Healthcare (Medicare)

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 by, and funded pursuant to, federal Medicaid program provisions. Existing law sets forth different mechanisms for health care coverage for individuals, including the Medi-Cal program, the federal Medicare Program, an employer-sponsored plan, and a plan through the California Health Benefit Exchange, also known as Covered California. Existing law imposes various taxes on residents, such as sales and use taxes and personal income tax, and authorizes cities and counties to impose local sales and use taxes in conformity with the Sales and Use Tax Law. This bill would state that every person who is a resident subject to a tax and whose income is at or below 138% of the federal poverty level using the modified adjusted gross income methodology, as specified, is entitled to access to the public health care coverage their tax dollars support. The bill would require the State Department of Health Care Services to ensure that these individuals have access to public health care coverage through programs it administers, including Medi-Cal. To the extent that these provisions would alter the population of beneficiaries for Medi-Cal, the bill would impose a state-mandated local program. The bill would make related findings and declarations. 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 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 through various delivery systems, including fee-for-service and managed care. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law establishes the California Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services for older individuals under the state's Medi-Cal State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the department, and PACE organizations. Existing law requires the department to pay capitation rates to health plans participating in the Medi-Cal managed care program using actuarial methods. Existing law requires the department to develop and pay capitation rates to entities contracted pursuant to the PACE program, using actuarial methods consistent with those provisions, with specified exceptions. Existing law requires the department to consult with those contracted entities in developing a rate methodology. This bill would require the department to notify the contracting PACE organization of the proposed rates at least 60 days prior to submission to the federal Centers for Medicare and Medicaid Services (CMS) for approval. The bill would authorize the department to define a reasonable date by which the PACE organization must submit written questions or feedback concerning the proposed rates. The bill would require the department to respond in writing to those questions or feedback by no later than 30 days prior to submitting the rates to CMS.

Existing federal law provides for the 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. Existing federal law specifies parts of Medicare that cover specific services, such as Medicare Part B, which generally covers medically necessary services and supplies and preventive services. 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 federal law additionally provides for the issuance of Medicare supplement policies or certificates, also known as Medigap coverage, which are advertised, marketed, or designed primarily as a supplement to reimbursements under the Medicare Program for the hospital, medical, or surgical expenses of persons eligible for the Medicare Program, including coverage of Medicare deductible, copayment, or coinsurance amounts, as specified. Existing law, among other provisions, requires supplement benefit plans to be uniform in structure, language, designation, and format with the standard benefit plans, as prescribed. Existing law prohibits an issuer from denying or conditioning the offering or effectiveness of any Medicare supplement contract, policy, or certificate available for sale in this state, or discriminating in the pricing of a contract, policy, or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant in the case of an application that is submitted prior to or during the 6-month period beginning with the first day of the first month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B. Existing law requires an issuer to make available specified Medicare supplement benefit plans to a qualifying applicant under those circumstances who is 64 years of age or younger who does not have end stage renal disease. This bill would delete the exclusion of otherwise qualified applicants who have end stage renal disease, thereby making the specified Medicare supplement benefit plans available to those individuals. The bill, on and after January 1, 2027, would prohibit an issuer of Medicare supplement coverage in this state from denying or conditioning the issuance or effectiveness of any Medicare supplement coverage available for sale in the state, or discriminate in the pricing of that coverage because of the health status, claims experience, receipt of health care, medical condition, or age of an applicant, except as specified, if an application for coverage is submitted during an open enrollment period, as specified in the bill. The bill would entitle an individual enrolled in Medicare Part B to a 90-day annual open enrollment period beginning on January 1 of each year, as specified, during which period the bill would require applications to be accepted for any Medicare supplement coverage available from an issuer, as specified. The bill would require the open enrollment period to be a guaranteed issue period. The bill would authorize premium rates offered to applicants during the open enrollment period to vary based on the applicants' age at the time of issue, as specified, but would prohibit the premiums from varying based on age after the contract is issued. Because a violation of the bill's requirements 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.

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, including emergency or nonemergency medical or nonmedical transportation services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under this bill, commencing on July 1, 2027, and subject to an appropriation, Medi-Cal fee-for-service reimbursement for nonemergency ambulance transportation services, as defined, would be in an amount equal to 80% of the amount set forth in the federal Medicare ambulance fee schedule for the corresponding level of service, adjusted by the Geographic Practice Cost Index, as specified. The bill would require the department to establish a Medi-Cal managed care directed payment program for nonemergency ambulance transportation services, with the reimbursement rates set in an amount equal to at least the amount set forth under fee-for-service reimbursement. The bill would require the department to maximize federal financial participation in implementing the above-described provisions to the extent allowable. To the extent that federal financial participation is unavailable, the bill would require the department to implement the provisions using state funds, as specified. Under the bill, whenever the medical necessity of nonemergency ambulance transportation services needs to be certified for purposes of Medi-Cal coverage, either a physician or a nonphysician authorized under certain federal regulations would be permitted to complete that certification, as specified. The bill would require the department to revise and update the Medi-Cal provider manual or any guidance, as applicable, to implement this provision. Existing Medi-Cal regulations require that records of medical transportation providers include, among other information, odometer readings at each pickup and delivery location. Under this bill, for purposes of documenting mileage in their records under the Medi-Cal program, medical transportation providers would be authorized to utilize vehicle Global Positioning System (GPS) tracking, digital mapping software or applications, or another reasonable mechanism identified by the department, as specified, in addition to the above-described odometer readings. The bill would require the department to revise and update any corresponding regulations, including the above-described provision.

This measure would declare that the fiscal health of the state's Medi-Cal program is in jeopardy and threatens the health and safety of California residents and would call upon the federal Centers for Medicare and Medicaid Services to initiate an audit of the state's Medi-Cal program to help restore the fiscal health of the program and support the health of California residents.

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. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally requires a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2022, to provide coverage without cost sharing for a colorectal cancer screening test assigned either a grade of A or a grade of B by the United States Preventive Services Task Force and for a required colonoscopy for a positive result on a test with those grades. This bill would additionally require that coverage if the screening test is approved by the United States Food and Drug Administration and either meets requirements for coverage established by the federal Centers for Medicare and Medicaid Services, as specified, or is included in the most recently published guidelines from the American Cancer Society.

This measure would call on the state's Representatives in Congress to support legislation to repeal all of the provisions of the federal One Big Beautiful Bill Act that adversely affect Social Security, Medicare, and Medicaid programs, to oppose privatization of these programs, and to protect and improve these programs, and would call on the President of the United States to immediately restore program staffing levels, to work with Congress to protect and improve these programs, and to disavow any efforts to privatize Social Security.

Existing law requires a hospital to provide patients with a written notice containing information about the availability of the hospital's discount payment and charity care policies, including information about eligibility and the contact information for a hospital employee or office from which a person may obtain further information about these policies. Existing law defines "charity care" and "discount payment" for these purposes. Existing law requires a hospital to provide to the Department of Health Care Access and Information a copy of its discount payment policy, charity care policy, eligibility procedures for those policies, review process, and the application for charity care or discounted payment programs, among other information. A violation of these provisions results in an administrative penalty, as specified. This bill would, commencing July 1, 2027, require a hospital to screen a patient to determine if they meet specific criteria, including that the patient is enrolled in CalFresh or CalWORKs, and, if they do, presumptively determine that a patient is eligible for participation under the hospital's charity care policy and discount payment policy. The bill would require a hospital to screen a patient for eligibility if the patient meets other specified criteria, including, among others, that the patient is uninsured. The bill would prohibit a hospital from requiring a patient to apply for the federal Medicare program, the Medi-Cal program, or other coverage before the patient is screened for or provided with discounted payment, as specified. The bill would require a hospital to provide patients with the ability to opt out of the screening process through a specified form. The bill would authorize a hospital, at its discretion or as established in its charity care policy or discount payment policy, to make presumptive determinations of eligibility or to conduct screening for patients that do not meet the criteria described above. The bill would authorize certain procedures and tools for screening, including, among others, allowing a hospital to use third-party software tools or services or to contract with a third party under specified conditions. The bill would require a hospital to provide a specified written notice to those patients determined to be eligible, presumptively or otherwise, under these provisions and would prohibit any billing statements from being sent prior to the written notice. The bill would require the billing statements to reflect the adjustments made to the patient's hospital charges under the hospital's charity care policy or discount payment policy.