
(f) For purposes of Section 14712, the allocation of funds
pursuant to Section 5892 which are used to provide services to
Medi-Cal beneficiaries shall be included in calculating anticipated
county matching funds and the transfer to the State Department of
Health Care Services of the anticipated county matching funds needed
for community mental health programs.
SEC. 46. Section 14005.22 is added to the Welfare and Institutions
Code, to read:
14005.22. (a) A woman is eligible for Medi-Cal benefits under
Section 1396a(a)(10)(A)(i)(III) of Title 42 of the United States Code
if her income is less than or equal to 109 percent of the federal
poverty level as determined, counted, and valued in accordance with
the requirements of Section 1396a(e)(14) of Title 42 of the United
States Code, as added by the federal Patient Protection and
Affordable Care Act (Public Law 111-148) and as amended by the
federal Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152) and any subsequent amendments, and she meets all other
eligibility requirements.
(b) To the extent permitted by state and federal law, a woman
eligible under this section shall be required to enroll in a Medi-Cal
managed care health plan in those counties in which a Medi-Cal
managed care health plan is available.
(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, 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.
Notwithstanding Section 10231.5 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, in compliance with Section 9795 of the Government Code, until
regulations have been adopted.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 47. Section 14005.225 is added to the Welfare and
Institutions Code, to read:
14005.225. (a) The department shall seek any state plan
amendments or federal waivers necessary to provide pregnant women
whose income is over 109 percent of, and is up to and including 138
percent of, the federal poverty level as determined, counted, and
valued in accordance with the requirements of Section 1396a(e)(14) of
Title 42 of the United States Code, as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148) and as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments, with full
scope Medi-Cal benefits without a share of cost during their
pregnancy and through the end of the calendar month in which the 60th
day after the end of their pregnancy falls.
(b) To the extent permitted by state and federal law, a woman
eligible under this section shall be required to enroll in a Medi-Cal
managed care health plan in those counties in which a Medi-Cal
managed care health plan is available.
(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, 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.
Notwithstanding Section 10231.5 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, in compliance with Section 9795 of the Government Code, until
regulations have been adopted.
(d) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 48. Section 14043.38 of the Welfare and Institutions Code is
amended to read:
14043.38. (a) Provider types are designated as "limited,"
"moderate," or "high" categorical risk by the federal government in
Section 424.518 of Title 42 of the Code of Federal Regulations. The
department shall, at minimum, utilize the federal regulations in
determining a provider's or applicant's categorical risk.
(b) In accordance with Section 455.450 of Title 42 of the Code of
Federal Regulations, the department shall designate a provider or
applicant as a "high" categorical risk if any of the following occur:
(1) The department imposes a payment suspension based on a
credible allegation of fraud, waste, or abuse.
(2) The provider or applicant has an existing Medicaid overpayment
based on fraud, waste, or abuse.
(3) The provider or applicant has been excluded by the federal
Office of the Inspector General or another state's Medicaid program
within the previous 10 years.
(4) The federal Centers for Medicare and Medicaid Services lifted
a temporary moratorium within the previous six months for the
particular provider type submitting the application, the applicant
would have been prevented from enrolling based on that previous
moratorium, and the applicant applies for enrollment as a provider at
any time within six months from the date the moratorium was lifted.
(c) If the department designates a provider or applicant as a
"high" categorical risk, the department or its designee shall do both
of the following:
(1) Conduct a criminal background check of the provider or
applicant, and any person with a 5-percent or greater direct or
indirect ownership interest in the provider or applicant.
(2) Require the provider or applicant, and any person with a
5-percent or greater direct or indirect ownership interest in the
provider or applicant, to submit a set of fingerprints within 30 days
of the department's request, in a manner determined by the
department.
(d) (1) The department shall submit to the Department of Justice
fingerprint images and related information required by the Department
of Justice of Medi-Cal providers or applicants determined to be a
"high" categorical risk pursuant to subdivision (a), and any person
with a 5-percent or greater direct or indirect ownership interest in
those providers and applicants, for the purposes of obtaining
information as to the existence and content of a record of state or
federal convictions and state or federal arrests and also information
as to the existence and content of a record of state or federal
arrests for which the Department of Justice establishes that the
person is free on bail or on his or her recognizance pending trial or
appeal.
(2) When received, the Department of Justice shall forward to the
Federal Bureau of Investigation requests for federal summary criminal
history information received pursuant to this section. The
Department of Justice shall review the information returned from the
Federal Bureau of Investigation and compile and disseminate a
response to the department.
(3) The Department of Justice shall provide a state or federal
level response to the department pursuant to paragraph (1) of
subdivision (p) of Section 11105 of the Penal Code.
(4) The department shall request from the Department of Justice
subsequent notification service, as provided pursuant to Section
11105.2 of the Penal Code, for persons described in paragraph (1).
(5) The Department of Justice shall charge a fee sufficient to
cover the cost of processing the request described in this section.
That fee shall be paid by the subject of the criminal background
check.
(e) For persons subject to the requirements of subdivision (a) of
Section 15660, the procedure for obtaining and submitting
fingerprints and notification by the Department of Justice of
criminal record information set forth in subdivision (c) of Section
15660 shall apply instead of the procedure set forth in subdivision
(d).
SEC. 49. Section 14104.35 is added to the Welfare and Institutions
Code, to read:
14104.35. (a) Any contract amendments, modifications, or change
orders to a fiscal intermediary contract entered into by the
department for the purposes of implementing Section 14104.3 shall be
exempt, except as provided in subdivision (b), from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code and any policies, procedures, or regulations authorized by that
part.
(b) Subdivision (a) shall not exempt the department from
establishing a competitive bid process for awarding new contracts
pursuant to Section 14104.3.
SEC. 50. Section 14131.11 is added to the Welfare and Institutions
Code, to read:
14131.11. (a) Notwithstanding any other provision of this chapter
or Chapter 8 (commencing with Section 14200), any increase in the
amount charged to the Medi-Cal program for patient care or treatment
that is directly related to an identifiable provider-preventable
condition is excluded from reimbursement under Medi-Cal, in
accordance with criteria set forth in federal and state law and the
state's Medi-Cal State Plan, except when the provider-preventable
condition existed prior to the initiation of treatment for that
patient by that provider.
(b) The exclusion from reimbursement specified in subdivision (a)
applies to the amounts charged for the care and treatment of
individuals eligible under the Medi-Cal program, both in
fee-for-service and managed care delivery systems, including
individuals dually eligible for both the Medicare and Medi-Cal
programs, individuals eligible under the California Children's
Services Program, and individuals eligible under the Genetically
Handicapped Persons Program.
(c) Exclusion from reimbursement under Medi-Cal pursuant to this
section for increased amounts charged to Medi-Cal related to a
provider-preventable condition shall be limited to the extent the
identified provider-preventable condition would otherwise result in
an increase in payment and the state can reasonably isolate for
nonpayment the portion of the payment directly related to treatment
for, and related to, the provider-preventable condition.
(d) For health care-acquired conditions, the department may limit
application of the exclusion from reimbursement as appropriate for
specific populations, including, but not limited to, the pediatric
population, after consultation with the federal government and
stakeholders.
(e) For health care-acquired conditions, the exclusion of
reimbursement is initially limited to only those services provided by
inpatient hospitals. For other provider-preventable conditions, the
exclusion from reimbursement applies to health care services provided
by any provider. This subdivision shall not limit the department
from excluding from reimbursement those services provided in
additional care settings as determined by the department. The
department shall notify and consult with appropriate stakeholders
prior to implementing, interpreting, or making specific this
subdivision.
(f) Medi-Cal providers, in both fee-for-service and managed care
delivery systems, shall report the occurrence of any
provider-preventable condition in any individual identified in
subdivision (b) that did not exist prior to initiation of treatment
by that provider. The report shall be made to the department as
specified by the department, regardless of whether or not the
provider seeks Medi-Cal reimbursement for services to treat the
provider-preventable condition.
(g) If a provider in either a fee-for-service or managed care
delivery system receives a Medi-Cal payment or reimbursement for any
increase in costs for patient care or treatment directly related to
an identifiable provider-preventable condition that was not present
when the individual initiated treatment with that provider, the
provider shall reimburse those costs to the department or plan.
(h) For purposes of this section, "provider-preventable condition,"
"health care-acquired condition," and "other provider-preventable
condition" are defined as set forth in Section 447.26(b) of Title 42
of the Code of Federal Regulations.
(i) A provider is prohibited from pursuing payment or
reimbursement from a beneficiary for any increased amounts directly
related to treatment for, and related to, the provider-preventable
condition.
(j) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section
by means of plan letters, plan or provider bulletins, or similar
instructions, without taking regulatory action, until the time
regulations are adopted. Prior to issuing any letter, bulletin, or
similar instruction authorized pursuant to this section, the
department shall notify and consult with stakeholders, including
advocates, providers, and beneficiaries. The department shall notify
the appropriate policy and fiscal committees of the Legislature of
its intent to issue instructions under this section at least five
days in advance of the issuance. It is the intent of the Legislature
that the department be provided temporary authority as necessary to
implement program changes until completion of the regulatory process,
which shall further address and take into account the input of
stakeholders.
(2) The department shall adopt emergency regulations pursuant to
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code no later than January 1, 2017. The
department may readopt any emergency regulation authorized by this
section that is the same as or substantially equivalent to an
emergency regulation previously adopted under this section. The
initial adoption of emergency regulations and one readoption of
emergency regulations implementing this section shall be deemed an
emergency and necessary for the immediate preservation of the public
peace, health, safety, or general welfare.
(3) Initial emergency regulations and the one readoption of
emergency regulations authorized by this section shall be exempt from
review by the Office of Administrative Law. The initial emergency
regulations and the one readoption of emergency regulations shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and each shall remain in effect for no more than
180 days, by which time final regulations may be adopted.
(k) The department shall seek any necessary federal approvals for
the implementation of this section.
(l) This section shall be implemented only to the extent that
federal financial participation is not jeopardized.
(m) This section shall be implemented in accordance with the
methodology set forth in the state plan in effect on July 1, 2012,
and subsequently in accordance with any future methodologies approved
by the federal Centers for Medicare and Medicaid Services.
SEC. 51. Section 14132.275 of the Welfare and Institutions Code,
as amended by Section 13 of Chapter 37 of the Statutes of 2013, is
amended to read:
14132.275. (a) The department shall seek federal approval to
establish the demonstration project described in this section
pursuant to a Medicare or a Medicaid demonstration project or waiver,
or a combination thereof. Under a Medicare demonstration, the
department may contract with the federal Centers for Medicare and
Medicaid Services (CMS) and demonstration sites to operate the
Medicare and Medicaid benefits in a demonstration project that is
overseen by the state as a delegated Medicare benefit administrator,
and may enter into financing arrangements with CMS to share in any
Medicare program savings generated by the demonstration project.
(b) After federal approval is obtained, the department shall
establish the demonstration project that enables dual eligible
beneficiaries to receive a continuum of services that maximizes
access to, and coordination of, benefits between the Medi-Cal and
Medicare programs and access to the continuum of long-term services
and supports and behavioral health services, including mental health
and substance use disorder treatment services. The purpose of the
demonstration project is to integrate services authorized under the
federal Medicaid Program (Title XIX of the federal Social Security
Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program
(Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395
et seq.)). The demonstration project may also include additional
services as approved through a demonstration project or waiver, or a
combination thereof.
(c) For purposes of this section, the following definitions shall
apply:
(1) "Behavioral health" means Medi-Cal services provided pursuant
to Section 51341 of Title 22 of the California Code of Regulations
and Drug Medi-Cal substance abuse services provided pursuant to
Section 51341.1 of Title 22 of the California Code of Regulations,
and any mental health benefits available under the Medicare Program.
(2) "Capitated payment model" means an agreement entered into
between CMS, the state, and a managed care health plan, in which the
managed care health plan receives a capitation payment for the
comprehensive, coordinated provision of Medi-Cal services and
benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and
Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares
the savings with the state from improved provision of Medi-Cal and
Medicare services that reduces the cost of those services. Medi-Cal
services include long-term services
and supports as defined in Section 14186.1,
behavioral health services, and any additional services offered by
the demonstration site.
(3) "Demonstration site" means a managed care health plan that is
selected to participate in the demonstration project under the
capitated payment model.
(4) "Dual eligible beneficiary" means an individual 21 years of
age or older who is enrolled for benefits under Medicare Part A (42
U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j
et seq.) and is eligible for medical assistance under the Medi-Cal
State Plan.
(d) No sooner than March 1, 2011, the department shall identify
health care models that may be included in the demonstration project,
shall develop a timeline and process for selecting, financing,
monitoring, and evaluating the demonstration sites, and shall provide
this timeline and process to the appropriate fiscal and policy
committees of the Legislature. The department may implement these
demonstration sites in phases.
(e) The department shall provide the fiscal and appropriate policy
committees of the Legislature with a copy of any report submitted to
CMS to meet the requirements under the demonstration project.
(f) Goals for the demonstration project shall include all of the
following:
(1) Coordinate Medi-Cal and Medicare benefits across health care
settings and improve the continuity of care across acute care,
long-term care, behavioral health, including mental health and
substance use disorder services, and home- and community-based
services settings using a person-centered approach.
(2) Coordinate access to acute and long-term care services for
dual eligible beneficiaries.
(3) Maximize the ability of dual eligible beneficiaries to remain
in their homes and communities with appropriate services and supports
in lieu of institutional care.
(4) Increase the availability of and access to home- and
community-based services.
(5) Coordinate access to necessary and appropriate behavioral
health services, including mental health and substance use disorder
services.
(6) Improve the quality of care for dual eligible beneficiaries.
(7) Promote a system that is both sustainable and person and
family centered by providing dual eligible beneficiaries with timely
access to appropriate, coordinated health care services and community
resources that enable them to attain or maintain personal health
goals.
(g) No sooner than March 1, 2013, demonstration sites shall be
established in up to eight counties, and shall include at least one
county that provides Medi-Cal services via a two-plan model pursuant
to Article 2.7 (commencing with Section 14087.3) and at least one
county that provides Medi-Cal services under a county organized
health system pursuant to Article 2.8 (commencing with Section
14087.5). The director shall consult with the Legislature, CMS, and
stakeholders when determining the implementation date for this
section. In determining the counties in which to establish a
demonstration site, the director shall consider the following:
(1) Local support for integrating medical care, long-term care,
and home- and community-based services networks.
(2) A local stakeholder process that includes health plans,
providers, mental health representatives, community programs,
consumers, designated representatives of in-home supportive services
personnel, and other interested stakeholders in the development,
implementation, and continued operation of the demonstration site.
(h) In developing the process for selecting, financing,
monitoring, and evaluating the health care models for the
demonstration project, the department shall enter into a memorandum
of understanding with CMS. Upon completion, the memorandum of
understanding shall be provided to the fiscal and appropriate policy
committees of the Legislature and posted on the department's Internet
Web site.
(i) The department shall negotiate the terms and conditions of the
memorandum of understanding, which shall address, but are not
limited to, the following:
(1) Reimbursement methods for a capitated payment model. Under the
capitated payment model, the demonstration sites shall meet all of
the following requirements:
(A) Have Medi-Cal managed care health plan and Medicare dual
eligible-special needs plan contract experience, or evidence of the
ability to meet these contracting requirements.
(B) Be in good financial standing and meet licensure requirements
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), except for county organized health system plans that
are exempt from licensure pursuant to Section 14087.95.
(C) Meet quality measures, which may include Medi-Cal and Medicare
Healthcare Effectiveness Data and Information Set measures and other
quality measures determined or developed by the department or CMS.
(D) Demonstrate a local stakeholder process that includes dual
eligible beneficiaries, managed care health plans, providers, mental
health representatives, county health and human services agencies,
designated representatives of in-home supportive services personnel,
and other interested stakeholders that advise and consult with the
demonstration site in the development, implementation, and continued
operation of the demonstration project.
(E) Pay providers reimbursement rates sufficient to maintain an
adequate provider network and ensure access to care for
beneficiaries.
(F) Follow final policy guidance determined by CMS and the
department with regard to reimbursement rates for providers pursuant
to paragraphs (4) to (7), inclusive, of subdivision (o).
(G) To the extent permitted under the demonstration, pay
noncontracted hospitals prevailing Medicare fee-for-service rates for
traditionally Medicare covered benefits and prevailing Medi-Cal
fee-for-service rates for traditionally Medi-Cal covered benefits.
(2) Encounter data reporting requirements for both Medi-Cal and
Medicare services provided to beneficiaries enrolling in the
demonstration project.
(3) Quality assurance withholding from the demonstration site
payment, to be paid only if quality measures developed as part of the
memorandum of understanding and plan contracts are met.
(4) Provider network adequacy standards developed by the
department and CMS, in consultation with the Department of Managed
Health Care, the demonstration site, and stakeholders.
(5) Medicare and Medi-Cal appeals and hearing process.
(6) Unified marketing requirements and combined review process by
the department and CMS.
(7) Combined quality management and consolidated reporting process
by the department and CMS.
(8) Procedures related to combined federal and state contract
management to ensure access, quality, program integrity, and
financial solvency of the demonstration site.
(9) To the extent permissible under federal requirements,
implementation of the provisions of Sections 14182.16 and 14182.17
that are applicable to beneficiaries simultaneously eligible for
full-scope benefits under Medi-Cal and the Medicare Program.
(10) (A) In consultation with the hospital industry, CMS approval
to ensure that Medicare supplemental payments for direct graduate
medical education and Medicare add-on payments, including indirect
medical education and disproportionate share hospital adjustments
continue to be made available to hospitals for services provided
under the demonstration.
(B) The department shall seek CMS approval for CMS to continue
these payments either outside the capitation rates or, if contained
within the capitation rates, and to the extent permitted under the
demonstration project, shall require demonstration sites to provide
this reimbursement to hospitals.
(11) To the extent permitted under the demonstration project, the
default rate for noncontracting providers of physician services shall
be the prevailing Medicare fee schedule for services covered by the
Medicare program and the prevailing Medi-Cal fee schedule for
services covered by the Medi-Cal program.
(j) (1) The department shall comply with and enforce the terms and
conditions of the memorandum of understanding with CMS, as specified
in subdivision (i). To the extent that the terms and conditions do
not address the specific selection, financing, monitoring, and
evaluation criteria listed in subdivision (i), the department:
(A) Shall require the demonstration site to do all of the
following:
(i) Comply with additional site readiness criteria specified by
the department.
(ii) Comply with long-term services and supports requirements in
accordance with Article 5.7 (commencing with Section 14186).
(iii) To the extent permissible under federal requirements, comply
with the provisions of Sections 14182.16 and 14182.17 that are
applicable to beneficiaries simultaneously eligible for full-scope
benefits under both Medi-Cal and the Medicare Program.
(iv) Comply with all transition of care requirements for Medicare
Part D benefits as described in Chapters 6 and 14 of the Medicare
Managed Care Manual, published by CMS, including transition
timeframes, notices, and emergency supplies.
(B) May require the demonstration site to forgo charging premiums,
coinsurance, copayments, and deductibles for Medicare Part C and
Medicare Part D services.
(2) The department shall notify the Legislature within 30 days of
the implementation of each provision in paragraph (1).
(k) The director may enter into exclusive or nonexclusive
contracts on a bid or negotiated basis and may amend existing managed
care contracts to provide or arrange for services provided under
this section. Contracts entered into or amended pursuant to this
section shall be exempt from the provisions of Chapter 2 (commencing
with Section 10290) of Part 2 of Division 2 of the Public Contract
Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of
Division 3 of Title 2 of the Government Code.
( l ) (1) (A) Except for the exemptions provided for in
this section and in Section 14132.277, the department shall enroll
dual eligible beneficiaries into a demonstration site unless the
beneficiary makes an affirmative choice to opt out of enrollment or
is already enrolled on or before June 1, 2013, in a managed care
organization 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) that has previously contracted with
the department as a primary care case management plan pursuant to
Article 2.9 (commencing with Section 14088) to provide services to
beneficiaries who are HIV positive or who have been diagnosed with
AIDS or in any entity with a contract with the department pursuant to
Chapter 8.75 (commencing with Section 14591).
(B) Dual eligible beneficiaries who opt out of enrollment into a
demonstration site may choose to remain enrolled in fee-for-service
Medicare or a Medicare Advantage plan for their Medicare benefits,
but shall be mandatorily enrolled into a Medi-Cal managed care health
plan pursuant to Section 14182.16, except as exempted under
subdivision (c) of Section 14182.16.
(C) (i) Persons meeting requirements for the Program of
All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75
(commencing with Section 14591) or a managed care organization
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) that has previously contracted with the
department as a primary care case management plan pursuant to Article
2.9 (commencing with Section 14088) of Chapter 7 to provide services
to beneficiaries who are HIV positive or who have been diagnosed
with AIDS may select either of these managed care health plans for
their Medicare and Medi-Cal benefits if one is available in that
county.
(ii) In areas where a PACE plan is available, the PACE plan shall
be presented as an enrollment option, included in all enrollment
materials, enrollment assistance programs, and outreach programs
related to the demonstration project, and made available to
beneficiaries whenever enrollment choices and options are presented.
Persons meeting the age qualifications for PACE and who choose PACE
shall remain in the fee-for-service Medi-Cal and Medicare programs,
and shall not be assigned to a managed care health plan for the
lesser of 60 days or until they are assessed for eligibility for PACE
and determined not to be eligible for a PACE plan. Persons enrolled
in a PACE plan shall receive all Medicare and Medi-Cal services from
the PACE program pursuant to the three-way agreement between the PACE
program, the department, and the Centers for Medicare and Medicaid
Services.
(2) To the extent that federal approval is obtained, the
department may require that any beneficiary, upon enrollment in a
demonstration site, remain enrolled in the Medicare portion of the
demonstration project on a mandatory basis for six months from the
date of initial enrollment. After the sixth month, a dual eligible
beneficiary may elect to enroll in a different demonstration site, a
different Medicare Advantage plan, fee-for-service Medicare, PACE, or
a managed care organization 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) that has
previously contracted with the department as a primary care case
management plan pursuant to Article 2.9 (commencing with Section
14088) to provide services to beneficiaries who are HIV positive or
who have been diagnosed with AIDS, for his or her Medicare benefits.
(A) During the six-month mandatory enrollment in a demonstration
site, a beneficiary may continue receiving services from an
out-of-network Medicare provider for primary and specialty care
services only if all of the following criteria are met:
(i) The dual eligible beneficiary demonstrates an existing
relationship with the provider prior to enrollment in a demonstration
site.
(ii) The provider is willing to accept payment from the
demonstration site based on the current Medicare fee schedule.
(iii) The demonstration site would not otherwise exclude the
provider from its provider network due to documented quality of care
concerns.
(B) The department shall develop a process to inform providers and
beneficiaries of the availability of continuity of services from an
existing provider and ensure that the beneficiary continues to
receive services without interruption.
(3) (A) Notwithstanding subparagraph (A) of paragraph (1), a dual
eligible beneficiary shall be excluded from enrollment in the
demonstration project if the beneficiary meets any of the following:
(i) The beneficiary has a prior diagnosis of end-stage renal
disease. This clause shall not apply to beneficiaries diagnosed with
end-stage renal disease subsequent to enrollment in the demonstration
project. The director may, with stakeholder input and federal
approval, authorize beneficiaries with a prior diagnosis of end-stage
renal disease in specified counties to voluntarily enroll in the
demonstration project.
(ii) The beneficiary has other health coverage, as defined in
paragraph (5) of subdivision (b) of Section 14182.16.
(iii) The beneficiary is enrolled in a home- and community-based
waiver that is a Medi-Cal benefit under Section 1915(c) of the
federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except
for persons enrolled in Multipurpose Senior Services Program
services.
(iv) The beneficiary is receiving services through a regional
center or state developmental center.
(v) The beneficiary resides in a geographic area or ZIP Code not
included in managed care, as determined by the department and CMS.
(vi) The beneficiary resides in one of the Veterans' Homes of
California, as described in Chapter 1 (commencing with Section 1010)
of Division 5 of the Military and Veterans Code.
(B) (i) Beneficiaries who have been diagnosed with HIV/AIDS may
opt out of the demonstration project at the beginning of any month.
The State Department of Public Health may share relevant data
relating to a beneficiary's enrollment in the AIDS Drug Assistance
Program with the department, and the department may share relevant
data relating to HIV-positive beneficiaries with the State Department
of Public Health.
(ii) The information provided by the State Department of Public
Health pursuant to this subparagraph shall not be further disclosed
by the State Department of Health Care Services, and shall be subject
to the confidentiality protections of subdivisions (d) and (e) of
Section 121025 of the Health and Safety Code, except this information
may be further disclosed as follows:
(I) To the person to whom the information pertains or the
designated representative of that person.
(II) To the Office of AIDS within the State Department of Public
Health.
(C) Beneficiaries who are Indians receiving Medi-Cal services in
accordance with Section 55110 of Title 22 of the California Code of
Regulations may opt out of the demonstration project at the beginning
of any month.
(D) The department, with stakeholder input, may exempt specific
categories of dual eligible beneficiaries from enrollment
requirements in this section based on extraordinary medical needs of
specific patient groups or to meet federal requirements.
(4) For the 2013 calendar year, the department shall offer federal
Medicare Improvements for Patients and Providers Act of 2008 (Public
Law 110-275) compliant contracts to existing Medicare Advantage Dual
Special Needs Plans (D-SNP plans) to continue to provide Medicare
benefits to their enrollees in their service areas as approved on
January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare
Advantage and D-SNP plans shall be exempt from the enrollment
provisions of subparagraph (A) of paragraph (1), but may voluntarily
choose to enroll in the demonstration project. Enrollment into the
demonstration project's managed care health plans shall be reassessed
in 2014 depending on federal reauthorization of the D-SNP model and
the department's assessment of the demonstration plans.
(5) For the 2013 calendar year, demonstration sites shall not
offer to enroll dual eligible beneficiaries eligible for the
demonstration project into the demonstration site's D-SNP.
(6) The department shall not terminate contracts in a
demonstration site with a managed care organization 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) that has previously contracted with the department as a
primary care case management plan pursuant to Article 2.9 (commencing
with Section 14088) to provide services to beneficiaries who are HIV
positive beneficiaries or who have been diagnosed with AIDS and with
any entity with a contract pursuant to Chapter 8.75 (commencing with
Section 14591), except as provided in the contract or pursuant to
state or federal law.
(m) Notwithstanding Section 10231.5 of the Government Code, the
department shall conduct an evaluation, in partnership with CMS, to
assess outcomes and the experience of dual eligibles in these
demonstration sites and shall provide a report to the Legislature
after the first full year of demonstration operation, and annually
thereafter. A report submitted to the Legislature pursuant to this
subdivision shall be submitted in compliance with Section 9795 of the
Government Code. The department shall consult with stakeholders
regarding the scope and structure of the evaluation.
(n) This section shall be implemented only if and to the extent
that federal financial participation or funding is available.
(o) It is the intent of the Legislature that:
(1) In order to maintain adequate provider networks, demonstration
sites shall reimburse providers at rates sufficient to ensure access
to care for beneficiaries.
(2) Savings under the demonstration project are intended to be
achieved through shifts in utilization, and not through reduced
reimbursement rates to providers.
(3) Reimbursement policies shall not prevent demonstration sites
and providers from entering into payment arrangements that allow for
the alignment of financial incentives and provide opportunities for
shared risk and shared savings in order to promote appropriate
utilization shifts, which encourage the use of home- and
community-based services and quality of care for dual eligible
beneficiaries enrolled in the demonstration sites.
(4) To the extent permitted under the demonstration project, and
to the extent that a public entity voluntarily provides an
intergovernmental transfer for this purpose, both of the following
shall apply:
(A) The department shall work with CMS in ensuring that the
capitation rates under the demonstration project are inclusive of
funding currently provided through certified public expenditures
supplemental payment programs that would otherwise be impacted by the
demonstration project.
(B) Demonstration sites shall pay to a public entity voluntarily
providing intergovernmental transfers that previously received
reimbursement under a certified public expenditures supplemental
payment program, rates that include the additional funding under the
capitation rates that are funded by the public entity's
intergovernmental transfer.
(5) The department shall work with CMS in developing other
reimbursement policies and shall inform demonstration sites,
providers, and the Legislature of the final policy guidance.
(6) The department shall seek approval from CMS to permit the
provider payment requirements contained in subparagraph (G) of
paragraph (1) and paragraphs (10) and (11) of subdivision (i), and
Section 14132.276.
(7) Demonstration sites that contract with hospitals for hospital
services on a fee-for-service basis that otherwise would have been
traditionally Medicare services will achieve savings through
utilization changes and not by paying hospitals at rates lower than
prevailing Medicare fee-for-service rates.
(p) The department shall enter into an interagency agreement with
the Department of Managed Health Care to perform some or all of the
department's oversight and readiness review activities specified in
this section. These activities may include providing consumer
assistance to beneficiaries affected by this section and conducting
financial audits, medical surveys, and a review of the adequacy of
provider networks of the managed care health plans participating in
this section. The interagency agreement shall be updated, as
necessary, on an annual basis in order to maintain functional clarity
regarding the roles and responsibilities of the Department of
Managed Health Care and the department. The department shall not
delegate its authority under this section as the single state
Medicaid agency to the Department of Managed Health Care.
(q) (1) Beginning with the May Revision to the 2013-14 Governor's
Budget, and annually thereafter, the department shall report to the
Legislature on the enrollment status, quality measures, and state
costs of the actions taken pursuant to this section.
(2) (A) By January 1, 2013, or as soon thereafter as practicable,
the department shall develop, in consultation with CMS and
stakeholders, quality and fiscal measures for health plans to reflect
the short- and long-term results of the implementation of this
section. The department shall also develop quality thresholds and
milestones for these measures. The department shall update these
measures periodically to reflect changes in this program due to
implementation factors and the structure and design of the benefits
and services being coordinated by managed care health plans.
(B) The department shall require health plans to submit Medicare
and Medi-Cal data to determine the results of these measures. If the
department finds that a health plan is not in compliance with one or
more of the measures set forth in this section, the health plan
shall, within 60 days, submit a corrective action plan to the
department for approval. The corrective action plan shall, at a
minimum, include steps that the health plan shall take to improve its
performance based on the standard or standards with which the health
plan is out of compliance. The plan shall establish interim
benchmarks for improvement that shall be expected to be met by the
health plan in order to avoid a sanction pursuant to Section 14304.
Nothing in this subparagraph is intended to limit Section 14304.
(C) The department shall publish the results of these measures,
including via posting on the department's Internet Web site, on a
quarterly basis.
(r) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section
and any applicable federal waivers and state plan amendments by means
of all-county letters, plan letters, plan or provider bulletins, or
similar instructions, without taking regulatory action. Prior to
issuing any letter or similar instrument authorized pursuant to this
section, the department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.
(s) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 52. Section 14132.277 of the Welfare and Institutions Code is
amended to read:
14132.277. (a) For purposes of this section, the following
definitions shall apply:
(1) "Alternate health care service plan" means a prepaid health
plan that is a nonprofit health care service plan with at least 3.5
million enrollees statewide, that owns or operates its own
pharmacies, and that provides medical services to enrollees in
specific geographic regions through an exclusive contract with a
single medical group in each specific geographic region in which it
operates to provide services to enrollees.
(2) "Cal MediConnect plan" means a health plan or other qualified
entity jointly selected by the state and CMS for participation in the
demonstration project.
(3) "CMS" means the federal Centers for Medicare and Medicaid
Services.
(4) "Coordinated Care Initiative county" means the Counties of
Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego,
San Mateo, and Santa
Clara, and any other county identified in Appendix 3 of the
Memorandum of Understanding Between the Centers for Medicare and
Medicaid Services and the State of California, Regarding a
Federal-State Partnership to Test a Capitated Financial Alignment
Model for Medicare-Medicaid Enrollees, inclusive of all amendments,
as authorized by Section 14132.275.
(5) "D-SNP plan" means a Medicare Advantage Dual Special Needs
Plan.
(6) "D-SNP contract" means a federal Medicare Improvements for
Patients and Provider Act of 2008 (Public Law 110-275) compliant
contract between the department and a D-SNP plan.
(7) "Demonstration project" means the demonstration project
authorized by Section 14132.275.
(8) "Excluded beneficiaries" means those beneficiaries who are not
eligible to participate in the demonstration project pursuant to
subdivision (l) of Section 14132.275.
(9) "FIDE-SNP plan" means a Medicare Advantage Fully-Integrated
Dual Eligible Special Needs Plan.
(10) "Non-Coordinated Care Initiative counties" means counties not
participating in the demonstration project.
(b) For the 2014 calendar year, the department shall offer D-SNP
contracts to existing D-SNP plans to continue to provide benefits to
their enrollees in their service areas as approved on January 1,
2013. The director may include in any D-SNP contract provisions
requiring that the D-SNP plan do the following:
(1) Submit to the department a complete and accurate copy of the
bid submitted by the plan to CMS for its D-SNP contract.
(2) Submit to the department copies of all utilization and quality
management reports submitted to CMS.
(c) In Coordinated Care Initiative counties, Medicare Advantage
plans and D-SNP plans may continue to enroll beneficiaries in 2014.
In the 2014 calendar year, beneficiaries enrolled in a Medicare
Advantage or D-SNP plan operating in a Coordinated Care Initiative
county shall be exempt from the enrollment provisions of subparagraph
(A) of paragraph (1) of subdivision (l) of Section 14132.275. Those
beneficiaries may at any time voluntarily choose to disenroll from
their Medicare Advantage or D-SNP plan and enroll in a demonstration
site operating pursuant to subdivision (g) of Section 14132.275. If a
beneficiary chooses to do so, that beneficiary may subsequently
disenroll from the demonstration site and return to fee-for-service
Medicare or to a D-SNP plan or Medicare Advantage plan.
(d) For the 2015 calendar year and the remainder of the
demonstration project, in Coordinated Care Initiative counties, the
department shall offer D-SNP contracts to D-SNP plans that were
approved for the D-SNP plan's service areas as of January 1, 2013. In
Coordinated Care Initiative counties, the department shall enter
into D-SNP contracts with D-SNP plans only for excluded beneficiaries
and for those beneficiaries identified in paragraphs (2) and (5) of
subdivision (g).
(e) For the 2015 calendar year and the remainder of the
demonstration project, in non-Coordinated Care Initiative counties,
the department shall offer D-SNP contracts to D-SNP plans.
(f) The director may include in a D-SNP contract offered pursuant
to subdivision (d) or (e) provisions requiring that the D-SNP plan do
the following:
(1) Submit to the department a complete and accurate copy of the
bid submitted by the plan to CMS for its D-SNP contract.
(2) Submit to the department copies of all utilization and quality
management reports submitted to CMS.
(g) For the 2015 calendar year and the remainder of the
demonstration project, in Coordinated Care Initiative counties, the
enrollment provisions of subdivision (l) of Section 14132.275 shall
apply subject to the following:
(1) Beneficiaries enrolled in a FIDE-SNP plan or a Medicare
Advantage plan, other than a D-SNP plan, shall be exempt from the
enrollment provisions of subparagraph (A) of paragraph (1) of
subdivision (l) of Section 14132.275.
(2) Where the D-SNP plan is not a Cal MediConnect plan,
beneficiaries enrolled as of December 31, 2014, in a D-SNP plan shall
be exempt from the enrollment provisions of subparagraph (A) of
paragraph (1) of subdivision (l) of Section 14132.275. Those
beneficiaries may at any time voluntarily choose to disenroll from
their D-SNP plan and enroll in a demonstration site operating
pursuant to subdivision (g) of Section 14132.275. A dual eligible
beneficiary who is enrolled as of December 31, 2014, in a D-SNP plan
that is not a Cal MediConnect plan and who opts out of a
demonstration site during the course of the demonstration project may
choose to reenroll in that D-SNP plan.
(3) Where the D-SNP is a Cal MediConnect plan, beneficiaries
enrolled in a D-SNP plan who are eligible for the demonstration
project shall be subject to the enrollment provisions of subparagraph
(A) of paragraph (1) of subdivision (l) of Section 14132.275.
(4) For FIDE-SNP plans serving beneficiaries in Coordinated Care
Initiative counties, the department shall require the following
provisions:
(A) After December 31, 2014, enrollment in Los Angeles County
shall not exceed 6,000 additional beneficiaries at any point during
the term of the demonstration project. After December 31, 2014,
enrollment in the combined Riverside and San Bernardino counties
shall not exceed 1,500 additional beneficiaries at any point during
the term of the demonstration project.
(B) Any necessary data or information requirements provided by the
FIDE-SNP to ensure contract compliance.
(5) Beneficiaries enrolled in an alternate health care service
plan (AHCSP) who become dually eligible for Medicare and Medicaid
benefits while enrolled in that AHCSP may elect to enroll in the
AHCSP's D-SNP plan subject to the following requirements:
(A) The beneficiary was a member of the AHCSP immediately prior to
becoming dually eligible for Medicare and Medicaid benefits.
(B) Upon mutual agreement between a Cal MediConnect Plan operated
by a health authority or commission contracting with the department
and the AHCSP, the AHCSP shall take full financial and programmatic
responsibility for the long-term supports and services of the D-SNP
enrollee, including, but not limited to, in-home supportive services,
long term skilled nursing care, community based adult services,
multipurpose senior services program services, and other Medi-Cal
benefits offered in the demonstration project.
(6) Prior to assigning a beneficiary in a Medi-Cal managed care
health plan pursuant to Section 14182.16, the department shall
determine whether the beneficiary is already a member of the AHCSP.
If so, the beneficiary shall be assigned to a Medi-Cal managed care
health plan operated by a health authority or commission contracting
with the department and subcontracting with the AHCSP.
SEC. 53. Section 14132.915 is added to the Welfare and
Institutions Code, to read:
14132.915. (a) (1) The department shall establish a list of
performance measures to ensure the dental fee-for-service program
meets quality and access criteria required by the department. The
performance measures shall be designed to evaluate utilization,
access, availability, and effectiveness of preventive care and
treatment.
(2) Prior to establishing the quality and access criteria
described in paragraph (1), the department shall consult with
stakeholders, including representatives from counties, local dental
societies, nonprofit entities, legal aid entities, and other
interested parties.
(3) The performance measures established by the department to
monitor the dental fee-for-service program for children shall
include, but not be limited to, all of the following:
(A) Overall utilization of dental services.
(B) Number of annual dental visits, preventive dental services,
dental treatment services, and examinations and oral health
evaluations.
(C) Number of applications of dental sealants.
(D) Continuity of care and overall utilization over an extended
period of time.
(E) All of the following ratios:
(i) Sealant to restoration.
(ii) Filling to preventive services.
(iii) Treatment to caries prevention.
(4) The performance measures established by the department to
monitor the dental fee-for-service program for adults shall include,
but not be limited to, all of the following:
(A) Number of annual dental visits and preventive dental services.
(B) Treatment to caries prevention ratio.
(5) The performance measures shall be reported as aggregate
numbers and as percentages, if appropriate, using standards that are
as equivalent to those used by managed care entities as feasible.
Performance measures for the dental fee-for-service program for
children shall be reported by age groupings if appropriate.
(b) The department shall include the initial list of performance
measures in any dental contract entered into between the department
and a fee-for-service contractor on or after enactment of this
section.
(c) To ensure that the dental health needs of Medi-Cal
beneficiaries are met, the department shall, when evaluating
performance measures for retention on, addition to, or deletion from,
the list of performance measures, consider all of the following
criteria:
(1) Annual and multiyear Medi-Cal dental fee-for-service trended
data.
(2) Other state and national dental program performance and
quality measures.
(3) Other state and national performance ratings.
(d) Commencing October 1, 2014, for the 2013 calendar year, and
annually on or before October 1 for each preceding calendar year
thereafter, the list of performance measures established by the
department along with the data of the dental fee-for-service program
performance shall be posted on the department's Internet Web site.
(e) The department may amend or remove performance measures and
establish additional performance measures in accordance with all of
the following:
(1) The department shall consider performance measures established
by other states, the federal government, and national organizations
developing dental program performance and quality measures.
(2) The department shall notify a fee-for-service contractor, at
least 30 days prior to the implementation date, of any updates or
changes to performance measures. The department shall also post these
updates or changes on its Internet Web site at least 30 days prior
to implementation in order to maintain transparency to the public.
(3) In establishing the performance measures, the department shall
consult with stakeholders, including representatives from counties,
local dental societies, nonprofit entities, legal aid entities, and
other interested parties.
(f) The department shall annually prepare a summary report of the
nature and types of complaints and grievances regarding access to,
and quality of, dental services, including the outcome. Commencing no
sooner than October 1, 2015, for the prior calendar year, and
annually thereafter, for each preceding calendar year, this report
shall be posted on the department's Internet Web site.
SEC. 54. Section 14148.65 is added to the Welfare and Institutions
Code, to read:
14148.65. (a) (1) It is the intent of the Legislature, in adding
this section and Sections 14005.22 and 14148.67, to help prevent
premature delivery and low-birth weights, the leading cause of infant
morbidity and mortality, and to promote women's overall health,
well-being, and financial security, while maximizing federal funds.
(2) It is, therefore, the intent of the Legislature to maintain
and not to alter, reduce, suspend, restrict, or otherwise limit any
Medi-Cal benefits or services currently available to eligible
pregnant women receiving only pregnancy-related and postpartum
services through the Medi-Cal program to the extent those services
and benefits are not available through the beneficiary's qualified
health plan through the Exchange.
(3) It is further the intent of the Legislature to maximize
federal funding while making no-cost health care coverage available
to pregnant women receiving only pregnancy-related and postpartum
services who opt to enroll or remain enrolled in a qualified health
plan through the Exchange. To this end, it is the intent of the
Legislature to enact an affordability and benefit program for
pregnant women within the applicable income range within the
Exchange. The intent of the Legislature is to enact a program within
the Exchange that would provide pregnant women with no-share of cost
health benefits so that pregnant women may receive a benefit package
equal to full-scope, comprehensive benefits that are provided for
Medi-Cal beneficiaries who are pregnant. It is also the intent of the
Legislature that no-cost health coverage for pregnant women
receiving only pregnancy-related and postpartum services means
Exchange qualified health plans and providers serving beneficiaries
pursuant to those plans are prohibited from charging, billing,
requesting, or requiring the women to pay any of the costs or charges
for any services covered by the Exchange qualified health plan, or
any premiums or cost sharing during their pregnancy and postpartum
coverage as provided in paragraph (1) of subdivision (b) of Section
14148.67. The Legislature reaffirms that Medi-Cal providers are
prohibited from charging, billing, requesting, or requiring
beneficiaries to pay for or refusing to provide Medi-Cal covered
services that are not available through an eligible woman's Exchange
qualified health plan.
(b) After the director determines in writing that CalHEERS has
been programmed for implementation of this section, but no sooner
than January 1, 2015, the department, in coordination with the
Exchange, shall implement this section for women eligible for
Medi-Cal pregnancy-related and postpartum services who are or will be
enrolled in individual health care coverage through the Exchange. At
the applicant's or beneficiary's option, the department shall allow
the individual to enroll or remain enrolled in an Exchange qualified
health plan while at the same time enrolling or remaining enrolled in
the Medi-Cal program, and shall ensure that the beneficiary receives
the services and benefits to which she is entitled as a result of
her eligibility for and enrollment in the Medi-Cal program as
follows:
(1) If a beneficiary is only eligible for pregnancy-related and
postpartum services under this chapter and the beneficiary has opted
to enroll or remain enrolled in both Medi-Cal and coverage under a
qualified health plan offered under the Exchange, the department
shall pay both of the following on behalf of the beneficiary in
accordance with Section 14148.67:
(A) The beneficiary's premium costs for Exchange coverage, minus
the beneficiary's premium tax credit authorized by Section 36B of
Title 26 of the United States Code and its implementing regulations
during the beneficiary's period of eligibility for pregnancy-related
and postpartum services under this chapter.
(B) The beneficiary's cost sharing for benefits and services under
the Exchange qualified health plan during the beneficiary's period
of eligibility for pregnancy-related and postpartum services under
this chapter.
(2) The department shall provide beneficiaries who are receiving
benefits under this section with only those Medi-Cal benefits for
pregnancy-related and postpartum services that are covered under the
Medi-Cal program and, except when otherwise required by state or
federal law, that are not available through the beneficiary's
qualified health plan. These beneficiaries shall retain all rights
and responsibilities to which they are legally entitled under the
Medi-Cal program. The beneficiaries shall have the right to access
Medi-Cal providers' services through the Medi-Cal program that are
not contracting with the Exchange qualified health plan as required
under state or federal law, including, but not limited to, the right
to access family planning services, services provided by
Comprehensive Perinatal Services Program (CPSP) Medi-Cal providers,
perinatal specialists, certified nurse-midwife services, and
alternative and freestanding birth center services, to the extent
those services are not available through the beneficiary's Exchange
qualified health plan, except when state or federal law requires the
right to access the service without regard to its availability
through the beneficiary's Exchange qualified health plan. The
department shall implement its policies and procedures on other
health care coverage in a manner consistent with this subdivision.
(3) Nothing in this section shall preclude a beneficiary from
opting to enroll or remain enrolled in Medi-Cal for pregnancy-related
and postpartum services without enrolling or remaining enrolled in
an Exchange qualified health plan or from enrolling or remaining
enrolled in an Exchange qualified health plan without enrolling or
remaining enrolled in Medi-Cal for pregnancy-related and postpartum
services.
(c) The department shall consult with the Exchange, Exchange
contracting health care service plans and health insurers, and
stakeholders, including consumer advocates, Medi-Cal providers,
counties, the State Department of Public Health, county maternal,
child, and adolescent health directors, and county CPSP coordinators,
in the development and implementation of all of the following:
(1) Processes and procedures to inform affected applicants and
beneficiaries in a clear, consumer-friendly manner of all of their
enrollment options under the Medi-Cal program and the Exchange, of
the manner in which they may receive the benefits and services
covered through the Exchange coverage, and of the manner in which
they may receive benefits and services under this section. This
information shall be provided at the time of application and renewal
and when a beneficiary who is enrolled in the Medi-Cal program or in
an Exchange qualified health plan informs Medi-Cal or the Exchange
qualified health plan that she is pregnant.
(2) A process and procedure for applicants and beneficiaries who
are eligible for the Medi-Cal program based on pregnancy to exercise
the option to remain in or enroll in Exchange coverage and receive
Medi-Cal coverage for pregnancy-related and postpartum services not
covered by the beneficiary's Exchange qualified health plan and
related assistance for premiums and cost sharing as outlined in
subdivision (b) or to remain in or enroll in Medi-Cal and not enroll
in Exchange coverage. The process and all options shall be made
available to women at the time of applying to the Medi-Cal program or
the Exchange and during their enrollment in Medi-Cal or Exchange
coverage, as applicable.
(3) The process for implementing other health coverage policy and
the right to access Medi-Cal providers' services through the Medi-Cal
program that are not contracting with the Exchange qualified health
plan, including, but not limited to, family planning services,
services provided by CPSP Medi-Cal providers, perinatal specialists,
certified nurse-midwife services, and alternative and freestanding
birth center services, to the extent those services are not available
through the beneficiary's Exchange qualified health plan, except
when state or federal law requires the right to access the service
without regard to its availability through the beneficiary's Exchange
qualified health plan.
(4) Standardized notices and procedures to inform affected
Medi-Cal applicants and beneficiaries and affected individuals
applying for or enrolled in the Exchange of the option and the
process for eligible women to enroll or remain enrolled in Exchange
coverage and receive Medi-Cal pregnancy-related and postpartum
coverage under this section or to remain in or enroll in Medi-Cal and
not enroll in Exchange coverage.
(5) Standardized notices and procedures to inform Medi-Cal
beneficiaries receiving benefits under this section that infants born
to pregnant women receiving Medi-Cal benefits at the time of birth
are automatically eligible for the Medi-Cal program throughout the
infant's first year of life and of the processes for enrolling their
newborns in the Medi-Cal program without an application.
(6) Provider notices to ensure that Medi-Cal providers are aware
of the Medi-Cal pregnancy program under this section for women
enrolled in the Exchange and that providers comply with state and
federal laws applicable to Medi-Cal pregnancy coverage for women who
exercise the option to remain in Exchange coverage.
(7) Monitoring and data reporting required by subdivision (e).
(d) All notices developed under subdivision (c) shall be
accessible to persons who have limited English language proficiency
and persons with disabilities consistent with all federal and state
requirements.
(e) (1) In addition, the department shall consult with the
Exchange and Exchange contracting qualified health plans in the
development of a process for the department to make the payment of
premiums and cost sharing under this section and in the development
of a process for the department to evaluate the birth outcomes of
women who are receiving benefits under this section.
(2) (A) The department shall consult with the Exchange regarding
the inclusion of certified CPSP Medi-Cal providers in qualified
health plan provider networks. Additionally, the department shall
encourage certified CPSP Medi-Cal providers to contract with Exchange
qualified health plans in order to serve the beneficiaries who are
receiving services under this section.
(B) The department shall monitor the birth outcomes of women who
are receiving benefits under this section and the birth outcomes of
women receiving full scope and limited scope pregnancy services under
the Medi-Cal program, shall monitor access to and the utilization of
CPSP services from Medi-Cal providers by beneficiaries receiving
benefits under this section, and shall assess if there are any
differences in birth outcomes between pregnant women receiving full
scope and limited scope services under the Medi-Cal program and women
receiving benefits under this section.
(C) To the extent possible, the department shall assess CPSP
Medi-Cal provider participation as contracted providers with Exchange
qualified health plans.
(f) (1) The department may contract with public or private
entities, or both, including the Exchange, to implement this section
and Section 14148.67. Contracts entered into under these sections may
be on a noncompetitive bid basis and are exempt from the following:
(A) Part 2 (commencing with Section 10100) of Division 2 of the
Public Contract Code and any policies, procedures, or regulations
authorized by that part.
(B) Article 4 (commencing with Section 19130) of Chapter 5 of Part
2 of Division 5 of Title 2 of the Government Code.
(C) Review or approval of contracts by the Department of General
Services.
(2) For contracts entered into under this subdivision, the
department shall not be required to specify the amounts encumbered
for each contract, but may allocate funds to each contract based on
the projected or actual beneficiary enrollments to a total amount not
to exceed the amount appropriated for the program.
(g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, 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.
Notwithstanding Section 10231.5 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, in compliance with Section 9795 of the Government Code, until
regulations have been adopted.
(h) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
(i) For purposes of this section, the following definitions shall
apply:
(1) "Beneficiary" means a woman eligible for Medi-Cal
pregnancy-related and postpartum services.
(2) "CalHEERS" means the California Healthcare Eligibility,
Enrollment, and Retention System developed under Section 15926.
(3) "Cost sharing" means the expenditures, required by or on
behalf of the beneficiary by her qualified health plan with respect
to essential health benefits, and includes deductibles, coinsurance,
copayments, and similar charges, but excludes premiums, and spending
by an eligible beneficiary for benefits or services not covered by
the qualified health plan.
(4) "Exchange" means the California Health Benefit Exchange
established in Title 22 (commencing with Section 100500) of the
Government Code.
(5) "Postpartum services" means those services and benefits
provided during a postpartum period under Section 14005.18.
SEC. 55. Section 14148.67 is added to the Welfare and Institutions
Code, to read:
14148.67. (a) When implementing the premium and cost-sharing
payments required under Sections 14102 and 14148.65, the department
shall make the premium and cost-sharing payments required under those
sections to the beneficiary's qualified health plan in conformity
with the requirements of this section.
(b) (1) The beneficiary shall not be charged, billed, asked, or
required to make any premium or cost-sharing payments to his or her
qualified health plan or service provider for any services that are
subject to premium or cost-sharing payments by the department under
Section 14102 or 14148.65.
(2) If the beneficiary makes any premium or cost-sharing payments
to his or her plan or provider for services that are subject to
premium or cost-sharing payments by the department under Section
14102 or 14148.65, the department shall reimburse the beneficiary for
those payments. The department shall make every reasonable effort to
do both of the following:
(A) Make the reimbursement process simple and easy for
beneficiaries to use.
(B) Promptly reimburse beneficiaries under this paragraph.
(3) If, as a result of reconciliation in a tax year where the
beneficiary was eligible for covered premium payments under Section
14102 or 14148.65, the beneficiary owes and makes a tax payment to
the federal government to return a portion of the advanced premium
tax credit to which the beneficiary was not entitled and the
beneficiary notifies the department, the department shall reimburse
the beneficiary for the
amount of the tax payment related to the tax credits for covered
premium payments under Section 14102 or 14148.65.
(4) If, as a result of reconciliation in a tax year where the
beneficiary was eligible for covered premium payments under Section
14102 or 14148.65, the federal government owes and makes a tax refund
to the beneficiary based upon the beneficiary's advanced premium tax
credit, the beneficiary shall reimburse the department for the
portion of the refund that is related to the tax credits that were
applied to the premium payments made by the department.
(c) (1) Except as provided in paragraph (2), beneficiaries who are
eligible for benefits under Section 14102 or 14148.65 shall be
eligible for the premium and cost-sharing payments required under
those sections only up to the amount necessary to pay for the second
lowest silver level plan in his or her qualified health plan pricing
region, as modified by cost-sharing reductions.
(2) If a beneficiary selects or remains in a metal level plan that
is more expensive than the metal level plan amount limit required
under paragraph (1), the beneficiary may select or remain in that
plan only if he or she agrees to be responsible for paying all
applicable premium and cost-sharing charges that are in excess of
what is covered by the department. The department shall not be
responsible for paying for any premium or cost sharing that is in
excess of the metal level plan amount limit required under paragraph
(1).
(d) The department shall consult with the Exchange, Exchange
contracting health care service plans and health insurers, and
stakeholders, including consumer advocates, Medi-Cal providers, and
the counties, in the development and implementation of the following:
(1) Processes and procedures to inform affected applicants and
beneficiaries in a clear, consumer-friendly manner of all of their
enrollment options under the Medi-Cal program and the Exchange, of
the manner in which they may receive the benefits and services
covered through the Exchange coverage, and of the manner in which
they may receive benefits and services under Section 14102.
(2) Provider notices to ensure that Medi-Cal providers are aware
of the Medi-Cal program under Section 14102 and that providers comply
with state laws applicable to Medi-Cal coverage for individuals
eligible under Section 14102.
(e) All notices developed under subdivision (d) shall be
accessible to persons with limited English language proficiency and
persons with disabilities consistent with all federal and state
requirements.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted. The
department shall adopt regulations by July 1, 2017, 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.
Notwithstanding Section 10231.5 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, in compliance with Section 9795 of the Government Code, until
regulations have been adopted.
(g) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 56. Section 14154 of the Welfare and Institutions Code is
amended to read:
14154. (a) (1) The department shall establish and maintain a plan
whereby costs for county administration of the determination of
eligibility for benefits under this chapter will be effectively
controlled within the amounts annually appropriated for that
administration. The plan, to be known as the County Administrative
Cost Control Plan, shall establish standards and performance
criteria, including workload, productivity, and support services
standards, to which counties shall adhere. The plan shall include
standards for controlling eligibility determination costs that are
incurred by performing eligibility determinations at county
hospitals, or that are incurred due to the outstationing of any other
eligibility function. Except as provided in Section 14154.15,
reimbursement to a county for outstationed eligibility functions
shall be based solely on productivity standards applied to that
county's welfare department office.
(2) (A) The plan shall delineate both of the following:
(i) The process for determining county administration base costs,
which include salaries and benefits, support costs, and staff
development.
(ii) The process for determining funding for caseload changes,
cost-of-living adjustments, and program and other changes.
(B) The annual county budget survey document utilized under the
plan shall be constructed to enable the counties to provide
sufficient detail to the department to support their budget requests.
(3) The plan shall be part of a single state plan, jointly
developed by the department and the State Department of Social
Services, in conjunction with the counties, for administrative cost
control for the California Work Opportunity and Responsibility to
Kids (CalWORKs), CalFresh, and Medical Assistance (Medi-Cal)
programs. Allocations shall be made to each county and shall be
limited by and determined based upon the County Administrative Cost
Control Plan. In administering the plan to control county
administrative costs, the department shall not allocate state funds
to cover county cost overruns that result from county failure to meet
requirements of the plan. The department and the State Department of
Social Services shall budget, administer, and allocate state funds
for county administration in a uniform and consistent manner.
(4) The department and county welfare departments shall develop
procedures to ensure the data clarity, consistency, and reliability
of information contained in the county budget survey document
submitted by counties to the department. These procedures shall
include the format of the county budget survey document and process,
data submittal and its documentation, and the use of the county
budget survey documents for the development of determining county
administration costs. Communication between the department and the
county welfare departments shall be ongoing as needed regarding the
content of the county budget surveys and any potential issues to
ensure the information is complete and well understood by involved
parties. Any changes developed pursuant to this section shall be
incorporated within the state's annual budget process by no later
than the 2011-12 fiscal year.
(5) The department shall provide a clear narrative description
along with fiscal detail in the Medi-Cal estimate package, submitted
to the Legislature in January and May of each year, of each component
of the county administrative funding for the Medi-Cal program. This
shall describe how the information obtained from the county budget
survey documents was utilized and, if applicable, modified and the
rationale for the changes.
(6) Notwithstanding any other law, the department shall develop
and implement, in consultation with county program and fiscal
representatives, a new budgeting methodology for Medi-Cal county
administrative costs that reflects the impact of PPACA implementation
on county administrative work. The new budgeting methodology shall
be used to reimburse counties for eligibility processing and case
maintenance for applicants and beneficiaries.
(A) The budgeting methodology may include, but is not limited to,
identification of the costs of eligibility determinations for
applicants, and the costs of eligibility redeterminations and case
maintenance activities for recipients, for different groupings of
cases, based on variations in time and resources needed to conduct
eligibility determinations. The calculation of time and resources
shall be based on the following factors: complexity of eligibility
rules, ongoing eligibility requirements, and other factors as
determined appropriate by the department. The development of the new
budgeting methodology may include, but is not limited to, county
survey of costs, time and motion studies, in-person observations by
department staff, data reporting, and other factors deemed
appropriate by the department.
(B) The new budgeting methodology shall be clearly described,
state the necessary data elements to be collected from the counties,
and establish the timeframes for counties to provide the data to the
state.
(C) The new budgeting methodology developed pursuant to this
paragraph shall be implemented no sooner than the 2015-16 fiscal
year. The department may develop a process for counties to phase in
the requirements of the new budgeting methodology.
(D) The department shall provide the new budgeting methodology to
the legislative fiscal committees by March 1 of the fiscal year
immediately preceding the first fiscal year of implementation of the
new budgeting methodology.
(E) To the extent that the funding for the county budgets
developed pursuant to the new budget methodology is not fully
appropriated in any given fiscal year, the department, with input
from the counties, shall identify and consider options to align
funding and workload responsibilities.
(F) For purposes of this paragraph, "PPACA" means the federal
Patient Protection and Affordable Care Act (Public Law 111-148), as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments.
(G) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this paragraph
by means of all-county letters, plan letters, plan or provider
bulletins, or similar instructions until the time any necessary
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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 implementation
of the new budgeting methodology pursuant to this paragraph, and
notwithstanding Section 10231.5 of the Government Code, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
(b) Nothing in this section, Section 15204.5, or Section 18906
shall be construed to limit the administrative or budgetary
responsibilities of the department in a manner that would violate
Section 14100.1, and thereby jeopardize federal financial
participation under the Medi-Cal program.
(c) (1) The Legislature finds and declares that in order for
counties to do the work that is expected of them, it is necessary
that they receive adequate funding, including adjustments for
reasonable annual cost-of-doing-business increases. The Legislature
further finds and declares that linking appropriate funding for
county Medi-Cal administrative operations, including annual
cost-of-doing-business adjustments, with performance standards will
give counties the incentive to meet the performance standards and
enable them to continue to do the work they do on behalf of the
state. It is therefore the Legislature's intent to provide
appropriate funding to the counties for the effective administration
of the Medi-Cal program at the local level to ensure that counties
can reasonably meet the purposes of the performance measures as
contained in this section.
(2) It is the intent of the Legislature to not appropriate funds
for the cost-of-doing-business adjustment for the 2008-09, 2009-10,
2010-11, 2011-12, 2012-13, and 2014-15 fiscal years.
(d) The department is responsible for the Medi-Cal program in
accordance with state and federal law. A county shall determine
Medi-Cal eligibility in accordance with state and federal law. If in
the course of its duties the department becomes aware of accuracy
problems in any county, the department shall, within available
resources, provide training and technical assistance as appropriate.
Nothing in this section shall be interpreted to eliminate any remedy
otherwise available to the department to enforce accurate county
administration of the program. In administering the Medi-Cal
eligibility process, each county shall meet the following performance
standards each fiscal year:
(1) Complete eligibility determinations as follows:
(A) Ninety percent of the general applications without applicant
errors and are complete shall be completed within 45 days.
(B) Ninety percent of the applications for Medi-Cal based on
disability shall be completed within 90 days, excluding delays by the
state.
(2) (A) The department shall establish best-practice guidelines
for expedited enrollment of newborns into the Medi-Cal program,
preferably with the goal of enrolling newborns within 10 days after
the county is informed of the birth. The department, in consultation
with counties and other stakeholders, shall work to develop a process
for expediting enrollment for all newborns, including those born to
mothers receiving CalWORKs assistance.
(B) Upon the development and implementation of the best-practice
guidelines and expedited processes, the department and the counties
may develop an expedited enrollment timeframe for newborns that is
separate from the standards for all other applications, to the extent
that the timeframe is consistent with these guidelines and
processes.
(3) Perform timely annual redeterminations, as follows:
(A) Ninety percent of the annual redetermination forms shall be
mailed to the recipient by the anniversary date.
(B) Ninety percent of the annual redeterminations shall be
completed within 60 days of the recipient's annual redetermination
date for those redeterminations based on forms that are complete and
have been returned to the county by the recipient in a timely manner.
(C) Ninety percent of those annual redeterminations where the
redetermination form has not been returned to the county by the
recipient shall be completed by sending a notice of action to the
recipient within 45 days after the date the form was due to the
county.
(D) If a child is determined by the county to change from no share
of cost to a share of cost and the child meets the eligibility
criteria for the Healthy Families Program established under Section
12693.98 of the Insurance Code, the child shall be placed in the
Medi-Cal-to-Healthy Families Bridge Benefits Program, and these cases
shall be processed as follows:
(i) Ninety percent of the families of these children shall be sent
a notice informing them of the Healthy Families Program within five
working days from the determination of a share of cost.
(ii) Ninety percent of all annual redetermination forms for these
children shall be sent to the Healthy Families Program within five
working days from the determination of a share of cost if the parent
has given consent to send this information to the Healthy Families
Program.
(iii) Ninety percent of the families of these children placed in
the Medi-Cal-to-Healthy Families Bridge Benefits Program who have not
consented to sending the child's annual redetermination form to the
Healthy Families Program shall be sent a request, within five working
days of the determination of a share of cost, to consent to send the
information to the Healthy Families Program.
(E) Subparagraph (D) shall not be implemented until 60 days after
the Medi-Cal and Joint Medi-Cal and Healthy Families applications and
the Medi-Cal redetermination forms are revised to allow the parent
of a child to consent to forward the child's information to the
Healthy Families Program.
(e) The department shall develop procedures in collaboration with
the counties and stakeholder groups for determining county review
cycles, sampling methodology and procedures, and data reporting.
(f) On January 1 of each year, each applicable county, as
determined by the department, shall report to the department on the
county's results in meeting the performance standards specified in
this section. The report shall be subject to verification by the
department. County reports shall be provided to the public upon
written request.
(g) If the department finds that a county is not in compliance
with one or more of the standards set forth in this section, the
county shall, within 60 days, submit a corrective action plan to the
department for approval. The corrective action plan shall, at a
minimum, include steps that the county shall take to improve its
performance on the standard or standards with which the county is out
of compliance. The plan shall establish interim benchmarks for
improvement that shall be expected to be met by the county in order
to avoid a sanction.
(h) (1) If a county does not meet the performance standards for
completing eligibility determinations and redeterminations as
specified in this section, the department may, at its sole
discretion, reduce the allocation of funds to that county in the
following year by 2 percent. Any funds so reduced may be restored by
the department if, in the determination of the department, sufficient
improvement has been made by the county in meeting the performance
standards during the year for which the funds were reduced. If the
county continues not to meet the performance standards, the
department may reduce the allocation by an additional 2 percent for
each year thereafter in which sufficient improvement has not been
made to meet the performance standards.
(2) No reduction of the allocation of funds to a county shall be
imposed pursuant to this subdivision for failure to meet performance
standards during any period of time in which the
cost-of-doing-business increase is suspended.
(i) The department shall develop procedures, in collaboration with
the counties and stakeholders, for developing instructions for the
performance standards established under subparagraph (D) of paragraph
(3) of subdivision (d), no later than September 1, 2005.
(j) No later than September 1, 2005, the department shall issue a
revised annual redetermination form to allow a parent to indicate
parental consent to forward the annual redetermination form to the
Healthy Families Program if the child is determined to have a share
of cost.
(k) The department, in coordination with the Managed Risk Medical
Insurance Board, shall streamline the method of providing the Healthy
Families Program with information necessary to determine Healthy
Families eligibility for a child who is receiving services under the
Medi-Cal-to-Healthy Families Bridge Benefits Program.
( l ) Notwithstanding Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code, and except as provided in subparagraph (G) of paragraph (6) of
subdivision (a), the department shall, without taking any further
regulatory action, implement, interpret, or make specific this
section and any applicable federal waivers and state plan amendments
by means of all-county letters or similar instructions.
SEC. 57. Section 14165.50 of the Welfare and Institutions Code is
amended to read:
14165.50. (a) To facilitate the financial viability of a new
private nonprofit hospital that will serve the population of South
Los Angeles that was formerly served by the Los Angeles County Martin
Luther King, Jr.-Harbor Hospital, Medi-Cal funding shall, at a
minimum, be made available, as specified in this section, or pursuant
to mechanisms that provide equivalent funding under successor or
modified Medi-Cal payment systems.
(b) Medi-Cal payment for hospital services provided by the new
hospital, exclusive of any payments under the Medi-Cal Hospital
Reimbursement Improvement Act of 2013 (Article 5.230 (commencing with
Section 14169.50)) or funded by another statewide hospital fee
program, and exclusive of the supplemental payments specified in
subdivision (d), shall include consideration of the new hospital's
projected Medi-Cal costs for providing the services as set forth in
this section.
(1) (A) Subject to paragraph (2) of subdivision (c), and
notwithstanding any other law, Medi-Cal payments made to the new
hospital on a fee-for-service basis, including payments made pursuant
to the methodology authorized under Section 14105.28 or successor or
modified methodologies, shall provide compensation that is, at a
minimum, equal to 100 percent of the new hospital's projected
Medi-Cal costs for each fiscal year.
(B) To the extent supplemental payments are necessary for any
fiscal year to meet the applicable minimum reimbursement level as
described in subparagraph (A), the department shall seek federal
approval, as necessary, to enable the new hospital to receive the
Medi-Cal supplemental payments.
(2) (A) To the extent permitted under federal law, the department
shall require Medi-Cal managed care plans serving Medi-Cal
beneficiaries in the County of Los Angeles to pay the new hospital
amounts determined necessary to meet compensation levels for services
provided to managed care enrollees that are no less than the amount
to which the new hospital would have received on a fee-for-service
basis pursuant to paragraph (1). The amounts shall be determined in
consultation with the new hospital, the County of Los Angeles, and
the Medi-Cal managed care plan, and shall be subject to paragraph (2)
of subdivision (c).
(B) Consistent with federal law, the capitation rates paid to
Medi-Cal managed care plans serving Medi-Cal beneficiaries in the
County of Los Angeles shall be determined to reflect the obligations
described in subparagraph (A). The increased payments to Medi-Cal
managed care plans that would be paid consistent with actuarial
certification and enrollment in the absence of this paragraph shall
not be reduced as a consequence of this paragraph.
(C) A Medi-Cal managed care plan receiving the increased payments
described in subparagraph (B) shall not impose a fee or retention
amount, or reduce other payments to the new hospital that would
result in a direct or indirect reduction to the amounts required to
be paid under subparagraph (A).
(3) This subdivision shall not be construed to result in payments
that are less than the rates of compensation that would be payable to
the new hospital for Medi-Cal services without regard to the
requirements of paragraphs (1) and (2).
(c) If the applicable minimum reimbursement levels required in
subdivision (b) result in payments to the new hospital that are above
the levels of compensation that would have been payable absent that
requirement, and to the extent a nonfederal share is necessary with
respect to the additional compensation, the following provisions
shall apply:
(1) (A) For each fiscal year through the 2016-17 fiscal year,
General Fund amounts appropriated in the annual Budget Act for the
Medi-Cal program shall fund the nonfederal share of the additional
payments to the extent that the rates of compensation for inpatient
hospital services provided by the new hospital that would have been
payable in the absence of the requirements of subdivision (b) are
less than 77 percent of the new hospital's projected Medi-Cal costs.
With respect to the nonfederal share of the additional payments
described in paragraph (2) of subdivision (b), however, this
subparagraph shall be applicable only for inpatient services provided
in conjunction with the implementation of Section 14182, and other
mandatory managed care enrollment provisions implemented subsequent
to January 1, 2011.
(B) For the 2017-18 fiscal year and each subsequent fiscal year,
General Fund amounts appropriated in the annual Budget Act for the
Medi-Cal program shall fund the nonfederal share of the additional
payments to the extent that the rates of compensation for inpatient
hospital services provided by the new hospital that would have been
payable in the absence of the requirements of subdivision (b) are
less than 72 percent of the new hospital's projected Medi-Cal costs.
With respect to the nonfederal share of the additional payments
described in paragraph (2) of subdivision (b), however, this
subparagraph shall be applicable only for inpatient services provided
in conjunction with the implementation of Section 14182, and other
mandatory managed care enrollment provisions implemented subsequent
to January 1, 2011.
(2) (A) The remaining necessary nonfederal share of the
additional payments, after taking into account the General Fund
amounts described in paragraph (1), may be funded with public funds
that are transferred to the state from the County of Los Angeles, at
the county's election, pursuant to Section 14164. To the extent the
county elects not to fund any portion of the remaining necessary
nonfederal share, the applicable minimum reimbursement levels
required in subdivision (b) shall be reduced accordingly.
(B) Any public funds transferred to the state for payments to the
new hospital as described in this paragraph with respect to a fiscal
period shall be expended solely for the nonfederal share of the
payments. Notwithstanding any other law, except as provided in
subdivision (m), the department shall not impose any fee or
assessment in connection with the transferred funds or the payments
provided for under this section, including, but not limited to,
reimbursement for state staffing or administrative costs.
(C) If any portion of the funds transferred pursuant to this
paragraph is not expended, or not expected to be expended, for the
specified rate amounts required in subdivision (b), the unexpended
funds shall be returned promptly to the transferring county.
(3) This subdivision shall not be construed to reduce the
nonfederal share of payments funded by General Fund amounts below the
amounts that would be funded without regard to the minimum payment
levels required under this section.
(d) (1) In addition to payments meeting the applicable minimum
reimbursement levels described in subdivision (b), the new hospital
shall be eligible to receive supplemental payments. The supplemental
payments shall be provided annually in amounts determined in
consultation with the new hospital and the County of Los Angeles, and
subject to paragraph (3).
(2) The department shall seek federal approval, as necessary, to
enable the new hospital to receive supplemental payments that are in
addition to the applicable
minimum reimbursement levels required in subdivision (b). The
supplemental payments may be provided for under the mechanisms
described in Sections 14166.12 and 14301.4 or successor or modified
mechanisms, or any other federally permissible payment mechanism.
Supplemental payments that are payable through a Medi-Cal managed
care plan shall be subject to the same requirements described in
subparagraph (C) of paragraph (2) of subdivision (b).
(3) If a nonfederal share is necessary to fund the supplemental
payments, the County of Los Angeles may voluntarily provide public
funds that are transferred to the state pursuant to Section 14164.
The county may specify the type of supplemental payment for which it
is transferring funds, and any other category relevant to the
payment, including, but not limited to, fee-for-service supplemental
payment, managed care rate range payment, and payment for services
rendered to newly eligible beneficiaries as defined in subdivision
(s) of Section 17612.2.
(4) Any public funds transferred to the state for supplemental
payments to the new hospital as described in this subdivision with
respect to a fiscal period shall be expended solely for the
nonfederal share of the supplemental payments as specified pursuant
to paragraph (3). Notwithstanding any other law, subdivision (o) of
Section 14166.12 shall not apply, and the department shall not assess
the fee described in subdivision (d) of Section 14301.4, or any
other similar fee, except as provided in subdivision (m). If any
portion of the funds transferred pursuant to this subdivision is not
expended, or not expected to be expended, for the specified
supplemental payments, the unexpended funds shall be returned
promptly to the transferring county.
(e) Notwithstanding any other law, all payments provided for under
this section shall be treated as having been paid for purposes of
any determination of available room under the federal upper payment
limit, as specified in Part 447 of Title 42 of the Code of Federal
Regulations, with respect to the applicable class of services and
class of health care provider.
(f) (1) For purposes of this article, "new hospital" means a
health facility that is certified under Title XVIII and Title XIX of
the federal Social Security Act, and is licensed pursuant to Chapter
2 (commencing with Section 1250) of Division 2 of the Health and
Safety Code to provide acute inpatient hospital services, and
includes all components of the facility, with an inpatient hospital
service location on the campus of the former Los Angeles County
Martin Luther King, Jr.-Harbor Hospital.
(2) "Medi-Cal managed care plan" shall have the meaning provided
in paragraph (5) of subdivision (b) of Section 14199.1.
(g) For purposes of this article, the new hospital's projected
Medi-Cal costs shall be based on the cost finding principles applied
under subdivision (b) of Section 14166.4, except that the projected
costs shall not be multiplied by the federal medical assistance
percentage and are not subject to the reimbursement limitations set
forth in Article 7.5 (commencing with Section 51536) of Chapter 3 of
Subdivision 1 of Division 3 of Title 22 of the California Code of
Regulations. The projected Medi-Cal costs shall be determined prior
to the start of each fiscal year in consultation with the new
hospital, using the best available and reasonable current estimates
or projections made with respect to the new hospital for an annual
period, and shall be considered final as of the start of the fiscal
year for purposes of the minimum payment levels described in
subdivision (b).
(h) Notwithstanding any other law, the new hospital shall not be
eligible to receive payments pursuant to Section 14166.11. This
subdivision, however, shall not be construed to preclude the hospital
from eligibility for disproportionate share status, or from receipt
of any federal Medicaid disproportionate share hospital payments to
which it would be entitled, pursuant to the Medi-Cal State Plan.
(i) Except as specified in subdivision (h), this section shall not
be construed to preclude the new hospital from receiving any other
payment for which it is eligible in addition to the payments provided
for by this section.
(j) Notwithstanding any other law, for purposes of Article 12
(commencing with Section 17612.1) of Chapter 6 of Part 5, the
intergovernmental transfers described in this section as reflected in
the actual net expenditures for all operating budget units of the
County of Los Angeles Department of Health Services shall not be
reduced in any manner in the determination of total costs under
paragraph (6) of subdivision (b) of Section 17612.5, by application
of the imputed other entity intergovernmental transfer amounts or
otherwise.
(k) Notwithstanding the rulemaking provisions of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code, the department may implement this section by
means of all-facility letters, all-county letters, or similar
instructions, without taking further regulatory action. This section
shall not be construed to preclude the department from adopting
regulations.
( l ) (1) The department shall obtain federal
approvals or waivers as necessary to implement this section and to
obtain federal matching funds to the maximum extent permitted by
federal law. This section shall be implemented only if, and to the
extent that, federal financial participation is available and this
section does not jeopardize the federal financial participation
available for any other state program.
(2) This section shall be implemented only if, and to the extent
that, any necessary federal approvals are obtained.
(m) As part of its voluntary participation to provide the
nonfederal share of payments under this section, the County of Los
Angeles shall agree to reimburse the state for the nonfederal share
of state staffing and administrative costs directly attributable to
the cost of administrating the payments and associated
intergovernmental transfers. The costs shall be documented and
subject to review by the county.
SEC. 58. Section 15800 of the Welfare and Institutions Code is
amended to read:
15800. (a) (1) Commencing October 1, 2013, the State Department
of Health Care Services shall administer the AIM-Linked Infants
Program to address the health care needs of children formerly covered
pursuant to clause (ii) of subparagraph (A) of paragraph (6) of
subdivision (a) of Section 12693.70 of the Insurance Code. The
department is vested with the same powers, purposes,
responsibilities, and jurisdiction exercised by the Managed Risk
Medical Insurance Board as they relate to those children. Nothing in
this paragraph shall be construed to alter, diminish, or supersede
the authority of the Managed Risk Medical Insurance Board to exercise
the same powers, purposes, responsibilities, and jurisdiction within
the Healthy Families Program established under Part 6.2 (commencing
with Section 12693) of Division 2 of the Insurance Code.
(2) (A) Commencing on July 1, 2014, the State Department of Health
Care Services shall administer any other programs under, and
succeeds to and is vested with the same powers, purposes,
responsibilities, and jurisdiction exercised by, the Managed Risk
Medical Insurance Board.
(B) Commencing on July 1, 2014, any reference in any statute,
except for this chapter, Chapter 3 (commencing with Section 15850),
and Section 12739.61 of, and Part 6.8 (commencing with Section
12739.77) of Division 2 of, the Insurance Code, and in any
regulation, contract, or any other document, to the Managed Risk
Medical Insurance Board is deemed to instead refer to the State
Department of Health Care Services.
(3) The department may, before October 1, 2013, conduct transition
activities necessary to ensure the efficient transfer of the program
identified in paragraph (1) and populations served by that program.
(4) The department may, before July 1, 2014, conduct transition
activities necessary to ensure the efficient transfer of the programs
identified in paragraph (2) and populations served by these
programs.
(b) The department shall seek any federal waivers, approvals, and
state plan amendments necessary to implement this part. This part
shall only be implemented to the extent that necessary federal
approvals are obtained and federal financial participation is
available for eligible programs and services.
SEC. 59. Section 15801 of the Welfare and Institutions Code is
amended to read:
15801. (a) The terms of all regulations and orders adopted by
the Managed Risk Medical Insurance Board in effect preceding July 1,
2014, that relate to the operation of the program and to the children
transferred by the act that added this section and are not rendered
legally unenforceable by the act that added this section shall be
fully enforceable by the State Department of Health Care Services
within the AIM-Linked Infants Program and the Medi-Cal Access Program
unless and until the department adopts regulations for the Medi-Cal
Access Program. Nothing in this subdivision shall be construed to
alter, diminish, or supersede the authority of the Managed Risk
Medical Insurance Board to interpret, enforce, maintain, or amend the
same regulations for purposes of the Healthy Families Program
established under Part 6.2 (commencing with Section 12693) of
Division 2 of the Insurance Code.
(b) All regulations and orders adopted by the Managed Risk Medical
Insurance Board that relate to the programs transferred pursuant to
paragraph (2) of subdivision (a) of Section 15800 in effect on July
1, 2014, and not rendered legally unenforceable by the act adding
this subdivision shall remain in effect and shall be fully
enforceable unless and until readopted, amended, or repealed by the
State Department of Health Care Services, or until they expire by
their own terms.
SEC. 60. Section 15802.5 is added to the Welfare and Institutions
Code, to read:
15802.5. Effective on July 1, 2014, all permanent or probationary
civil service employees who are employed by the Managed Risk Medical
Insurance Board shall be transferred to the State Department of
Health Care Services or the California Health Benefits Exchange as
described in Section 12739.78 of the Insurance Code, and their civil
service status, position, and rights, including return rights, shall
be determined pursuant to Section 12739.78 of the Insurance Code.
SEC. 61. Section 15803 of the Welfare and Institutions Code is
amended to read:
15803. (a) To implement this part and clause (ii) of subparagraph
(A) of paragraph (6) of subdivision (a) of Section 12693.70 of the
Insurance Code, the State Department of Health Care Services may
contract with public or private entities. Contracts entered into
under this part may be on a noncompetitive bid basis and are exempt
from the following:
(1) Part 2 (commencing with Section 10100) of Division 2 of the
Public Contract Code and any policies, procedures, or regulations
authorized by that part.
(2) Article 4 (commencing with Section 19130) of Chapter 5 of Part
2 of Division 5 of Title 2 of the Government Code.
(3) Review or approval of contracts by the Department of General
Services.
(b) During the transition of the programs to the department, the
department shall also be exempt from the review or approval of
feasibility study reports and the requirements of Sections 4819.35 to
4819.37, inclusive, and 4920 to 4928, inclusive, of the State
Administrative Manual.
(c) For contracts entered into under this part, the State
Department of Health Care Services shall not be required to specify
the amounts encumbered for each contract, but may allocate funds to
each contract based on the projected or actual subscriber enrollments
to a total amount not to exceed the amount appropriated for the
program including family contributions.
SEC. 62. Section 15804 of the Welfare and Institutions Code is
amended to read:
15804. On October 1, 2013, or when the State Department of Health
Care Services has implemented Chapter 2 (commencing with Section
15810), whichever occurs later, the Managed Risk Medical Insurance
Board shall cease to provide coverage to the children transferred to
the AIM-Linked Infants Program, pursuant to Section 15800.
SEC. 63. Section 15805 of the Welfare and Institutions Code is
amended to read:
15805. (a) (1) The Managed Risk Medical Insurance Board shall
provide the State Department of Health Care Services any data,
information, or record concerning the Healthy Families Program or the
Access for Infants and Mothers Program as are necessary to implement
this part and clause (ii) of subparagraph (A) of paragraph (6) of
subdivision (a) of Section 12693.70 of the Insurance Code.
(2) All books, documents, files, property, data, information, or
record in possession of the Managed Risk Medical Insurance Board,
except for personnel records related to staff transferred to the
California Health Benefits Exchange pursuant to Section 12739.61 or
12739.78 of the Insurance Code, shall be transferred to the State
Department of Health Care Services on July 1, 2014.
(3) Until the transition of duties from the Managed Risk Medical
Insurance Board to the State Department of Health Care Services
required under subdivision (a) of Section 15800 is complete, any
book, document, file, property, data, information, or record in the
possession of the Managed Risk Medical Insurance Board pertaining to
functions, programs, and subscribers to be transferred to the State
Department of Health Care Services pursuant to subdivision (a) of
Section 15800 shall immediately be made available to the State
Department of Health Care Services upon request for review,
inspection, and copying, including electronic transmittal, including
records otherwise not subject to disclosure under Chapter 3.5
(commencing with Section 6250) of Division 7 of Title 1 of the
Government Code.
(b) Notwithstanding any other law, all of the following shall
apply:
(1) The term "book, document, file, property, data, information,
or record" shall include, but is not limited to, personal information
as defined in Section 1798.3 of the Civil Code.
(2) Any book, document, file, property, data, information, or
record shall be exempt from disclosure under the California Public
Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7
of the Government Code) and any other law, to the same extent that
it was exempt from disclosure or privileged prior to the provision of
the book, document, file, property, data, information, or record to
the department.
(3) The provision of any book, document, file, property, data,
information, or record to the department shall not constitute a
waiver of any evidentiary privilege or exemption from disclosure.
(4) The department shall keep all books, documents, files,
property, data, information, or records provided by the Managed Risk
Medical Insurance Board confidential to the full extent permitted by
law, including, but not limited to, the California Public Records Act
(Chapter 3.5 (commencing with Section 6250) of Division 7 of the
Government Code), and consistent with the Managed Risk Medical
Insurance Board's contractual obligations to keep books, documents,
files, property, data, information, or records confidential.
SEC. 64. Section 15806 is added to the Welfare and Institutions
Code, to read:
15806. (a) A contract, lease, license, bond, or any other
agreement to which the Managed Risk Medical Insurance Board is a
party is not void or voidable by reason of the act that added this
section, but shall continue in full force and effect, with the State
Department of Health Care Services assuming all of the rights,
obligations, liabilities, and duties of the Managed Risk Medical
Insurance Board and any of its predecessors that relate to the
duties, powers, purposes, responsibilities, and jurisdiction vested
by the act that added this section in the State Department of Health
Care Services. The assumption by the State Department of Health Care
Services does not in any way affect the rights of the parties to the
contract, lease, license, or agreement.
(b) This section shall become operative on July 1, 2014.
SEC. 65. The heading of Chapter 2 (commencing with Section 15810)
of Part 3.3 of Division 9 of the Welfare and Institutions Code is
amended to read:
CHAPTER 2. MEDI-CAL ACCESS PROGRAM
SEC. 66. Section 15810 of the Welfare and Institutions Code is
amended to read:
15810. (a) This chapter shall be known, and may be cited, as
the AIM-Linked Infants Program.
(b) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 67. Section 15810 is added to the Welfare and Institutions
Code, to read:
15810. (a) This chapter, formerly known as the AIM-Linked Infants
Program, shall be known, and may be cited, as the Medi-Cal Access
Program.
(b) This section shall become operative on July 1, 2014.
SEC. 68. Section 15811 of the Welfare and Institutions Code is
amended to read:
15811. (a) The definitions contained in this section govern the
construction of this chapter, unless the context requires otherwise.
(b) "AIM-linked infant" means any infant born to a woman whose
enrollment in the Access for Infants and Mothers Program under Part
6.3 (commencing with Section 12695) of Division 2 of the Insurance
Code begins after June 30, 2004.
(c) "Department" means the State Department of Health Care
Services.
(d) "Program" means the AIM-Linked Infants Program.
(e) "Subscriber" means an individual who is eligible for and
enrolled in the program.
(f) "Subscriber contribution" means the cost to the subscriber to
participate in the program.
(g) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 69. Section 15811 is added to the Welfare and Institutions
Code, to read:
15811. (a) The definitions contained in this section govern the
construction of this chapter, unless the context requires otherwise.
(b) "Access-linked infant" means any infant born to a woman
enrolled in either the program under this chapter or the Access for
Infants and Mothers Program under Part 6.3 (commencing with Section
12695) of Division 2 of the Insurance Code.
(c) "Applicant" means an individual who applies for coverage
through the program.
(d) "Department" means the State Department of Health Care
Services.
(e) "Fund" means the Perinatal Insurance Fund.
(f) "Health education services relating to tobacco use" means
tobacco use prevention and education services, including, when
appropriate, tobacco use cessation services, in accordance with
protocols established by the department in coordination with the
California Tobacco Control Program of the State Department of Public
Health.
(g) "Participating health plan" means a health plan with which the
department contracts to provide health care services to individuals
eligible pursuant to Section 15832.
(h) "Program" means the Medi-Cal Access Program.
(i) "Subscriber" means an individual who is eligible for and
enrolled in the program.
(j) "Subscriber contribution" means the cost to the subscriber to
participate in the program.
(k) This section shall become operative on July 1, 2014.
SEC. 70. Section 15814 is added to the Welfare and Institutions
Code, to read:
15814. (a) The department, in coordination with the California
Tobacco Control Program of the State Department of Public Health,
shall develop protocols relating to health education for tobacco use
to the extent necessary to comply with paragraph (1) of subdivision
(b) of Section 30122 of the Revenue and Taxation Code. These
protocols shall include, but not be limited to, all of the following:
(1) Referral to perinatal and related support services.
(2) Outreach services and assessment of smoking status.
(3) Individualized counseling and advocacy services.
(4) Motivational messages.
(5) Cessation services, if appropriate.
(6) Incentives to maintain a healthy lifestyle.
(7) Followup assessment.
(8) Maintenance and relapse prevention services.
(b) This section shall become operative on July 1, 2014.
SEC. 71. Section 15818 is added to the Welfare and Institutions
Code, to read:
15818. (a) Each participating health plan contracting with the
department pursuant to this chapter shall provide health education
services related to tobacco use to all program participants to the
extent necessary to comply with paragraph (1) of subdivision (b) of
Section 30122 of the Revenue and Taxation Code.
(b) The education activities required by subdivision (a) shall
include all of the following:
(1) Dissuading persons from beginning to smoke.
(2) Encouraging smoking cessation.
(3) Providing information on the health effects of tobacco use on
the user, children, and nonsmokers.
(c) This section shall become operative on July 1, 2014.
SEC. 72. Section 15826 of the Welfare and Institutions Code is
amended to read:
15826. (a) The department shall administer the program and may
do all of the following:
(1) Determine eligibility criteria for the program. These criteria
shall include the requirements set forth in Section 15832.
(2) Determine the eligibility of AIM-linked infants.
(3) Determine when subscribers are covered and the extent and
scope of coverage.
(4) Determine subscriber contribution amounts schedules.
Subscriber contributions shall not be greater than those applicable
on March 23, 2010, for infants enrolled pursuant to clause (ii) of
subparagraph (A) of paragraph (6) of subdivision (a) of Section
12693.70 of the Insurance Code.
(5) Provide coverage through Medi-Cal delivery systems and
contract for the administration of the program and the enrollment of
subscribers. Any contract entered into pursuant to this chapter shall
be exempt from any provision of law relating to competitive bidding,
and shall be exempt from the review or approval of any division of
the Department of General Services. The department shall not be
required to specify the amounts encumbered for each contract, but may
allocate funds to each contract based on projected and actual
subscriber enrollments in a total amount not to exceed the amount
appropriated for the program.
(6) Authorize expenditures to pay program expenses that exceed
subscriber contributions, and to administer the program as necessary.
(7) Develop a promotional component of the program to make
Californians aware of the program and the opportunity that it
presents.
(8) (A) Issue rules and regulations as necessary to administer
the program.
(B) During the 2011-12 to 2014-15 fiscal years, inclusive, the
adoption and readoption of regulations pursuant to this chapter shall
be deemed to be an emergency that calls for immediate action to
avoid serious harm to the public peace, health, safety, or general
welfare for purposes of Sections 11346.1 and 11349.6 of the
Government Code, and the department is hereby exempted from the
requirement that the department describe facts showing the need for
immediate action.
(9) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
chapter.
(b) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 73. Section 15826 is added to the Welfare and Institutions
Code, to read:
15826. (a) The department shall administer the program and may do
all of the following:
(1) Determine eligibility criteria for the program. These criteria
shall include the requirements set forth in Section 15832.
(2) Determine the eligibility of applicants.
(3) Determine when subscribers are covered and the extent and
scope of coverage.
(4) Determine subscriber contribution amounts schedules, subject
to the following:
(A) Subscriber contributions for Access-linked infants shall not
be greater than those applicable on March 23, 2010, for infants
enrolled pursuant to clause (ii) of subparagraph (A) of paragraph (6)
of subdivision (a) of Section 12693.70 of the Insurance Code.
(B) Subscriber contributions for mothers shall conform with the
maintenance of effort requirements under the federal Patient
Protection and Affordable Care Act (Public Law 111-148), or any
amendment or extension of that act.
(5) Provide coverage through Medi-Cal delivery systems and
contract for the administration of the program and the enrollment of
subscribers. Any contract entered into pursuant to this chapter shall
be exempt from any provision of law relating to competitive bidding,
and shall be exempt from the review or approval of any division of
the Department of General Services. The department shall not be
required to specify the amounts encumbered for each contract, but may
allocate funds to each contract based on projected and actual
subscriber enrollments in a total amount not to exceed the amount
appropriated for the program.
(6) Authorize expenditures to pay program expenses that exceed
subscriber contributions, and to administer the program as necessary.
(7) Develop a promotional component of the program to make
Californians aware of the program and the opportunity that it
presents.
(8) (A) Issue rules and regulations as necessary to administer the
program.
(B) During the 2011-12 to 2014-15 fiscal years, inclusive, the
adoption and readoption of regulations pursuant to this chapter shall
be deemed to be an emergency that calls for immediate action to
avoid serious harm to the public peace, health, safety, or general
welfare for purposes of Sections 11346.1 and 11349.6 of the
Government Code, and the department is hereby exempted from the
requirement that the department describe facts showing the need for
immediate action and from review by the Office of Administrative Law.
(9) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
chapter.
(b) This section shall become operative on July 1, 2014.
SEC. 74. Section 15827 is added to the Welfare
and Institutions Code, to read:
15827. (a) The department shall administer the program in a
manner that ensures that program expenditures do not exceed amounts
available in the fund.
(b) This section shall be implemented only if and to the extent
that it does not jeopardize the state's ability to receive federal
financial participation under the federal Patient Protection and
Affordable Care Act (Public Law 111-148), or any amendment or
extension of that act.
(c) This section shall become operative on July 1, 2014.
SEC. 75. Section 15832 of the Welfare and Institutions Code is
amended to read:
15832. To be eligible to participate in the program, a person
shall meet all of the following requirements:
(a) (1) Be a child under two years of age who is delivered by a
mother enrolled in the program under Part 6.3 (commencing with
Section 12695) of Division 2 of the Insurance Code. Except as stated
in this section, these infants shall be automatically enrolled in the
program.
(2) For the applicable month, not be enrolled in
employer-sponsored health care coverage, or have been enrolled in
that health care coverage in the prior three months or enrolled in
full-scope Medi-Cal without a share of cost. Exceptions may be
identified in regulations or other guidance and shall, at minimum,
include all exceptions applicable to the Healthy Families Program on
and after March 23, 2010.
(3) Be subject to subscriber contributions as determined by the
department. The subscriber contributions shall not be greater than
those applicable on March 23, 2010, for infants enrolled in the
Healthy Families Program pursuant to clause (ii) of subparagraph (A)
of paragraph (6) of subdivision (a) of Section 12693.70 of the
Insurance Code.
(b) For AIM-linked infants identified in subdivision (a), all of
the following shall apply:
(1) Enrollment shall cover the first 12 months of the infant's
life unless he or she is eligible for Medi-Cal benefits under Section
14005.26. If the infant is eligible under Section 14005.26, he or
she shall be automatically enrolled in the Medi-Cal program on that
basis.
(2) (A) At the end of the 12 months, as a condition of continued
eligibility, the subscriber shall provide income information. The
infant shall be disenrolled from the program if the annual household
income exceeds 300 percent of the federal poverty level, or if the
infant is eligible for full-scope Medi-Cal with no share of cost.
(B) Effective January 1, 2014, when determining eligibility for
benefits under the program, income shall be determined, counted, and
valued in accordance with the requirements of Section 1397bb(b)(1)(B)
of Title 42 of the United States Code as added by the federal
Patient Protection and Affordable Care Act (Public Law 111-148) and
as amended by the federal Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152) and any subsequent amendments.
(3) At the end of their first and second year in the program,
infants shall be screened for eligibility for the Medi-Cal program.
(c) If at any time the director determines that the eligibility
criteria established under this chapter for the program may
jeopardize the state's ability to receive federal financial
participation under the federal Patient Protection and Affordable
Care Act (Public Law 111-148), or any amendment or extension of that
act, the director may alter the eligibility criteria to the extent
necessary for the state to receive that federal financial
participation.
(d) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 76. Section 15832 is added to the Welfare and Institutions
Code, to read:
15832. (a) To be eligible to participate in the program, a person
shall meet all of the requirements in either paragraph (1) or (2):
(1) (A) Be a woman who is pregnant or in her postpartum period as
specified in Section 15840 and who is a resident of the state. A
person who is a member of a federally recognized California Indian
tribe is a resident of the state for these purposes.
(B) Have a household income that is above 208 percent of the
official federal poverty level but does not exceed 317 percent of the
official federal poverty level.
(C) Agree to the payment of the complete subscriber contribution.
A federally recognized California Indian tribal government may make
the subscriber contributions on behalf of a member of the tribe only
if a contribution on behalf of members of federally recognized
California Indian tribes does not limit or preclude federal financial
participation under Title XXI of the Social Security Act (42 U.S.C.
Sec. 1397aa et seq.). If a federally recognized California Indian
tribal government makes a contribution on behalf of a member of the
tribe, the tribal government shall ensure that the subscriber is made
aware of all the health care delivery options available in the
county where the member resides.
(2) (A) Be a child under two years of age who is delivered by a
mother enrolled in the program under this chapter or Part 6.3
(commencing with Section 12695) of Division 2 of the Insurance Code.
Except as stated in this section, these infants shall be
automatically enrolled in the program.
(B) For the applicable month, not be enrolled in
employer-sponsored health care coverage, or have been enrolled in
that health care coverage in the prior three months or enrolled in
full-scope Medi-Cal without a share of cost. Exceptions may be
identified in regulations or other guidance and shall, at minimum,
include all exceptions applicable to the Healthy Families Program on
and after March 23, 2010.
(C) Be subject to subscriber contributions as determined by the
department.
(3) For AIM-linked infants identified in paragraph (2), all of the
following shall apply:
(A) Enrollment in the program shall cover the first 12 months of
the infant's life unless he or she is determined eligible for
Medi-Cal benefits under Section 14005.26. An infant shall be screened
for eligibility under Section 14005.26 immediately after he or she
is born. If the infant is eligible under Section 14005.26, he or she
shall be automatically enrolled in the Medi-Cal program on that
basis.
(B) (i) At the end of the 12 months, as a condition of continued
eligibility, the subscriber shall provide income information. The
infant shall be disenrolled from the program if the annual household
income exceeds 317 percent of the federal poverty level, or if the
infant is eligible for full-scope Medi-Cal with no share of cost.
(ii) Effective January 1, 2014, when determining eligibility for
benefits under the program, income shall be determined, counted, and
valued in accordance with the requirements of Section 1397bb(b)(1)(B)
of Title 42 of the United States Code as added by the federal
Patient Protection and Affordable Care Act (Public Law 111-148) and
as amended by the federal Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152) and any subsequent amendments.
(C) At the end of their first and second year in the program,
infants shall be screened for eligibility for the Medi-Cal program.
(4) If at any time the director determines that the eligibility
criteria established under this chapter for the program may
jeopardize the state's ability to receive federal financial
participation under the federal Patient Protection and Affordable
Care Act (Public Law 111-148), or any amendment or extension of that
act, the director may alter the eligibility criteria to the extent
necessary for the state to receive that federal financial
participation.
(b) This section shall become operative on July 1, 2014.
SEC. 77. Section 15833 is added to the Welfare and Institutions
Code, to read:
15833. (a) A person eligible pursuant to paragraph (1) of
subdivision (a) of Section 15832 shall not be eligible to participate
in the program if, at the time of application, she is eligible for
Medi-Cal without a share of cost or for Medicare.
(b) This section shall become operative on July 1, 2014.
SEC. 78. Section 15835 is added to the Welfare and Institutions
Code, to read:
15835. (a) Subscribers enrolled pursuant to paragraph (1) of
subdivision (a) of Section 15832 shall not be disenrolled for failure
to pay subscriber contributions. The department may impose or
contract for collection actions to collect unpaid subscriber
contributions.
(b) This section shall become operative on July 1, 2014.
SEC. 79. Section 15839 is added to the Welfare and Institutions
Code, to read:
15839. (a) Services that would be covered under the program that
are provided to pregnant women who, after receiving those services,
are subsequently determined to be eligible for coverage under this
chapter may be reimbursed as determined by the department. In no case
shall services received prior to 40 days before a woman's date of
application be eligible for reimbursement.
(b) This section shall become operative on July 1, 2014.
SEC. 80. Section 15840 of the Welfare and Institutions Code is
amended to read:
15840. (a) At a minimum, coverage provided pursuant to this
chapter shall be provided to eligible AIM-linked infants less than
two years of age.
(b) Coverage provided pursuant to this chapter shall include, at a
minimum, those services required to be provided by health care
service plans approved by the Secretary of Health and Human Services
as a federally qualified health care service plan pursuant to Section
417.101 of Title 42 of the Code of Federal Regulations.
(c) Medically necessary prescription drugs shall be a required
benefit in the coverage provided pursuant to this chapter.
(d) This section shall become inoperative on July 1, 2014, and, as
of January 1, 2015, is repealed, unless a later enacted statute,
that becomes operative on or before January 1, 2015, deletes or
extends the dates on which it becomes inoperative and is repealed.
SEC. 81. Section 15840 is added to the Welfare and Institutions
Code, to read:
15840. (a) At a minimum, coverage provided pursuant to this
chapter shall be provided to subscribers during one pregnancy, and
until the end of the month in which the 60th day after pregnancy
occurs, and to eligible children less than two years of age who were
born of a pregnancy covered under this program or the Access for
Infants and Mothers program under Part 6.3 (commencing with Section
12695) of Division 2 of the Insurance Code to a woman enrolled in the
Access for Infants and Mothers program.
(b) Coverage provided pursuant to this chapter shall include, at a
minimum, those services required to be provided by health care
service plans approved by the Secretary of Health and Human Services
as a federally qualified health care service plan pursuant to Section
417.101 of Title 42 of the Code of Federal Regulations.
(c) Medically necessary prescription drugs shall be a required
benefit in the coverage provided pursuant to this chapter.
(d) To the extent required pursuant to Section 15818 to comply
with paragraph (1) of subdivision (b) of Section 30122 of the Revenue
and Taxation Code, health education services related to tobacco use
shall be a benefit in the coverage provided under this chapter.
(e) This section shall become operative on July 1, 2014.
SEC. 82. Section 15841 is added to the Welfare and Institutions
Code, to read:
15841. (a) Through its courts, statutes, and under its
Constitution, California protects a woman's right to reproductive
privacy. California reaffirms these protections and specifically its
Supreme Court decision in People v. Belous (1969) 71 Cal.2d 954,
966-68.
(b) The State Department of Health Care Services may accept or use
moneys under Title XXI of the Social Security Act (known as the
Children's Health Insurance Program or CHIP), as interpreted in
Section 457.10 of Title 42 of the Code of Federal Regulations, to
fund services for women pursuant to Section 14007.7 and this chapter
only when, during the period of coverage, the woman is the
beneficiary. The scope of services covered under Medi-Cal and this
chapter, as defined in statutes, regulations, and state plans, is not
altered by this section or the state plan amendment submitted
pursuant to this section.
(c) California's CHIP plan and any amendments submitted and
implemented pursuant to this section shall be consistent with
subdivisions (a) and (b).
(d) This section is a declaration of existing law.
(e) This section shall become operative on July 1, 2014.
SEC. 83. Section 15847 is added to the Welfare and Institutions
Code, to read:
15847. (a) It shall constitute unfair competition for purposes of
Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of
the Business and Professions Code for an insurer, an insurance agent
or broker, or an administrator, as defined in Section 1759 of the
Insurance Code, to refer an individual employee or employee's
dependent to the program, or arrange for an individual employee or
employee's dependent to apply to the program, for the purpose of
separating that employee or employee's dependent from group health
coverage provided in connection with the employee's employment.
(b) Any employee described in subdivision (a) shall have a
personal right of action to enforce subdivision (a).
(c) This section shall become operative on July 1, 2014.
SEC. 84. Section 15847.3 is added to the Welfare and Institutions
Code, to read:
15847.3. (a) It shall constitute an unfair labor practice
contrary to public policy, and enforceable under Section 95 of the
Labor Code, for any employer to refer an individual employee or
employee's dependent to the program, or to arrange for an individual
employee or employee's dependent to apply to the program, for the
purpose of separating that employee or employee's dependent from
group health coverage provided in connection with the employee's
employment.
(b) This section shall become operative on July 1, 2014.
SEC. 85. Section 15847.5 is added to the Welfare and Institutions
Code, to read:
15847.5. (a) It shall constitute an unfair labor practice
contrary to public policy and enforceable under Section 95 of the
Labor Code for any employer to change the employee-employer
share-of-cost ratio or to make any other modification of maternity
care coverage for employees or employees' dependents that results in
the enrollment of the employees or employees' dependents in the
program established pursuant to this chapter.
(b) This section shall become operative on July 1, 2014.
SEC. 86. Section 15847.7 is added to the Welfare and Institutions
Code, to read:
15847.7. (a) For purposes of Sections 15847, 15847.3, and
15847.5, "group health coverage" includes any nonprofit hospital
service plan, health care service plan, self-insured employee welfare
benefit plan, or disability insurance providing medical or hospital
benefits.
(b) This section shall become operative on July 1, 2014.
SEC. 87. Section 15848 is added to the Welfare and Institutions
Code, to read:
15848. (a) The Perinatal Insurance Fund is continued in existence
in the State Treasury under the administration of the department.
(b) Amounts deposited in the fund shall only be used for the
purposes specified by this chapter.
(c) Notwithstanding Section 13340 of the Government Code, the fund
is hereby continuously appropriated, without regard to fiscal years,
to the department, for the purposes specified in this chapter.
(d) This section shall become operative on July 1, 2014.
SEC. 88. Section 15848.5 is added to the Welfare and Institutions
Code, to read:
15848.5. (a) The department shall authorize the expenditure of
money in the fund to cover program expenses, including program
expenses that exceed subscriber contributions.
(b) From money appropriated by the Legislature to the fund, the
department may expend sufficient funds for operating expenses
incurred in carrying out this chapter.
(c) The department shall develop and utilize all appropriate cost
containment measures to maximize the coverage offered under the
program.
(d) This section shall become operative on July 1, 2014.
SEC. 89. Chapter 3 (commencing with Section 15850) is added to
Part 3.3 of Division 9 of the Welfare and Institutions Code, to read:
CHAPTER 3. COUNTY HEALTH INITIATIVE MATCHING FUND
15850. This chapter shall be known and may be cited as the County
Health Initiative Matching Fund.
15850.1. For purposes of this chapter, the following definitions
shall apply:
(a) "Administrative costs" means those expenses that are described
in Section 1397ee(a)(1)(D) of Title 42 of the United States Code.
(b) "Applicant" means a county, county agency, a local initiative,
or a county organized health system.
(c) "Department" means the State Department of Health Care
Services.
(d) "Child" means a person under 19 years of age.
(e) "Comprehensive health insurance coverage" means the coverage
provided in Section 2103 of the Social Security Act (42 U.S.C. Sec.
1397cc) and shall be equivalent to the coverage provided to state
employees through the Public Employees' Retirement System for the
most recent plan year preceding the applicable program plan year,
except that the plans may provide a mechanism for inpatient hospital
care provided under the mental health benefit through which
applicants may agree to a treatment plan in which each inpatient day
may be substituted for two residential treatment days or three day
treatment program days.
(f) "County organized health system" means a health system
implemented pursuant to Article 2.8 (commencing with Section 14087.5)
of Chapter 7 of Part 3 of this division and Article 1 (commencing
with Section 101675) of Chapter 3 of Part 4 of Division 101 of the
Health and Safety Code.
(g) "Fund" means the County Health Initiative Matching Fund.
(h) "Local initiative" means a prepaid health plan that is
organized by, or designated by, a county government or county
governments, or organized by stakeholders, of a region designated by
the department to provide comprehensive health care to eligible
Medi-Cal beneficiaries. The entities established pursuant to Sections
14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96 are
local initiatives.
(i) "Optional targeted low-income children group" means the
population described in Section 1905(u)(2)(B) of the Society Security
Act (42 U.S.C. Sec. 1396d(u)(2)(B)) and in Section 14005.26.
(j) "Access program" means the Medi-Cal Access Program under
Chapter 2 (commencing with Section 15810).
(k) "Health care service plan" includes Medi-Cal managed care
plans contracting with the department under Chapter 7 (commencing
with Section 14000) or Chapter 8 (commencing with Section 14200) of
Part 3.
15850.5. (a) Notwithstanding any other law, except as provided in
subdivision (b), each applicant who was participating in the County
Health Initiative Matching Fund on March 23, 2010, pursuant to Part
6.4 (commencing with Section 12699.50) of Division 2 of the Insurance
Code, shall participate in the program established by this chapter,
maintaining eligibility standards, methodologies, and procedures at
least as favorable to eligible individuals as those in effect on
March 23, 2010, and in a manner that satisfies the maintenance of
effort obligation established in Section 2105(d)(3) of the Social
Security Act (42 U.S.C. Sec. 1397ee(d)(3)).
(b) (1) If an applicant county participating in the County Health
Initiative Matching Fund on March 23, 2010, elects to cease funding
the nonfederal share of program expenditures made pursuant to Section
15852, the department shall administer the program within that
applicant county consistent with subdivision (a).
(2) Notwithstanding any other law, the state general fund shall
provide funding amounts equal to the total nonfederal share of all
expenditures incurred by the department pursuant to paragraph (1).
(3) The nonfederal share amounts described in paragraph (2) shall
be deposited in the County Health Initiative Matching Fund created
pursuant to Section 15852, and those funds shall be used by the
department for purposes otherwise consistent with that section.
(c) Notwithstanding any other law, as of the enactment of this
section, the department shall not approve any additional applicant
for participation under this chapter other than those applicants
participating as of March 23, 2010.
(d) This section shall only be operative to extent that federal
financial participation is not jeopardized and any necessary federal
approvals are secured.
(e) This section shall become inoperative on the date that the
maintenance of effort obligation pursuant to Section 2105(d)(3) of
the Social Security Act (42 U.S.C. Sec. 1397ee(d)(3)) is no longer
applicable to the state for purposes of this chapter.
15852. (a) The County Health Initiative Matching Fund is hereby
continued in existence within the State Treasury. The fund shall
accept funding, including but not limited to, funding from
intergovernmental transfers as follows:
(1) The nonfederal matching fund requirement for federal financial
participation through the State Children's Health Insurance Program
(Subchapter 21 (commencing with Section 1397aa) of Chapter 7 of Title
42 of the United States Code).
(2) Funding associated with a proposal approved pursuant to
subdivision (e) Section 15853.
(3) State general fund amounts pursuant to subdivision (b) of
Section 15850.5.
(b) Notwithstanding Section 13340 of the Government Code, amounts
deposited in the fund shall be continuously appropriated to the
department without regard to fiscal year, and shall be used only for
the purposes specified by this section.
(c) The department shall administer this fund and the provisions
of this chapter for the express purpose of allowing local or state
funds to be used to facilitate increasing the state's ability to
utilize federal funds available to California and for costs
associated with a proposal pursuant to subdivision (e) of Section
15853 or for costs incurred by the department pursuant to paragraph
(1) of subdivision (b) of Section 15850.5. Federal funds shall be
used prior to the expiration of their authority for programs designed
to improve and expand access for uninsured persons.
(d) The department shall be reimbursed from the fund to cover the
cost to administer the program.
15853. (a) (1) An applicant that will provide an
intergovernmental transfer may submit a proposal to the department
for funding for the purpose of providing comprehensive health
insurance coverage to any 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, and
whose family income is at or below 317 percent of the federal poverty
level or, at the option of the applicant, at or below 411 percent of
the federal poverty level, in specific geographic areas, as
published quarterly in the Federal Register by the United States
Department of Health and Human Services, as determined, counted and
valued in accordance with the requirements of Section 1396a(e)(14) of
Title 42 of the United States Code, as added by the federal Patient
Protection and Affordable Care Act (Public Law 111-148) and as
amended by the federal Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152) and any subsequent amendments, and which
child meets both of the following requirements:
(A) Does not qualify for the optional targeted low-income children
group or the Access program.
(B) Does not qualify for Medi-Cal with no share of cost pursuant
to Chapter 7 (commencing with Section 14000) of Part 3.
(2) In its application, the applicant shall specify the income
level at or below 411 percent of the federal poverty level for which
it will provide coverage.
(3) The intergovernmental transfer amount is limited to the
expenditures which would be eligible for federal financial
participation.
(b) The proposal shall guarantee at least one year of
intergovernmental transfer funding by the applicant at a level that
ensures compliance with the requirements of any applicable approved
federal waiver or state plan amendment as well as the department's
requirements for the sound operation of the proposed project, and
shall, on an annual basis, either commit to fully funding the
necessary intergovernmental amount or withdraw from the program. The
department may identify specific geographical areas that, compared to
the national level, have a higher cost of living or housing or a
greater need for additional health services, using data obtained from
the most recent federal census, the federal Consumer Expenditure
Survey, or from other sources. The proposal may include an
administrative mechanism for outreach and eligibility.
(c) The applicant may include in its proposal reimbursement of
medical, dental, vision, or mental health services delivered to
children who are eligible under the Access program or under the
Medi-Cal program as an optional targeted low-income children group
beneficiary, if these services are part of an overall program with
the measurable goal of enrolling served children in the Access
program or the optional targeted low-income children group.
(d) If a child is determined to be eligible for benefits for the
treatment of an eligible medical condition under the California
Children's Services Program pursuant to Article 5 (commencing with
Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health
and Safety Code, the health, dental, or vision plan providing
services to the child pursuant to this chapter shall not be
responsible for the provision of, or payment for, those authorized
services for that child. The proposal from an applicant shall contain
provisions to ensure that a child whom the health, dental, or vision
plan reasonably believes would be eligible for services under the
California Children's Services Program is referred to that program.
The California Children's Services Program shall provide case
management and authorization of services if the child is found to be
eligible for the California Children's Services Program. Diagnosis
and treatment services that are authorized by the California Children'
s Services Program shall be performed by paneled providers for that
program and approved special care centers of that program and
approved by the California Children's Services Program. All other
services provided under
the proposal from the applicant shall be made available pursuant to
this chapter to a child who is eligible for services under the
California Children's Services Program.
(e) Notwithstanding any other provision of this section, an
applicant may submit a proposal to the department for the purposes of
providing comprehensive health insurance coverage to children whose
coverage is not eligible for funding under Title XXI of the Social
Security Act (42 U.S.C. Sec. 1397aa, et seq.), or to a combination of
children whose coverage is eligible for funding under Title XXI of
the Social Security Act and children whose coverage is not eligible
for that funding. To be approved by the department, these proposals
shall comply with both of the following requirements:
(1) Meet all applicable requirements for funding under this
chapter, except for availability of funding through Title XXI of the
Social Security Act.
(2) Provide for the administration of children's coverage by the
department through the administrative infrastructure serving the
Medi-Cal program, and through health care service plans serving the
Medi-Cal program.
(f) Implementation of this section is conditioned on the
department obtaining necessary federal approval of these provisions.
(g) Notwithstanding any other provision of this part, the status
of any application previously submitted to, and approved by, the
Managed Risk Medical Insurance Board pursuant to Part 6.4 (commencing
with Section 12699.50) of Division 2 of the Insurance Code shall not
be altered as a result of the assumption by the department, pursuant
to this chapter, of the responsibilities previously exercised by the
Managed Risk Medical Insurance Board.
15854. (a) The department, in consultation with other appropriate
parties, shall establish the criteria for evaluating an applicant's
proposal, which shall include, but not be limited to, the following:
(1) The extent to which the program described in the proposal
provides comprehensive coverage including health, dental, and vision
benefits.
(2) Whether the proposal includes a promotional component to
notify the public of its provision of health insurance to eligible
children.
(3) The simplicity of the proposal's procedures for applying to
participate and for determining eligibility for participation in its
program.
(4) The extent to which the proposal provides for coordination and
conformity with benefits provided through the Medi-Cal program.
(5) The extent to which the proposal provides for coordination and
conformity with existing Medi-Cal administrative entities in order
to prevent administrative duplication and fragmentation.
(6) The ability of the health care providers designated in the
proposal to serve the eligible population and the extent to which the
proposal includes traditional and safety net providers, as defined
by the department.
(7) The extent to which the proposal intends to work with the
school districts and county offices of education.
(8) The total amount of funds available to the applicant to
implement the program described in its proposal, and the percentage
of this amount proposed for administrative costs as well as the cost
to the state to administer the proposal.
(9) The extent to which the proposal seeks to minimize the
substitution of private employer health insurance coverage for health
benefits provided through a governmental source.
(10) The extent to which local resources may be available after
the depletion of federal funds to continue any current program
expansions for persons covered under local health care financing
programs or for expanded benefits.
(11) For the purposes of defining an applicant's eligibility for
funding under this chapter, the following shall apply:
(A) The same income methodology shall be used for the proposed
program that is currently used for the Medi-Cal program.
(B) Only participating Medi-Cal managed care plans may be used.
However, the department may permit exceptions to this requirement
consistent with the purpose, of this chapter.
(b) The department may, in its sole discretion, approve or
disapprove projects for funding pursuant to this chapter on an annual
basis.
(c) To the extent that an applicant's proposal pursuant to this
chapter provides for health plan or administrative services under a
contract entered into by the department or at rates negotiated for
the applicant by the department, a contract entered into by the
department or by an applicant shall be exempt from any provision of
law relating to competitive bidding, and shall be exempt from the
review or approval of any division of the Department of General
Services to the same extent as contracts entered into pursuant to
subdivision (p) of Section 14005.26. The department and the applicant
shall not be required to specify the amounts encumbered for each
contract, but may allocate funds to each contract based on the
projected or actual subscriber enrollments to a total amount not to
exceed the amount appropriated for the project including family
contributions.
15855. The department shall review each funding proposal
submitted by an applicant in accordance with the criteria described
in Section 15854 and based on that criteria, approve or reject the
proposal.
15856. (a) Upon its approval of a proposal that shall include any
allowable amount of federal funds under Title XXI of the Social
Security Act (42 U.S.C. Sec. 1397aa et seq.), the department may
provide the applicant reimbursement in an amount equal to the amount
that the applicant will contribute to implement the program described
in its proposal, plus the appropriate and allowable amount of
federal funds. Not more than 10 percent of the County Health
Initiative Matching Fund and matching federal funds shall be expended
in any one fiscal year for administrative costs, including the costs
to the state to administer the proposal, unless the department
permits the expenditure consistent with the availability of federal
matching funds not needed for the purposes described in paragraph (3)
of subdivision (a) of Section 15862, or unless the department
determines that an expenditure for administrative costs has no impact
on available federal funding. The department may audit the expenses
incurred by the applicant in implementing its program to ensure that
the expenditures comply with the provisions of this chapter. No
reimbursement may be made to an applicant that fails to meet its
financial participation obligation under this chapter. The state's
reasonable startup costs and ongoing costs for administering the
program shall be reimbursed by those entities applying for funding.
(b) Any program approved pursuant to subdivision (e) of Section
15853 that requires any funding not allowable for a federal match
under Title XXI of the Social Security Act shall provide the
department with the total amount of funds needed to provide that
portion of coverage not eligible for federal matching funds,
including reasonable startup costs and ongoing costs for
administering the program.
(c) Each applicant that is provided funds under this chapter shall
submit to the department a plan to limit initial and continuing
enrollment in its program in the event the amount of moneys for its
program is insufficient to maintain health insurance coverage for
those participating in the program.
(d) (1) Notwithstanding any other provision of this chapter, the
state shall be held harmless, in accordance with paragraphs (2) and
(3), from any federal audit disallowance and interest resulting from
payments made to a participating applicant pursuant to this section,
for the disallowed claim.
(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any participating applicant
has received reimbursement for services rendered or other activities
performed, the department shall recoup from the participating
applicant that submitted the disallowed claim, through offsets or by
a direct billing, amounts equal to the amount of the disallowance and
interest for the disallowed claim. All subsequent claims submitted
to the department applicable to any previously disallowed service,
activity, or claim may be held in abeyance, with no payment made,
until the federal disallowance issue is resolved.
(3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating applicant has received reimbursement for
services rendered or activities performed by an entity under contract
with, and on behalf of, the participating applicant, the department
shall be held harmless by that particular participating applicant for
100 percent of the amount of the federal audit disallowance and
interest for the disallowed claim.
15857. Each health care service plan, specialized health care
service plan, and health insurer that contracts to provide health
care benefits under this chapter shall be licensed by the Department
of Managed Health Care or the Department of Insurance, or be a
Medi-Cal managed care plan.
15858. (a) The department shall administer the provisions of this
chapter and may do all of the following:
(1) Administer the expenditure of moneys from the fund.
(2) (A) Issue rules and regulations as necessary.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this chapter and any
applicable federal waivers and state plan amendments by means of
all-county letters, plan letters, plan or provider bulletins, or
similar instructions until the time regulations are adopted.
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, and notwithstanding
Section 10231.5 of the Government Code, the department shall provide
a status report to the Legislature pursuant to Section 9795 of the
Government Code on a semiannual basis until regulations have been
adopted.
(3) Enter into contracts.
(4) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
chapter.
15859. All expenses incurred by the department in administering
this chapter, including, but not limited to, expenses for developing
standards and processes to implement any of the provisions of this
chapter, evaluating applications, or processing or granting appeals
growing out of any of the provisions of this chapter, shall be paid
from the fund or directly by applicants, except that the department
may accept funding from a not-for-profit group or foundation, or from
a governmental entity providing grants for health-related
activities, to administer this chapter.
15860. Nothing in this chapter creates a right or an entitlement
to the provision of health insurance coverage or health care
benefits. Except as provided in Section 15850.5, no costs shall
accrue to the state for the provision of these services. The state
shall not be liable beyond the assets of the fund for any obligation
incurred or liabilities sustained by applicants in the operation of
the fund or of the projects authorized by this chapter.
15861. To the extent necessary to obtain federal financial
participation for projects approved pursuant to this chapter, the
department shall apply for one or more waivers or shall file state
plan amendments pursuant to the federal State Children's Health
Insurance Program (Subchapter 21 (commencing with Section 1397aa) of
Chapter 7 of Title 42 of the United States Code) to allow a county
agency, local initiative, or county organized health system to apply
for matching funds through the federal State Children's Health
Insurance Program (Subchapter 21 (commencing with Section 1397aa) of
Chapter 7 of Title 42 of the United States Code) using local funds
for the state matching funds.
15862. (a) The provisions of this chapter shall be implemented
only if all of the following conditions are met:
(1) Federal financial participation is available for this purpose.
(2) Federal participation is approved.
(3) The department determines that federal funds under Title XXI
of the Social Security Act remain available after providing funds for
all current enrollees and eligible children that are likely to
enroll in the optional targeted low-income children group and, to the
extent funded through the federal Children's Health Insurance
Program (Subchapter 21 (commencing with Section 1397aa) of Chapter 7
of Title 42 of the United States Code), the Medi-Cal Access program
and Medi-Cal program, as determined by a Department of Finance
estimate.
(4) Funds are appropriated specifically for this purpose.
(b) The department may accept funding necessary for the
preparation of the federal waiver applications or state plan
amendments described in Section 15861 from a not-for-profit group or
foundation but only to the extent that such funding may be eligible
for federal financial participation.
15863. The state shall be held harmless for any federal
disallowance resulting from this chapter and any other expenses or
liabilities, including, but not limited to, the cost of processing or
granting appeals, unless the department is acting pursuant to
Section 15850.5. An applicant receiving supplemental reimbursement
pursuant to this chapter shall be liable for any reduced federal
financial participation, and any other expenses or liabilities,
including, but not limited to, the costs of processing or granting
appeals, resulting from the implementation of this chapter with
respect to that applicant. The state may recoup any federal
disallowance from the applicant for which it can be held harmless.
15864. This chapter shall become operative on July 1, 2014.
SEC. 90. Chapter 4 (commencing with Section 15870) is added to
Part 3.3 of Division 9 of the Welfare and Institutions Code, to read:
CHAPTER 4. CALIFORNIA MAJOR RISK MEDICAL INSURANCE PROGRAM
Article 1. General
15870. For the purposes of this chapter, the following terms have
the following meanings:
(a) "Applicant" means an individual who applies for major risk
medical coverage through the program.
(b) "Department" means the State Department of Health Care
Services.
(c) "Exchange" means the California Health Benefit Exchange
established pursuant to Section 100500 of the Government Code.
(d) "Fund" means the Major Risk Medical Insurance Fund, from which
the department may authorize expenditures to pay for medically
necessary services which exceed subscribers' contributions, and for
administration of the program.
(e) "Major risk medical coverage" means the payment for medically
necessary services provided by institutional and professional
providers.
(f) "Participating health plan" means either of the following
entities that contracts with the department to administer major risk
medical coverage to program subscribers:
(1) A private insurer holding a valid outstanding certificate of
authority from the Insurance Commissioner.
(2) A health care service plan as defined under subdivision (f) of
Section 1345 of the Health and Safety Code.
(g) "Plan rates" means the total monthly amount charged by a
participating health plan for a category of risk.
(h) "Program" means the California Major Risk Medical Insurance
Program.
(i) "Subscriber" means an individual who is eligible for and
receives major risk medical coverage through the program, and
includes a member of a federally recognized California Indian tribe.
(j) "Subscriber contribution" means the portion of participating
health plan rates paid by the subscriber, or paid on behalf of the
subscriber by a federally recognized California Indian tribal
government. If a federally recognized California Indian tribal
government makes a contribution on behalf of a member of the tribe,
the tribal government shall ensure that the subscriber is made aware
of all the health plan options available in the county where the
member resides.
15872. The California Major Risk Medical Insurance Program is
hereby established within, and shall be administered by, the
department.
15872.5. This chapter shall become operative on July 1, 2014.
Article 2. Powers and Duties
15873. The department shall have the authority:
(a) To establish eligibility criteria, notwithstanding Section
15884, and determine the eligibility of applicants.
(b) To determine the major risk medical coverage to be provided to
program subscribers.
(c) To research and assess the needs of persons not adequately
covered by existing private and public health care delivery systems
and promote means of assuring the availability of adequate health
care services.
(d) To approve subscriber contributions, and plan rates, and
establish program contribution amounts.
(e) To provide major risk medical coverage for subscribers or to
contract with a participating health plan or plans or other vendor to
provide or administer major risk medical coverage for subscribers.
(f) To authorize expenditures from the fund to pay program
expenses which exceed subscriber contributions.
(g) To contract for administration of the program or any portion
thereof with any public agency, including any agency of state
government, or with any private entity.
(h) (1) To issue rules and regulations to carry out the purposes
of this chapter.
(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department, without taking any further regulatory action, shall
implement, interpret, or make specific this section and any
applicable federal waivers and state plan amendments by means of plan
letters, plan or provider bulletins, or similar instructions until
the time regulations are adopted. 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, and notwithstanding Section 10231.5 of the
Government Code, the department shall provide a status report to the
Legislature pursuant to Section 9795 of the Government Code on a
semiannual basis until regulations have been adopted.
(i) To authorize expenditures from the fund or from other moneys
appropriated in the annual Budget Act for purposes relating to
Section 10127.16 of the Insurance Code, and Section 1373.622 of the
Health and Safety Code.
(j) To exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed upon it
under this chapter.
15876. Plan rates for major risk medical benefits approved for
the program shall not be excessive, inadequate, or unfairly
discriminatory, but shall be adequate to pay anticipated costs of
claims or services and administration.
Article 3. Policies Issued by the Department
15878. The department may place a lien on compensation or
benefits recovered or recoverable by a subscriber from any party or
parties responsible for the compensation or benefits for which
benefits have been provided under a policy issued under this article
or Article 4 (commencing with Section 15881).
15879. Except as provided in Article 3.5 (commencing with Section
14124.70) of Chapter 7 of Part 3, benefits received under this
article or Article 4 (commencing with Section 15881) are in excess of
and secondary to, any other form of health benefits coverage.
15880. Benefits under this article or Article 4 (commencing with
Section 15881) shall be subject to required subscriber copayments and
deductibles as the department may authorize. Any authorized
copayments shall not exceed 25 percent and any authorized deductible
shall not exceed an annual household deductible amount of five
hundred dollars ($500). However, health plans not utilizing a
deductible may be authorized to charge an office visit copayment of
up to twenty-five dollars ($25). If the department contracts with
participating health plans pursuant to Article 4 (commencing with
Section 15881), copayments or deductibles shall be authorized in a
manner consistent with the basic method of operation of the
participating health plans. The aggregate amount of deductible and
copayments payable annually under this section shall not exceed two
thousand five hundred dollars ($2,500) for an individual and four
thousand dollars ($4,000) for a family.
Article 4. Participating Health Plans
15881. The department shall provide coverage through
participating health plans and may contract for the processing of
applications, the enrollment of subscribers, and activities necessary
to administer the program. A contract entered into pursuant to this
chapter shall be exempt from any provision of law relating to
competitive bidding, and shall be exempt from the review or approval
of any division of the Department of General Services. The department
shall not be required to specify the amounts encumbered for each
contract but may allocate funds to each contract based on projected
and actual subscriber enrollments in a total amount not to exceed
revenue available for the program.
15882. The department may provide or purchase stop-loss coverage
under which the program and participating health plans share the risk
for health plan expenses which exceed plan rates.
15883. The department shall withdraw its approval of any
participating health benefits plan for noncompliance with program
standards, nonpayment of claims, or other good cause shown. Approval
shall not be withdrawn except after reasonable notice to the health
plan, program subscribers enrolled in the plan, physicians or
organizations of physicians offering services through the plan, and
all interested parties.
Article 5. Subscriber Eligibility and Enrollment
15884. (a) Each resident of the state meeting the eligibility
criteria of this section and who is unable to secure adequate private
health coverage is eligible to apply for major risk medical coverage
through the program. For these purposes, "resident" includes a
member of a federally recognized California Indian tribe.
(b) To be eligible for enrollment in the program, an applicant
shall have been rejected for health care coverage by at least one
private health plan. An applicant shall be deemed to have been
rejected if the only private health coverage that the applicant could
secure would do one of the following:
(1) Impose substantial waivers that the department determines
would leave a subscriber without adequate coverage for medically
necessary services.
(2) Afford limited coverage that the department determines would
leave the subscriber without adequate coverage for medically
necessary services.
(3) Afford coverage only at an excessive price, which the
department determines is significantly above standard average
individual coverage rates.
(c) Rejection for policies or certificates of specified disease or
policies or certificates of hospital confinement indemnity, as
described in Section 10198.61 of the Insurance Code, shall not be
deemed to be rejection for the purposes of eligibility for
enrollment.
(d) The department may permit dependents of eligible subscribers
to enroll in major risk medical coverage through the program if the
department determines the enrollment can be carried out in an
actuarially and administratively sound manner.
(e) Notwithstanding the provisions of this section, the department
shall prescribe a period of time during which a resident is
ineligible to apply for major risk medical coverage through the
program if the resident either voluntarily disenrolls from, or was
terminated for nonpayment of the premium from, a private health plan
after enrolling in that private health plan pursuant to either
Section 10127.16 of the Insurance Code, and Section 1373.622 of the
Health and Safety Code.
15884.5. (a) It shall constitute unfair competition for purposes
of Chapter 5 (commencing with Section 17200) of Part 2 of Division 7
of the Business and Professions Code for an insurer, an insurance
agent or broker, or an administrator, as defined in Section 1759 of
the Insurance Code, to refer an individual employee, or his or her
dependents, to the program, or arrange for an individual employee, or
his or her dependents, to apply to the program, for the purpose of
separating that employee, or his or her dependents, from group health
coverage provided in connection with the employees employment.
(b) It shall constitute an unfair labor practice contrary to
public policy and enforceable under Section 95 of the Labor Code for
any employer to refer an individual employee, or his or her
dependents, to the program, or to arrange for an individual employee,
or his or her dependents, to apply to the program, for the purpose
of separating that employee, or his or her dependents, from group
health coverage provided in connection with the employee's
employment.
(c) As used in this section, "group health coverage" includes any
nonprofit hospital service plan, health care service plan,
self-insured employee welfare benefit plan, or disability insurance
providing medical or hospital benefits.
15885. The department may permit the exclusion of coverage or
benefits for charges or expenses incurred by a subscriber during the
first six months of enrollment in the program for any condition for
which, during the six months immediately preceding enrollment in the
program medical advice, diagnosis, care, or treatment was recommended
or received as to the condition during that period.
However, the exclusion from coverage of this section shall be
waived to the extent to which the subscriber was covered under any
creditable coverage, as defined in Section 10900 of the Insurance
Code, that was terminated, provided the subscriber has applied for
enrollment in the program not later than 63 days following
termination of the prior coverage, or within 180 days of termination
of coverage if the subscriber lost his or her previous creditable
coverage because the subscriber's employment ended, the availability
of health coverage offered through employment or sponsored by an
employer terminated, or an employer's contribution toward health
coverage terminated. The exclusion from coverage of this section
shall also be waived as to any condition of a subscriber previously
receiving coverage under a
plan of another state similar to the program established by this
chapter if the subscriber was eligible for benefits under that
other-state coverage for the condition. The department may establish
alternative mechanisms applicable to enrollment in participating
health plans. These mechanisms may include, but are not limited to, a
postenrollment waiting period.
15885.5. Where more than one participating health plan is
offered, the department shall make available to applicants eligible
to enroll in the program sufficient information to make an informed
choice among the various types of participating health plans. Each
applicant shall be issued an appropriate document setting forth or
summarizing the services to which an enrollee is entitled, procedures
for obtaining major risk medical coverage, a list of contracting
health plans and providers, and a summary of grievance procedures.
15886. After the applicant notifies the department in writing of
his or her choice of participating health plan, the department shall
assist the applicant in enrolling as a subscriber and securing major
risk medical coverage for the subscriber and any dependents.
15886.5. A subscriber may request a change in coverage based upon
a change in the family status of any dependent, by filing an
application within 30 days after the occurrence of the change in
family status, or at other times and under conditions as may be
prescribed by the department.
15887. Health coverage secured through the program shall permit a
covered dependent of a subscriber to elect to continue the same
coverage upon the death of the subscriber, or upon the subscriber
becoming eligible for Medicare Part A and Part B.
15887.5. A transfer of enrollment from one participating health
plan to another may be made by a subscriber at times and under
conditions as may be prescribed by the department.
15888. If a subscriber is dissatisfied with any action or failure
to act which has occurred in connection with a participating plan's
coverage, the subscriber shall have the right to appeal to the
department and shall be accorded an opportunity for a fair hearing.
Hearings may be conducted, insofar as practicable, pursuant to the
provisions of Chapter 5 (commencing with Section 11500) of Part 1 of
Division 3 of Title 2 of the Government Code.
15888.5. Subscribers and their dependents who become eligible for
Medicare Part A and Part B, excluding those on Medicare solely
because of end-stage renal disease, shall not be enrolled, or
continue to be enrolled, in major risk medical coverage afforded by
this chapter.
Article 6. Plan Rates and Compensation from the Fund
15890. Upon enrollment as a subscriber in the program, the
subscriber shall be responsible for payment of the subscriber
contribution. Termination of coverage by a participating health plan
for nonpayment of the subscriber contribution shall be governed by
the same laws and regulations by which the participating health plan
is regulated as to all its subscribers and enrollees.
15890.5. Each health plan contracting with the department
pursuant to Article 4 (commencing with Section 15881) shall submit
annually to the department rates which it estimates are sufficient to
cover the cost of providing major risk medical coverage to its
subscribers. The rates shall be submitted on the basis of categories
of risk which shall be established by the department.
15891. (a) The department shall establish program contribution
amounts for each category of risk for each participating health plan.
The program contribution amounts shall be based on the average
amount of subsidy funds required for the program as a whole. To
determine the average amount of subsidy funds required, the
department shall calculate a loss ratio, including all medical costs,
administration fees, and risk payments, for the program in the prior
calendar year. The loss ratio shall be calculated using 125 percent
of the standard average individual rates for comparable coverage as
the denominator, and all medical costs, administration fees, and risk
payments as the numerator. The average amount of subsidy funds
required is calculated by subtracting 100 percent from the program
loss ratio. For purposes of calculating the program loss ratio, no
participating health plan's loss ratio shall be less than 100 percent
and participating health plans with fewer than 1,000 program members
shall be excluded from the calculation.
Subscriber contributions shall be established to encourage members
to select those health plans requiring subsidy funds at or below the
program average subsidy. Subscriber contribution amounts shall be
established so that no subscriber receives a subsidy greater than the
program average subsidy, except that:
(1) In all areas of the state, at least one plan shall be
available to program participants at an average subscriber
contribution of 125 percent of the standard average individual rates
for comparable coverage.
(2) No subscriber contribution shall be increased by more than 10
percent above 125 percent of the standard average individual rates
for comparable coverage.
(3) Subscriber contributions for participating health plans
joining the program after January 1, 1997, shall be established at
125 percent of the standard average individual rates for comparable
coverage for the first two benefit years the plan participates in the
program.
(b) The department shall pay program contribution amounts to
participating health plans from the Major Risk Medical Insurance
Fund.
(c) Commencing January 1, 2013, in addition to the amount of
subsidy funds required pursuant to subdivision (a), the department
may further subsidize subscriber contributions so that the amount
paid by each subscriber is below 125 percent of the standard average
individual risk rate for comparable coverage but no less than 100
percent of the standard average individual risk rate for comparable
coverage. For purposes of calculating premiums for the following
products, any reference to, or use of, subscriber contributions,
premiums, average premiums, or amounts paid by subscribers in the
program shall be construed to mean subscriber contributions as
described in subdivision (a) without application of the additional
subsidies permitted by this subdivision:
(1) Standard benefit plans pursuant to Section 10127.16 of the
Insurance Code and Section 1373.622 of the Health and Safety Code.
(2) Health benefit plans and health care service plan contracts
for federally eligible defined individuals pursuant to Sections
10901.3 and 10901.9 of the Insurance Code and Sections 1399.805 and
1399.811 of the Health and Safety Code.
(3) Conversion coverage pursuant to Section 12682.1 of the
Insurance Code and Section 1373.6 of the Health and Safety Code.
15891.5. A participating health plan may charge subscriber
contributions under this article that do not exceed the difference
between its plan rate for the category of risk and the program
contribution amount for the category of risk.
Article 7. Major Risk Medical Insurance Fund
15893. (a) There is hereby continued in existence in the State
Treasury a special fund known as the Major Risk Medical Insurance
Fund that is, notwithstanding Section 13340 of the Government Code,
continuously appropriated to the department for the purposes
specified in Section 15894, Section 10127.16 of the Insurance Code,
and Section 1373.622 of the Health and Safety Code.
(b) Funds may be deposited in the Major Risk Medical Insurance
Fund from one or more of the following accounts in the Cigarette and
Tobacco Products Surtax Fund:
(1) The Hospital Services Account.
(2) The Physician Services Account.
(3) The Unallocated Account.
15893.5. Notwithstanding Section 15893, funds placed in the Major
Risk Medical Insurance Fund pursuant to Section 1341.45 of the
Health and Safety Code shall not be continuously appropriated.
15894. Except as provided in Section 15894.5, the department
shall authorize the expenditure of money in the fund to cover program
expenses, including program expenses that exceed subscriber
contributions, and to cover expenses relating to Section 10127.16 of
the Insurance Code, or to Section 1373.622 of the Health and Safety
Code. The department shall determine the amount of funds expended for
each of these purposes, taking into consideration the requirements
of this chapter, Section 10127.16 of the Insurance Code, and Section
1373.622 of the Health and Safety Code.
15894.5. From money appropriated by the Legislature to the fund,
the department may expend sufficient funds to carry out the purposes
of this chapter and of Section 10127.16 of the Insurance Code, and
Section 1373.622 of the Health and Safety Code.
However, the state shall not be liable beyond the assets of the
fund for any obligations incurred, or liabilities sustained, in the
operation of the California Major Risk Medical Insurance Program or
for the expenditures described in Section 10127.16 of the Insurance
Code, and Section 1373.622 of the Health and Safety Code.
15895. Any moneys remaining in the fund at the end of any fiscal
year may be carried forward to the next succeeding fiscal year.
15895.5. The department shall establish a reserve which is
sufficient to prudently operate the program.
SEC. 91. The balances of the funds for the appropriations provided
by Item 4560-001-3085 of Section 2.00 of the Budget Act of 2011, as
added by Chapter 33 of the Statutes of 2011, payable from the Mental
Health Services Fund, are hereby reappropriated and, notwithstanding
any other law, shall be available for encumbrance until June 30,
2015.
SEC. 92. Between July 1, 2014, and October 31, 2015, inclusive,
the State Department of Public Health shall convene a quarterly
meeting of stakeholders, including, but not limited to, community
organizations, food banks, nonprofit organizations, program
contractors, and counties, to solicit input and receive feedback on
the development, integration, and evaluation of nutrition education
and obesity prevention programs, and to help minimize any disruption
to services in the Supplemental Nutrition Assistance Program
Education (SNAP-Ed) program during the transition of work from
contracted vendors to the civil service.
SEC. 93. By August 1, 2014, the State Department of Health Care
Services shall establish a work group composed of stakeholders,
including health care providers, county representatives, labor,
health plans and insurance representatives, consumer advocates,
immigrant policy advocates, and employers of low-wage workers to
develop a plan to utilize available Major Risk Medical Insurance Fund
moneys, including moneys in the Managed Care Administrative Fines
and Penalties Fund transferred pursuant to paragraph (2) of
subdivision (c) of Section 1341.45 of the Health and Safety Code, and
any other available funds in the Cigarette and Tobacco Products
Surtax Fund, in order to provide subsidized health care coverage for
individuals not eligible for or receiving comprehensive health care.
SEC. 94. By August 1, 2014, the State Department of Health Care
Services shall work with stakeholders, including consumer advocates,
county representatives, and health care providers, to develop a
notice to be sent or made available to individuals who both (1) are
enrolled in a state health care program administered by the State
Department of Health Care Services that does not provide minimum
essential coverage and (2) have been determined, by the State
Department of Health Care Services, to potentially be eligible for
Medi-Cal or coverage through California Health Benefit Exchange. The
notice shall inform the enrollees that they may qualify for Medi-Cal
or comprehensive coverage through Covered California. The notice
shall also include information about the open enrollment period for
the California Health Benefit Exchange and shall indicate that there
is continuous enrollment for the Medi-Cal program. The notice may be
made available through means that include, but not limited to, health
care provider offices and postings on Internet Web sites.
SEC. 95. (a) Beginning October 2014, the State Department of
Public Health shall, on a quarterly basis, report to the fiscal and
appropriate policy committees of the Legislature and post on its
Internet Web Site all of the following:
(1) Beginning with 2011-12 by fiscal year and by quarter for the
budget year, workload and performance metrics related to the volume,
timeliness of initiation, timeliness of completion, and disposition
of all of the following:
(A) Investigations of complaints related to paraprofessionals
certified by the State Department of Public Health.
(B) Investigations of complaints and entity-reported incidents
related to long-term care facilities licensed or certified by the
State Department of Public Health, including the number of complaint
investigations initiated within 10 days and the number of complaint
investigations prioritized as involving immediate jeopardy initiated
within 24 hours.
(C) State relicensing and federal recertification surveys.
(2) Information on Licensing and Certification Program vacancy
rates and hiring by position classification, including any positions
established administratively.
(3) By October 2016, the State Department of Public Health shall
begin reporting workload and performance metrics related to the
volume, timeliness of initiation, timeliness of completion, and
disposition of complaints for all facility types.
(b) Beginning August 2014, the State Department of Public Health
shall hold semiannual meetings for all interested stakeholders to
provide feedback on improving the Licensing and Certification Program
to ensure that Californians receive the highest quality of medical
care in health facilities. Once they are available under subdivision
(a), the State Department of Public Health shall present the
quarterly workload and performance metrics at these meetings.
(c) The State Department of Public Health shall report to the
fiscal and appropriate policy committees of the Legislature and post
on its Internet Web site, all of the following:
(1) By October 2014, the status and use of the $1.4 million
appropriated in the 2014-15 fiscal year from the Internal
Departmental Quality Improvement Account for the Licensing and
Certification Program Evaluation and the outcomes from this effort.
The State Department of Public Health shall report on the status of
the fund thereafter in the Licensing and Certification Estimate.
(2) By October 2014, and in the Licensing and Certification
Program November Licensing and Certification Estimate, for the
2015-16 fiscal year an update on the State Department of Public
Health's efforts to evaluate and reform the Licensing and
Certification Program timekeeping systems and estimate methodology.
(3) By October 2014, and annually thereafter in the Licensing and
Certification Program Estimate, an update on the Los Angeles County
contract and Licensing and Certification's oversight of this
contract.
(4) By December 1, 2014, an assessment of the possibilities of
using professional position classifications other than Health
Facility Evaluator Nurses to perform licensing and certification
survey or complaint workload.
(d) Any reports required to be submitted to the fiscal and
appropriate policy committees of the Legislature pursuant to this
section shall be submitted notwithstanding Section 10231.5 of the
Government Code.
SEC. 96. The Legislature finds and declares that Section 45 of
this act clarifies procedures and terms of the Mental Health Services
Act within the meaning of Section 18 of the Mental Health Services
Act.
SEC. 97. The Legislature finds and declares all of the following:
(a) During the 2009-10 Regular Session of the Legislature, the
Legislature enacted Assembly Bill 2599 (Chapter 267 of the Statutes
of 2011), which, among other things, recognizes the importance of
facilitating the success of a new, nonprofit hospital to serve the
population of South Los Angeles that was formerly served by the Los
Angeles County Martin Luther King, Jr.-Harbor Hospital.
(b) It remains the intent of the Legislature that adequate and
predictable funding in support of the new hospital be provided
through current Medi-Cal funding or equivalent funding under
successor or modified Medi-Cal payment systems, for purposes related
to meeting the health care needs of the population formerly served by
the Los Angeles County Martin Luther King, Jr.-Harbor Hospital.
(c) It is the intent of the Legislature that the State Department
of Health Care Services, the County of Los Angeles, and the new,
nonprofit hospital operating on the site of the former Los Angeles
County Martin Luther King, Jr.-Harbor Hospital campus shall annually
determine the best means to provide funding to the new hospital in a
manner that will be federally approved.
(d) It is the intent of the Legislature that funding to the new
hospital will be claimed and provided in a manner that maximizes
federal Medicaid funding to the state by considering the overall
aggregate impact on funding with respect to Medi-Cal hospital
providers in the state.
SEC. 98. Through its courts, statutes, and under its Constitution,
California protects a woman's right to reproductive privacy. The
Legislature hereby reaffirms these protections and specifically the
California Supreme Court decisions in People v. Belous (1969) 71
Cal.2d 954, Committee To Defend Reproductive Rights v. Myers (1981)
29 Cal.3d 252, and American Academy of Pediatrics v. Lungren (1997)
16 Cal.4th 307. It is the intent of the Legislature that this act not
be interpreted to limit a woman's rights under the California
Constitution and these California Supreme Court decisions.
SEC. 99. The Legislature finds and declares that Section 2 of
this act, which amends Section 6254 of the Government Code, imposes a
limitation on the public's right of access to the meetings of public
bodies or the writings of public officials and agencies within the
meaning of Section 3 of Article I of the California Constitution.
Pursuant to that constitutional provision, the Legislature makes the
following findings to demonstrate the interest protected by this
limitation and the need for protecting that interest:
In order to protect the confidentiality of certain negotiations,
negotiated rates, and privileged work product, it is necessary that
this act limit the public's right of access to that information.
SEC. 100. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
SEC. 101. This act is a bill providing for appropriations related
to the Budget Bill within the meaning of subdivision (e) of Section
12 of Article IV of the California Constitution, has been identified
as related to the budget in the Budget Bill, and shall take effect
immediately.