Existing law, the federal Patient Protection and Affordable Care Act, requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that makes available qualified health plans to qualified individuals and small employers. Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. 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 also provides for the regulation of health insurers by the Department of Insurance. Under existing law, carriers that sell any products outside the California Health Benefit Exchange (Exchange) are required to fairly and affirmatively offer, market, and sell all products made available to individuals or small employers in the Exchange to individuals or small employers, respectively, purchasing coverage outside the Exchange. Existing law also requires carriers that participate in the Exchange to fairly and affirmatively offer, market, and sell in the Exchange at least one product within 5 levels of specified coverage. This bill would exempt a bridge plan product, as defined, from that latter requirement. This bill would, among other things, also require the Exchange to enter into contracts with and certify as a qualified health plan bridge plan products that meet specified requirements, including being a Medi-Cal managed care plan. The bill would also require the Exchange to make available bridge plan products to eligible individuals. The bill would authorize the Exchange, after consulting with stakeholders, to adopt regulations to implement those provisions, and until January 1, 2016, exempt the adoption, amendment, or repeal of those regulations from the Administrative Procedure Act. The bill would require the Exchange to annually prepare a specified written report on the implementation and performance of the Exchange functions during the preceding fiscal year, and to prepare, or contract for the preparation of, an evaluation of the bridge plan program using the first 3 years of experience with the program, as specified. The bill would authorize a health care service plan or insurance carrier offering a bridge plan product in the Exchange to limit the products it offers in the Exchange to the bridge plan product, except as required by federal law. The bill would define "bridge plan product" as an individual health benefit plan offered by a licensed health care service plan or health insurer that contracts with the Exchange, as specified. The bill would also require the State Department of Health Care Services to impose specified requirements in its contracts with a health care service plan or health insurer to provide Medi-Cal managed care coverage but would authorize the department to contract with the Exchange to delegate the implementation of those provisions. The bill would require the Exchange to seek federal approval to allow specified individuals the option to enroll in a different bridge plan product if the individual's primary care provider is included in the contracted network of the different bridge plan product and either the bridge plan product for which the individual is eligible is not offered in that individual's service area or is not offered as a bridge plan product by the Exchange. The bill would provide that its provisions would become inoperative on the October 1 that is 5 years after the date that federal approval of the bridge plan option occurs.
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Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, 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. This bill would, commencing January 1, 2014, implement various provisions of the federal Patient Protection and Affordable Care Act (Affordable Care Act) , as amended, by, among other things, modifying provisions relating to determining eligibility for certain groups. The bill would, in this regard, extend Medi-Cal eligibility to specified former foster children. The bill would also add, commencing January 1, 2014, mental health services and substance use disorder services included in the essential health benefits package, as adopted by the state and approved by the United States Secretary of Health and Human Services, to the schedule of Medi-Cal benefits, as specified. The bill would require the department to seek approval from the United States Secretary of Health and Human Services to provide, effective January 1, 2014, specified individuals with an alternative benefit package, which would provide the same schedule of benefits provided to full-scope Medi-Cal beneficiaries qualifying under the modified adjusted gross income (MAGI) income standard, except as specified. The bill would provide that the implementation of the optional expansion of Medi-Cal benefits to adults who meet specified eligibility requirements shall be contingent on the federal medical assistance percentage (FMAP) payable to the state under the Affordable Care Act not being reduced to specified percentages, as specified. Because counties are required to make Medi-Cal eligibility determinations and this bill would expand Medi-Cal eligibility, the bill would impose a state-mandated local program. This bill would require that a person who wishes to apply for an insurance affordability program, as defined, be allowed to file an application on his or her own behalf or on behalf of his or her family and would authorize a person to be accompanied, assisted, and represented in the application and renewal process by an individual or organization of his or her choice. This bill would also require the department, to the extent required by federal law, to provide assistance to any applicant or beneficiary who requests help with the application or redetermination. The bill would require the department to file a state plan amendment to exercise a federal option to allow beneficiaries to use projected annual household income and to allow applicants and beneficiaries to use reasonably predictable annual income, as specified. This bill would require the department to seek any federal waivers necessary to use eligibility information of certain individuals who have been determined eligible for the CalFresh program to determine their eligibility for Medi-Cal and to automatically enroll parents who apply for Medi-Cal who have one or more children who are eligible based on determined income level at or below a specified standard. The bill would authorize the department to seek any federal waivers or state plan amendments necessary to use the eligibility information of individuals determined eligible for other state-only funded health care programs and county general assistance programs to determine an applicant's Medi-Cal eligibility to the extent that there is no General Fund impact. This bill would require the department to provide Medi-Cal benefits during the presumptive eligibility period to individuals who have been determined eligible on the basis of preliminary information by a qualified hospital, as specified. Existing law requires the department to adopt regulations for use by the county in determining whether an applicant is a resident of the state and of the county, subject to the requirements of federal law. Existing law requires that the regulations require that state residency be established only if certain requirements are met, including the requirement that the applicant makes specified declarations under penalty of perjury. This bill would revise those provisions to, among other things, further prescribe the circumstances under which state residency may be established and to require the department to electronically verify an individual's state residency using certain sources and would set forth how an individual may establish state residency if the department is unable to electronically verify his or her state residency. The bill would, for purposes of establishing state residency, authorize an individual to make various declarations under penalty of perjury, and would authorize other individuals, such as parents or legal guardians, to make various declarations under penalty of perjury regarding the individual's state residency if the individual is incapable of indicating intent. By expanding the crime of perjury, the bill would impose a state-mandated local program. This bill would provide that any individual who is 21 years of age or older, does not have minor children eligible for Medi-Cal benefits, would be eligible for Medi-Cal benefits but for a specified five-year eligibility limitation, and who is enrolled in and covered through the California Health Benefit Exchange with an advanced premium tax credit shall be eligible for specified Medi-Cal benefits and insurance premium costs and cost-sharing charges paid by the department, as specified. Under existing law, one of the ways by which Medi-Cal services are provided is pursuant to contracts with various types of managed care plans. This bill would require Medi-Cal managed care plans to provide mental health benefits covered by the state plan, as prescribed. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that with regard to certain mandates no reimbursement is required by this act for a specified reason. With regard to any other mandates, this bill would provide that, if the Commission on State Mandates determines that the bill contains costs so mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above. This bill would become operative only if AB 1 of the First Extraordinary Session is enacted and takes effect.
(1) Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA) , enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires each health insurance issuer that offers health insurance coverage in the individual or group market in a state to accept every employer and individual in the state that applies for that coverage and to renew that coverage at the option of the plan sponsor or the individual. PPACA prohibits a group health plan and a health insurance issuer offering group or individual health insurance coverage from imposing any preexisting condition exclusion with respect to that plan or coverage. PPACA allows the premium rate charged by a health insurance issuer offering small group or individual coverage to vary only by rating area, age, tobacco use, and whether the coverage is for an individual or family and prohibits discrimination against individuals based on health status, as specified. PPACA requires an issuer to consider all enrollees in its individual market plans to be part of a single risk pool and to consider all enrollees in its small group market plans to be part of a single risk pool, as specified. PPACA also requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers, 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 plans offering coverage in the individual market to offer coverage for a child subject to specified requirements. Existing law establishes the California Health Benefit Exchange (Exchange) to facilitate the purchase of qualified health plans through the Exchange by qualified individuals and qualified small employers by January 1, 2014. This bill would require a health care service plan, on and after October 1, 2013, to offer, market, and sell all of the plan's health benefit plans that are sold in the individual market for policy years on or after January 1, 2014, to all individuals and dependents in each service area in which the plan provides or arranges for the provision of health care services, as specified, but would require plans to limit enrollment in individual health benefit plans to specified open enrollment and special enrollment periods. The bill would prohibit these health care service plans from imposing any preexisting condition exclusion upon any individual and from conditioning the issuance or offering of individual health benefit plans on any health status-related factor, as specified. The bill would require a health care service plan to consider the claims experience of all enrollees of its nongrandfathered individual health benefit plans offered in the state to be part of a single risk pool, as specified, would require the plan to establish a specified index rate for that market, and would authorize the plan to vary premiums from the index rate based only on specified factors. The bill would authorize plans to use only age, geographic region, and family size for purposes of establishing rates for individual health benefit plans, as specified. The bill would require plans to provide specified information regarding the Exchange to applicants for and subscribers of individual health benefit plans offered outside the Exchange. The bill would prohibit a plan from advertising or marketing an individual grandfathered health plan for the purpose of enrolling a dependent of the subscriber in the plan and would also require plans to annually issue a specified notice to subscribers enrolled in a grandfathered plan. The bill would authorize the director to require a plan to discontinue offering individual plan contracts if the director determines the plan does not have sufficient financial viability or organizational capacity, as specified. The bill would make certain of these provisions inoperative if, and 12 months after, specified provisions of PPACA are repealed or amended, as specified. Existing law requires health care service plans to guarantee issue their small employer health benefit plans, as specified. With respect to nongrandfathered small employer health benefit plans for plan years on or after January 1, 2014, among other things, existing law provides certain exceptions from the guarantee issue requirement, allows the premium for small employer health benefit plans to vary only by age, geographic region, and family size, as specified, and requires plans to provide special enrollment periods and coverage effective dates consistent with the individual nongrandfathered market in the state. Existing law provides that these provisions shall be inoperative if specified provisions of PPACA are repealed. This bill would modify the small employer special enrollment periods and coverage effective dates for purposes of consistency with the individual market reforms described above. The bill would also modify the exceptions from the guarantee issue requirement and the manner in which a plan determines premium rates for a small employer health benefit plan, as specified. The bill would also require a plan to consider the claims experience of all enrollees of its nongrandfathered small employer health benefit plans offered in this state to be part of a single risk pool, as specified, would require the plan to establish a specified index rate for that market, and would authorize the plan to vary premiums from the index rate based only on specified factors. The bill would make certain of these provisions inoperative, as specified, if, and 12 months after, specified provisions of PPACA are repealed. Because a willful violation of these requirements with respect to health care service plans would be a crime, the bill would impose a state-mandated local program. (2) PPACA requires a state or the United States Secretary of Health and Human Services to implement a risk adjustment program for the 2014 benefit year and every benefit year thereafter, under which a charge is assessed on low actuarial risk plans and a payment is made to high actuarial risk plans, as specified. If a state that elects to operate an American Health Benefit Exchange elects not to administer this risk adjustment program, the secretary will operate the program and issuers will be required to submit data for purposes of the program to the secretary. This bill would require that any data submitted by health care service plans to the secretary for purposes of the risk adjustment program also be submitted to the Department of Managed Health Care in the same format. The bill would require the department to use that data for specified purposes. (3) PPACA requires health insurance issuers to provide a summary of benefits and coverage explanation pursuant to specified standards to applicants and enrollees or policyholders. Existing law requires health care service plans to use disclosure forms that contain specified information regarding the contracts issued by the plan, including the benefits and coverage of the contract, and the exceptions, reductions, and limitations that apply to the contract. Existing law requires health care service plans that offer individual or small group coverage to also provide a uniform health plan benefits and coverage matrix containing the plan's major provisions, as specified. This bill would require that certain health care service plan contracts satisfy these requirements by providing a uniform summary of benefits and coverage required by federal law. (4) This bill would become operative only if AB 2 of the 2013–14 First Extraordinary Session is enacted and becomes effective. (5) 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.
This measure would designate April 7 to 13, 2013, inclusive, as Cancer Prevention Week, and would encourage individuals to participate in the Cancer Prevention Study - 3.
Existing law regulates general acute care hospitals, acute psychiatric hospitals, and special hospitals, as defined. Existing law required, by January 1, 2002, the State Department of Public Health to adopt regulations establishing the minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit for general acute care hospitals, acute psychiatric hospitals, and special hospitals. Existing law requires these ratios to constitute the minimum number of registered and licensed nurses that shall be allocated and additional staff to be assigned in accordance with a documented patient classification system for determining nursing requirements. Existing law requires the department to promulgate regulations that include specified criteria for the purpose of assessing an administrative penalty against general acute care hospitals, acute psychiatric hospitals, and special hospitals. Existing law authorizes the department to assess a licensee of these hospitals an administrative penalty, as specified, for a violation of existing law or for a deficiency constituting an immediate jeopardy violation, except that no penalty shall be assessed if it is a minor violation. Existing law provides that a person who willfully or repeatedly violates a rule or regulation adopted pursuant to these provisions is guilty of a misdemeanor. This bill would eliminate the requirement that the department promulgate regulations to assess an administrative penalty, as well as associated provisions, and instead would require the department to use the specified criteria to determine the amount of the administrative penalty. This bill would require general acute care hospitals to maintain a patient classification system that is reviewed and updated annually. By requiring general acute care hospitals to maintain a patient classification system, this bill would expand the definition of a crime and would impose a state-mandated local program. Existing law requires that every health facility for which a license or special permit has been issued shall be periodically inspected by the State Department of Public Health, or by another governmental entity under contract with the department. Existing law requires the department to inspect the facility for compliance with provisions of state law and regulations during a state periodic inspection, or at the same time as a federal periodic inspection. This bill would require the inspections to include review of compliance with state requirements for staffing, including the regulations adopted by the department establishing nurse-to-patient ratios and regulations regarding patient classification systems. 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.
Commencing January 1, 2014, existing law, the federal Patient Protection and Affordable Care Act (PPACA) , requires a health insurance issuer that offers coverage in the small group or individual market to ensure that such coverage includes the essential health benefits package, as defined. PPACA requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers by January 1, 2014. Existing law provides for the regulation of health insurers by the Department of Insurance and requires health insurance policies to cover various benefits. This bill would require an individual or small group health insurance policy issued, amended, or renewed on or after January 1, 2014, to cover essential health benefits, which would be defined to include the health benefits covered by particular benchmark plans. The bill would prohibit treatment limits imposed on these benefits from exceeding the corresponding limits imposed by the benchmark plans and would generally prohibit an insurer from making substitutions of the benefits required to be covered. The bill would specify that these provisions apply regardless of whether the policy is offered inside or outside the Exchange but would provide that they do not apply to grandfathered plans or plans that cover excepted benefits, as specified. The bill would prohibit a health insurer, when issuing, delivering, renewing, offering, selling, or marketing a policy, from indicating or implying that the policy covers essential health benefits unless the policy covers essential health benefits as provided in the bill. The bill would authorize the Department of Insurance to adopt emergency regulations implementing these provisions until March 1, 2016, and enact other related provisions. These provisions would only be implemented to the extent essential health benefits are required pursuant to PPACA. The bill would provide that it shall become operative only if AB 1453 is also enacted.
Existing law provides for licensing and regulation of health care service plans by the Department of Managed Health Care. Existing law provides for licensing and regulation of health insurers by the Insurance Commissioner. Existing law requires the department and the commissioner to establish an independent medical review system under which a patient may seek an independent medical review whenever health care services have been denied, modified, or delayed by a health care service plan or health insurer and the patient has previously filed a grievance that remains unresolved after 30 days. Existing law requires medical professionals selected by an independent medical review organization to review medical treatment decisions to meet certain minimum requirements, including that the medical professional be a clinician knowledgeable in the treatment of the patient's medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of treatment under review. Existing law requires a plan or insurer to provide a one-page application form to an enrollee or insured to be used to initiate a review pursuant to these provisions. This bill would make certain changes to requirements applicable to an independent medical review organization, effective on July 1, 2015. The bill would require the medical professional to be a clinician expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating patients with the same or similar condition. The bill would require the application form provided to an enrollee or insured seeking independent review to be one or 2 pages and to include a section designed to collect information on the enrollee's or insured's ethnicity, race, and primary language spoken, which would be provided at the option of the enrollee or insured and used only for statistical purposes. Existing law requires the Director of Managed Health Care and the Insurance Commissioner to adopt the determination of an independent medical review organization as a director or commissioner decision. Existing law requires the decisions to be made available, on request, to the public at cost. Existing law requires certain information to be removed from the decision, including the name of the health plan. This bill would require the decisions to be made available at no charge in a searchable database on the Internet Web site of the Department of Managed Health Care or the Department of Insurance, as applicable, and would require the databases to include other specified information. These requirements would also become effective on July 1, 2015.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensing 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 Insurance Commissioner. Except as specified, existing law prohibits a provider of health care, a health care service plan, or contractor from disclosing medical information regarding a patient of the provider of health care or an enrollee or subscriber of a health care service plan without first obtaining an authorization. Existing law, the federal Patient Protection and Affordable Care Act (PPACA) , requires the Secretary of Health and Human Services to make available to qualified entities, as defined, specified claims data relating to Medicare in order to evaluate the performance of providers and suppliers. Existing federal regulations require a qualified entity, as defined, to comply with specified requirements for Medicare claims data error correction. This bill would provide that no contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health care service plan or a health insurer and a provider or supplier, as specified, shall prohibit, condition, or in any way restrict the disclosure of claims data related to health care services provided to specified individuals, to a qualified entity, as defined. The bill would require a health care service plan or health insurer to comply with all state and federal laws and implementing regulations for the protection of data privacy and security. Because a willful violation of these requirements by a health care service plan would constitute a crime, the bill would impose a state-mandated local program. This bill would further require a qualified entity, as defined, to comply with specified requirements for error correction for all claims data received, including data received from sources other than Medicare. Because a willful violation of the act by a health care service plan would constitute 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 federal law, the federal Patient Protection and Affordable Care Act (PPACA) enacts various health care coverage market reforms that take effect January 1, 2014. Among other things, PPACA requires each health insurance issuer that offers health insurance coverage in the individual or group market in a state to accept every employer and individual in the state that applies for that coverage and to renew that coverage at the option of the plan sponsor or the individual. PPACA prohibits a group health plan and a health insurance issuer offering group or individual health insurance coverage from imposing any preexisting condition exclusion with respect to that plan or coverage. PPACA allows the premium rate charge by a health insurance issuer offering small group or individual coverage to vary only by family composition, rating area, age, and tobacco use, as specified, and prohibits discrimination against individuals based on health status. Existing law provides for the regulation of health insurers by the Insurance Commissioner and requires insurers offering coverage in the individual market to offer coverage for a child subject to specified requirements. This bill would require a health insurer, on and after October 1, 2013, to offer, market, and sell all of the insurer's health benefit plans that are sold in the individual market to all individuals and dependents in each service area in which the insurer provides or arranges for the provision of health care services, with coverage effective on or after January 1, 2014, as specified, but would require insurers to limit enrollment in individual health benefit plans to specified open enrollment and special enrollment periods. The bill would prohibit these health benefit plans from imposing any preexisting condition upon any individual. Commencing January 1, 2014, the bill would prohibit a health insurer from establishing rules of eligibility for individual health benefit plans on any health status-related factor, as specified, and would authorize insurers to use only age, geographic region, and whether the plan covers an individual or family for purposes of establishing rates for individual health benefit plans, as specified. The bill would require a health insurer to issue a specified notice at least 60 days prior to the renewal date of an individual grandfathered health plan to all subscribers and policyholders of the plan. The bill would make certain of these provisions inoperative if the corresponding provisions of PPACA are repealed and would make other conforming changes. The bill would provide that it shall become operative only if AB 1461 is also enacted.