Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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. Under existing law, home- and community-based services (HCBS) approved by the United States Department of Health and Human Services are covered for eligible individuals to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with certain federal provisions. Existing law authorizes the Director of Health Care Services to seek waivers for any or all approvable HCBS. Existing law sets forth provisions for the implementation of the Nursing Facility/Acute Hospital Transition and Diversion Waiver, which is the predecessor of the Home and Community-Based Alternatives (HCBA) Waiver, for purposes of providing care management services to individuals who are at risk of nursing facility or institutional placement. This bill would recast those provisions to refer to the HCBA Waiver. The bill would delete a provision authorizing the expansion of the number of waiver slots up to 5,000 additional slots, and would instead require the enrollment of all eligible individuals who apply for the HCBA Waiver. The bill would require the department, by March 1, 2026, to seek any necessary amendments to the waiver to ensure that there is sufficient capacity to enroll all eligible individuals who are currently on a waiting list for the waiver, as specified. The bill would require the department, by March 1, 2026, to submit a rate study to the appropriate fiscal and policy committees of the Legislature addressing the sustainability, quality, and transparency of rates for the HCBA Waiver. The bill would require that the study include an assessment of the effectiveness of the methods used to pay for services under the waiver, with consideration of certain factors. The bill would make related legislative findings.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, housing transition navigation services, housing deposits, and housing tenancy sustaining services. Existing law, subject to an appropriation, requires the department to complete an independent analysis to determine whether network adequacy exists to obtain federal approval for a covered Medi-Cal benefit that provides housing support services. Existing law requires that the analysis take into consideration specified information, including the number of providers in relation to each region's or county's number of people experiencing homelessness. Existing law requires the department to report the outcomes of the analysis to the Legislature by January 1, 2024. This bill would delete the requirement for the department to complete that analysis, and instead would make housing support services for specified populations a covered Medi-Cal benefit when the Legislature has made an appropriation for purposes of the housing support services. The bill would require the department to seek federal approval for the housing support services benefit, as specified. Under the bill, subject to an appropriation by the Legislature, a Medi-Cal beneficiary would be eligible for those services if they either experience homelessness or are at risk of homelessness. Under the bill, the services would include housing transition navigation services, housing deposits, and housing tenancy sustaining services, as defined. The bill would authorize the department to implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar instruction, and to enter into exclusive or nonexclusive contracts, or amend existing contracts for its purposes, as specified. The bill would authorize these provisions to be modified by the department to the extent necessary to meet the requirements of federal law or regulations, to obtain federal approval, or to enhance the probability that federal approval can be obtained, 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's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law prohibits a contract between a plan or insurer and a dentist from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee's contract or the insured's policy. Existing law requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services. Existing law requires a health care service plan or health insurer to comply with specified timely access requirements. For a specified plan or insurer offering coverage for dental services, existing law requires urgent dental appointments to be offered within 72 hours of a request, nonurgent dental appointments to be offered within 36 business days of a request, and preventive dental care appointments to be offered within 40 business days of a request, as specified. Existing law requires a contract between a health care service plan and health care provider to ensure compliance with network adequacy standards and to require reporting by providers to plans to ensure compliance. Under existing law, a health care service plan is required to annually report to the Department of Managed Health Care on this compliance. Existing law authorizes the Department of Insurance to issue guidance to insurers regarding annual timely access and network reporting methodologies. If a health care service plan or health insurer pays a contracting dental provider directly for covered services, this bill would require the plan or insurer to pay a noncontracting dental provider directly for covered services if the noncontracting provider submits to the plan or insurer a written assignment of benefits form signed by the enrollee or insured. The bill would require the plan or insurer to provide a predetermination or prior authorization to the dental provider and to reimburse the provider for not less than that amount, except as specified. The bill would require the plan or insurer to notify the enrollee or insured that the provider was paid and that the out-of-network cost may count towards their annual or lifetime maximum. The bill would require a noncontracting dental provider to make specified disclosures to an enrollee or insured before accepting an assignment of benefits. This bill would require specified plans and insurers that cover dental services to offer urgent dental appointments within 48 hours of a request, nonurgent dental appointments within 18 business days of a request, and preventive dental care appointments within 20 business days of a request, as specified. The bill would subject dentists to the relevant department's regulatory geographic accessibility standards. The bill would require plans and insurers to report comprehensive information regarding the networks that each dental provider serves. The bill would require the Department of Managed Health Care or the Department of Insurance to review the adequacy of an entire dental provider network, including the portions of the network serving plans and insurers not regulated by the respective department. Because a willful violation of the above-described provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. 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.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 law, the Medi-Cal Long-Term Care Reimbursement Act, requires the department, subject to any necessary federal approvals, for managed care rating periods that begin between January 1, 2023, and December 31, 2026, inclusive, to establish and implement the Workforce and Quality Incentive Program. Under that program, a network provider furnishing skilled nursing facility services to a Medi-Cal managed care enrollee is authorized to earn performance-based directed payments from the Medi-Cal managed care plan with which they contract, as specified, in addition to other certain payments. This bill would remove from the above-described provision the qualification that the provider be within the network. The bill would make conforming changes to related provisions. Under the bill, pursuant to conditions of eligibility for directed payments under certain federal regulations, payments made under the Workforce and Quality Incentive Program would be retroactively calculated and paid based on the total number of days, effective July 9, 2024, during which the facility provided services to Medi-Cal beneficiaries, regardless of whether the facility was a network provider.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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. Under existing law, community health worker (CHW) services are a covered Medi-Cal benefit subject to any necessary federal approvals. CHW is defined as a liaison, link, or intermediary between health and social services and the community to facilitate access to services and to improve the access and cultural competence of service delivery. Existing law requires a Medi-Cal managed care plan to engage in outreach and education efforts to enrollees with regard to the CHW services benefit, as specified. Existing law requires the department to inform stakeholders about implementation of the benefit. This bill would require the department to annually conduct an analysis of the CHW services benefit, submit the analysis to the Legislature, and publish the analysis on the department's internet website, with the first analysis due July 1, 2027. The bill would require the analysis to include, at a minimum, an assessment of the above-described outreach and education efforts conducted by each Medi-Cal managed care plan, an assessment of the CHW benefit utilization and services, a demographic disaggregation of CHWs providing the CHW benefit and the Medi-Cal beneficiaries receiving services, and data on Medi-Cal reimbursements for CHW services billed to the department, as specified.
Existing law requires the State Department of Public Health to conduct various programs related to disease prevention and health promotion, including a program for identifying, screening, and providing followup care related to exposure to diethylstilbestrol while pregnant, which can cause fetal abnormalities. Existing law states the intention of the Legislature to fund this program in subsequent fiscal years through the normal budgetary process. This bill would direct, upon appropriation of funds, as specified, the State Department of Public Health, by January 1, 2028, to develop and administer a program related to drug-induced movement disorder awareness, as specified. The bill would repeal the program on January 1, 2032. The bill would include related findings and declarations.
Existing law establishes various public social services programs under the jurisdiction of the State Department of Social Services, including, among others, the California Work Opportunity and Responsibility to Kids (CalWORKs) program, the CalFresh program, the California Food Assistance Program (CFAP) , the In-Home Supportive Services (IHSS) program, and the Cash Assistance Program for Immigrants (CAPI) . Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 law, the Knox-Keene Health Care Service Plan Act of 1975, requires a health care service plan to provide an enrollee who has been displaced or whose health may otherwise be affected by a state of emergency, as declared by the Governor, or a health emergency, as declared by the State Public Health Officer, with access to medically necessary health care services, as specified. This bill would require the State Department of Social Services, for purposes of CalWORKs, CalFresh, CFAP, IHSS, and CAPI, and the State Department of Health Care Services, for Medi-Cal purposes, to provide continuous eligibility for the applicable programs to a recipient or beneficiary who has been affected by a state of emergency, including through displacement. For Medi-Cal purposes, the bill would specify additional qualifying circumstances, including certain disruptions in providers, infrastructure, or other services, and would also require this continuous eligibility in the case of effect an by a health emergency. The bill would authorize the State Department of Health Care Services to implement these Medi-Cal provisions by providing continuous eligibility to all Medi-Cal beneficiaries within a geographic region where the department finds that multiple Medi-Cal beneficiaries within the geographic region have experienced any of these circumstances due to a state of emergency or health emergency. Under the bill, the continuous eligibility would maintain a recipient's or beneficiary's current scope of benefits under the applicable program for certain timelines. The bill would require the 2 departments to implement the continuous eligibility through automated programming of eligibility systems, with notifications, as specified. The bill would require a county to immediately restore eligibility for the applicable program for any recipient or beneficiary whose eligibility was discontinued and who informs the county that they have been impacted as described above, without requesting any further verifications from the recipient or beneficiary. In the case of CalWORKs, CalFresh, CFAP, IHSS, and CAPI, if a recipient fails to submit a semiannual report or an annual redetermination or recertification of eligibility, if applicable, the bill would require the county to determine that the recipient had good cause for failing to submit that information. The bill would set forth related provisions for the county, the State Department of Social Services, and the Director of Social Services. Under the bill, these provisions would be implemented only to the extent not in conflict with federal law. The bill would authorize the Director of Social Services to waive, subject to receipt of any necessary federal approvals, the enforcement of specific federal requirements, regulations, or standards necessary to implement the above-described applicable provisions. Under the bill, implementation of the Medi-Cal provisions would be conditioned on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would authorize the Director of Social Services or the Director of Health Care Services to issue county directives regarding compliance with the respective provisions. By creating new duties for counties with regard to eligibility for the above-described programs, the bill would impose a state-mandated local program. Existing law continuously appropriates moneys from the General Fund to defray a portion of county costs under the CalWORKs program. This bill would instead provide that the continuous appropriation would not be made for purposes of implementing these provisions. 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, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
Existing law establishes the Tobacco Education and Research Oversight Committee (TEROC) to advise the State Department of Public Health and the State Department of Education with respect to policy development, integration, and evaluation of tobacco education programs funded under specified provisions. This bill would require TEROC to develop and oversee a statewide community education plan to translate, disseminate, and apply research findings from the Tobacco-Related Disease Research Program related to teenage vaping and nicotine cessation. The bill would require TEROC to develop a plan to identify and share best practices on effective, developmentally appropriate nicotine cessation strategies for youth, as specified. The bill would also require the State Department of Public Health to establish a pilot program in the County of Los Angeles, the County of Sacramento, and the County of Santa Clara to, among other things, implement targeted intervention programs for youth under 21 years of age who are addicted to nicotine and to prioritize developmentally appropriate cessation strategies over traditional nicotine replacement therapies.
Existing law authorizes a county to establish a homeless adult and family multidisciplinary personnel team, as defined, with the goal of facilitating the expedited identification, assessment, and linkage of homeless individuals to housing and supportive services within that county and to allow provider agencies to share confidential information for the purpose of coordinating housing and supportive services to ensure continuity of care. This bill would authorize a county to also establish a behavioral health multidisciplinary personnel team, as defined, with the goal of facilitating the expedited identification, assessment, and linkage of a justice-involved person, as defined, diagnosed with a mental illness to supportive services within that county while incarcerated and upon release from county jail and to allow provider agencies and members of the personnel team to share confidential information, as specified, for the purpose of coordinating supportive services to ensure continuity of care. The bill would require the sharing of information permitted under these provisions to be governed by protocols developed in each county, as specified. This bill would authorize a behavioral health multidisciplinary personnel team to designate a qualified person to be a member of the team for a particular case and would require a member who receives information or records regarding a justice-involved person in their capacity as a member of the team to be under the same privacy and confidentiality obligations and subject to the same confidentiality penalties as the person disclosing or providing the information or records. The bill would also require the information or records to be maintained in a manner that ensures the maximum protection of privacy and confidentiality rights.
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 provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth specified prior authorization limitations for health care service plans and health insurers. This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, that provides coverage for physical therapy from imposing prior authorization for the initial 12 physical therapy treatment visits for a new condition. The bill would authorize prior authorization for physical therapy for a recurring condition, as specified. The bill would require a physical therapy provider to verify an enrollee's or an insured's coverage and disclose their share of the cost of care, as specified. The bill would require a physical therapy provider to obtain separate written consent for costs that may not be covered by the enrollee's or insured's plan contract or policy, that includes a written estimate of the cost of care for which the enrollee or insured is responsible if coverage is denied or otherwise not applicable. With respect to health care service plans, the bill would specify that its provisions do not apply to Medi-Cal managed care plan contracts. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program. 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.
