AB 2200: Guaranteed Health Care for All.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2024-04-30
Current Status:
Failed
(2024-05-16: Joint Rule 62(a), file notice suspended. (Page 5215.))
Introduced
In Committee
First Chamber
In Committee
Second Chamber
Enacted
Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), requires each state to establish an American Health Benefit Exchange to facilitate the purchase of qualified health benefit 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, also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under PPACA.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, 1975 (Knox-Keene), 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 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, the California Guaranteed Health Care for All Act, would create the California Guaranteed Health Care for All program, or CalCare, to provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state. Under the bill, CalCare would be a health care service plan subject to Knox-Keene. The bill, among other things, would provide that CalCare cover a wide range of medical benefits and other services and would incorporate the health care benefits and standards of other existing federal and state provisions, including the federal Childrens Health Insurance Program, Medi-Cal, ancillary health care or social services covered by regional centers for persons with developmental disabilities, Knox-Keene, and the federal Medicare Program. The bill would make specified persons eligible to enroll as CalCare members during the implementation period, and would provide for automatic enrollment. The bill would require the board to seek all necessary waivers, approvals, and agreements to allow various existing federal health care payments to be paid to CalCare, which would then assume responsibility for all benefits and services previously paid for with those funds.
This bill would create the CalCare Board to govern CalCare, made up of 9 voting members with demonstrated and acknowledged expertise in health care, and appointed as provided, plus the Secretary of California Health and Human Services or their designee as a nonvoting, ex officio member. The bill would provide the board with all the powers and duties necessary to establish CalCare, including determining when individuals may start enrolling into CalCare, employing necessary staff, negotiating pricing for covered pharmaceuticals and medical supplies, establishing a prescription drug formulary, and negotiating and entering into necessary contracts. The bill would require the board, on or before July 1 of an unspecified year, to conduct and deliver a fiscal analysis to determine whether or not CalCare may be implemented and if revenue is more likely than not to pay for program costs, as specified. The bill would establish an Advisory Commission on Long-Term Services and Supports to advise the board on matters of policy related to long-term services and supports. The bill would require the board to convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare, an Advisory Committee on Public Employees Retirement System Health Benefits to provide recommendations related to public employee retiree health benefits, and a CalCare Health Workforce Working Group to provide the board with input on issues related to health care workforce education, recruitment, and retention. The bill would establish an Office of Health Equity within CalCare and under the direction of the Director of the Department of Health Care Access and Information to ensure health equity under the program and other health programs of the California Health and Human Services Agency and to support the board through specified actions.
This bill would provide for the participation of health care providers in CalCare, including the requirements of a participation agreement between a health care provider and the board, provide for payment for health care items and services, and specify program participation standards. The bill would prohibit a participating provider from discriminating against a person by, among other things, reducing or denying a persons benefits under CalCare because of a specified characteristic, status, or condition of the person.
This bill would prohibit a participating provider from billing or entering into a private contract with an individual eligible for CalCare benefits regarding a covered benefit, but would authorize contracting for a health care item or service that is not a covered benefit if specified criteria are met. The bill would authorize health care providers to collectively negotiate fee-for-service rates of payment for health care items and services using a 3rd-party third-party representative, as provided. The bill would require the board to annually determine an institutional providers global budget, to be used to cover operating expenses related to covered health care items and services for that fiscal year, and would authorize payments under the global budget.
This bill would state the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. The bill would create the CalCare Trust Fund in the State Treasury, as a continuously appropriated fund, consisting of any federal and state moneys received for the purposes of the act. The bill would specify uses for moneys in the CalCare budget, including special projects for which not-for-profit or governmental entities may apply. Because the bill would create a continuously appropriated fund, it would make an appropriation.
This bill would prohibit specified provisions of this act from becoming operative until the Secretary of California Health and Human Services gives written notice to the Secretary of the Senate and the Chief Clerk of the Assembly that the CalCare Trust Fund has the revenues to fund the costs of implementing the act. The California Health and Human Services Agency would be required to publish a copy of the notice on its internet website.
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.
Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), requires each state to establish an American Health Benefit Exchange to facilitate the purchase of qualified health benefit 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, also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under PPACA.
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 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, the California Guaranteed Health Care for All Act, would create the California Guaranteed Health Care for All program, or CalCare, to provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state. The bill, among other things, would provide that CalCare cover a wide range of medical benefits and other services and would incorporate the health care benefits and standards of other existing federal and state provisions, including the federal Childrens Health Insurance Program, Medi-Cal, ancillary health care or social services covered by regional centers for persons with developmental disabilities, Knox-Keene, and the federal Medicare program. Program. The bill would make specified persons eligible to enroll as CalCare members during the implementation period, and would provide for automatic enrollment. The bill would require the board to seek all necessary waivers, approvals, and agreements to allow various existing federal health care payments to be paid to CalCare, which would then assume responsibility for all benefits and services previously paid for with those funds.
This bill would create the CalCare Board to govern CalCare, made up of 9 voting members with demonstrated and acknowledged expertise in health care, and appointed as provided, plus the Secretary of California Health and Human Services or their designee as a nonvoting, ex officio member. The bill would provide the board with all the powers and duties necessary to establish CalCare, including determining when individuals may start enrolling into CalCare, employing necessary staff, negotiating pricing for covered pharmaceuticals and medical supplies, establishing a prescription drug formulary, and negotiating and entering into necessary contracts. The bill would require the board, on or before July 1 of an unspecified year, to conduct and deliver a fiscal analysis to determine whether or not CalCare may be implemented and if revenue is more likely than not to pay for program costs, as specified. The bill would establish an Advisory Commission on Long-Term Services and Supports to advise the board on matters of policy related to long-term services and supports. The bill would require the board to convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare, an Advisory Committee on Public Employees Retirement System Health Benefits to provide recommendations related to public employee retiree health benefits, and a CalCare Health Workforce Working Group to provide the board with input on issues related to health care workforce education, recruitment, and retention. The bill would establish an Office of Health Equity within CalCare and under the direction of the Director of the Department of Health Care Access and Information to ensure health equity under the program and other health programs of the California Health and Human Services Agency and to support the board through specified actions.
This bill would provide for the participation of health care providers in CalCare, including the requirements of a participation agreement between a health care provider and the board, provide for payment for health care items and services, and specify program participation standards. The bill would prohibit a participating provider from discriminating against a person by, among other things, reducing or denying a persons benefits under CalCare because of a specified characteristic, status, or condition of the person.
This bill would prohibit a participating provider from billing or entering into a private contract with an individual eligible for CalCare benefits regarding a covered benefit, but would authorize contracting for a health care item or service that is not a covered benefit if specified criteria are met. The bill would authorize health care providers to collectively negotiate fee-for-service rates of payment for health care items and services using a 3rd-party representative, as provided. The bill would require the board to annually determine an institutional providers global budget, to be used to cover operating expenses related to covered health care items and services for that fiscal year, and would authorize payments under the global budget.
This bill would state the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. The bill would create the CalCare Trust Fund in the State Treasury, as a continuously appropriated fund, consisting of any federal and state moneys received for the purposes of the act. The bill would specify uses for moneys in the CalCare budget, including special projects for which not-for-profit or governmental entities may apply. Because the bill would create a continuously appropriated fund, it would make an appropriation.
This bill would prohibit specified provisions of this act from becoming operative until the Secretary of California Health and Human Services gives written notice to the Secretary of the Senate and the Chief Clerk of the Assembly that the CalCare Trust Fund has the revenues to fund the costs of implementing the act. The California Health and Human Services Agency would be required to publish a copy of the notice on its internet website.
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.
Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), requires each state to establish an American Health Benefit Exchange to facilitate the purchase of qualified health benefit 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, also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under PPACA.
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 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, the California Guaranteed Health Care for All Act, would create the California Guaranteed Health Care for All program, or CalCare, to provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state. The bill, among other things, would provide that CalCare cover a wide range of medical benefits and other services and would incorporate the health care benefits and standards of other existing federal and state provisions, including the federal Childrens Health Insurance Program, Medi-Cal, ancillary health care or social services covered by regional centers for persons with developmental disabilities, Knox-Keene, and the federal Medicare program. The bill would make specified persons eligible to enroll as CalCare members during the implementation period, and would provide for automatic enrollment. The bill would require the board to seek all necessary waivers, approvals, and agreements to allow various existing federal health care payments to be paid to CalCare, which would then assume responsibility for all benefits and services previously paid for with those funds.
This bill would create the CalCare Board to govern CalCare, made up of 9 voting members with demonstrated and acknowledged expertise in health care, and appointed as provided, plus the Secretary of California Health and Human Services or their designee as a nonvoting, ex officio member. The bill would provide the board with all the powers and duties necessary to establish CalCare, including determining when individuals may start enrolling into CalCare, employing necessary staff, negotiating pricing for covered pharmaceuticals and medical supplies, establishing a prescription drug formulary, and negotiating and entering into necessary contracts. The bill would require the board, on or before July 1 of an unspecified year, to conduct and deliver a fiscal analysis to determine whether or not CalCare may be implemented and if revenue is more likely than not to pay for program costs, as specified. The bill would establish an Advisory Commission on Long-Term Services and Supports to advise the board on matters of policy related to long-term services and supports. The bill would require the board to convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare, an Advisory Committee on Public Employees Retirement System Health Benefits to provide recommendations related to public employee retiree health benefits, and a CalCare Health Workforce Working Group to provide the board with input on issues related to health care workforce education, recruitment, and retention. The bill would establish an Office of Health Equity within CalCare and under the direction of the Director of the Department of Health Care Access and Information to ensure health equity under the program and other health programs of the California Health and Human Services Agency and to support the board through specified actions.
This bill would provide for the participation of health care providers in CalCare, including the requirements of a participation agreement between a health care provider and the board, provide for payment for health care items and services, and specify program participation standards. The bill would prohibit a participating provider from discriminating against a person by, among other things, reducing or denying a persons benefits under CalCare because of a specified characteristic, status, or condition of the person.
This bill would prohibit a participating provider from billing or entering into a private contract with an individual eligible for CalCare benefits regarding a covered benefit, but would authorize contracting for a health care item or service that is not a covered benefit if specified criteria are met. The bill would authorize health care providers to collectively negotiate fee-for-service rates of payment for health care items and services using a 3rd-party representative, as provided. The bill would require the board to annually determine an institutional providers global budget, to be used to cover operating expenses related to covered health care items and services for that fiscal year, and would authorize payments under the global budget.
This bill would state the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. The bill would create the CalCare Trust Fund in the State Treasury, as a continuously appropriated fund, consisting of any federal and state moneys received for the purposes of the act. The bill would specify uses for moneys in the CalCare budget, including special projects for which not-for-profit or governmental entities may apply. Because the bill would create a continuously appropriated fund, it would make an appropriation.
This bill would prohibit specified provisions of this act from becoming operative until the Secretary of California Health and Human Services gives written notice to the Secretary of the Senate and the Chief Clerk of the Assembly that the CalCare Trust Fund has the revenues to fund the costs of implementing the act. The California Health and Human Services Agency would be required to publish a copy of the notice on its internet website.
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.
(a)The Legislature finds and declares all of the following:
(1)Although the federal Patient Protection and Affordable Care Act (PPACA) brought many improvements in health care and health care coverage, PPACA still leaves many Californians without coverage or with inadequate coverage.
(2)Californians, as individuals, employers, and taxpayers, have experienced a rise in the cost of health care and health care coverage in recent years, including rising premiums, deductibles, and copayments, as well as restricted provider networks and high out-of-network charges.
(3)Businesses have also experienced increases in the costs of health care benefits for their employees, and many employers are shifting a larger share of the cost of coverage to their employees or dropping coverage entirely.
(4)Individuals often find that they are deprived of affordable care and choice because of decisions by health benefit plans guided by the plans economic needs rather than patients health care needs.
(5)To address the fiscal crisis facing the health care system and the state, and to ensure Californians get the health care they need, comprehensive health care coverage needs to be provided.
(6)Billions of dollars that could be spent on providing equal access to health care are wasted on administrative costs necessary in a multipayer health care system. Resources and costs spent on administration would be dramatically reduced in a single-payer system, allowing health care professionals and hospitals to focus on patient care instead.
(7)It is the intent of the Legislature to establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
(b)(1)It is further the intent of the Legislature to establish the California Guaranteed Health Care for All program to provide universal health care coverage for every Californian, funded by broad-based revenue.
(2)It is the intent of the Legislature to work to obtain waivers and other approvals relating to Medi-Cal, the federal Childrens Health Insurance Program, Medicare, PPACA, and any other federal programs pertaining to the provision of health care so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the CalCare Trust Fund.
(3)Under those waivers and approvals, those funds would be used for health care coverage that provides health care benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums.
(4)Those programs would be replaced and merged into CalCare, which will operate as a true single-payer program.
(5)If any necessary waivers or approvals are not obtained, it is the intent of the Legislature that the state use state plan amendments and seek waivers and approvals to maximize, and make as seamless as possible, the use of funding from federally matched public health programs and other federal health programs in CalCare.
(6)Even if other programs, including Medi-Cal or Medicare, may contribute to paying for care, it is the goal of this act that the coverage be delivered by CalCare, and, as much as possible, that the multiple sources of funding be pooled with other CalCare program funds.
(7)It is the intent of the Legislature to provide universal health care coverage with greater benefits and access to providers than existing health coverage plans, including for Californians who primarily receive care through an integrated health care delivery system, that is free at the point of service and does not have deductibles, coinsurance, premiums, or other cost-sharing.
(c)This act does not create an employment benefit, nor does the act require, prohibit, or limit providing a health care employment benefit.
(d)(1)It is not the intent of the Legislature to change or impact in any way the role or authority of a licensing board or state agency that regulates the standards for or provision of health care and the standards for health care providers as established under current law, including the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code.
(2)This act would in no way authorize the CalCare Board, the California Guaranteed Health Care for All program, or the Secretary of California Health and Human Services to establish or revise licensure standards for health care professionals or providers.
(e)It is the intent of the Legislature that neither health information technology nor clinical practice guidelines limit the effective exercise of the professional judgment of physicians, registered nurses, and other licensed health care professionals. Physicians, registered nurses, and other licensed health care professionals shall be free to override health information technology and clinical practice guidelines if, in their professional judgment and in accordance with their scope of practice and licensure, it is in the best interest of the patient and consistent with the patients wishes.
(f)(1)It is the intent of the Legislature to prohibit CalCare, a state agency, a local agency, or a public employee acting under color of law from providing or disclosing to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(2)This act would also prohibit law enforcement agencies from using CalCares funds, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of any requirement that individuals register with the federal government or any federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Part 2 (commencing with Section 51) of Division 1 of the Civil Code).
(g)It is the further intent of the Legislature to address the high cost of prescription drugs and ensure they are affordable for patients.
SEC. 2.Title 23 (commencing with Section 100600) is added to the Government Code, to read:23.The California Guaranteed Health Care for All Act1.General Provisions100600.This title shall be known, and may be cited, as the California Guaranteed Health Care for All Act.
100601.There is hereby established in state government the California Guaranteed Health Care for All program, or CalCare, to be governed by the CalCare Board pursuant to Chapter 2 (commencing with Section 100610).
100602.For the purposes of this title, the following definitions apply:
(a)Activities of daily living means basic personal everyday activities including eating, toileting, grooming, dressing, bathing, and transferring.
(b)Advisory commission means the Advisory Commission on Long-Term Services and Supports established pursuant to Section 100614.
(c)Affordable Care Act or 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 amendments to, or regulations or guidance issued under, those acts.
(d)Allied health practitioner means a group of health professionals who apply their expertise to prevent disease transmission and diagnose, treat, and rehabilitate people of all ages and in all specialties, together with a range of technical and support staff, by delivering direct patient care, rehabilitation, treatment, diagnostics, and health improvement interventions to restore and maintain optimal physical, sensory, psychological, cognitive, and social functions. Examples include audiologists, occupational therapists, social workers, and radiographers.
(e)Board means the CalCare Board described in Section 100610.
(f)CalCare or California Guaranteed Health Care for All means the California Guaranteed Health Care for All program established in Section 100601.
(g)Capital expenditures means expenses for the purchase, lease, construction, or renovation of capital facilities, health information technology, artificial intelligence, and major equipment, including costs associated with state grants, loans, lines of credit, and lease-purchase arrangements.
(h)Carrier means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.
(i)Committee means the CalCare Public Advisory Committee established pursuant to Section 100611.
(j)County organized health system means a health system implemented pursuant to Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code, and Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.(k)(j)Essential community provider means a provider, as defined in Section 156.235(c) of Title 45 of the Code of Federal Regulations, as published February 27, 2015, in the Federal Register (80 FR 10749), that serves predominantly low-income, medically underserved individuals and that is one of the following:
(1)A community clinic, as defined in subparagraph (A) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(2)A free clinic, as defined in subparagraph (B) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(3)A federally qualified health center, as defined in Section 1395x(aa)(4) or Section 1396d(l)(2)(B) of Title 42 of the United States Code.
(4)A rural health clinic, as defined in Section 1395x(aa)(2) or 1396d(l)(1) of Title 42 of the United States Code.
(5)An Indian Health Service Facility, as defined in subdivision (v) of Section 2699.6500 of Title 10 of the California Code of Regulations.
(l)(k)Federally matched public health program means the states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(m)(l)Fund means the CalCare Trust Fund established pursuant to Article 2 (commencing with Section 100675) of Chapter 7.
(n)(m)Global budget means the payment negotiated between an institutional provider and the board pursuant to Section 100651.
(o)(n)Group practice means a professional corporation under the Moscone-Knox Professional Corporation Act (Part 4 (commencing with Section 13400) of Division 3 of Title 1 of the Corporations Code) that is a single corporation or partnership composed of licensed doctors of medicine, doctors of osteopathy, or other licensed health care professionals, and that provides health care items and services primarily directly through physicians or other health care professionals who are either employees or partners of the organization.
(p)(o)Health care professional means a health care professional licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or licensed pursuant to the Osteopathic Act or the Chiropractic Act, who, in accordance with the professionals scope of practice, may provide health care items and services under this title.
(q)(p)Health care item or service means a health care item or service that is included as a benefit under CalCare.
(r)(q)Health professional education expenditures means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities.
(s)(r)Home- and community-based services means an integrated continuum of service options available locally for older individuals and functionally impaired persons who seek to maximize self-care and independent living in the home or a home-like environment, which includes the home- and community-based services that are available through Medi-Cal pursuant to the home- and community-based waiver program under Section 1915 of the federal Social Security Act (42 U.S.C. Sec. 1396n) as of January 1, 2019.
(t)(s)Implementation period means the period under paragraph (6) of subdivision (e) of Section 100612 during which CalCare is subject to special eligibility and financing provisions until it is fully implemented under that section.
(u)(t)Institutional provider means an entity that provides health care items and services and is licensed pursuant to any of the following:
(1)A health facility, as defined in Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)A clinic licensed pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code.
(3)A long-term health care facility, as defined in Section 1418 of the Health and Safety Code, or a program developed pursuant to paragraph (1) of subdivision (i) of Section 100612.
(4)A county medical facility licensed pursuant to Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code.
(5)A residential care facility for persons with chronic, life-threatening illness licensed pursuant to Chapter 3.01 (commencing with Section 1568.01) of Division 2 of the Health and Safety Code.
(6)An Alzheimers daycare resource center licensed pursuant to Chapter 3.1 (commencing with Section 1568.15) of Division 2 of the Health and Safety Code.
(7)A residential care facility for the elderly licensed pursuant to Chapter 3.2 (commencing with Section 1569) of Division 2 of the Health and Safety Code.
(8)A hospice licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code.
(9)A pediatric day health and respite care facility licensed pursuant to Chapter 8.6 (commencing with Section 1760) of Division 2 of the Health and Safety Code.
(10)A mental health care provider licensed pursuant to Division 4 (commencing with Section 4000) of the Welfare and Institutions Code.
(11)A federally qualified health center, as defined in Section 1395x(aa)(4) or 1396d(l)(2)(B) of Title 42 of the United States Code.
(v)(u)Instrumental activities of daily living means activities related to living independently in the community, including meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
(w)(v)Integrated health care delivery system has the same meaning as defined in paragraph (13) of subdivision (b) of Section 1182.14 of the Labor Code.
(x)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, including the entities established pursuant to Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96 of the Welfare and Institutions Code.(y)(w)Long-term services and supports means long-term care, treatment, maintenance, or services related to health conditions, injury, or age, that are needed to support the activities of daily living and the instrumental activities of daily living for a person with a disability, including all long-term services and supports as defined in Section 14186.1 of the Welfare and Institutions Code, home- and community-based services, additional services and supports identified by the board to support people with disabilities to live, work, and participate in their communities, and those as defined by the board.
(z)(x)Medicaid or medical assistance means a program that is one of the following:
(1)The states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(2)The federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(aa)(y)Medically necessary or appropriate means the health care items, services, or supplies needed or appropriate to prevent, diagnose, or treat an illness, injury, condition, or disease, or its symptoms, and that meet accepted standards of medicine as determined by a patients treating physician or other individual health care professional who is treating the patient, and, according to that health care professionals scope of practice and licensure, is authorized to establish a medical diagnosis and has made an assessment of the patients condition.
(ab)(z)Medicare means Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) and the programs thereunder.
(ac)(aa)Member means an individual who is enrolled in CalCare.
(ad)(ab)Out-of-state health care service means a health care item or service provided in person to a member while the member is temporarily, for no more than 90 days, and physically located out of the state under either of the following circumstances:
(1)It is medically necessary or appropriate that the health care item or service be provided while the member physically is out of the state.
(2)It is medically necessary or appropriate, and cannot be provided in the state, because the health care item or service can only be provided by a particular health care provider physically located out of the state.
(ae)(ac)Participating provider means an individual or entity that is a health care provider qualified under Section 100640 that has a participation agreement pursuant to Section 100641 in effect with the board to furnish health care items or services under CalCare.
(af)(ad)Prescription drugs means prescription drugs as defined in subdivision (n) of Section 130501 of the Health and Safety Code.
(ag)(ae)Resident means an individual whose primary place of abode is in this state, without regard to the individuals immigration status, who meets the California residence requirements adopted by the board pursuant to subdivision (k) (m) of Section 100610. The board shall be guided by the principles and requirements set forth in the Medi-Cal program under Article 7 (commencing with Section 50320) of Chapter 2 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations.
(ah)(af)Rural or medically underserved area has the same meaning as a health professional shortage area in Section 254e of Title 42 of the United States Code.
100603.This title does not preempt a city, county, or city and county from adopting additional health care coverage for residents in that city, county, or city and county that provides more protections and benefits to California residents than this title.
100604.To the extent any law is inconsistent with this title or the legislative intent of the California Guaranteed Health Care for All Act, this title shall apply and prevail, except when explicitly provided otherwise by this title.
2.Governance100610.(a)CalCare shall be governed by an executive board, known as the CalCare Board, consisting of nine voting members who are residents of California. The CalCare Board shall be an independent public entity not affiliated with an agency or department. Of the members of the board, five four shall be appointed by the Governor, two shall be appointed by the Senate Committee on Rules, and two shall be appointed by the Speaker of the Assembly. Assembly, and one shall be determined by the committee established pursuant to Section 100611. The Secretary of California Health and Human Services or the secretarys designee shall serve as a nonvoting, ex officio member of the board.
(b)(1)A member of the board, other than an ex officio member, shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(2)Appointments by the Governor shall be subject to confirmation by the Senate. A member of the board may continue to serve until the appointment and qualification of the members successor. Vacancies shall be filled by appointment for the unexpired term. The board shall elect a chairperson on an annual basis.
(c)(1)Each person appointed to the board shall have demonstrated and acknowledged expertise in health care policy or delivery.
(2)Appointing authorities shall also consider the expertise of the other members of the board and attempt to make appointments so that the boards composition reflects a diversity of expertise in the various aspects of health care and the diversity of various regions within the state.
(3)Appointments to the board shall be made as follows:
(A)Two health care professionals who practice medicine. At least one shall be a practicing physician or medical doctor.
(B)One registered nurse.
(C)One public health or mental health professional.
(D)One mental health professional. (E)(D)One member with an institutional provider background.
(F)One representative(E)Two representatives of a not-for-profit organization that advocates for individuals who use health care in California California.
(G)(F)One representative of a labor organization.
(H)(G)One member of the committee established pursuant to Section 100611, who shall serve on a rotating basis to be determined by the committee.
(d)Each member of the board shall have the responsibility and duty to meet the requirements of this title and all applicable state and federal laws and regulations, to serve the public interest of the individuals, employers, and taxpayers seeking health care coverage through CalCare, and to ensure the operational well-being and fiscal solvency of CalCare.
(e)(1)An appointee to the board designated in subparagraph (D), (E), (F), or (G) of paragraph (3) of subdivision (c) shall not receive financial compensation from, or be employed by, a participating provider under CalCare and shall not otherwise receive funding from CalCare.
(2)An appointee to the board designated in subparagraph (A), (B), or (C) of paragraph (3) of subdivision (c) shall not receive financial compensation from a participating provider under CalCare and shall not otherwise receive funding from CalCare, except for the purposes of employment by a participating provider to provide direct patient care and in a position that is not as an officer or a managerial, supervisory, or confidential position.
(3)For purposes of this subdivision, an appointees prohibited financial compensation and employment does not include employment by a participating provider as a tenured academic instructor with duties and compensation unrelated to the health care operations of the entity.
(4)For purposes of this subdivision, financial compensation does not include compensation received pursuant to a retirement plan.
(5)For purposes of this subdivision, financial compensation does not include clinical volunteer services if all of the following conditions are met:
(A)The board member is a health care professional who was actively participating in that profession before appointment to the board.
(B)The board member does not receive compensation for performing volunteer services and does not have an ownership interest or other financial interest in the entity, facility, clinic, or provider group.
(C)The clinical volunteer services are performed at the University of California or a nonprofit educational institution, a facility, clinic, or provider group operated by, or affiliated with, an academic medical center of either the University of California or a nonprofit educational institution, or a facility, clinic, or provider group operated by a state agency or county health system.
(6)For purposes of paragraph (5), compensation and financial interest for a health care professional who performs clinical volunteer services does not include either of the following:
(A)A contribution to a professional liability insurance program made by the entity, facility, clinic, or provider group for the member or staff.
(B)The provision of physical space, equipment, support staff, or other supports made by the entity, facility, clinic, or provider group for the member or staff necessary for the performance of clinical volunteer services described in paragraph (5).
(f)The representation of varied interest groups on the board shall be deemed essential to obtaining information for the development of policy and decisions of the board. It shall not be a conflict of interest for appointees to the board designated in subparagraph (A), (B), (C), or (D) of paragraph (3) of subdivision (c) to serve as members of the board. If any board member has a financial interest, as described in Section 87103, the interest shall be disclosed as a matter of official public record and shall be described with particularity, as determined by the other members of the board. A board member shall not make, participate in making, or in any way attempt to use their position to influence a decision of the board in which the member knows or has reason to know that they have a financial interest.
(e)(g)In making appointments to the board, the appointing authorities shall take into consideration the racial, ethnic, gender, and geographical diversity of the state so that the boards composition reflects the communities of California.
(f)(h)(1)A member of the board or of the staff of the board shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health care professional, institutional provider, or group practice while serving on the board or on the staff of the board, except board members who are practicing health care professionals may be employed by an institutional provider or group practice. A member of the board or of the staff of the board shall not be a board member or an employee of a trade association of health professionals, institutional providers, or group practices while serving on the board or on the staff of the board. A member of the board or of the staff of the board may be a health care professional if that member does not have an ownership interest in an institutional provider or a professional health care practice.
(2)Notwithstanding Section 11009, a board member shall receive compensation for service on the board. A board member may receive a per diem and reimbursement for travel and other necessary expenses, as provided in Section 103 of the Business and Professions Code, while engaged in the performance of official duties of the board.
(g)(i)A member of the board shall not make, participate in making, or in any way attempt to use the members official position to influence the making of a decision that the member knows, or has reason to know, will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on the member or a person in the members immediate family, or on either of the following:
(1)Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status, aggregating two hundred fifty dollars ($250) or more in value provided to, received by, or promised to the member within 12 months before the decision is made.
(2)Any business entity in which the member is a director, officer, partner, trustee, employee, or holds any position of management.
(h)(j)There shall not be liability in a private capacity on the part of the board or a member of the board, or an officer or employee of the board, for or on account of an act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this title or affairs related to this title.
(i)(k)The board shall hire an executive director to organize, administer, and manage the operations of the board. The executive director shall be exempt from civil service and shall serve at the pleasure of the board.
(j)(l)The board shall be subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2), except that the board may hold closed sessions when considering matters related to litigation, personnel, contracting, and provider rates.
(k)(m)The board may adopt rules and regulations as necessary to implement and administer this title in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
(n)Any violation of this section by a board member shall constitute grounds for disqualification as a board member.
100611.(a)The board shall convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare. The committee shall consist of members who are residents of California.
(b)Members of the committee shall be appointed by the board for a term of two years. These members may be reappointed for succeeding two-year terms.
(c)The members of the committee shall be as follows:
(1)Four health care professionals.
(2)One registered nurse.
(3)One representative of a licensed health facility.
(4)One representative of an essential community provider.
(5)One representative of a physician organization or medical group.
(6)One behavioral health provider.
(7)One dentist or oral care specialist.
(8)One representative of private hospitals.
(9)One representative of public hospitals.
(10)One individual who is enrolled in and uses health care items and services under CalCare.
(11)Two representatives of organizations that advocate for individuals who use health care in California, including at least one representative of an organization that advocates for the disabled community.
(12)Two representatives of organized labor, including at least one labor organization representing registered nurses.
(d)In convening the committee pursuant to this section, the board shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the social and geographic diversity of the state.
(e)Members of the committee shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies, and shall receive one hundred fifty dollars ($150) for each full day of attending meetings of the committee. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the committee during any particular 24-hour period.
(f)The committee shall meet at least once every quarter, and shall solicit input on agendas and topics set by the board. All meetings of the committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The committee shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)Committee members, or their assistants, clerks, or deputies, shall not use for personal benefit any information that is filed with, or obtained by, the committee and that is not generally available to the public.
100612.(a)The board shall have all powers and duties necessary to establish and implement CalCare. The board shall provide, under CalCare, comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state.
(b)The board shall, to the maximum extent possible, organize, administer, and market CalCare and services as a single-payer program under the name CalCare or any other name as the board determines, regardless of which law or source the definition of a benefit is found, including, on a voluntary basis, retiree health benefits. In implementing this title, the board shall avoid jeopardizing federal financial participation in the programs that are incorporated into CalCare and shall take care to promote public understanding and awareness of available benefits and programs.
(c)The board shall consider any matter to effectuate the provisions and purposes of this title. The board shall not have executive, administrative, or appointive duties except as otherwise provided by law.
(d)The board shall designate the executive director to employ necessary staff and authorize reasonable, necessary expenditures from the CalCare Trust Fund to pay program expenses and to administer CalCare. The executive director shall hire or designate another to hire staff, who shall not be exempt from civil service, to implement fully the purposes and intent of CalCare. The executive director, or the executive directors designee, shall give preference in hiring to all individuals displaced or unemployed as a direct result of the implementation of CalCare, including as set forth in Section 100615.
(e)The board shall do or delegate to the executive director all of the following:
(1)Determine goals, standards, guidelines, and priorities for CalCare.
(2)Annually assess projected revenues and expenditures and ensure the financial solvency of CalCare.
(3)Develop CalCares budget pursuant to Section 100676 to ensure adequate funding to meet the health care needs of the population, and review all budgets annually to ensure they address disparities in service availability and health care outcomes and for sufficiency of rates, fees, and prices to address disparities.
(4)Establish standards and criteria for the development and submission of provider operating and capital expenditure requests pursuant to Article 2 (commencing with Section 100650) of Chapter 5.
(5)Establish standards and criteria for the allocation of funds from the CalCare Trust Fund pursuant to Section 100676.
(6)Determine when individuals may begin enrolling in CalCare. There shall be an implementation period that begins on the date that individuals may begin enrolling in CalCare and ends on a date determined by the board.
(7)Establish an enrollment system that ensures all eligible California residents, including those who travel out of state, those who have disabilities that limit their mobility, hearing, vision, or mental or cognitive capacity, those who cannot read, and those who do not speak or write English, are aware of their right to health care and are formally enrolled in CalCare.
(8)Negotiate payment rates, set payment methodologies, and set prices involving aspects of CalCare and establish procedures thereto, including procedures for negotiating fee-for-service payment to certain participating providers pursuant to Chapter 8 (commencing with Section 100685).
(9)Oversee the establishment, as part of the administration of CalCare, of the committee pursuant to Section 100611.
(10)Implement policies to ensure that all Californians receive culturally, linguistically, and structurally competent care, pursuant to Chapter 6 (commencing with Section 100660), ensure that all disabled Californians receive care in accordance with the federal Americans with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) and Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. Sec. 794), and develop mechanisms and incentives to achieve these purposes and a means to monitor the effectiveness of efforts to achieve these purposes.
(11)Establish standards for mandatory reporting by participating providers and penalties for failure to report, including reporting of data pursuant to Section 100617 and to Section 100641.
(12)Implement policies to ensure that all residents of this state have access to medically appropriate, coordinated mental health services.
(13)Ensure the establishment of policies that support the public health.
(14)Meet regularly with the committee.
(15)Determine an appropriate level of, and provide support during the transition for, training and job placement for persons who are displaced from employment as a result of the initiation of CalCare pursuant to Section 100615.
(16)In consultation with the Department of Managed Health Care, oversee the establishment of a system for resolution of disputes pursuant to Section 100637 and a system for independent medical review pursuant to Section 100637.
(17)Establish and maintain an internet website that provides information to the public about CalCare that includes information that supports choice of providers and facilities and informs the public about meetings of the board and the committee.
(18)Establish a process that is accessible to all Californians for CalCare to receive the concerns, opinions, ideas, and recommendations of the public regarding all aspects of CalCare.
(19)(A)Annually prepare a written report on the implementation and performance of CalCare functions during the preceding fiscal year, that includes, at a minimum:
(i)The manner in which funds were expended.
(ii)The progress toward and achievement of the requirements of this title.
(iii)CalCares fiscal condition.
(iv)Recommendations for statutory changes.
(v)Receipt of payments from the federal government and other sources.
(vi)Whether current year goals and priorities have been met.
(vii)Future goals and priorities.
(B)The report shall be transmitted to the Legislature and the Governor, on or before October 1 of each year and at other times pursuant to this division, and shall be made available to the public on the internet website of CalCare.
(C)A report made to the Legislature pursuant to this subdivision shall be submitted pursuant to Section 9795.
(f)The board may do or delegate to the executive director all of the following:
(1)Negotiate and enter into any necessary contracts, including contracts with health care providers and health care professionals.
(2)Sue and be sued.
(3)Receive and accept gifts, grants, or donations of moneys from any agency of the federal government, any agency of the state, and any municipality, county, or other political subdivision of the state.
(4)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 by regulation.
(5)Share information with relevant state departments, consistent with the confidentiality provisions in this title, necessary for the administration of CalCare.
(g)(1)A carrier shall not offer benefits or cover health care items or services for which coverage is offered to individuals under CalCare.
(2)Notwithstanding paragraph (1), if otherwise authorized under state law, a carrier may offer benefits to cover health care items or services that are not offered to individuals under CalCare.
(3)This title does not prohibit a carrier from offering either of the following:
(A)Benefits to or for individuals, including their families, who are employed or self-employed in the state, but who are not residents of the state.
(B)Benefits during the implementation period to individuals who enrolled or may enroll as members of CalCare.
(4)Paragraph (1) applies to a carrier except as otherwise prohibited by federal law.
(h)After the end of the implementation period, a person shall not be a board member unless the person is a member of CalCare, except the ex officio member.
(i)No later than two years after the effective date of this section, the board shall develop proposals for the following:
(1)In consultation with the Advisory Committee on Public Employees Retirement System Health Benefits established under Section 100616, accommodating employer retiree health benefits for people who have been members of the Public Employees Retirement System, but live as retirees out of the state.
(2)Accommodating employer retiree health benefits for people who earned or accrued those benefits while residing in the state before the implementation of CalCare and live as retirees out of the state.
(j)The board shall develop a proposal for CalCare coverage of health care items and services currently covered under the workers compensation system, including whether and how to continue funding for those item and services under that system and how to incorporate experience rating.
100613.The board may contract with not-for-profit organizations to provide both of the following:
(a)Assistance to CalCare members with respect to selection of a participating provider, enrolling, obtaining health care items and services, disenrolling, and other matters relating to CalCare.
(b)Assistance to a health care provider providing, seeking, or considering whether to provide health care items and services under CalCare.
100614.(a)There is hereby established in state government an Advisory Commission on Long-Term Services and Supports, to advise the board on matters of policy related to long-term services and supports for CalCare.
(b)The advisory commission shall consist of 11 members who are residents of California. Of the members of the advisory commission, five shall be appointed by the Governor, three shall be appointed by the Senate Committee on Rules, and three shall be appointed by the Speaker of the Assembly. The members of the advisory commission shall include all of the following:
(1)At least two people with disabilities who use long-term services and supports.
(2)At least two older adults who use long-term services and supports.
(3)At least two providers of long-term services and supports, including one family attendant or family caregiver.
(4)At least one representative of a disability rights organization.
(5)At least one representative or member of a labor organization representing workers who provide long-term services and supports.
(6)At least one representative of a group representing seniors.
(7)At least one researcher or academic in long-term services and supports.
(c)In making appointments pursuant to this section, the Governor, the Senate Committee on Rules, and the Speaker of the Assembly shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the diversity of the population of people who use long-term services and supports, including their race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geographic location, and socioeconomic status.
(d)(1)A member of the advisory commission may continue to serve until the appointment and qualification of that members successor. Vacancies shall be filled by appointment for the unexpired term.
(2)Members of the advisory commission shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(3)Vacancies that occur shall be filled within 30 days after the occurrence of the vacancy, and shall be filled in the same manner in which the vacating member was initially selected or appointed. The Secretary of California Health and Human Services shall notify the appropriate appointing authority of any expected vacancies on the long-term services and supports advisory commission.
(e)Members of the advisory commission shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies. Members shall also receive one hundred fifty dollars ($150) for each full day of attending meetings of the advisory commission. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the advisory commission during any particular 24-hour period.
(f)The advisory commission shall meet at least six times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The advisory commission shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)It is unlawful for the advisory commission members or any of their assistants, clerks, or deputies to use for personal benefit any information that is filed with, or obtained by, the advisory commission and that is not generally available to the public.
100615.(a)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for program assistance to individuals employed or previously employed in the fields of health insurance, health care service plans, or other third-party payments for health care, individuals providing services to health care providers to deal with third-party payers for health care, individuals who may be affected by and who may experience economic dislocation as a result of the implementation of this title, and individuals whose jobs may be or have been ended as a result of the implementation of CalCare, consistent with otherwise applicable law.
(b)Assistance described in subdivision (a) shall include job training and retraining, job placement, preferential hiring, wage replacement, retirement benefits, and education benefits.
100616.(a)The board shall establish an Advisory Committee on Public Employees Retirement System Health Benefits to provide input, including recommendations, to the board on matters of policy related to public employee retiree health benefits and CalCare, including all of the following:
(1)Processes to obtain approval of CalCare as a health benefits plan under public pension or retirement systems.
(2)Recommendations to the Legislature and Governor to provide tax or other accommodations for people who have accrued retiree health benefit contributions under public employees retirement systems.
(3)Recommendations to, and coordination with, public employee retirement system boards to fully integrate beneficiaries into CalCare.
(4)Processes to change or phase out health benefits under public employees retirement systems to fully integrate beneficiaries into CalCare.
(5)Federal approvals that may support transition of Medicare plans under public employees retirement systems to CalCare.
(b)(1)The board shall appoint the members of the advisory committee during the implementation period. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the advisory committee, the board shall aim for broad representation, including, at a minimum, the following representatives of public sector labor organizations: the Public Employees Retirement System, the State Teachers Retirement System, the University of California Retirement System, and locally administered public pension or retirement systems. At a minimum, one-half of the advisory committee members shall be representatives of public sector labor organizations.
(2)Each appointed member shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(3)Advisory committee members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the advisory committee shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the advisory committee members.
(4)Advisory committee members shall receive reimbursement for travel and other actual costs.
(c)The advisory committee shall meet at least four times per year in a place convenient to the public. All meetings of the advisory committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(d)The board shall consider input, including recommendations, from the advisory committee, along with public comments, in the boards deliberation and decisionmaking.
100617.(a)The board shall utilize the data collected pursuant to Chapter 1 (commencing with Section 128675) of Part 5 of Division 107 of the Health and Safety Code to assess patient outcomes and to review utilization of health care items and services paid for by CalCare.
(b)As applicable to the type of provider, the board shall require and enforce the collection and availability of all of the following data to promote transparency, assess quality of care, compare patient outcomes, and review utilization of health care items and services paid for by CalCare, which shall be reported to the board and, as applicable, the Department of Health Care Access and Information or the Medical Board of California:
(1)Inpatient discharge data, including severity of illness and risk of mortality, with respect to each discharge.
(2)Emergency department, ambulatory surgical center, and other outpatient department data, including cost data, charge data, length of stay, and patients unit of observation with respect to each individual receiving health care items and services.
(3)For hospitals and other providers receiving global budgets, annual financial data, including all of the following:
(A)Community benefit activities, including charity care, to which Section 501(r) of Title 26 of the United States Code applies, provided by the provider in dollar value at cost.
(B)Number of employees by employee classification or job title and by patient care unit or department.
(C)Number of hours worked by the employees in each patient care unit or department.
(D)Employee wage information by job title and patient care unit or department.
(E)Number of registered nurses per staffed bed by patient care unit or department.
(F)A description of all information technology, including health information technology and artificial intelligence, used by the provider and the dollar value of that information technology.
(G)Annual spending on information technology, including health information technology, artificial intelligence, purchases, upgrades, and maintenance.
(4)Risk-adjusted and raw outcome data, including:
(A)Risk-adjusted outcome reports for medical, surgical, and obstetric procedures selected by the Department of Health Care Access and Information pursuant to Sections 128745 to 128750, inclusive, of the Health and Safety Code.
(B)Any other risk-adjusted outcome reports that the board may require for medical, surgical, and obstetric procedures and conditions as it deems appropriate.
(5)A disclosure made by a provider as set forth in Article 6 (commencing with Section 650) of Chapter 1 of Division 2 of the Business and Professions Code.
(c)(1)The Medical Board of California shall collect data for the outpatient surgery settings that the Medical Board of California regulates that meets the Ambulatory Surgery Data Record requirements of Section 128737 of the Health and Safety Code, and shall submit that data to the CalCare Board.
(2)The CalCare Board shall make that data available as required pursuant to subdivision (d).
(d)The board shall make all disclosed data collected under this section publicly available and searchable through an internet website and through the Department of Health Care Access and Information public data sets.
(e)Consistent with state and federal privacy laws, the board shall make available data collected through CalCare to the Department of Health Care Access and Information and the California Health and Human Services Agency, consistent with this title and otherwise applicable law, to promote and protect public, environmental, and occupational health.
(f)Before full implementation of CalCare, and, for providers seeking to receive global budgets or salaried payments under Article 2 (commencing with Section 100650) of Chapter 5, as applicable, before the negotiation of initial payments, the board shall provide for the collection and availability of the following data:
(1)The number of patients served.
(2)The dollar value of the care provided, at cost, for all of the following categories of Department of Health Care Access and Information data items:
(A)Patients receiving charity care.
(B)Contractual adjustments of county and indigent programs, including traditional and managed care.
(C)Bad debts or any other unpaid charges for patient care that the provider sought, but was unable to collect.
(g)The board shall regularly analyze information reported under this section and shall establish rules and regulations to allow researchers, scholars, participating providers, and others to access and analyze data for purposes consistent with this title, without compromising patient privacy.
(h)(1)The board shall establish regulations for the collection and reporting of data to promote transparency, assess patient outcomes, and review utilization of services provided by physicians and other health care professionals, as applicable, and paid for by CalCare.
(2)In implementing this section, the board shall utilize data that is already being collected pursuant to other state or federal laws and regulations whenever possible.
(3)Data reporting required by participating providers under this section shall supplement the data collected by the Department of Health Care Access and Information and shall not modify or alter other reporting requirements to governmental agencies.
(i)The board shall not utilize quality or other review measures established under this section for the purposes of establishing payment methods to providers.
(j)The board may coordinate and cooperate with the Department of Health Care Access and Information or other health planning agencies of the state to implement the requirements of this section.
100618.(a)The board shall establish and use a process to enter into participation agreements with health care providers and other contracts with contractors. A contract entered into pursuant to this title shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of the Department of General Services. The board shall adopt a CalCare Contracting Manual incorporating procurement and contracting policies and procedures that shall be followed by CalCare. The policies and procedures in the manual shall be substantially similar to the provisions contained in the State Contracting Manual.
(b)The adoption, amendment, or repeal of a regulation by the board to implement this section, including the adoption of a manual pursuant to subdivision (a) and any procurement process conducted by CalCare in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
100619.(a)Notwithstanding any other law, CalCare, a state or local agency, or a public employee acting under color of law shall not provide or disclose to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(b)Notwithstanding any other law, law enforcement agencies shall not use CalCare moneys, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of a requirement that individuals register with the federal government or a federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Section 51 of the Civil Code).
100620.(a)On or before July 1, ____, the board shall conduct and deliver a fiscal analysis to determine both of the following:
(1)Whether or not CalCare may be implemented.
(2)If revenue is more likely than not to be sufficient to pay for program costs within eight years of CalCares implementation.
(b)The board may contract with one or more independent entities with the appropriate expertise or coordinate with other state agencies to conduct the fiscal analysis.
(c)The board shall deliver, and upon request present, the fiscal analysis to the Chair of the Senate Committee on Health, the Chair of the Assembly Committee on Health, the Chair of the Senate Committee on Appropriations, and the Chair of the Assembly Committee on Appropriations.
3.Eligibility and Enrollment100630.(a)Every resident of the state shall be eligible and entitled to enroll as a member of CalCare.
(b)(1)A member shall not be required to pay a fee, payment, or other charge for enrolling in or being a member of CalCare.
(2)A member shall not be required to pay a premium, copayment, coinsurance, deductible, or any other form of cost sharing for all covered benefits under CalCare.
(c)A college, university, or other institution of higher education in the state may purchase coverage under CalCare for a student, or a students dependent, who is not a resident of the state.
(d)An individual entitled to benefits through CalCare may obtain health care items and services from any institution, agency, or individual participating provider.
(e)The board shall establish a process for automatic CalCare enrollment at the time of birth in California.
100631.(a)All residents of this state, no matter what their sex, race, color, religion, ancestry, national origin, disability, age, previous or existing medical condition, genetic information, marital status, familial status, military or veteran status, sexual orientation, gender identity or expression, pregnancy, pregnancy-related medical condition, including termination of pregnancy, citizenship, primary language, or immigration status, are entitled to full and equal accommodations, advantages, facilities, privileges, or services in all health care providers participating in CalCare.
(b)Subdivision (a) prohibits a participating provider, or an entity conducting, administering, or funding a health program or activity pursuant to this title, from discriminating based upon the categories described in subdivision (a) in the provision, administration, or implementation of health care items and services through CalCare.
(c)Discrimination prohibited under this section includes the following:
(1)Exclusion of a person from participation in or denial of the benefits of CalCare, except as expressly authorized by this title for the purposes of enforcing eligibility standards in Section 100630.
(2)Reduction of a persons benefits.
(3)Any other discrimination by any participating provider or any entity conducting, administering, or funding a health program or activity pursuant to this title.
(d)Section 52 of the Civil Code shall apply to discrimination under this section.
(e)Except as otherwise provided in this section, a participating provider or entity is in violation of subdivision (b) if the complaining party demonstrates that any of the categories listed in subdivision (a) was a motivating factor for any health care practice, even if other factors also motivated the practice.
4.Benefits100635.(a)Individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to a participating provider for the health care items and services in subdivision (c), if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.
(b)The determination of medical necessity or appropriateness shall be made by the members treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards established in Chapter 6 (commencing with Section 100660), and by the board, and other laws of the state.
(c)Covered health care benefits for members include all of the following categories of health care items and services:
(1)Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services.
(2)Inpatient and outpatient health care professional services and other ambulatory patient services.
(3)Primary and preventive services, including chronic disease management.
(4)Prescription drugs, biological products, and all contraceptive items approved by the United States Food and Drug Administration.
(5)Medical devices, equipment, appliances, and assistive technology.
(6)Mental health and substance abuse treatment services, including inpatient and outpatient care.
(7)Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.
(8)Comprehensive reproductive care, including abortion, contraception, and assisted reproductive technology, maternity care, and newborn care.
(9)Pediatrics.
(10)Oral health, audiology, and vision services.
(11)Rehabilitative and habilitative services and devices, including inpatient and outpatient care.
(12)Emergency services and transportation.
(13)Early and periodic screening, diagnostic, and treatment services as defined in Section 1396d(r) of Title 42 of the United States Code.
(14)Comprehensive gender-affirming health care.
(15)Necessary transportation for health care items and services for persons with disabilities or who may qualify as low income.
(16)Long-term services and supports described in Section 100636, including long-term services and supports covered under Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code) or the federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
(17)Care coordination.
(18)Any additional health care items and services the board authorizes to be added to CalCare benefits.
(d)The categories of covered health care items and services under subdivision (c) include all the following:
(1)Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual.
(2)Child and adult immunizations.
(3)Hospice care.
(4)Care in a skilled nursing facility.
(5)Home health care, including health care provided in an assisted living facility.
(6)Prenatal and postnatal care.
(7)Podiatric care.
(8)Blood and blood products.
(9)Dialysis.
(10)Community-based adult services as defined under Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code as of January 1, 2021.
(11)Dietary and nutritional therapies determined appropriate by the board.
(12)Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture.
(13)Health care items and services previously covered by county integrated health and human services programs pursuant to Chapter 12.96 (commencing with Section 18990) and Chapter 12.991 (commencing with Section 18991) of Part 6 of Division 9 of the Welfare and Institutions Code.
(14)Health care items and services previously covered by a regional center for persons with developmental disabilities pursuant to Chapter 5 (commencing with Section 4620) of Division 4.5 of the Welfare and Institutions Code.
(15)Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers.
(e)Covered health care items and services under CalCare include all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:
(1)The federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
(2)Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(3)The federal Medicare Program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(4)Health care service plans pursuant to 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).
(5)Health insurers, as defined in Section 106 of the Insurance Code, pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code.
(6)All essential health benefits mandated by the federal Patient Protection and Affordable Care Act as of January 1, 2017.
(f)Health care items and services covered under CalCare shall not be subject to prior authorization or a limitation applied through the use of step therapy protocols.
100636.(a)Subject to the other provisions of this title, individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this title, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:
(1)Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living.
(2)Is a disability, as defined in Section 12102(1)(A) of Title 42 of the United States Code, that substantially limits one or more of the members major life activities.
(b)The board shall adopt regulations that provide for the following:
(1)The determination of individual eligibility for long-term services and supports under this section.
(2)The assessment of the long-term services and supports needed for an eligible individual.
(3)The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program established in Title II or Title XVI of the federal Social Security Act to the long-term services and supports under this section.
(c)Long-term services and supports provided pursuant to this section shall do all of the following:
(1)Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting.
(2)Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care.
(3)Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the members maximum possible autonomy and the members maximum possible civic, social, and economic participation.
(4)Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization.
(5)Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipients type or level of disability, service need, or age.
(6)Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the members needs.
(7)Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity.
(8)Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions.
(9)Ensure that long-term services and supports provide recipients the option of self-direction of service, including under the Self-Directed Services Program described in Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code, from either the recipient or care coordinators of the recipients choosing.
(d)In developing regulations to implement this section, the board shall consult the advisory commission established pursuant to Section 100614.
100637.(a)(1)The board shall, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.
(2)In implementing this section, the board shall not remove or eliminate covered health care items and services under CalCare that are listed in this chapter.
(b)The board shall establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare.
(c)The board shall establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the Independent Medical Review System established in the Department of Managed Health Care pursuant to Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.
(d)For the purposes of this chapter:
(1)Coverage decision means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A coverage decision does not encompass a decision regarding a disputed health care item or service.
(2)Disputed health care item or service means a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision.
5.Delivery of Care1.Health Care Providers100640.(a)(1)A health care provider or entity is qualified to participate as a provider in CalCare if the health care provider furnishes health care items and services while the provider, or, if the provider is an entity, the individual health care professional of the entity furnishing the health care items and services, is physically present within the State of California, and if the provider meets all of the following:
(A)The provider or entity is a health care professional, group practice, or institutional health care provider licensed to practice in California.
(B)The provider or entity agrees to accept CalCare rates as payment in full for all covered health care items and services.
(C)The provider or entity has filed with the board a participation agreement described in Section 100641.
(D)The provider or entity is otherwise in good standing.
(2)The board shall establish and maintain procedures and standards for recognizing health care providers located out of the state for purposes of providing coverage under CalCare for members who require out-of-state health care services while the member is temporarily located out of the state.
(b)A provider or entity shall not be qualified to furnish health care items and services under CalCare if the provider or entity does not provide health care items or services directly to individuals, including the following:
(1)Entities or providers that contract with other entities or providers to provide health care items and services shall not be considered a qualified provider for those contracted items and services.
(2)Entities that are approved to coordinate care plans under the Medicare Advantage program established in Part C of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1851 et seq.) as of January 1, 2020, but do not directly provide health care items and services.
(c)A health care provider qualified to participate under this section may provide covered health care items or services under CalCare, as long as the health care provider is legally authorized to provide the health care item or service for the individual and under the circumstances involved.
(d)(1)The board shall establish and maintain procedures for members and individuals eligible to enroll in CalCare to enroll onsite at a participating provider.
(2)A participating provider shall accept onsite enrollment of members and eligible individuals under the procedures established pursuant to paragraph (1).
(e)The board shall establish and maintain procedures and standards for members to select a primary care provider, which may be an internist, a pediatrician, a physician who practices family medicine, a gynecologist, a physician who practices geriatric medicine, or, at the option of a member who has a chronic condition that requires specialty care, a specialist health care professional who regularly and continually provides treatment to the member for that condition, and other participating providers.
(f)A referral from a primary care provider is not required for a member to see a participating provider.
(g)A member may choose to receive health care items and services under CalCare from a participating provider, subject to the willingness or availability of the provider, and consistent with the provisions of this title relating to discrimination, and the appropriate clinically relevant circumstances and standards.
100641.(a)A health care provider shall enter into a participation agreement with the board to qualify as a participating provider under CalCare.
(b)A participation agreement between the board and a health care provider shall include provisions for at least the following, as applicable to each provider:
(1)Health care items and services to members shall be furnished by the provider without discrimination, as required by Section 100631. This paragraph does not require the provision of a type or class of health care items or services that are outside the scope of the providers normal practice.
(2)A charge shall not be made to a member for a covered health care item or service, other than for payment authorized by this title. Except as described in Section 100644, a contract shall not be entered into with a patient for a covered health care item or service.
(3)The provider shall follow the policies and procedures in the CalCare Contracting Manual established pursuant to Section 100618.
(4)The provider shall furnish information reasonably required by the board and shall meet the reporting requirements of Sections 100617 and 100661 for at least the following:
(A)Quality review by designated entities.
(B)Making payments, including the examination of records as necessary for the verification of information on which those payments are based.
(C)Statistical or other studies required for the implementation of this title.
(D)Other purposes specified by the board.
(5)If the provider is not an individual, the provider shall not employ or use an individual or other provider that has had a participation agreement terminated for cause to provide covered health care items and services.
(6)If the provider is paid on a fee-for-service basis for covered health care items and services, the provider shall submit bills and required supporting documentation relating to the provision of covered health care items or services within 30 days after the date of providing those items or services.
(7)The provider shall submit information and any other required supporting documentation reasonably required by the board on a quarterly basis that relates to the provision of covered health care items and services and describes health care items and services furnished with respect to specific individuals.
(8)(A)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall disclose the following to the board:
(i)Any case mix indexes, diagnosis coding software, procedure coding software, or other coding system utilized by the provider for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Any case mix indexes, diagnosis coding guidelines, procedure coding guidelines, or coding tip sheets used by the provider for the purposes of meeting payment or disclosure requirements under this title.
(B)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall not do the following:
(i)Use proprietary case mix indexes, diagnosis coding software, procedure coding software, or other coding system for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Require another health care professional to apply case mix indexes, diagnosis coding software, procedure coding software, or other coding system in a manner that limits the clinical diagnosis, treatment process, or a treating health care professionals judgment in determining a diagnosis or treatment process, including the use of leading queries or prohibitions on using certain codes.
(iii)Provide financial incentives or disincentives to physicians, registered nurses, or other health care professionals for particular coding query results or code selections.
(iv)Use case mix indexes, diagnosis coding software, procedure coding software, or other coding system that make suggestions for higher severity diagnoses or higher cost procedure coding.
(9)The provider shall comply with the duty of patient advocacy and reporting requirements described in Section 100661.
(10)If the provider is not an individual, the provider shall ensure that a board member, executive, or administrator of the provider shall not receive compensation from, own stock or have other financial investments in, or receive services as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(11)If the provider is a not-for-profit hospital subject to Article 2 (commencing with Section 127340) of Chapter 2 of Part 2 of Division 107 of the Health and Safety Code, the hospital shall submit to the board the community benefits plan developed pursuant to Article 2 (commencing with Section 127340) of the Health and Safety Code.
(12)Health care items and services to members shall be furnished by a health care professional while the professional is physically present within the State of California.
(13)The provider shall not enter into risk-bearing, risk-sharing, or risk-shifting agreements with other health care providers or entities other than CalCare.
(c)This section does not limit the formation of group practices.
100642.(a)A participation agreement may be terminated with appropriate notice by the board for failure to meet the requirements of this title or may be terminated by a provider.
(b)A participating provider shall be provided notice and a reasonable opportunity to correct deficiencies before the board terminates an agreement, unless a more immediate termination is required for public safety or similar reasons.
(c)The procedures and penalties under the Medi-Cal program for fraud or abuse pursuant to Sections 14107, 14107.11, 14107.12, 14107.13, 14107.2, 14107.3, 14107.4, 14107.5, and 14108 of the Welfare and Institutions Code shall apply to an applicant or provider under CalCare.
(d)For purposes of this section:
(1)Applicant means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the board to participate as a provider in CalCare.
(2)Provider means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to CalCare program members.
100643.(a)A person shall not discharge or otherwise discriminate against an employee on account of the employee or a person acting pursuant to a request of the employee for any of the following:
(1)Notifying the board, executive director, or employees employer of an alleged violation of this title, including communications related to carrying out the employees job duties.
(2)Refusing to engage in a practice made unlawful by this title, if the employee has identified the alleged illegality to the employer.
(3)Providing, causing to be provided, or being about to provide or cause to be provided to the provider, the federal government, or the Attorney General information relating to a violation of, or an act or omission the provider or representative reasonably believes to be a violation of, this title.
(4)Testifying before or otherwise providing information relevant for a state or federal proceeding regarding this title or a proposed amendment to this title.
(5)Commencing, causing to be commenced, or being about to commence or cause to be commenced a proceeding under this title.
(6)Testifying or being about to testify in a proceeding.
(7)Assisting or participating, or being about to assist or participate, in a proceeding or other action to carry out the purposes of this title.
(8)Objecting to, or refusing to participate in, an activity, policy, practice, or assigned task that the employee or representative reasonably believes to be in violation of this title or any order, rule, regulation, standard, or ban under this title.
(b)An employee covered by this section who alleges discrimination by an employer in violation of subdivision (a) may bring an action governed by the rules and procedures, legal burdens of proof, and remedies applicable under the False Claims Act (Article 9 (commencing with Section 12650) of Chapter 6 of Part 2 of Division 3 of Title 2) or Section 12990, or an action against unfair competition pursuant to Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions Code.
(c)(1)This section does not diminish the rights, privileges, or remedies of an employee under any other law, regulation, or collective bargaining agreement. The rights and remedies in this section shall not be waived by an agreement, policy, form, or condition of employment.
(2)This section does not preempt or diminish any other law or regulation against discrimination, demotion, discharge, suspension, threats, harassment, reprimand, retaliation, or any other manner of discrimination.
(d)For purposes of this section:
(1)Employer means a person engaged in profit or not-for-profit business or industry, including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees, and who is subject to liability for violating this title.
(2)Employee means an individual performing activities under this title on behalf of an employer.
100644.(a)This section shall be effective on the date the implementation period ends pursuant to paragraph (6) of subdivision (e) of Section 100612.
(b)(1)An institutional or other health care provider with a participation agreement in effect shall not bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is a covered benefit through CalCare.
(2)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is not a covered benefit through CalCare if the following requirements are met:
(A)The contract and provider meet the requirements specified in paragraphs (3) and (4).
(B)The health care item or service is not payable or available through CalCare.
(C)The provider does not receive reimbursement, directly or indirectly, from CalCare for the health care item or service, and does not receive an amount for the health care item or service from an organization that receives reimbursement, directly or indirectly, for the health care item or service from CalCare.
(3)(A)A contract described in paragraph (2) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the health care item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (2) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service.
(ii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iii)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(iv)The individual understands that the provider is providing services outside the scope of CalCare.
(4)A participating provider that enters into a contract described in paragraph (2) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the noncovered health care item or service, state that the provider will not submit a claim to CalCare for a noncovered health care item or service provided to a member, and be signed by the provider.
(5)If a provider signing an affidavit described in paragraph (4) knowingly and willfully submits a claim to CalCare for a noncovered health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract, all of the following apply:
(A)A contract described in paragraph (2) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(6)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual ineligible for benefits under CalCare for a health care item or service. Consistent with Section 100619, the institutional or other health care provider shall report to the board, on an annual basis, aggregate information regarding services furnished to ineligible individuals.
(c)(1)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits under CalCare for a health care item or service that is a covered benefit through CalCare only if the contract and provider meet the requirements specified in paragraphs (2) and (3).
(2)(A)A contract described in paragraph (1) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (1) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual understands that the individual has the right to have the health care item or service provided by another provider for which payment would be made under CalCare.
(ii)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service, even if the health care item or service is otherwise covered under CalCare.
(iii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iv)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(v)The individual understands that the provider is providing services outside the scope of CalCare.
(3)A provider that enters into a contract described in paragraph (1) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the health care item or service, state that the provider will not submit a claim to CalCare for a health care item or service provided to a member during a two-year period beginning on the date the affidavit was signed, and be signed by the provider.
(4)If a provider who signed an affidavit described in paragraph (3) knowingly and willfully submits a claim to CalCare for a health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract described in an affidavit signed pursuant to paragraph (3), all of the following apply:
(A)A contract described in paragraph (1) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare program, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(5)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual for a health care item or service that is not a benefit under CalCare.
2.Payment for Health Care Items and Services100650.(a)The board shall adopt regulations regarding contracting for, and establishing payment methodologies for, covered health care items and services provided to members under CalCare by participating providers. All payment rates under CalCare shall be reasonable and reasonably related to all of the following:
(1)The cost of efficiently providing health care items and services.
(2)Ensuring availability and accessibility of CalCare health care services, including compliance with state requirements regarding network adequacy, timely access, and language access.
(3)Maintaining an optimal workforce and the health care facilities necessary to deliver quality, equitable health care.
(b)(1)Payment for health care items and services shall be considered payment in full.
(2)A participating provider shall not charge a rate in excess of the payment established through CalCare for a health care item or service furnished under CalCare and shall not solicit or accept payment from any member or third party for a health care item or service furnished under CalCare, except as provided under a federal program.
(3)This section does not preclude CalCare from acting as a primary or secondary payer in conjunction with another third-party payer when permitted by a federal program.
(c)Not later than the beginning of each fiscal quarter during which an institutional provider of care, including a hospital, skilled nursing facility, and chronic dialysis clinic, is to furnish health care items and services under CalCare, the board shall pay to each institutional provider a lump sum to cover all operating expenses under a global budget as set forth in Section 100651. An institutional provider receiving a global budget payment shall accept that payment as payment in full for all operating expenses for health care items and services furnished under CalCare, whether inpatient or outpatient, by the institutional provider.
(d)(1)A group practice, county organized health system, or local initiative practice may elect to be paid for health care items and services furnished under CalCare either on a fee-for-service basis under Section 100655 or on a salaried basis.
(2)A group practice, county organized health system, or local initiative practice that elects to be paid on a salaried basis shall negotiate salaried payment rates with the board annually, and the board shall pay the group practice, county organized health system, or local initiative practice at the beginning of each month.
(3)The board may determine whether a group practice, county organized health system, or local initiative practice may elect to be paid on an hourly or other time-based rate for certain health care items and services furnished under CalCare, including primary and preventive care and care coordination.
(e)Health care items and services provided to members under CalCare by individual providers or any other providers not paid under subdivision (c) or (d) shall be paid for on a fee-for-service basis under Section 100655.
(f)Capital-related expenses for specifically identified capital expenditures incurred by participating providers shall meet the requirements under Section 100656.
(g)Payment methodologies and payment rates shall include a distinct component of reimbursement for direct and indirect costs incurred by the institutional provider for graduate medical education, as applicable.
(h)The board shall adopt, by regulation, payment methodologies and procedures for paying for out-of-state health care services.
(i)(1)This article does not regulate, interfere with, diminish, or abrogate a collective bargaining agreement, established employee rights, or the right, obligation, or authority of a collective bargaining representative under state or local law.
(2)This article does not compel, regulate, interfere with, or duplicate the provisions of an established training program that is operated under the terms of a collective bargaining agreement or unilaterally by an employer or bona fide labor union.
(j)The board shall determine the appropriate use and allocation of the special projects budget for the construction, renovation, or staffing of health care facilities in rural, underserved, or health professional or medical shortage areas, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
100651.(a)An institutional providers global budget shall be determined before the start of a fiscal year through negotiations between the provider and the board. The global budget shall be negotiated annually based on the payment factors described in subdivision (d).
(b)An institutional providers global budget shall be used only to cover operating expenses associated with direct care for patients for health care items and services covered under CalCare. An institutional providers global budget shall not be used for capital expenditures, and capital expenditures shall not be included in the global budget.
(c)The board, on a quarterly basis, shall review whether requirements of the institutional providers participation agreement and negotiated global budget have been performed and shall determine whether adjustment to the institutional providers payment is warranted.
(d)A payment negotiated pursuant to subdivision (a) shall take into account, with respect to each provider, all of the following:
(1)The historical volume of services provided for each health care item and service in the previous three-year period.
(2)The actual expenditures of a provider in the providers most recent Medicare cost report for each health care item and service, or other cost report that may otherwise be adopted by the board, compared to the following:
(A)The expenditures of other comparable institutional providers in the state.
(B)The normative payment rates established under the comparative payment rate systems pursuant to Section 100654, including permissible adjustments to the rates for the health care items and services.
(C)Projected changes in the volume and type of health care items and services to be furnished.
(D)Employee wages and compensation.
(E)The providers maximum capacity to provide health care items and services.
(F)Education and prevention programs.
(G)Health care workforce recruitment and retention programs, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(H)Permissible adjustments to the providers operating budget from the previous fiscal year due to factors including an increase in primary or specialty care access, efforts to decrease health care disparities in rural or medically underserved areas, a response to emergent conditions, and proposed changes to patient care programs at the institutional level.
(I)Any other factor determined appropriate by the board.
(3)In a rural or medically underserved area, the need to mitigate the impact of the availability and accessibility of health care services through increased global budget payment.
(e)A payment negotiated pursuant to subdivision (a) or payment methodology shall not do any of the following:
(1)Take into account capital expenditures of the provider or any other expenditure not directly associated with furnishing health care items and services under CalCare.
(2)Be used by a provider for capital expenditures or other expenditures associated with capital projects.
(3)Exceed the providers capacity to furnish health care items and services covered under CalCare.
(4)Be used to pay or otherwise compensate a board member, executive, or administrator of the institutional provider who has an interest or relationship prohibited under paragraph (10) of subdivision (b) of Section 100641 or paragraph (3) of subdivision (c) of Section 100661.
(5)Take into account relief pending appeal granted to a provider under Section 100653.
(f)The board may negotiate changes to an institutional providers global budget based on factors not prohibited under subdivision (e) or any other provision of this title.
(g)Subject to subdivision (i) of Section 100650, compensation costs for an employee, contractor employee, or subcontractor employee of an institutional provider receiving a global budget shall meet the compensation cap established in Section 4304(a)(16) of Title 41 of the United States Code and its implementing regulations, except that the board may establish one or more narrowly targeted exceptions for scientists, engineers, or other specialists upon a determination that those exceptions are needed to ensure CalCare continued access to needed skills and capabilities.
(h)A payment to an institutional provider pursuant to this section shall not allow a participating provider to retain revenue generated from outsourcing health care items and services covered under CalCare, unless that revenue was considered part of the global budget negotiation process. This subdivision shall apply to revenue from outsourcing health care items and services that were previously furnished by employees of the participating provider who were subject to a collective bargaining agreement.
(i)For the purposes of this section, operating expenses of a provider include the following:
(1)The costs associated with covered health care items and services under CalCare, including the following:
(A)Compensation for health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider.
(B)Pharmaceutical products administered by health care professionals at the institutional providers facility or facilities.
(C)Purchasing supplies.
(D)Maintenance of medical devices and health care technologies, including diagnostic testing equipment, except that health information technology that is not necessary to comply with data collection and reporting requirements under this title or otherwise required by law and artificial intelligence shall be considered capital expenditures, unless otherwise determined by the board.
(E)Incidental services necessary for safe patient care.
(F)Patient care, education, and preventive health programs, and necessary staff to implement those programs.
(G)Occupational health and safety programs and public health programs, and necessary staff to implement those programs for the continued education and health and safety of clinicians and other individuals employed by the institutional provider.
(H)Infectious disease response preparedness, including the maintenance of a one-year or 365-day stockpile of personal protective equipment, occupational testing and surveillance, and contact tracing.
(I)Recruitment, retention, and training of health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(2)Administrative costs of the institutional provider.
100652.(a)The board shall consider a request for interim payment, filed by an institutional provider that is subject to the payments or global budget, or filed by health care workers of an institutional provider that is subject to the payment or global budget or their representatives, based on the following:
(1)The overall financial condition of the institutional provider, including bankruptcy or financial solvency.
(2)Excessive risks to the ongoing operation of the institutional provider.
(3)Justifiable differences in costs among providers, including providing a service not available from other providers in the region, or the need for health care services in rural areas with a shortage of health professionals or medically underserved areas and populations.
(4)Factors that led to increased costs for the institutional provider that can reasonably be considered to be unanticipated and out of the control of the provider. Those factors may include:
(A)Natural disasters.
(B)Outbreaks of epidemics or infectious diseases.
(C)Unanticipated facility or equipment repairs or purchases.
(D)Significant and unanticipated increases in pharmaceutical or medical device prices.
(E)Public health emergencies.
(5)Changes in state or federal laws that result in a change in costs.
(6)Reasonable increases in labor costs, including salaries and benefits, and changes in collective bargaining agreements, prevailing wage, or local law.
(b)The board shall establish uniform written procedures under which it reviews requests for interim payment pursuant to subdivision (a), including procedures to provide immediate payment in the event of a public health emergency.
(c)On a quarterly basis, the board shall review the global budget and payments to institutional providers that are not-for-profit or governmental entities and may initiate an interim payment review under subdivision (b) based on the factors set forth in this section.
100653.(a)The board shall consider an appeal of payments, the global budget, or a determination of a request for interim payment, filed by an institutional provider that is subject to the payment or global budget. budget or filed by health care workers of an institutional provider that is subject to the payment or global budget or their representatives.
(b)(1)The payments set and global budget negotiated by the board to be paid to the institutional provider shall stay in effect during the appeal process, subject to relief pending appeal under this subdivision.
(2)The board shall have the power to grant interim relief based on fairness. The board shall develop regulations governing interim relief. The board shall establish uniform written procedures for the submission, processing, and consideration of an interim relief appeal by an institutional provider. A decision on interim relief shall be granted within one month of the filing of an interim relief appeal. An institutional provider shall certify in its interim relief appeal that the request is made on the basis that the challenged amount is arbitrary and capricious, or that the institutional provider has experienced a bona fide emergency based on unanticipated costs or costs outside the control of the entity, including those described in paragraph (4) of subdivision (a) of Section 100652.
(c)(1)In accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2), the board may delegate the conduct of a hearing to an administrative law judge, who shall issue a proposed decision with findings of fact and conclusions of law.
(2)The administrative law judge may hold evidentiary hearings and shall issue a proposed decision with findings of fact and conclusions of law, including a recommended adjusted payment or global budget, within four months of the filing of the appeal.
(3)Within 30 days of receipt of the proposed decision by the administrative law judge, the board may approve, disapprove, or modify the decision, and shall issue a final decision for the appealing institutional provider.
(d)A final determination by the board shall be subject to judicial review pursuant to Section 1094.5 of the Code of Civil Procedure.
100654.(a)The board shall use existing Medicare prospective payment systems to establish and serve as the comparative payment rate system in global budget negotiations described in subparagraph (B) of paragraph (2) of subdivision (d) of Section 100651. The board shall update the comparative payment rate system annually.
(b)To develop the comparative payment rate system, the board shall use only the operating base payment rates under each Medicare prospective payment system with applicable adjustments.
(c)The comparative rate system shall not include value-based purchasing adjustments or capital expenses base payment rates that may be included in Medicare prospective payment systems.
(d)In the first year that global budget payments are available to institutional providers, and for purposes of selecting a comparative payment rate system used during initial global budget negotiations for an institutional provider, the board shall take into account the appropriate Medicare prospective payment system from the most recent year to determine what operating base payment the institutional provider would have been paid for covered health care items and services furnished the preceding year with applicable adjustments, excluding value-based purchasing adjustments, based on the prospective payment system.
100655.(a)The board shall engage in good faith negotiations with health care providers representatives under Chapter 8 (commencing with Section 100685) to determine rates of fee-for-service payments for health care items and services furnished under CalCare.
(b)There shall be a rebuttable presumption that the Medicare fee-for-service rates of reimbursement constitute reasonable fee-for-service payment rates. The fee schedule shall be updated annually.
(c)Payments to individual providers under this article shall not include payments to individual providers in salaried positions at institutional providers receiving global budgets under Section 100651 or individual health care professionals who are employed by or otherwise receive compensation or payment for health care items and services furnished under CalCare from group practices, county organized health systems, or local initiatives practices that receive payment under CalCare on a salaried basis.
(d)To establish the fee-for-service payment rates, the board shall ensure that the fee schedule compensates physicians and other health care professionals at a rate that reflects the value for health care items and services furnished.
(e)In a rural or medically underserved area, the board may mitigate the impact of the availability and accessibility of health care services through increased individual provider payment.
(f)The board shall consider a request for interim payment, filed by a health care provider that is subject to the payments under this section, or by health care workers of a health care provider that is subject to the payments under this section or their representatives, based on the factors and procedures developed pursuant to Section 100652.
100656.(a)(1)The board shall adopt, by regulation, payment methodologies for the payment of capital expenditures for specifically identified capital projects incurred by not-for-profit or governmental entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)The board shall prioritize allocation of funding under this subdivision to projects that propose to use the funds to improve service in a rural or medically underserved area, or to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status. The board shall consider the impact of any prior reduction in services or facility closure by a not-for-profit or governmental entity as part of the application review process.
(3)For the purposes of funding capital expenditures under this section, health care facilities and governmental entities shall apply to the board in a time and manner specified by the board. All capital-related expenses generated by a capital project shall have received prior approval from the board to be paid under CalCare.
(b)Approval of an application for capital expenditures shall be based on achievement of the program standards described in Chapter 6 (commencing with Section 100660).
(c)The board shall not grant funding for capital expenditures for capital projects that are financed directly or indirectly through the diversion of private or other non-CalCare program funding that results in reductions in care to patients, including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability.
(d)A participating provider shall not use operating funds or payments from CalCare for the operating expenses associated with a capital asset that was not funded by CalCare without the approval of the board.
(e)A participating provider shall not do either of the following:
(1)Use funds from CalCare designated for operating expenses or payments for capital expenditures.
(2)Use funds from CalCare designated for capital expenditures or payments for operating expenses.
100657.(a)(1)A margin generated by a participating provider receiving a global budget under CalCare may be retained and used to meet the health care needs of CalCare members.
(2)A participating provider shall not retain a margin if that margin was generated through inappropriate limitations on access to health care, compromises in the quality of care, or actions that adversely affected or are likely to adversely affect the health of the persons receiving services from an institutional provider, group practice, or other participating provider under CalCare.
(3)The board shall evaluate the source of margin generation.
(b)A payment under CalCare, including provider payments for operating expenses or capital expenditures, shall not take into account, include a process for the funding of, or be used by a provider for any of the following:
(1)Marketing, which does not include education and prevention programs paid under a global budget.
(2)The profit or net revenue, or increasing the profit, net revenue, or financial result of the provider.
(3)An incentive payment, bonus, or compensation based on patient utilization of health care items or services or any financial measure applied with respect to the provider or a group practice or other entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(4)A bonus, incentive payment, or incentive adjustment from CalCare to a participating provider.
(5)A bonus, incentive payment, or compensation based on the financial results of any other health care provider with which the provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship.
(6)A bonus, incentive payment, or compensation based on the financial results of an integrated health care delivery system, group practice, or other provider.
(7)State political contributions.
(c)(1)The board shall establish and enforce penalties for violations of this section, consistent with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
(2)Penalty payments collected for violations of this section shall be remitted to the CalCare Trust Fund for use in CalCare.
100658.(a)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, and other relevant state agencies, negotiate prices to be paid for pharmaceuticals, medical supplies, medical technology, and medically necessary assistive equipment covered through CalCare. Negotiations by the board shall be on behalf of the entire CalCare program. A state agency shall cooperate to provide data and other information to the board.
(b)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, the CalCare Public Advisory Committee, patient advocacy organizations, physicians, registered nurses, pharmacists, and other health care professionals, establish a prescription drug formulary system. To establish the prescription drug formulary system, the board shall do all of the following:
(1)Promote the use of generic and biosimilar medications.
(2)Consider the clinical efficacy of medications.
(3)Update the formulary frequently and allow health care professionals, other clinicians, and members to petition the board to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary.
(4)Consult with patient advocacy organizations, physicians, nurses, pharmacists, and other health care professionals to determine the clinical efficacy and need for the inclusion of specific medications in the formulary.
(c)The prescription drug formulary system shall not require a prior authorization determination for coverage under CalCare and shall not apply treatment limitations through the use of step therapy protocols.
(d)(1)The prescription drug formulary system shall include coverage for prescription drugs in a manner in which there is no cost sharing for CalCare enrollees.
(2)The board may consider cost sharing for providers that prescribe drugs with a lower cost medically equivalent generic or lower cost drug substitution.
(3)The prescription drug formulary system shall include antiretroviral drugs that are medically necessary for the prevention of HIV/AIDS, including preexposure prophylaxis as defined in subdivision (b) of Section 4052.02 of the Business and Professions Code and postexposure prophylaxis as defined in subdivision (b) of Section 4052.03 of the Business and Professions Code, in a manner in which there is no cost sharing for CalCare enrollees.
(d)(e)The board shall promulgate regulations regarding the use of off-formulary medications that allow for patient access.
6.Program Standards1.Standard of Care100660.CalCare shall establish a single standard of safe, therapeutic, and effective care for all residents of the state by the following means:
(a)The board shall establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:
(1)The scope, quality, and accessibility of health care items and services.
(2)Relations between participating providers and members.
(3)Relations between institutional providers, group practices, and individual health care organizations, including credentialing for participation in CalCare and clinical and admitting privileges, and terms, methods, and rates of payment.
(b)The board shall establish requirements and standards, by regulation, under CalCare that include provisions to promote all of the following:
(1)Simplification, transparency, uniformity, and fairness in the following:
(A)Health care provider credentialing for participation in CalCare.
(B)Health care provider clinical and admitting privileges in health care facilities.
(C)Clinical placement for educational purposes, including clinical placement for prelicensure registered nursing students without regard to degree type, that prioritizes nursing students in public education programs.
(D)Payment procedures and rates.
(E)Claims processing.
(2)In-person primary and preventive care, efficient and effective health care items and services, quality assurance, and promotion of public, environmental, and occupational health.
(3)Elimination of health care disparities.
(4)Nondiscrimination pursuant to Section 100631.
(5)Accessibility of health care items and services, including accessibility for people with disabilities and people with limited ability to speak or understand English.
(6)Providing health care items and services in a culturally, linguistically, and structurally competent manner.
(7)Prevention-oriented care.
(c)The board shall establish requirements and standards, to the extent authorized by federal law, by regulation, for replacing and merging with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the Affordable Care Act, and federally matched public health programs.
(d)A participating provider shall furnish information as required by the Department of Health Care Access and Information pursuant to Sections 100617 and 100641, and to Division 107 (commencing with Section 127000) of the Health and Safety Code, and permit examination of that information by the board as reasonably required for purposes of reviewing accessibility and utilization of health care items and services, quality assurance, cost containment, the making of payments, and statistical or other studies of the operation of CalCare or for protection and promotion of public, environmental, and occupational health.
(e)The board shall use the data furnished under this title to ensure that clinical practices meet the utilization, quality, and access standards of CalCare. The board shall not use a standard developed under this chapter for the purposes of establishing a payment incentive or adjustment under CalCare.
(f)To develop requirements and standards and making other policy determinations under this chapter, the board shall consult with representatives of members, health care providers, health care organizations, labor organizations representing health care employees, and other interested parties.
(g)The board shall coordinate with the Office of Health Equity, the Department of Health Care Access and Information, and the Department of Managed Health Care to do both of the following:
(1)Monitor participating providers for, and establish procedures related to, compliance with the requirements and standards established under this section.
(2)Establish programs, including special projects under Section 100677, to ensure or manage CalCare member access to in-person primary and preventive care, efficient and effective health care items and services, and quality care.
100661.(a)(1)As part of a health care practitioners duty to advocate for medically appropriate health care for their patients pursuant to Sections 510 and 2056 of the Business and Professions Code, a participating provider has a duty to act in the exclusive interest of the patient.
(2)The duty described in paragraph (1) applies to a health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare.
(b)Consistent with subdivision (a) and with Sections 510 and 2056 of the Business and Professions Code:
(1)An individuals treating physician, or other health care professional who is authorized to diagnose the individual in accordance with all applicable scope of practice and other license requirements and is treating the individual, is responsible for the determination of the medically necessary or appropriate care for the individual.
(2)A participating provider or health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare from a participating provider or other person participating in CalCare shall use reasonable care and diligence in safeguarding an individual under the care of the provider or professional and shall not impair an individuals treating physician or other health care provider treating the individual from advocating for medically necessary or appropriate care under this section.
(c)A health care provider or health care professional described in subdivision (a) violates the duty established under this section for any of the following:
(1)Having a pecuniary interest or relationship, including an interest or relationship disclosed under subdivision (d), that impairs the providers ability to provide medically necessary or appropriate care.
(2)Accepting a bonus, incentive payment, or compensation based on any of the following:
(A)A patients utilization of services.
(B)The financial results of another health care provider with which the participating provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship, or of a person that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(C)The financial results of an institutional provider, group practice, or person that contracts with, provides health care items or services under, or otherwise receives payment from CalCare.
(3)Having a board member, executive, or administrator that receives compensation from, owns stock or has other financial investments in, or serves as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(d)To evaluate and review compliance with this section, a participating provider shall report, at least annually, to the Department of Health Care Access and Information all of the following:
(1)A beneficial interest required to be disclosed to a patient pursuant to Section 654.2 of the Business and Professions Code.
(2)A membership, proprietary interest, coownership, or profit-sharing arrangement, required to be disclosed to a patient pursuant to Section 654.1 of the Business and Professions Code.
(3)A subcontract entered into that contains incentive plans that involve general payments, including capitation payments or shared risk agreements, that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions.
(4)Bonus or other incentive arrangements used in compensation agreements with another health care provider or an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(5)An offer, delivery, receipt, or acceptance of rebates, refunds, commission, preference, patronage dividend, discount, or other consideration for a referral made in exception to Section 650 of the Business and Professions Code.
(e)The board may adopt regulations as necessary to implement and enforce this section and may adopt regulations to expand reporting requirements under this section.
(f)For purposes of this section, person means an individual, partnership, corporation, limited liability company, or other organization, or any combination thereof, including a medical group practice, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer.
100662.(a)An individuals treating physician, nurse, or other health care professional, in implementing a patients medical or nursing care plan and in accordance with their scope of practice and licensure, may override health information technology or clinical practice guidelines, including standards and guidelines implemented by a participating provider through the use of health information technology, including electronic health record technology, clinical decision support technology, and computerized order entry programs.
(b)An override described in subdivision (a) shall, in the independent professional judgment of the treating physician, nurse, or other health care professional, meet all of the following requirements:
(1)The override is consistent with the treating physicians, nurses, or other health care professionals determination of medical necessity or appropriateness or nursing assessment.
(2)The override is in the best interest of the patient.
(3)The override is consistent with the patients wishes.
2.Health Equity100665.(a)There is hereby established, within CalCare, the Office of Health Equity. The Director of the Department of Health Care Access and Information shall be the director of the office and shall carry out all functions of that position, including enforcement.
(b)The office shall be responsible for coordination and collaboration across the programs and activities of CalCare and the California Health and Human Services Agency with respect to ensuring health equity under CalCare and other health programs of the California Health and Human Services Agency.
(c)The office shall do all of the following:
(1)Support the board through data collection and analysis of, and recommendations to address, all of the following:
(A)The disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, disability, sex, including gender identity and sexual orientation, geographic location, socioeconomic status, incarceration, housing status, and other population-based characteristics.
(B)Barriers to health, including barriers relating to income, education, housing, food insecurity, employment status, working conditions, and conditions related to the physical environment.
(C)Barriers to health care access, including lack of trust and awareness, lack of transportation, geography, hospital and service closures, lack of health care infrastructure and facilities, lack of health care professional staffing and recruitment, disparities in quality of care received, and disparities in utilization of care.
(D)Inequitable distribution of health care services, including health care professional shortage areas, medically underserved areas, medically underserved populations, and trends in hospital closures and service reductions.
(E)Discrimination in health care settings and the use of racially biased or other discriminatory practice guidelines, health care technologies, and algorithms.
(F)Increasing access to high-quality primary health care, particularly in medically underserved areas and for medically underserved populations populations.
(G)Prevention-oriented care through the identification of social determinants of health and gaps in human services programs that address social determinants of health.
(2)Ensure that analysis and data collected under this section are made publicly available and allow for the analysis of cross-sectional information on peoples identities.
(3)Support the board through the development and coordination of programs and recommendations to enhance health equity in California, including programs and recommendations on all of the following:
(A)Improving the provision of culturally, linguistically, and structurally competent care.
(B)Increasing diversity in the health care workforce.
(C)Ensuring sufficient health care professionals and facilities to meet the health care needs across the state.
(D)Ensuring equitable access and distribution of health care professionals and facilities to meet the health care needs across the state.
(E)Recruitment and retention of a health care workforce that meets the cultural, linguistic, and other needs of Californians.
(F)Recruitment and retention of a health care workforce in rural and medically underserved areas.
(4)Develop, coordinate, and provide recommendations on programs that expand the number of primary health care providers and practitioners, including primary care physicians, registered nurses, and dentists, in the state.
(5)Develop, coordinate, and provide recommendations on targeted programs and resources for federally qualified health centers, rural health centers, community health centers, and other community-based organizations that provide primary care in the state.
(6)Conduct ongoing research and evaluation on health equity and access to primary care in California.
(7)Support the board and the CalCare Public Advisory Committee through data collection and analysis and recommendations to develop, propose, and review special projects under Section 100677.
(8)Adopt and promulgate regulations for the purpose of carrying out this chapter.
(9)Establish advisory or technical committees, as necessary.
(d)For purposes of implementing this section, including hiring staff and consultants, through the procurement authority and processes of the department, facilitating and conducting meetings, conducting research and analysis, and developing the required reports, the office may enter into exclusive or nonexclusive contracts on a bid or negotiated basis. Until January 1, 2026, contracts entered into or amended pursuant to this chapter are exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and are exempt from the review or approval of any division of the Department of General Services.
3.Consumer Protections100667.(a)It is the intent of the Legislature that all existing consumer protections related to health care service plans, including network adequacy, timely access, and language access, apply to CalCare.
(b)It is the intent of the Legislature that all existing patient rights and protections in the delivery and provision of health care items and services apply to CalCare and participating providers in CalCare.
(c)This title does not diminish or eliminate any protections consumers have under existing state and federal law, including health care spending targets and data collection required by the Office of Health Care Affordability.
(d)For purposes of the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), the CalCare program is a health care service plan, including for purposes of the Independent Medical Review System established in Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.
(e)This title does not diminish or eliminate any of the rights and protections afforded to Californians by the Medicare and Medicaid programs under state and federal law or the Lanterman-Petris-Short Act (Part 1 (commencing with Section 5000) of Division 5 of the Welfare and Institutions Code).
7.Funding1.Federal Health Programs and Funding100670.(a)(1)The board is authorized to and shall seek all federal waivers and other federal approvals and arrangements and submit state plan amendments as necessary to operate CalCare consistent with this title.
(2)The board is authorized to apply for a federal waiver or federal approval as necessary to receive funds to operate CalCare pursuant to paragraph (1), including a waiver under Section 18052 of Title 42 of the United States Code.
(3)The board shall apply for federal waivers or federal approval pursuant to paragraph (1) by January 1, 2026.
(b)(1)The board shall apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the Affordable Care Act, and any other federal programs or laws, as appropriate, that are necessary to enable all CalCare members to receive all benefits under CalCare through CalCare, to enable the state to implement this title, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the CalCare Trust Fund, created pursuant to Section 100675, and to use those funds for CalCare and other provisions under this title.
(2)To the fullest extent possible, the board shall negotiate arrangements with the federal government to ensure that federal payments are paid to CalCare in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs. To the extent any federal funding is not paid directly to CalCare, the state shall direct the funding and moneys to CalCare.
(3)The board may require members or applicants to provide information necessary for CalCare to comply with any waiver or arrangement under this title. Information provided by members to the board for the purposes of this subdivision shall not be used for any other purpose.
(4)The board may take any additional actions necessary to effectively implement CalCare to the maximum extent possible as an independent single-payer program consistent with this title. It is the intent of the Legislature to establish CalCare, to the fullest extent possible, as an independent agency.
(c)The board may take actions consistent with this article to enable CalCare to administer Medicare in California. CalCare shall be a provider of supplemental insurance coverage and shall provide premium assistance for drug coverage under Medicare Part D for eligible members of CalCare.
(d)The board may waive or modify the applicability of any provisions of this title relating to any federally matched public health program or Medicare, as necessary, to implement any waiver or arrangement under this section or to maximize the federal benefits to CalCare under this section.
(e)The board may apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare. Enrollment in a federally matched public health program or Medicare shall not cause a member to lose a health care item or service provided by CalCare or diminish any right the member would otherwise have.
(f)(1)Notwithstanding any other law, the board, by regulation, shall increase the income eligibility level, increase or eliminate the resource test for eligibility, simplify any procedural or documentation requirement for enrollment, and increase the benefits for any federally matched public health program and for any program in order to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(2)The board may act under this subdivision, upon a finding approved by the Director of Finance and the board that the action does all of the following:
(A)Will help to increase the number of members who are eligible for and enrolled in federally matched public health programs, or for any program to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(B)Will not diminish any individuals access to a health care item or service or right the individual would otherwise have.
(C)Is in the interest of CalCare.
(D)Does not require or has received any necessary federal waivers or approvals to ensure federal financial participation.
(g)To enable the board to apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare, the board may require that every member or applicant provide the information necessary to enable the board to determine whether the applicant is eligible for a federally matched public health program or for Medicare, or any program or benefit under Medicare.
(h)As a condition of continued eligibility for health care items and services under CalCare, a member who is eligible for benefits under Medicare shall enroll in Medicare, including Parts A, B, and D.
(i)The board shall provide premium assistance for all members enrolling in a Medicare Part D drug coverage plan under Section 1860D of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.), limited to the low-income benchmark premium amount established by the federal Centers for Medicare and Medicaid Services and any other amount the federal agency establishes under its de minimis premium policy, except that those payments made on behalf of members enrolled in a Medicare Advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to CalCare.
(j)If the board has reasonable grounds to believe that a member may be eligible for an income-related subsidy under Section 1860D-14 of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-114), the member shall provide, and authorize CalCare to obtain, any information or documentation required to establish the members eligibility for that subsidy. The board shall attempt to obtain as much of the information and documentation as possible from records that are available to it.
(k)The board shall make a reasonable effort to notify members of their obligations under this section. After a reasonable effort has been made to contact the member, the member shall be notified in writing that the member has 60 days to provide the required information. If the required information is not provided within the 60-day period, the members coverage under CalCare may be suspended until the issue is resolved. Information provided by a member to the board for the purposes of this section shall not be used for any other purpose.
(l)The board shall assume responsibility for all benefits and services paid for by the federal government with those funds.
2.CalCare Trust Fund100675.(a)The CalCare Trust Fund is hereby created in the State Treasury for the purposes of this title to be administered by the CalCare Board. Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title. Any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year may be carried forward to the next succeeding fiscal year.
(b)Notwithstanding any other law, moneys deposited in the fund shall not be loaned to, or borrowed by, any other special fund or the General Fund, a county general fund or any other county fund, or any other fund.
(c)The board shall establish and maintain a prudent reserve in the fund to enable it to respond to costs including those of an epidemic, pandemic, natural disaster, or other health emergency, or market-shift adjustments related to patient volume.
(d)The board or staff of the board shall not utilize any funds intended for the administrative and operational expenses of the board for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.
(e)Notwithstanding Section 16305.7, all interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.
(f)The fund shall consist of all of the following:
(1)All moneys obtained pursuant to legislation enacted as proposed under Section 100680.
(2)Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials for health care programs established under Medicare, any federally matched public health program, or the Affordable Care Act.
(3)The amounts paid by the State Department of Health Care Services that are equivalent to those amounts that are paid on behalf of residents of this state under Medicare, any federally matched public health program, or the Affordable Care Act for health benefits that are equivalent to health benefits covered under CalCare.
(4)Federal and state funds for purposes of the provision of services authorized under Title XX of the federal Social Security Act (42 U.S.C. Sec. 1397 et seq.) that would otherwise be covered under CalCare.
(5)State moneys that would otherwise be appropriated to any governmental agency, office, program, instrumentality, or institution that provides health care items or services for services and benefits covered under CalCare. Payments to the fund pursuant to this section shall be in an amount equal to the money appropriated for those purposes in the fiscal year beginning immediately preceding the effective date of this title.
(g)All federal moneys shall be placed into the CalCare Federal Funds Account, which is hereby created within the CalCare Trust Fund.
(h)Moneys in the CalCare Trust Fund shall only be used for the purposes established in this title.
(i)(1)Before the delivery of the fiscal analysis required pursuant to Section 100620:
(A)Moneys in the CalCare Trust Fund shall not be used for startup and administrative costs to implement Section 100612.
(B)Moneys in the CalCare Trust Fund may be used to design and commission the fiscal analysis required pursuant to Section 100620.
(2)After delivery of the fiscal analysis required pursuant to Section 100620, moneys in the CalCare Trust Fund may be used for startup and administrative costs to implement Section 100612.
100676.(a)The board annually shall prepare a budget for CalCare that specifies a budget for all expenditures to be made for covered health care items and services and shall establish allocations for each of the budget components under subdivision (b) that shall cover a three-year period.
(b)The CalCare budget shall consist of at least the following components:
(1)An operating budget.
(2)A capital expenditures budget.
(3)A special projects budget.
(4)Program standards activities.
(5)Health professional education expenditures.
(6)Health care workforce recruitment and retention expenditures.
(7)Administrative costs.
(8)Prevention and public health activities.
(c)The board shall allocate the funds received among the components described in subdivision (b) to ensure the following:
(1)The operating budget allows for participating providers to meet the health care needs of the population.
(2)A fair allocation to the special projects budget to meet the purposes described in subdivision (f) in a reasonable timeframe.
(3)A fair allocation for program standards activities.
(4)The health professional education expenditures component is sufficient to meet the need for covered health care items and services.
(d)The operating budget described in paragraph (1) of subdivision (b) shall be used for payments to providers for health care items and services furnished by participating providers under CalCare.
(e)The capital expenditures budget described in paragraph (2) of subdivision (b) shall be used for the construction or renovation of health care facilities, excluding congregate or segregated facilities for individuals with disabilities who receive long-term services and supports under CalCare, and other capital expenditures.
(f)The special projects budget described in paragraph (3) of subdivision (b) shall be used for the payment to not-for-profit or governmental entities pursuant to Section 100677.
(g)For up to five years following the date on which benefits first become available under CalCare, at least 1 percent of the budget shall be allocated to programs providing transition assistance pursuant to Section 100615.
(h)During the implementation period and for at least five years following the date on which benefits first become available under CalCare, up to 1 percent of the budget shall be allocated to programs providing health care workforce education, recruitment, and retention pursuant to Section 100686.
100677.(a)(1)The special projects budget described in paragraph (3) of subdivision (b) of Section 100676 shall be used for the payment to not-for-profit entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code or governmental entities for the construction or renovation of health care facilities, major equipment purchases, staffing in a rural or medically underserved area, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(2)To mitigate the impact of the payments on the availability and accessibility of health care services, the special projects budget may be used to increase payment to providers in a rural or medically underserved area.
(b)(1)An agency of the state, a city, a county, a city and county, or another political subdivision of the state or a not-for-profit entity that is a health facility pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code may submit an application to the board for payment from the special projects budget for a special project under this section.
(2)The board shall develop criteria to evaluate applications for payment from the special projects budget for special projects in consultation with the CalCare Public Advisory Committee, the Office of Health Equity, the California Health Facilities Financing Authority, the Department of Health Care Access and Information, the State Department of Health Care Services, the Department of Managed Health Care, the State Department of Public Health, and other relevant state agencies.
(3)The criteria to evaluate applications shall consider factors, including if the special project will support a health facility in a rural or medically underserved area, and if the special project will address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(4)The criteria to evaluate applications shall also be used for identification and monitoring of health facilities at risk of understaffing in rural or medically underserved areas and of populations experiencing health disparities.
(c)(1)The board may issue a request for applications for a special project paid under subdivision (b) in consultation with the Office of Health Equity.
(2)The CalCare Public Advisory Committee may develop and recommend the board issue a request for applications for a special project paid under subdivision (b).
(d)(1)An applicant for payment from the special projects budget shall provide the board with financial, demographic, and other information regarding the proposed health care service area as determined by the board, in a format determined by the board, to review an application to receive payment from the special projects budget for a special project.
(2)An applicant for payment from the special projects budget shall submit a plan to the board detailing the projected uses of the proposed payment and strategies proposed to address a health disparity or other qualifying need identified by the board.
(e)(1)The board shall determine the application process and methodology for approval and distribution of payments from the special projects budget.
(2)In reviewing a plan submitted by an applicant for payment from the special projects budget under this section, the board shall evaluate if there is a reasonable likelihood that it will address a health disparity or other qualifying need identified by the board.
(3)The board shall provide public notice of an application submitted under this section and post a copy of the applicants plan submitted under this section on its internet website.
(4)The board shall make its application process and methodology publicly accessible on its internet website.
(f)(1)Within 90 days of receipt of a complete application for a payment from the special projects budget for a special project, the board shall provide a preliminary report to the applicant of the boards initial review of the application and provide public notice of the preliminary report.
(2)The board shall provide the public the opportunity to provide written comment on a preliminary report of an application for payment from the special projects budget for a special project.
(3)Before the board approves an application for payment from the special projects budgets for a special project, the CalCare Public Advisory Committee shall conduct at least one public hearing to receive public input and comment on the application.
(4)The CalCare Public Advisory Committee shall provide a recommendation to the board on the approval of an application submitted to the board under this section.
(g)The board shall have the authority to determine service provision requirements or other conditions in approving, and for the duration of, special projects payments to health facilities or that support health facilities. In making its determination, the board shall consider the impact of any changes to the health facilities service delivery on access to medical care.
3.CalCare Financing100680.(a)It is the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. In developing the revenue plan, it is the intent of the Legislature to consult with appropriate officials and stakeholders.
(b)It is the intent of the Legislature to enact legislation that would require all state revenues from CalCare to be deposited in an account within the CalCare Trust Fund to be established and known as the CalCare Trust Fund Account.
8.Transition100685.(a)An individual who meets all of the following requirements shall be eligible to enroll as a member of CalCare during the implementation period:
(1)The individual meets the eligibility standards established by the board under Section 100630.
(2)The individual is 55 years of age or older, 18 years of age or younger, or is currently enrolled in Medicare or Medicaid during the implementation period.
(b)The board shall ensure that all persons enrolled, or who seek to enroll, in a health plan during the implementation period are protected from disruptions in their care during the implementation period, including continuity of care with current health care teams.
(c)(1)During the implementation period, a carrier shall not end coverage for a CalCare member until the end of the implementation period except as expressly agreed upon under the terms of the plan.
(2)During the implementation period, a carrier shall not impose any exclusion or limitation of coverage on the basis of a persons disability, complex medical need, or chronic condition.
(3)This subdivision applies to a carrier except as otherwise prohibited by federal law.
(d)The board shall consult with the Advisory Commission on Long-Term Services and Supports, communities and advocacy organizations of persons living with disabilities, and other patient advocacy organizations to ensure that CalCare coverage during the implementation period takes into account the continuity of care for persons with disabilities, complex medical needs, or chronic conditions.
(e)In the case of inpatient hospital services and extended care services during a continuous period of stay that began before the end of the implementation period, and that had not ended as of the end of the implementation date, the board shall provide for continuation of benefits under CalCare until the end of the period of stay.
(f)During the implementation period, the board shall establish and maintain procedures that, to the greatest extent possible, provide for the following:
(1)Automatic enrollment in CalCare of individuals who are eligible to enroll in CalCare during the implementation period.
(2)Automatic enrollment in CalCare of individuals who will become eligible to enroll in CalCare after the end of the implementation period.
(g)(1)During the implementation period, the board shall establish and maintain procedures for individuals who will become eligible to enroll in CalCare after the end of the implementation period to select a primary care provider under subdivision (e) of Section 100630.
(2)During the implementation period, the board, to the greatest extent possible, shall establish and maintain procedures for individuals who are currently members of an integrated health care delivery system to automatically select participating providers in the individuals integrated health care delivery system care team as their primary care provider upon enrollment in CalCare.
(h)A person who is eligible to receive CalCare benefits during the implementation period may opt to maintain coverage outside of CalCare, including private health care coverage or coverage offered through the California Health Benefit Exchange, until the end of the implementation period.
100686.(a)(1)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for programs to address health care workforce education, recruitment, and retention to meet health workforce demands under CalCare, including programs implemented during the implementation period.
(2)The board shall coordinate with the CalCare Public Advisory Committee, the Office of Health Equity, the Department of Health Care Access and Information, the Labor and Workforce Development Agency, the California Health and Human Services Agency, and health care professional licensing boards, including the Board of Registered Nursing, Medical Board of California, and Dental Board of California, to implement programs and policies related to health care workforce education, recruitment, and retention.
(b)The board shall establish a CalCare Health Workforce Working Group to provide input, including recommendations, to the board and Secretary of Labor and Workforce Development on issues related to health care workforce education, recruitment, and retention, including all of the following:
(1)Programs and measures to expand clinical education capacity at California community colleges providing associate degree programs in health professions, including through programs to ensure the fair and equitable distribution of clinical placement at clinical education sites among approved health professions education programs and through programs to recruit and retain clinical faculty.
(2)Data collection and analysis and recommendations on health workforce attrition from direct care positions, including on moral distress and moral injury, safe staffing, and gaps in active California health professions licensees and those working in direct care.
(3)Identification and prioritization of geographical areas or populations in the state with unmet primary care or other health care needs, including access and availability of family physicians, primary care clinics, and registered nurses.
(4)Programs and measures to retain health care workforces, including public loan repayment assistance programs, minimum safe staffing requirements, investments in personal protective equipment, and occupational safety and health programs.
(5)Programs and measures to support expansion of graduate medical education programs and assistance for medical residents.
(6)Career ladders into health professions for ancillary and allied health workers, including licensed vocational nurses, certified nursing assistants, medical technicians, behavioral health technicians, health navigators, and community health workers.
(7)Career technical education pathways toward an associate degree at a California community college in a health professions education program.
(8)Programs to address barriers to health professions, including student debt levels, tuition assistance, childcare or other support, and debt-free residency or mentorship programs.
(c)The board shall appoint the members of the CalCare Health Workforce Working Group. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the working group, the board shall aim for broad representation, including, at a minimum, all of the following:
(1)Representatives of health professions and other health care workers, including specialties for primary care and behavioral health, physicians, registered nurses, and ancillary services.
(2)Representatives of labor organizations representing health care workers.
(3)Representatives of California community colleges, graduate medical education and training programs, and nursing education programs.
(4)Representatives of consumer and patient groups.
(5)Representatives of health care providers, including hospitals, nonacute care providers, and medical groups.
(d)(1)Each appointed member of the CalCare Health Workforce Working Group shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(2)Working group members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the working group shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the working group members.
(3)Working group members shall receive reimbursement for travel and other actual costs.
(e)The working group shall meet at least four times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(f)The board shall consider input, including recommendations, from the working group, along with public comments, in the boards deliberation and decisionmaking.
9.Collective Negotiation by Health Care Providers with CalCare1.Definitions100690.For purposes of this chapter, the following definitions apply:
(a)(1)Health care provider means a person who is licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code and who is either of the following:
(A)An individual who practices that profession as a health care professional or as an independent contractor.
(B)An owner, officer, shareholder, or proprietor of a health care group practice that has elected to receive fee-for-service payments from CalCare pursuant to subdivision (d) of Section 100650.
(2)A health care provider licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code who practices as an employee of a health care provider is not a health care provider for purposes of this chapter.
(b)Health care providers representative means a third party that is authorized by a health care provider to negotiate on their behalf with CalCare over terms and conditions affecting those health care providers.
2. Authorized Collective Negotiation100691.(a)Health care providers may meet and communicate for the purpose of collectively negotiating with CalCare on any matter relating to CalCare fee-for-service rates of payment for health care items and services or procedures related to fee-for-service payment under CalCare.
(b)This chapter does not allow a strike of CalCare by health care providers related to the collective negotiations.
(c)This chapter does not allow or authorize terms or conditions that would impede the ability of CalCare to comply with applicable state or federal law.
3.Collective Negotiation Requirements100692.(a)Collective negotiation under this chapter shall meet all of the following requirements:
(1)A health care provider may communicate with other health care providers regarding the terms and conditions to be negotiated with CalCare.
(2)A health care provider may communicate with a health care providers representative.
(3)A health care providers representative is the only party authorized to negotiate with CalCare on behalf of the health care providers as a group.
(4)A health care provider can be bound by the terms and conditions negotiated by the health care providers representative.
(b)This chapter does not affect or limit the right of a health care provider or group of health care providers to collectively petition a governmental entity for a change in a law, rule, or regulation.
(c)This chapter does not affect or limit collective action or collective bargaining on the part of a health care provider with the health care providers employer or any other lawful collective action or collective bargaining.
100693.(a)Before engaging in collective negotiations with CalCare on behalf of health care providers, a health care providers representative shall file with the board, in the manner prescribed by the board, information identifying the representative, the representatives plan of operation, and the representatives procedures to ensure compliance with this chapter.
(b)A person who acts as the representative of negotiating parties under this chapter shall pay a fee to the board to act as a representative. The board, by regulation, shall set fees in amounts deemed reasonable and necessary to cover the costs incurred by the board in administering this chapter.
4.Prohibited Collective Action100694.(a)This chapter does not authorize competing health care providers to act in concert in response to a health care providers representatives discussions or negotiations with CalCare, except as authorized by other law.
(b)A health care providers representative shall not negotiate an agreement that excludes, limits the participation or reimbursement of, or otherwise limits the scope of services to be provided by a health care provider or group of health care providers with respect to the performance of services that are within the health care providers scope of practice, license, registration, or certificate.
10.Operative Date100695.(a)Notwithstanding any other law, this title, except for Chapter 1 (commencing with Section 100600), Chapter 2 (commencing with Section 100610), and Article 1 (commencing with Section 100670) of Chapter 7, shall not become operative until the date the Secretary of California Health and Human Services notifies the Secretary of the Senate and the Chief Clerk of the Assembly in writing that the secretary has determined that the CalCare Trust Fund has the revenues to fund the costs of implementing this title.
(b)The California Health and Human Services Agency shall publish a copy of the notice on its internet website.
(c)The Secretary of California Health and Human Services shall make a notification pursuant to subdivision (a).
SEC. 3.The provisions of this act are severable. If any provision of this act or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
SEC. 4.The Legislature finds and declares that Section 2 of this act, which adds Sections 100610, 100617, and 100619 to the Government Code, imposes a limitation on the publics 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 private, confidential, and proprietary information, it is necessary for that information to remain confidential.
(a)The Legislature finds and declares all of the following:
(1)Although the federal Patient Protection and Affordable Care Act (PPACA) brought many improvements in health care and health care coverage, PPACA still leaves many Californians without coverage or with inadequate coverage.
(2)Californians, as individuals, employers, and taxpayers, have experienced a rise in the cost of health care and health care coverage in recent years, including rising premiums, deductibles, and copayments, as well as restricted provider networks and high out-of-network charges.
(3)Businesses have also experienced increases in the costs of health care benefits for their employees, and many employers are shifting a larger share of the cost of coverage to their employees or dropping coverage entirely.
(4)Individuals often find that they are deprived of affordable care and choice because of decisions by health benefit plans guided by the plans economic needs rather than patients health care needs.
(5)To address the fiscal crisis facing the health care system and the state, and to ensure Californians get the health care they need, comprehensive health care coverage needs to be provided.
(6)Billions of dollars that could be spent on providing equal access to health care are wasted on administrative costs necessary in a multipayer health care system. Resources and costs spent on administration would be dramatically reduced in a single-payer system, allowing health care professionals and hospitals to focus on patient care instead.
(7)It is the intent of the Legislature to establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
(b)(1)It is further the intent of the Legislature to establish the California Guaranteed Health Care for All program to provide universal health care coverage for every Californian, funded by broad-based revenue.
(2)It is the intent of the Legislature to work to obtain waivers and other approvals relating to Medi-Cal, the federal Childrens Health Insurance Program, Medicare, PPACA, and any other federal programs pertaining to the provision of health care so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the CalCare Trust Fund.
(3)Under those waivers and approvals, those funds would be used for health care coverage that provides health care benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums.
(4)Those programs would be replaced and merged into CalCare, which will operate as a true single-payer program.
(5)If any necessary waivers or approvals are not obtained, it is the intent of the Legislature that the state use state plan amendments and seek waivers and approvals to maximize, and make as seamless as possible, the use of funding from federally matched public health programs and other federal health programs in CalCare.
(6)Even if other programs, including Medi-Cal or Medicare, may contribute to paying for care, it is the goal of this act that the coverage be delivered by CalCare, and, as much as possible, that the multiple sources of funding be pooled with other CalCare program funds.
(7)It is the intent of the Legislature to provide universal health care coverage with greater benefits and access to providers than existing health coverage plans, including for Californians who primarily receive care through an integrated health care delivery system, that is free at the point of service and does not have deductibles, coinsurance, premiums, or other cost-sharing.
(c)This act does not create an employment benefit, nor does the act require, prohibit, or limit providing a health care employment benefit.
(d)(1)It is not the intent of the Legislature to change or impact in any way the role or authority of a licensing board or state agency that regulates the standards for or provision of health care and the standards for health care providers as established under current law, including the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code.
(2)This act would in no way authorize the CalCare Board, the California Guaranteed Health Care for All program, or the Secretary of California Health and Human Services to establish or revise licensure standards for health care professionals or providers.
(e)It is the intent of the Legislature that neither health information technology nor clinical practice guidelines limit the effective exercise of the professional judgment of physicians, registered nurses, and other licensed health care professionals. Physicians, registered nurses, and other licensed health care professionals shall be free to override health information technology and clinical practice guidelines if, in their professional judgment and in accordance with their scope of practice and licensure, it is in the best interest of the patient and consistent with the patients wishes.
(f)(1)It is the intent of the Legislature to prohibit CalCare, a state agency, a local agency, or a public employee acting under color of law from providing or disclosing to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(2)This act would also prohibit law enforcement agencies from using CalCares funds, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of any requirement that individuals register with the federal government or any federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Part 2 (commencing with Section 51) of Division 1 of the Civil Code).
(g)It is the further intent of the Legislature to address the high cost of prescription drugs and ensure they are affordable for patients.
SEC. 2.Title 23 (commencing with Section 100600) is added to the Government Code, to read:23.The California Guaranteed Health Care for All Act1.General Provisions100600.This title shall be known, and may be cited, as the California Guaranteed Health Care for All Act.
100601.There is hereby established in state government the California Guaranteed Health Care for All program, or CalCare, to be governed by the CalCare Board pursuant to Chapter 2 (commencing with Section 100610).
100602.For the purposes of this title, the following definitions apply:
(a)Activities of daily living means basic personal everyday activities including eating, toileting, grooming, dressing, bathing, and transferring.
(b)Advisory commission means the Advisory Commission on Long-Term Services and Supports established pursuant to Section 100614.
(c)Affordable Care Act or 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 amendments to, or regulations or guidance issued under, those acts.
(d)Allied health practitioner means a group of health professionals who apply their expertise to prevent disease transmission and diagnose, treat, and rehabilitate people of all ages and in all specialties, together with a range of technical and support staff, by delivering direct patient care, rehabilitation, treatment, diagnostics, and health improvement interventions to restore and maintain optimal physical, sensory, psychological, cognitive, and social functions. Examples include audiologists, occupational therapists, social workers, and radiographers.
(e)Board means the CalCare Board described in Section 100610.
(f)CalCare or California Guaranteed Health Care for All means the California Guaranteed Health Care for All program established in Section 100601.
(g)Capital expenditures means expenses for the purchase, lease, construction, or renovation of capital facilities, health information technology, artificial intelligence, and major equipment, including costs associated with state grants, loans, lines of credit, and lease-purchase arrangements.
(h)Carrier means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.
(i)Committee means the CalCare Public Advisory Committee established pursuant to Section 100611.
(j)County organized health system means a health system implemented pursuant to Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code, and Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.
(k)Essential community provider means a provider, as defined in Section 156.235(c) of Title 45 of the Code of Federal Regulations, as published February 27, 2015, in the Federal Register (80 FR 10749), that serves predominantly low-income, medically underserved individuals and that is one of the following:
(1)A community clinic, as defined in subparagraph (A) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(2)A free clinic, as defined in subparagraph (B) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(3)A federally qualified health center, as defined in Section 1395x(aa)(4) or Section 1396d(l)(2)(B) of Title 42 of the United States Code.
(4)A rural health clinic, as defined in Section 1395x(aa)(2) or 1396d(l)(1) of Title 42 of the United States Code.
(5)An Indian Health Service Facility, as defined in subdivision (v) of Section 2699.6500 of Title 10 of the California Code of Regulations.
(l)Federally matched public health program means the states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(m)Fund means the CalCare Trust Fund established pursuant to Article 2 (commencing with Section 100675) of Chapter 7.
(n)Global budget means the payment negotiated between an institutional provider and the board pursuant to Section 100651.
(o)Group practice means a professional corporation under the Moscone-Knox Professional Corporation Act (Part 4 (commencing with Section 13400) of Division 3 of Title 1 of the Corporations Code) that is a single corporation or partnership composed of licensed doctors of medicine, doctors of osteopathy, or other licensed health care professionals, and that provides health care items and services primarily directly through physicians or other health care professionals who are either employees or partners of the organization.
(p)Health care professional means a health care professional licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or licensed pursuant to the Osteopathic Act or the Chiropractic Act, who, in accordance with the professionals scope of practice, may provide health care items and services under this title.
(q)Health care item or service means a health care item or service that is included as a benefit under CalCare.
(r)Health professional education expenditures means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities.
(s)Home- and community-based services means an integrated continuum of service options available locally for older individuals and functionally impaired persons who seek to maximize self-care and independent living in the home or a home-like environment, which includes the home- and community-based services that are available through Medi-Cal pursuant to the home- and community-based waiver program under Section 1915 of the federal Social Security Act (42 U.S.C. Sec. 1396n) as of January 1, 2019.
(t)Implementation period means the period under paragraph (6) of subdivision (e) of Section 100612 during which CalCare is subject to special eligibility and financing provisions until it is fully implemented under that section.
(u)Institutional provider means an entity that provides health care items and services and is licensed pursuant to any of the following:
(1)A health facility, as defined in Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)A clinic licensed pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code.
(3)A long-term health care facility, as defined in Section 1418 of the Health and Safety Code, or a program developed pursuant to paragraph (1) of subdivision (i) of Section 100612.
(4)A county medical facility licensed pursuant to Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code.
(5)A residential care facility for persons with chronic, life-threatening illness licensed pursuant to Chapter 3.01 (commencing with Section 1568.01) of Division 2 of the Health and Safety Code.
(6)An Alzheimers daycare resource center licensed pursuant to Chapter 3.1 (commencing with Section 1568.15) of Division 2 of the Health and Safety Code.
(7)A residential care facility for the elderly licensed pursuant to Chapter 3.2 (commencing with Section 1569) of Division 2 of the Health and Safety Code.
(8)A hospice licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code.
(9)A pediatric day health and respite care facility licensed pursuant to Chapter 8.6 (commencing with Section 1760) of Division 2 of the Health and Safety Code.
(10)A mental health care provider licensed pursuant to Division 4 (commencing with Section 4000) of the Welfare and Institutions Code.
(11)A federally qualified health center, as defined in Section 1395x(aa)(4) or 1396d(l)(2)(B) of Title 42 of the United States Code.
(v)Instrumental activities of daily living means activities related to living independently in the community, including meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
(w)Integrated health care delivery system has the same meaning as defined in paragraph (13) of subdivision (b) of Section 1182.14 of the Labor Code.
(x)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, including the entities established pursuant to Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96 of the Welfare and Institutions Code.
(y)Long-term services and supports means long-term care, treatment, maintenance, or services related to health conditions, injury, or age, that are needed to support the activities of daily living and the instrumental activities of daily living for a person with a disability, including all long-term services and supports as defined in Section 14186.1 of the Welfare and Institutions Code, home- and community-based services, additional services and supports identified by the board to support people with disabilities to live, work, and participate in their communities, and those as defined by the board.
(z)Medicaid or medical assistance means a program that is one of the following:
(1)The states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(2)The federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(aa)Medically necessary or appropriate means the health care items, services, or supplies needed or appropriate to prevent, diagnose, or treat an illness, injury, condition, or disease, or its symptoms, and that meet accepted standards of medicine as determined by a patients treating physician or other individual health care professional who is treating the patient, and, according to that health care professionals scope of practice and licensure, is authorized to establish a medical diagnosis and has made an assessment of the patients condition.
(ab)Medicare means Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) and the programs thereunder.
(ac)Member means an individual who is enrolled in CalCare.
(ad)Out-of-state health care service means a health care item or service provided in person to a member while the member is temporarily, for no more than 90 days, and physically located out of the state under either of the following circumstances:
(1)It is medically necessary or appropriate that the health care item or service be provided while the member physically is out of the state.
(2)It is medically necessary or appropriate, and cannot be provided in the state, because the health care item or service can only be provided by a particular health care provider physically located out of the state.
(ae)Participating provider means an individual or entity that is a health care provider qualified under Section 100640 that has a participation agreement pursuant to Section 100641 in effect with the board to furnish health care items or services under CalCare.
(af)Prescription drugs means prescription drugs as defined in subdivision (n) of Section 130501 of the Health and Safety Code.
(ag)Resident means an individual whose primary place of abode is in this state, without regard to the individuals immigration status, who meets the California residence requirements adopted by the board pursuant to subdivision (k) of Section 100610. The board shall be guided by the principles and requirements set forth in the Medi-Cal program under Article 7 (commencing with Section 50320) of Chapter 2 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations.
(ah)Rural or medically underserved area has the same meaning as a health professional shortage area in Section 254e of Title 42 of the United States Code.
100603.This title does not preempt a city, county, or city and county from adopting additional health care coverage for residents in that city, county, or city and county that provides more protections and benefits to California residents than this title.
100604.To the extent any law is inconsistent with this title or the legislative intent of the California Guaranteed Health Care for All Act, this title shall apply and prevail, except when explicitly provided otherwise by this title.
2.Governance100610.(a)CalCare shall be governed by an executive board, known as the CalCare Board, consisting of nine voting members who are residents of California. The CalCare Board shall be an independent public entity not affiliated with an agency or department. Of the members of the board, five shall be appointed by the Governor, two shall be appointed by the Senate Committee on Rules, and two shall be appointed by the Speaker of the Assembly. The Secretary of California Health and Human Services or the secretarys designee shall serve as a nonvoting, ex officio member of the board.
(b)(1)A member of the board, other than an ex officio member, shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(2)Appointments by the Governor shall be subject to confirmation by the Senate. A member of the board may continue to serve until the appointment and qualification of the members successor. Vacancies shall be filled by appointment for the unexpired term. The board shall elect a chairperson on an annual basis.
(c)(1)Each person appointed to the board shall have demonstrated and acknowledged expertise in health care policy or delivery.
(2)Appointing authorities shall also consider the expertise of the other members of the board and attempt to make appointments so that the boards composition reflects a diversity of expertise in the various aspects of health care and the diversity of various regions within the state.
(3)Appointments to the board shall be made as follows:
(A)Two health care professionals who practice medicine. At least one shall be a practicing physician or medical doctor.
(B)One registered nurse.
(C)One public health professional.
(D)One mental health professional.
(E)One member with an institutional provider background.
(F)One representative of a not-for-profit organization that advocates for individuals who use health care in California
(G)One representative of a labor organization.
(H)One member of the committee established pursuant to Section 100611, who shall serve on a rotating basis to be determined by the committee.
(d)Each member of the board shall have the responsibility and duty to meet the requirements of this title and all applicable state and federal laws and regulations, to serve the public interest of the individuals, employers, and taxpayers seeking health care coverage through CalCare, and to ensure the operational well-being and fiscal solvency of CalCare.
(e)In making appointments to the board, the appointing authorities shall take into consideration the racial, ethnic, gender, and geographical diversity of the state so that the boards composition reflects the communities of California.
(f)(1)A member of the board or of the staff of the board shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health care professional, institutional provider, or group practice while serving on the board or on the staff of the board, except board members who are practicing health care professionals may be employed by an institutional provider or group practice. A member of the board or of the staff of the board shall not be a board member or an employee of a trade association of health professionals, institutional providers, or group practices while serving on the board or on the staff of the board. A member of the board or of the staff of the board may be a health care professional if that member does not have an ownership interest in an institutional provider or a professional health care practice.
(2)Notwithstanding Section 11009, a board member shall receive compensation for service on the board. A board member may receive a per diem and reimbursement for travel and other necessary expenses, as provided in Section 103 of the Business and Professions Code, while engaged in the performance of official duties of the board.
(g)A member of the board shall not make, participate in making, or in any way attempt to use the members official position to influence the making of a decision that the member knows, or has reason to know, will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on the member or a person in the members immediate family, or on either of the following:
(1)Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status status, aggregating two hundred fifty dollars ($250) or more in value provided to, received by, or promised to the member within 12 months before the decision is made.
(2)Any business entity in which the member is a director, officer, partner, trustee, employee, or holds any position of management.
(h)There shall not be liability in a private capacity on the part of the board or a member of the board, or an officer or employee of the board, for or on account of an act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this title or affairs related to this title.
(i)The board shall hire an executive director to organize, administer, and manage the operations of the board. The executive director shall be exempt from civil service and shall serve at the pleasure of the board.
(j)The board shall be subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2), except that the board may hold closed sessions when considering matters related to litigation, personnel, contracting, and provider rates.
(k)The board may adopt rules and regulations as necessary to implement and administer this title in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
100611.(a)The board shall convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare. The committee shall consist of members who are residents of California.
(b)Members of the committee shall be appointed by the board for a term of two years. These members may be reappointed for succeeding two-year terms.
(c)The members of the committee shall be as follows:
(1)Four health care professionals.
(2)One registered nurse.
(3)One representative of a licensed health facility.
(4)One representative of an essential community provider.
(5)One representative of a physician organization or medical group.
(6)One behavioral health provider.
(7)One dentist or oral care specialist.
(8)One representative of private hospitals.
(9)One representative of public hospitals.
(10)One individual who is enrolled in and uses health care items and services under CalCare.
(11)Two representatives of organizations that advocate for individuals who use health care in California, including at least one representative of an organization that advocates for the disabled community.
(12)Two representatives of organized labor, including at least one labor organization representing registered nurses.
(d)In convening the committee pursuant to this section, the board shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the social and geographic diversity of the state.
(e)Members of the committee shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies, and shall receive one hundred fifty dollars ($150) for each full day of attending meetings of the committee. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the committee during any particular 24-hour period.
(f)The committee shall meet at least once every quarter, and shall solicit input on agendas and topics set by the board. All meetings of the committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The committee shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)Committee members, or their assistants, clerks, or deputies, shall not use for personal benefit any information that is filed with, or obtained by, the committee and that is not generally available to the public.
100612.(a)The board shall have all powers and duties necessary to establish and implement CalCare. The board shall provide, under CalCare, comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state.
(b)The board shall, to the maximum extent possible, organize, administer, and market CalCare and services as a single-payer program under the name CalCare or any other name as the board determines, regardless of which law or source the definition of a benefit is found, including, on a voluntary basis, retiree health benefits. In implementing this title, the board shall avoid jeopardizing federal financial participation in the programs that are incorporated into CalCare and shall take care to promote public understanding and awareness of available benefits and programs.
(c)The board shall consider any matter to effectuate the provisions and purposes of this title. The board shall not have executive, administrative, or appointive duties except as otherwise provided by law.
(d)The board shall designate the executive director to employ necessary staff and authorize reasonable, necessary expenditures from the CalCare Trust Fund to pay program expenses and to administer CalCare. The executive director shall hire or designate another to hire staff, who shall not be exempt from civil service, to implement fully the purposes and intent of CalCare. The executive director, or the executive directors designee, shall give preference in hiring to all individuals displaced or unemployed as a direct result of the implementation of CalCare, including as set forth in Section 100615.
(e)The board shall do or delegate to the executive director all of the following:
(1)Determine goals, standards, guidelines, and priorities for CalCare.
(2)Annually assess projected revenues and expenditures and ensure the financial solvency of CalCare.
(3)Develop CalCares budget pursuant to Section 100676 to ensure adequate funding to meet the health care needs of the population, and review all budgets annually to ensure they address disparities in service availability and health care outcomes and for sufficiency of rates, fees, and prices to address disparities.
(4)Establish standards and criteria for the development and submission of provider operating and capital expenditure requests pursuant to Article 2 (commencing with Section 100650) of Chapter 5.
(5)Establish standards and criteria for the allocation of funds from the CalCare Trust Fund pursuant to Section 100676.
(6)Determine when individuals may begin enrolling in CalCare. There shall be an implementation period that begins on the date that individuals may begin enrolling in CalCare and ends on a date determined by the board.
(7)Establish an enrollment system that ensures all eligible California residents, including those who travel out of state, those who have disabilities that limit their mobility, hearing, vision, or mental or cognitive capacity, those who cannot read, and those who do not speak or write English, are aware of their right to health care and are formally enrolled in CalCare.
(8)Negotiate payment rates, set payment methodologies, and set prices involving aspects of CalCare and establish procedures thereto, including procedures for negotiating fee-for-service payment to certain participating providers pursuant to Chapter 8 (commencing with Section 100685).
(9)Oversee the establishment, as part of the administration of CalCare, of the committee pursuant to Section 100611.
(10)Implement policies to ensure that all Californians receive culturally, linguistically, and structurally competent care, pursuant to Chapter 6 (commencing with Section 100660), ensure that all disabled Californians receive care in accordance with the federal Americans with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) and Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. Sec. 794), and develop mechanisms and incentives to achieve these purposes and a means to monitor the effectiveness of efforts to achieve these purposes.
(11)Establish standards for mandatory reporting by participating providers and penalties for failure to report, including reporting of data pursuant to Section 100617 and to Section 100641.
(12)Implement policies to ensure that all residents of this state have access to medically appropriate, coordinated mental health services.
(13)Ensure the establishment of policies that support the public health.
(14)Meet regularly with the committee.
(15)Determine an appropriate level of, and provide support during the transition for, training and job placement for persons who are displaced from employment as a result of the initiation of CalCare pursuant to Section 100615.
(16)In consultation with the Department of Managed Health Care, oversee the establishment of a system for resolution of disputes pursuant to Section 100637 and a system for independent medical review pursuant to Section 100637.
(17)Establish and maintain an internet website that provides information to the public about CalCare that includes information that supports choice of providers and facilities and informs the public about meetings of the board and the committee.
(18)Establish a process that is accessible to all Californians for CalCare to receive the concerns, opinions, ideas, and recommendations of the public regarding all aspects of CalCare.
(19)(A)Annually prepare a written report on the implementation and performance of CalCare functions during the preceding fiscal year, that includes, at a minimum:
(i)The manner in which funds were expended.
(ii)The progress toward and achievement of the requirements of this title.
(iii)CalCares fiscal condition.
(iv)Recommendations for statutory changes.
(v)Receipt of payments from the federal government and other sources.
(vi)Whether current year goals and priorities have been met.
(vii)Future goals and priorities.
(B)The report shall be transmitted to the Legislature and the Governor, on or before October 1 of each year and at other times pursuant to this division, and shall be made available to the public on the internet website of CalCare.
(C)A report made to the Legislature pursuant to this subdivision shall be submitted pursuant to Section 9795.
(f)The board may do or delegate to the executive director all of the following:
(1)Negotiate and enter into any necessary contracts, including contracts with health care providers and health care professionals.
(2)Sue and be sued.
(3)Receive and accept gifts, grants, or donations of moneys from any agency of the federal government, any agency of the state, and any municipality, county, or other political subdivision of the state.
(4)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 by regulation.
(5)Share information with relevant state departments, consistent with the confidentiality provisions in this title, necessary for the administration of CalCare.
(g)(1)A carrier shall not offer benefits or cover health care items or services for which coverage is offered to individuals under CalCare.
(2)Notwithstanding paragraph (1), if otherwise authorized under state law, a carrier may offer benefits to cover health care items or services that are not offered to individuals under CalCare.
(3)This title does not prohibit a carrier from offering either of the following:
(A)Benefits to or for individuals, including their families, who are employed or self-employed in the state, but who are not residents of the state.
(B)Benefits during the implementation period to individuals who enrolled or may enroll as members of CalCare.
(4)Paragraph (1) applies to a carrier except as otherwise prohibited by federal law.
(h)After the end of the implementation period, a person shall not be a board member unless the person is a member of CalCare, except the ex officio member.
(i)No later than two years after the effective date of this section, the board shall develop proposals for the following:
(1)In consultation with the Advisory Committee on Public Employees Retirement System Health Benefits established under Section 100616, accommodating employer retiree health benefits for people who have been members of the Public Employees Retirement System, but live as retirees out of the state.
(2)Accommodating employer retiree health benefits for people who earned or accrued those benefits while residing in the state before the implementation of CalCare and live as retirees out of the state.
(j)The board shall develop a proposal for CalCare coverage of health care items and services currently covered under the workers compensation system, including whether and how to continue funding for those item and services under that system and how to incorporate experience rating.
100613.The board may contract with not-for-profit organizations to provide both of the following:
(a)Assistance to CalCare members with respect to selection of a participating provider, enrolling, obtaining health care items and services, disenrolling, and other matters relating to CalCare.
(b)Assistance to a health care provider providing, seeking, or considering whether to provide health care items and services under CalCare.
100614.(a)There is hereby established in state government an Advisory Commission on Long-Term Services and Supports, to advise the board on matters of policy related to long-term services and supports for CalCare.
(b)The advisory commission shall consist of eleven 11 members who are residents of California. Of the members of the advisory commission, five shall be appointed by the Governor, three shall be appointed by the Senate Committee on Rules, and three shall be appointed by the Speaker of the Assembly. The members of the advisory commission shall include all of the following:
(1)At least two people with disabilities who use long-term services and supports.
(2)At least two older adults who use long-term services and supports.
(3)At least two providers of long-term services and supports, including one family attendant or family caregiver.
(4)At least one representative of a disability rights organization.
(5)At least one representative or member of a labor organization representing workers who provide long-term services and supports.
(6)At least one representative of a group representing seniors.
(7)At least one researcher or academic in long-term services and supports.
(c)In making appointments pursuant to this section, the Governor, the Senate Committee on Rules, and the Speaker of the Assembly shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the diversity of the population of people who use long-term services and supports, including their race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geographic location, and socioeconomic status.
(d)(1)A member of the advisory commission may continue to serve until the appointment and qualification of that members successor. Vacancies shall be filled by appointment for the unexpired term.
(2)Members of the advisory commission shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(3)Vacancies that occur shall be filled within 30 days after the occurrence of the vacancy, and shall be filled in the same manner in which the vacating member was initially selected or appointed. The Secretary of California Health and Human Services shall notify the appropriate appointing authority of any expected vacancies on the long-term services and supports advisory commission.
(e)Members of the advisory commission shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies. Members shall also receive one hundred fifty dollars ($150) for each full day of attending meetings of the advisory commission. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the advisory commission during any particular 24-hour period.
(f)The advisory commission shall meet at least six times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The advisory commission shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)It is unlawful for the advisory commission members or any of their assistants, clerks, or deputies to use for personal benefit any information that is filed with, or obtained by, the advisory commission and that is not generally available to the public.
100615.(a)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for program assistance to individuals employed or previously employed in the fields of health insurance, health care service plans, or other third-party payments for health care, individuals providing services to health care providers to deal with third-party payers for health care, individuals who may be affected by and who may experience economic dislocation as a result of the implementation of this title, and individuals whose jobs may be or have been ended as a result of the implementation of CalCare, consistent with otherwise applicable law.
(b)Assistance described in subdivision (a) shall include job training and retraining, job placement, preferential hiring, wage replacement, retirement benefits, and education benefits.
100616.(a)The board shall establish an Advisory Committee on Public Employees Retirement System Health Benefits to provide input, including recommendations, to the board on matters of policy related to public employee retiree health benefits and CalCare, including all of the following:
(1)Processes to obtain approval of CalCare as a health benefits plan under public pension or retirement systems.
(2)Recommendations to the Legislature and Governor to provide tax or other accommodations for people who have accrued retiree health benefit contributions under public employees retirement systems.
(3)Recommendations to, and coordination with, public employee retirement system boards to fully integrate beneficiaries into CalCare.
(4)Processes to change or phase out health benefits under public employees retirement systems to fully integrate beneficiaries into CalCare.
(5)Federal approvals that may support transition of Medicare plans under public employees retirement systems to CalCare.
(b)(1)The board shall appoint the members of the advisory committee during the implementation period. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the advisory committee, the board shall aim for broad representation, including, at a minimum, the following representatives of public sector labor organizations, organizations: the Public Employees Retirement System, the State Teachers Retirement System, the University of California Retirement System, and locally administered public pension or retirement systems. At a minimum, one-half of the advisory committee members shall be representatives of public sector labor organizations.
(2)Each appointed member shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(3)Advisory committee members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the advisory committee shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the advisory committee members.
(4)Advisory committee members shall receive reimbursement for travel and other actual costs.
(c)The advisory committee shall meet at least four times per year in a place convenient to the public. All meetings of the advisory committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(d)The board shall consider input, including recommendations, from the advisory committee, along with public comments, in the boards deliberation and decisionmaking.
100617.(a)The board shall utilize the data collected pursuant to Chapter 1 (commencing with Section 128675) of Part 5 of Division 107 of the Health and Safety Code to assess patient outcomes and to review utilization of health care items and services paid for by CalCare.
(b)As applicable to the type of provider, the board shall require and enforce the collection and availability of all of the following data to promote transparency, assess quality of care, compare patient outcomes, and review utilization of health care items and services paid for by CalCare, which shall be reported to the board and, as applicable, the Department of Health Care Access and Information or the Medical Board of California:
(1)Inpatient discharge data, including severity of illness and risk of mortality, with respect to each discharge.
(2)Emergency department, ambulatory surgical center, and other outpatient department data, including cost data, charge data, length of stay, and patients unit of observation with respect to each individual receiving health care items and services.
(3)For hospitals and other providers receiving global budgets, annual financial data, including all of the following:
(A)Community benefit activities, including charity care, to which Section 501(r) of Title 26 of the United States Code applies, provided by the provider in dollar value at cost.
(B)Number of employees by employee classification or job title and by patient care unit or department.
(C)Number of hours worked by the employees in each patient care unit or department.
(D)Employee wage information by job title and patient care unit or department.
(E)Number of registered nurses per staffed bed by patient care unit or department.
(F)A description of all information technology, including health information technology and artificial intelligence, used by the provider and the dollar value of that information technology.
(G)Annual spending on information technology, including health information technology, artificial intelligence, purchases, upgrades, and maintenance.
(4)Risk-adjusted and raw outcome data, including:
(A)Risk-adjusted outcome reports for medical, surgical, and obstetric procedures selected by the Department of Health Care Access and Information pursuant to Sections 128745 to 128750, inclusive, of the Health and Safety Code.
(B)Any other risk-adjusted outcome reports that the board may require for medical, surgical, and obstetric procedures and conditions as it deems appropriate.
(5)A disclosure made by a provider as set forth in Article 6 (commencing with Section 650) of Chapter 1 of Division 2 of the Business and Professions Code.
(c)(1)The Medical Board of California shall collect data for the outpatient surgery settings that the Medical Board of California regulates that meets the Ambulatory Surgery Data Record requirements of Section 128737 of the Health and Safety Code, and shall submit that data to the CalCare board. Board.
(2)The CalCare board Board shall make that data available as required pursuant to subdivision (d).
(d)The board shall make all disclosed data collected under this section publicly available and searchable through an internet website and through the Department of Health Care Access and Information public data sets.
(e)Consistent with state and federal privacy laws, the board shall make available data collected through CalCare to the Department of Health Care Access and Information and the California Health and Human Services Agency, consistent with this title and otherwise applicable law, to promote and protect public, environmental, and occupational health.
(f)Before full implementation of CalCare, and, for providers seeking to receive global budgets or salaried payments under Article 2 (commencing with Section 100650) of Chapter 5, as applicable, before the negotiation of initial payments, the board shall provide for the collection and availability of the following data:
(1)The number of patients served.
(2)The dollar value of the care provided, at cost, for all of the following categories of Department of Health Care Access and Information data items:
(A)Patients receiving charity care.
(B)Contractual adjustments of county and indigent programs, including traditional and managed care.
(C)Bad debts or any other unpaid charges for patient care that the provider sought, but was unable to collect.
(g)The board shall regularly analyze information reported under this section and shall establish rules and regulations to allow researchers, scholars, participating providers, and others to access and analyze data for purposes consistent with this title, without compromising patient privacy.
(h)(1)The board shall establish regulations for the collection and reporting of data to promote transparency, assess patient outcomes, and review utilization of services provided by physicians and other health care professionals, as applicable, and paid for by CalCare.
(2)In implementing this section, the board shall utilize data that is already being collected pursuant to other state or federal laws and regulations whenever possible.
(3)Data reporting required by participating providers under this section shall supplement the data collected by the Department of Health Care Access and Information and shall not modify or alter other reporting requirements to governmental agencies.
(i)The board shall not utilize quality or other review measures established under this section for the purposes of establishing payment methods to providers.
(j)The board may coordinate and cooperate with the Department of Health Care Access and Information or other health planning agencies of the state to implement the requirements of this section.
100618.(a)The board shall establish and use a process to enter into participation agreements with health care providers and other contracts with contractors. A contract entered into pursuant to this title shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of the Department of General Services. The board shall adopt a CalCare Contracting Manual incorporating procurement and contracting policies and procedures that shall be followed by CalCare. The policies and procedures in the manual shall be substantially similar to the provisions contained in the State Contracting Manual.
(b)The adoption, amendment, or repeal of a regulation by the board to implement this section, including the adoption of a manual pursuant to subdivision (a) and any procurement process conducted by CalCare in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
100619.(a)Notwithstanding any other law, CalCare, a state or local agency, or a public employee acting under color of law shall not provide or disclose to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(b)Notwithstanding any other law, law enforcement agencies shall not use CalCare moneys, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of a requirement that individuals register with the federal government or a federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Section 51 of the Civil Code).
100620.(a)On or before July 1, ____, the board shall conduct and deliver a fiscal analysis to determine both of the following:
(1)Whether or not CalCare may be implemented.
(2)If revenue is more likely than not to be sufficient to pay for program costs within eight years of CalCares implementation.
(b)The board may contract with one or more independent entities with the appropriate expertise or coordinate with other state agencies to conduct the fiscal analysis.
(c)The board shall deliver, and upon request present, the fiscal analysis to the Chair of the Senate Committee on Health, the Chair of the Assembly Committee on Health, the Chair of the Senate Committee on Appropriations, and the Chair of the Assembly Committee on Appropriations.
3.Eligibility and Enrollment100630.(a)Every resident of the state shall be eligible and entitled to enroll as a member of CalCare.
(b)(1)A member shall not be required to pay a fee, payment, or other charge for enrolling in or being a member of CalCare.
(2)A member shall not be required to pay a premium, copayment, coinsurance, deductible, or any other form of cost sharing for all covered benefits under CalCare.
(c)A college, university, or other institution of higher education in the state may purchase coverage under CalCare for a student, or a students dependent, who is not a resident of the state.
(d)An individual entitled to benefits through CalCare may obtain health care items and services from any institution, agency, or individual participating provider.
(e)The board shall establish a process for automatic CalCare enrollment at the time of birth in California.
100631.(a)All residents of this state, no matter what their sex, race, color, religion, ancestry, national origin, disability, age, previous or existing medical condition, genetic information, marital status, familial status, military or veteran status, sexual orientation, gender identity or expression, pregnancy, pregnancy-related medical condition, including termination of pregnancy, citizenship, primary language, or immigration status, are entitled to full and equal accommodations, advantages, facilities, privileges, or services in all health care providers participating in CalCare.
(b)Subdivision (a) prohibits a participating provider, or an entity conducting, administering, or funding a health program or activity pursuant to this title, from discriminating based upon the categories described in subdivision (a) in the provision, administration, or implementation of health care items and services through CalCare.
(c)Discrimination prohibited under this section includes the following:
(1)Exclusion of a person from participation in or denial of the benefits of CalCare, except as expressly authorized by this title for the purposes of enforcing eligibility standards in Section 100630.
(2)Reduction of a persons benefits.
(3)Any other discrimination by any participating provider or any entity conducting, administering, or funding a health program or activity pursuant to this title.
(d)Section 52 of the Civil Code shall apply to discrimination under this section.
(e)Except as otherwise provided in this section, a participating provider or entity is in violation of subdivision (b) if the complaining party demonstrates that any of the categories listed in subdivision (a) was a motivating factor for any health care practice, even if other factors also motivated the practice.
4.Benefits100635.(a)Individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to a participating provider for the health care items and services in subdivision (c), if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.
(b)The determination of medical necessity or appropriateness shall be made by the members treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards established in Chapter 6 (commencing with Section 100660), and by the board, and other laws of the state.
(c)Covered health care benefits for members include all of the following categories of health care items and services:
(1)Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services.
(2)Inpatient and outpatient health care professional services and other ambulatory patient services.
(3)Primary and preventive services, including chronic disease management.
(4)Prescription drugs, biological products, and all contraceptive items approved by the United States Food and Drug Administration.
(5)Medical devices, equipment, appliances, and assistive technology.
(6)Mental health and substance abuse treatment services, including inpatient and outpatient care.
(7)Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.
(8)Comprehensive reproductive care, including abortion, contraception, and assistive assisted reproductive technology, maternity care, and newborn care.
(9)Pediatrics.
(10)Oral health, audiology, and vision services.
(11)Rehabilitative and habilitative services and devices, including inpatient and outpatient care.
(12)Emergency services and transportation.
(13)Early and periodic screening, diagnostic, and treatment services as defined in Section 1396d(r) of Title 42 of the United States Code.
(14)Comprehensive gender-affirming health care.
(15)Necessary transportation for health care items and services for persons with disabilities or who may qualify as low income.
(16)Long-term services and supports described in Section 100636, including long-term services and supports covered under Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code) or the federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)) seq.)).
(17)Care coordination.
(17)(18)Any additional health care items and services the board authorizes to be added to CalCare benefits.
(d)The categories of covered health care items and services under subdivision (c) include all the following:
(1)Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual.
(2)Child and adult immunizations.
(3)Hospice care.
(4)Care in a skilled nursing facility.
(5)Home health care, including health care provided in an assisted living facility.
(6)Prenatal and postnatal care.
(7)Podiatric care.
(8)Blood and blood products.
(9)Dialysis.
(10)Community-based adult services as defined under Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code as of January 1, 2021.
(11)Dietary and nutritional therapies determined appropriate by the board.
(12)Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture.
(13)Health care items and services previously covered by county integrated health and human services programs pursuant to Chapter 12.96 (commencing with Section 18990) and Chapter 12.991 (commencing with Section 18991) of Part 6 of Division 9 of the Welfare and Institutions Code.
(14)Health care items and services previously covered by a regional center for persons with developmental disabilities pursuant to Chapter 5 (commencing with Section 4620) of Division 4.5 of the Welfare and Institutions Code.
(15)Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers.
(e)Covered health care items and services under CalCare include all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:
(1)The federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
(2)Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(3)The federal Medicare program Program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(4)Health care service plans pursuant to 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).
(5)Health insurers, as defined in Section 106 of the Insurance Code, pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code.
(6)All essential health benefits mandated by the federal Patient Protection and Affordable Care Act as of January 1, 2017.
(f)Health care items and services covered under CalCare shall not be subject to prior authorization or a limitation applied through the use of step therapy protocols.
100636.(a)Subject to the other provisions of this title, individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this title, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:
(1)Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living.
(2)Is a disability, as defined in Section 12102(1)(A) of Title 42 of the United States Code, that substantially limits one or more of the members major life activities.
(b)The board shall adopt regulations that provide for the following:
(1)The determination of individual eligibility for long-term services and supports under this section.
(2)The assessment of the long-term services and supports needed for an eligible individual.
(3)The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program established in Title II or Title XVI of the federal Social Security Act to the long-term services and supports under this section.
(c)Long-term services and supports provided pursuant to this section shall do all of the following:
(1)Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting.
(2)Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care.
(3)Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the members maximum possible autonomy and the members maximum possible civic, social, and economic participation.
(4)Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization.
(5)Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipients type or level of disability, service need, or age.
(6)Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the members needs.
(7)Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity.
(8)Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions.
(9)Ensure that long-term services and supports provide recipients the option of self-direction of service, including under the Self-Directed Services Program described in Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code, from either the recipient or care coordinators of the recipients choosing.
(d)In developing regulations to implement this section, the board shall consult the advisory commission established pursuant to Section 100614.
100637.(a)(1)The board shall, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.
(2)In implementing this section, the board shall not remove or eliminate covered health care items and services under CalCare that are listed in this chapter.
(b)The board shall establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare.
(c)The board shall establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the Independent Medical Review System established in the Department of Managed Health Care pursuant to Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.
(d)For the purposes of this chapter:
(1)Coverage decision means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A coverage decision does not encompass a decision regarding a disputed health care item or service.
(2)Disputed health care item or service means a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision.
5.Delivery of Care1.Health Care Providers100640.(a)(1)A health care provider or entity is qualified to participate as a provider in CalCare if the health care provider furnishes health care items and services while the provider, or, if the provider is an entity, the individual health care professional of the entity furnishing the health care items and services, is physically present within the State of California, and if the provider meets all of the following:
(A)The provider or entity is a health care professional, group practice, or institutional health care provider licensed to practice in California.
(B)The provider or entity agrees to accept CalCare rates as payment in full for all covered health care items and services.
(C)The provider or entity has filed with the board a participation agreement described in Section 100641.
(D)The provider or entity is otherwise in good standing.
(2)The board shall establish and maintain procedures and standards for recognizing health care providers located out of the state for purposes of providing coverage under CalCare for members who require out-of-state health care services while the member is temporarily located out of the state.
(b)A provider or entity shall not be qualified to furnish health care items and services under CalCare if the provider or entity does not provide health care items or services directly to individuals, including the following:
(1)Entities or providers that contract with other entities or providers to provide health care items and services shall not be considered a qualified provider for those contracted items and services.
(2)Entities that are approved to coordinate care plans under the Medicare Advantage program established in Part C of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1851 et seq.) as of January 1, 2020, but do not directly provide health care items and services.
(c)A health care provider qualified to participate under this section may provide covered health care items or services under CalCare, as long as the health care provider is legally authorized to provide the health care item or service for the individual and under the circumstances involved.
(d)(1)The board shall establish and maintain procedures for members and individuals eligible to enroll in CalCare to enroll onsite at a participating provider.
(2)A participating provider shall accept onsite enrollment of members and eligible individuals under the procedures established pursuant to paragraph (1).
(e)The board shall establish and maintain procedures and standards for members to select a primary care provider, which may be an internist, a pediatrician, a physician who practices family medicine, a gynecologist, a physician who practices geriatric medicine, or, at the option of a member who has a chronic condition that requires specialty care, a specialist health care professional who regularly and continually provides treatment to the member for that condition, and other participating providers.
(f)A referral from a primary care provider is not required for a member to see a participating provider.
(g)A member may choose to receive health care items and services under CalCare from a participating provider, subject to the willingness or availability of the provider, and consistent with the provisions of this title relating to discrimination, and the appropriate clinically relevant circumstances and standards.
100641.(a)A health care provider shall enter into a participation agreement with the board to qualify as a participating provider under CalCare.
(b)A participation agreement between the board and a health care provider shall include provisions for at least the following, as applicable to each provider:
(1)Health care items and services to members shall be furnished by the provider without discrimination, as required by Section 100631. This paragraph does not require the provision of a type or class of health care items or services that are outside the scope of the providers normal practice.
(2)A charge shall not be made to a member for a covered health care item or service, other than for payment authorized by this title. Except as described in Section 100644, a contract shall not be entered into with a patient for a covered health care item or service.
(3)The provider shall follow the policies and procedures in the CalCare Contracting Manual established pursuant to Section 100618.
(4)The provider shall furnish information reasonably required by the board and shall meet the reporting requirements of Sections 100617 and 100661 for at least the following:
(A)Quality review by designated entities.
(B)Making payments, including the examination of records as necessary for the verification of information on which those payments are based.
(C)Statistical or other studies required for the implementation of this title.
(D)Other purposes specified by the board.
(5)If the provider is not an individual, the provider shall not employ or use an individual or other provider that has had a participation agreement terminated for cause to provide covered health care items and services.
(6)If the provider is paid on a fee-for-service basis for covered health care items and services, the provider shall submit bills and required supporting documentation relating to the provision of covered health care items or services within 30 days after the date of providing those items or services.
(7)The provider shall submit information and any other required supporting documentation reasonably required by the board on a quarterly basis that relates to the provision of covered health care items and services and describes health care items and services furnished with respect to specific individuals.
(8)(A)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall disclose the following to the board:
(i)Any case mix indexes, diagnosis coding software, procedure coding software, or other coding system utilized by the provider for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Any case mix indexes, diagnosis coding guidelines, procedure coding guidelines, or coding tip sheets used by the provider for the purposes of meeting payment or disclosure requirements under this title.
(B)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall not do the following:
(i)Use proprietary case mix indexes, diagnosis coding software, procedure coding software, or other coding system for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Require another health care professional to apply case mix indexes, diagnosis coding software, procedure coding software, or other coding system in a manner that limits the clinical diagnosis, treatment process, or a treating health care professionals judgment in determining a diagnosis or treatment process, including the use of leading queries or prohibitions on using certain codes.
(iii)Provide financial incentives or disincentives to physicians, registered nurses, or other health care professionals for particular coding query results or code selections.
(iv)Use case mix indexes, diagnosis coding software, procedure coding software, or other coding system that make suggestions for higher severity diagnoses or higher cost procedure coding.
(9)The provider shall comply with the duty of patient advocacy and reporting requirements described in Section 100661.
(10)If the provider is not an individual, the provider shall ensure that a board member, executive, or administrator of the provider shall not receive compensation from, own stock or have other financial investments in, or receive services as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(11)If the provider is a not-for-profit hospital subject to Article 2 (commencing with Section 127340) of Chapter 2 of Part 2 of Division 107 of the Health and Safety Code, the hospital shall submit to the board the community benefits plan developed pursuant to Article 2 (commencing with Section 127340) of the Health and Safety Code.
(12)Health care items and services to members shall be furnished by a health care professional while the professional is physically present within the State of California.
(13)The provider shall not enter into risk-bearing, risk-sharing, or risk-shifting agreements with other health care providers or entities other than CalCare.
(c)This section does not limit the formation of group practices.
100642.(a)A participation agreement may be terminated with appropriate notice by the board for failure to meet the requirements of this title or may be terminated by a provider.
(b)A participating provider shall be provided notice and a reasonable opportunity to correct deficiencies before the board terminates an agreement, unless a more immediate termination is required for public safety or similar reasons.
(c)The procedures and penalties under the Medi-Cal program for fraud or abuse pursuant to Sections 14107, 14107.11, 14107.12, 14107.13, 14107.2, 14107.3, 14107.4, 14107.5, and 14108 of the Welfare and Institutions Code shall apply to an applicant or provider under CalCare.
(d)For purposes of this section:
(1)Applicant means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the board to participate as a provider in CalCare.
(2)Provider means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to CalCare program members.
100643.(a)A person shall not discharge or otherwise discriminate against an employee on account of the employee or a person acting pursuant to a request of the employee for any of the following:
(1)Notifying the board, executive director, or employees employer of an alleged violation of this title, including communications related to carrying out the employees job duties.
(2)Refusing to engage in a practice made unlawful by this title, if the employee has identified the alleged illegality to the employer.
(3)Providing, causing to be provided, or being about to provide or cause to be provided to the provider, the federal government, or the Attorney General information relating to a violation of, or an act or omission the provider or representative reasonably believes to be a violation of, this title.
(4)Testifying before or otherwise providing information relevant for a state or federal proceeding regarding this title or a proposed amendment to this title.
(5)Commencing, causing to be commenced, or being about to commence or cause to be commenced a proceeding under this title.
(6)Testifying or being about to testify in a proceeding.
(7)Assisting or participating, or being about to assist or participate, in a proceeding or other action to carry out the purposes of this title.
(8)Objecting to, or refusing to participate in, an activity, policy, practice, or assigned task that the employee or representative reasonably believes to be in violation of this title or any order, rule, regulation, standard, or ban under this title.
(b)An employee covered by this section who alleges discrimination by an employer in violation of subdivision (a) may bring an action governed by the rules and procedures, legal burdens of proof, and remedies applicable under the False Claims Act (Article 9 (commencing with Section 12650) of Chapter 6 of Part 2 of Division 3 of Title 2) or Section 12990, or an action against unfair competition pursuant to Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions Code.
(c)(1)This section does not diminish the rights, privileges, or remedies of an employee under any other law, regulation, or collective bargaining agreement. The rights and remedies in this section shall not be waived by an agreement, policy, form, or condition of employment.
(2)This section does not preempt or diminish any other law or regulation against discrimination, demotion, discharge, suspension, threats, harassment, reprimand, retaliation, or any other manner of discrimination.
(d)For purposes of this section:
(1)Employer means a person engaged in profit or not-for-profit business or industry, including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees, and who is subject to liability for violating this title.
(2)Employee means an individual performing activities under this title on behalf of an employer.
100644.(a)This section shall be effective on the date the implementation period ends pursuant to paragraph (6) of subdivision (e) of Section 100612.
(b)(1)An institutional or other health care provider with a participation agreement in effect shall not bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is a covered benefit through CalCare.
(2)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is not a covered benefit through CalCare if the following requirements are met:
(A)The contract and provider meet the requirements specified in paragraphs (3) and (4).
(B)The health care item or service is not payable or available through CalCare.
(C)The provider does not receive reimbursement, directly or indirectly, from CalCare for the health care item or service, and does not receive an amount for the health care item or service from an organization that receives reimbursement, directly or indirectly, for the health care item or service from CalCare.
(3)(A)A contract described in paragraph (2) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the health care item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (2) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service.
(ii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iii)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(iv)The individual understands that the provider is providing services outside the scope of CalCare.
(4)A participating provider that enters into a contract described in paragraph (2) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the noncovered health care item or service, state that the provider will not submit a claim to CalCare for a noncovered health care item or service provided to a member, and be signed by the provider.
(5)If a provider signing an affidavit described in paragraph (4) knowingly and willfully submits a claim to CalCare for a noncovered health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract, all of the following apply:
(A)A contract described in paragraph (2) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(6)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual ineligible for benefits under CalCare for a health care item or service. Consistent with Section 100619, the institutional or other health care provider shall report to the board, on an annual basis, aggregate information regarding services furnished to ineligible individuals.
(c)(1)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits under CalCare for a health care item or service that is a covered benefit through CalCare only if the contract and provider meet the requirements specified in paragraphs (2) and (3).
(2)(A)A contract described in paragraph (1) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (1) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual understands that the individual has the right to have the health care item or service provided by another provider for which payment would be made under CalCare.
(ii)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service, even if the health care item or service is otherwise covered under CalCare.
(iii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iv)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(v)The individual understands that the provider is providing services outside the scope of CalCare.
(3)A provider that enters into a contract described in paragraph (1) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the health care item or service, state that the provider will not submit a claim to CalCare for a health care item or service provided to a member during a two-year period beginning on the date the affidavit was signed, and be signed by the provider.
(4)If a provider who signed an affidavit described in paragraph (3) knowingly and willfully submits a claim to CalCare for a health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract described in an affidavit signed pursuant to paragraph (3), all of the following apply:
(A)A contract described in paragraph (1) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare program, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(5)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual for a health care item or service that is not a benefit under CalCare.
2.Payment for Health Care Items and Services100650.(a)The board shall adopt regulations regarding contracting for, and establishing payment methodologies for, covered health care items and services provided to members under CalCare by participating providers. All payment rates under CalCare shall be reasonable and reasonably related to all of the following:
(1)The cost of efficiently providing health care items and services.
(2)Ensuring availability and accessibility of CalCare health care services, including compliance with state requirements regarding network adequacy, timely access, and language access.
(3)Maintaining an optimal workforce and the health care facilities necessary to deliver quality, equitable health care.
(b)(1)Payment for health care items and services shall be considered payment in full.
(2)A participating provider shall not charge a rate in excess of the payment established through CalCare for a health care item or service furnished under CalCare and shall not solicit or accept payment from any member or third party for a health care item or service furnished under CalCare, except as provided under a federal program.
(3)This section does not preclude CalCare from acting as a primary or secondary payer in conjunction with another third-party payer when permitted by a federal program.
(c)Not later than the beginning of each fiscal quarter during which an institutional provider of care, including a hospital, skilled nursing facility, and chronic dialysis clinic, is to furnish health care items and services under CalCare, the board shall pay to each institutional provider a lump sum to cover all operating expenses under a global budget as set forth in Section 100651. An institutional provider receiving a global budget payment shall accept that payment as payment in full for all operating expenses for health care items and services furnished under CalCare, whether inpatient or outpatient, by the institutional provider.
(d)(1)A group practice, county organized health system, or local initiative may elect to be paid for health care items and services furnished under CalCare either on a fee-for-service basis under Section 100655 or on a salaried basis.
(2)A group practice, county organized health system, or local initiative that elects to be paid on a salaried basis shall negotiate salaried payment rates with the board annually, and the board shall pay the group practice, county organized health system, or local initiative at the beginning of each month.
(3)The board may determine whether a group practice, county organized health system, or local initiative may elect to be paid on an hourly or other time-based rate for certain health care items and services furnished under CalCare, including primary and preventive care. care and care coordination.
(e)Health care items and services provided to members under CalCare by individual providers or any other providers not paid under subdivision (c) or (d) shall be paid for on a fee-for-service basis under Section 100655.
(f)Capital-related expenses for specifically identified capital expenditures incurred by participating providers shall meet the requirements under Section 100656.
(g)Payment methodologies and payment rates shall include a distinct component of reimbursement for direct and indirect costs incurred by the institutional provider for graduate medical education, as applicable.
(h)The board shall adopt, by regulation, payment methodologies and procedures for paying for out-of-state health care services.
(i)(1)This article does not regulate, interfere with, diminish, or abrogate a collective bargaining agreement, established employee rights, or the right, obligation, or authority of a collective bargaining representative under state or local law.
(2)This article does not compel, regulate, interfere with, or duplicate the provisions of an established training program that is operated under the terms of a collective bargaining agreement or unilaterally by an employer or bona fide labor union.
(j)The board shall determine the appropriate use and allocation of the special projects budget for the construction, renovation, or staffing of health care facilities in rural, underserved, or health professional or medical shortage areas, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
100651.(a)An institutional providers global budget shall be determined before the start of a fiscal year through negotiations between the provider and the board. The global budget shall be negotiated annually based on the payment factors described in subdivision (d).
(b)An institutional providers global budget shall be used only to cover operating expenses associated with direct care for patients for health care items and services covered under CalCare. An institutional providers global budget shall not be used for capital expenditures, and capital expenditures shall not be included in the global budget.
(c)The board, on a quarterly basis, shall review whether requirements of the institutional providers participation agreement and negotiated global budget have been performed and shall determine whether adjustment to the institutional providers payment is warranted.
(d)A payment negotiated pursuant to subdivision (a) shall take into account, with respect to each provider, all of the following:
(1)The historical volume of services provided for each health care item and service in the previous three-year period.
(2)The actual expenditures of a provider in the providers most recent Medicare cost report for each health care item and service, or other cost report that may otherwise be adopted by the board, compared to the following:
(A)The expenditures of other comparable institutional providers in the state.
(B)The normative payment rates established under the comparative payment rate systems pursuant to Section 100654, including permissible adjustments to the rates for the health care items and services.
(C)Projected changes in the volume and type of health care items and services to be furnished.
(D)Employee wages and compensation.
(E)The providers maximum capacity to provide health care items and services.
(F)Education and prevention programs.
(G)Health care workforce recruitment and retention programs, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(H)Permissible adjustments to the providers operating budget from the previous fiscal year due to factors including an increase in primary or specialty care access, efforts to decrease health care disparities in rural or medically underserved areas, a response to emergent conditions, and proposed changes to patient care programs at the institutional level.
(I)Any other factor determined appropriate by the board.
(3)In a rural or medically underserved area, the need to mitigate the impact of the availability and accessibility of health care services through increased global budget payment.
(e)A payment negotiated pursuant to subdivision (a) or payment methodology shall not do any of the following:
(1)Take into account capital expenditures of the provider or any other expenditure not directly associated with furnishing health care items and services under CalCare.
(2)Be used by a provider for capital expenditures or other expenditures associated with capital projects.
(3)Exceed the providers capacity to furnish health care items and services covered under CalCare.
(4)Be used to pay or otherwise compensate a board member, executive, or administrator of the institutional provider who has an interest or relationship prohibited under paragraph (10) of subdivision (b) of Section 100641 or paragraph (3) of subdivision (c) of Section 100661.
(5)Take into account relief pending appeal granted to a provider under Section 100653.
(f)The board may negotiate changes to an institutional providers global budget based on factors not prohibited under subdivision (e) or any other provision of this title.
(g)Subject to subdivision (i) of Section 100650, compensation costs for an employee, contractor employee, or subcontractor employee of an institutional provider receiving a global budget shall meet the compensation cap established in Section 4304(a)(16) of Title 41 of the United States Code and its implementing regulations, except that the board may establish one or more narrowly targeted exceptions for scientists, engineers, or other specialists upon a determination that those exceptions are needed to ensure CalCare continued access to needed skills and capabilities.
(h)A payment to an institutional provider pursuant to this section shall not allow a participating provider to retain revenue generated from outsourcing health care items and services covered under CalCare, unless that revenue was considered part of the global budget negotiation process. This subdivision shall apply to revenue from outsourcing health care items and services that were previously furnished by employees of the participating provider who were subject to a collective bargaining agreement.
(i)For the purposes of this section, operating expenses of a provider include the following:
(1)The costs associated with covered health care items and services under CalCare, including the following:
(A)Compensation for health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider.
(B)Pharmaceutical products administered by health care professionals at the institutional providers facility or facilities.
(C)Purchasing supplies.
(D)Maintenance of medical devices and health care technologies, including diagnostic testing equipment, except that health information technology that is not necessary to comply with data collection and reporting requirements under this title or otherwise required by law and artificial intelligence shall be considered capital expenditures, unless otherwise determined by the board.
(E)Incidental services necessary for safe patient care.
(F)Patient care, education, and preventive health programs, and necessary staff to implement those programs.
(G)Occupational health and safety programs and public health programs, and necessary staff to implement those programs for the continued education and health and safety of clinicians and other individuals employed by the institutional provider.
(H)Infectious disease response preparedness, including the maintenance of a one-year or 365-day stockpile of personal protective equipment, occupational testing and surveillance, and contact tracing.
(I)Recruitment, retention, and training of health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(2)Administrative costs of the institutional provider.
100652.(a)The board shall consider a request for interim payment, filed by an institutional provider that is subject to the payments or global budget, based on the following:
(1)The overall financial condition of the institutional provider, including bankruptcy or financial solvency.
(2)Excessive risks to the ongoing operation of the institutional provider.
(3)Justifiable differences in costs among providers, including providing a service not available from other providers in the region, or the need for health care services in rural areas with a shortage of health professionals or medically underserved areas and populations.
(4)Factors that led to increased costs for the institutional provider that can reasonably be considered to be unanticipated and out of the control of the provider. Those factors may include:
(A)Natural disasters.
(B)Outbreaks of epidemics or infectious diseases.
(C)Unanticipated facility or equipment repairs or purchases.
(D)Significant and unanticipated increases in pharmaceutical or medical device prices.
(E)Public health emergencies.
(5)Changes in state or federal laws that result in a change in costs.
(6)Reasonable increases in labor costs, including salaries and benefits, and changes in collective bargaining agreements, prevailing wage, or local law.
(b)The board shall establish uniform written procedures under which it reviews requests for interim payment pursuant to subdivision (a), including procedures to provide immediate payment in the event of a public health emergency.
(c)On a quarterly basis, the board shall review the global budget and payments to institutional providers that are not-for-profit or governmental entities and may initiate an interim payment review under subdivision (b) based on the factors set forth in this section.
100653.(a)The board shall consider an appeal of payments, the global budget, or a determination of a request for interim payment, filed by an institutional provider that is subject to the payment or global budget.
(b)(1)The payments set and global budget negotiated by the board to be paid to the institutional provider shall stay in effect during the appeal process, subject to relief pending appeal under this subdivision.
(2)The board shall have the power to grant interim relief based on fairness. The board shall develop regulations governing interim relief. The board shall establish uniform written procedures for the submission, processing, and consideration of an interim relief appeal by an institutional provider. A decision on interim relief shall be granted within one month of the filing of an interim relief appeal. An institutional provider shall certify in its interim relief appeal that the request is made on the basis that the challenged amount is arbitrary and capricious, or that the institutional provider has experienced a bona fide emergency based on unanticipated costs or costs outside the control of the entity, including those described in paragraph (4) of subdivision (a) of Section 100652.
(c)(1)In accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2), the board may delegate the conduct of a hearing to an administrative law judge, who shall issue a proposed decision with findings of fact and conclusions of law.
(2)The administrative law judge may hold evidentiary hearings and shall issue a proposed decision with findings of fact and conclusions of law, including a recommended adjusted payment or global budget, within four months of the filing of the appeal.
(3)Within 30 days of receipt of the proposed decision by the administrative law judge, the board may approve, disapprove, or modify the decision, and shall issue a final decision for the appealing institutional provider.
(d)A final determination by the board shall be subject to judicial review pursuant to Section 1094.5 of the Code of Civil Procedure.
100654.(a)The board shall use existing Medicare prospective payment systems to establish and serve as the comparative payment rate system in global budget negotiations described in subparagraph (B) of paragraph (2) of subdivision (d) of Section 100651. The board shall update the comparative payment rate system annually.
(b)To develop the comparative payment rate system, the board shall use only the operating base payment rates under each Medicare prospective payment system with applicable adjustments.
(c)The comparative rate system shall not include value-based purchasing adjustments or capital expenses base payment rates that may be included in Medicare prospective payment systems.
(d)In the first year that global budget payments are available to institutional providers, and for purposes of selecting a comparative payment rate system used during initial global budget negotiations for an institutional provider, the board shall take into account the appropriate Medicare prospective payment system from the most recent year to determine what operating base payment the institutional provider would have been paid for covered health care items and services furnished the preceding year with applicable adjustments, excluding value-based purchasing adjustments, based on the prospective payment system.
100655.(a)The board shall engage in good faith negotiations with health care providers representatives under Chapter 8 (commencing with Section 100685) to determine rates of fee-for-service payments for health care items and services furnished under CalCare.
(b)There shall be a rebuttable presumption that the Medicare fee-for-service rates of reimbursement constitute reasonable fee-for-service payment rates. The fee schedule shall be updated annually.
(c)Payments to individual providers under this article shall not include payments to individual providers in salaried positions at institutional providers receiving global budgets under Section 100651 or individual health care professionals who are employed by or otherwise receive compensation or payment for health care items and services furnished under CalCare from group practices, county organized health systems, or local initiatives that receive payment under CalCare on a salaried basis.
(d)To establish the fee-for-service payment rates, the board shall ensure that the fee schedule compensates physicians and other health care professionals at a rate that reflects the value for health care items and services furnished.
(e)In a rural or medically underserved area, the board may mitigate the impact of the availability and accessibility of health care services through increased individual provider payment.
100656.(a)(1)The board shall adopt, by regulation, payment methodologies for the payment of capital expenditures for specifically identified capital projects incurred by not-for-profit or governmental entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)The board shall prioritize allocation of funding under this subdivision to projects that propose to use the funds to improve service in a rural or medically underserved area, or to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status. The board shall consider the impact of any prior reduction in services or facility closure by a not-for-profit or governmental entity as part of the application review process.
(3)For the purposes of funding capital expenditures under this section, health care facilities and governmental entities shall apply to the board in a time and manner specified by the board. All capital-related expenses generated by a capital project shall have received prior approval from the board to be paid under CalCare.
(b)Approval of an application for capital expenditures shall be based on achievement of the program standards described in Chapter 6 (commencing with Section 100660).
(c)The board shall not grant funding for capital expenditures for capital projects that are financed directly or indirectly through the diversion of private or other non-CalCare program funding that results in reductions in care to patients, including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability.
(d)A participating provider shall not use operating funds or payments from CalCare for the operating expenses associated with a capital asset that was not funded by CalCare without the approval of the board.
(e)A participating provider shall not do either of the following:
(1)Use funds from CalCare designated for operating expenses or payments for capital expenditures.
(2)Use funds from CalCare designated for capital expenditures or payments for operating expenses.
100657.(a)(1)A margin generated by a participating provider receiving a global budget under CalCare may be retained and used to meet the health care needs of CalCare members.
(2)A participating provider shall not retain a margin if that margin was generated through inappropriate limitations on access to health care, compromises in the quality of care, or actions that adversely affected or are likely to adversely affect the health of the persons receiving services from an institutional provider, group practice, or other participating provider under CalCare.
(3)The board shall evaluate the source of margin generation.
(b)A payment under CalCare, including provider payments for operating expenses or capital expenditures, shall not take into account, include a process for the funding of, or be used by a provider for any of the following:
(1)Marketing, which does not include education and prevention programs paid under a global budget.
(2)The profit or net revenue, or increasing the profit, net revenue, or financial result of the provider.
(3)An incentive payment, bonus, or compensation based on patient utilization of health care items or services or any financial measure applied with respect to the provider or a group practice or other entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(4)A bonus, incentive payment, or incentive adjustment from CalCare to a participating provider.
(5)A bonus, incentive payment, or compensation based on the financial results of any other health care provider with which the provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship.
(6)A bonus, incentive payment, or compensation based on the financial results of an integrated health care delivery system, group practice, or other provider.
(7)State political contributions.
(c)(1)The board shall establish and enforce penalties for violations of this section, consistent with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
(2)Penalty payments collected for violations of this section shall be remitted to the CalCare Trust Fund for use in CalCare.
100658.(a)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, and other relevant state agencies, negotiate prices to be paid for pharmaceuticals, medical supplies, medical technology, and medically necessary assistive equipment covered through CalCare. Negotiations by the board shall be on behalf of the entire CalCare program. A state agency shall cooperate to provide data and other information to the board.
(b)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, the CalCare Public Advisory Committee, patient advocacy organizations, physicians, registered nurses, pharmacists, and other health care professionals, establish a prescription drug formulary system. To establish the prescription drug formulary system, the board shall do all of the following:
(1)Promote the use of generic and biosimilar medications.
(2)Consider the clinical efficacy of medications.
(3)Update the formulary frequently and allow health care professionals, other clinicians, and members to petition the board to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary.
(4)Consult with patient advocacy organizations, physicians, nurses, pharmacists, and other health care professionals to determine the clinical efficacy and need for the inclusion of specific medications in the formulary.
(c)The prescription drug formulary system shall not require a prior authorization determination for coverage under CalCare and shall not apply treatment limitations through the use of step therapy protocols.
(d)The board shall promulgate regulations regarding the use of off-formulary medications that allow for patient access.
6.Program Standards1.Standard of Care100660.CalCare shall establish a single standard of safe, therapeutic, and effective care for all residents of the state by the following means:
(a)The board shall establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:
(1)The scope, quality, and accessibility of health care items and services.
(2)Relations between participating providers and members.
(3)Relations between institutional providers, group practices, and individual health care organizations, including credentialing for participation in CalCare and clinical and admitting privileges, and terms, methods, and rates of payment.
(b)The board shall establish requirements and standards, by regulation, under CalCare that include provisions to promote all of the following:
(1)Simplification, transparency, uniformity, and fairness in the following:
(A)Health care provider credentialing for participation in CalCare.
(B)Health care provider clinical and admitting privileges in health care facilities.
(C)Clinical placement for educational purposes, including clinical placement for prelicensure registered nursing students without regard to degree type, that prioritizes nursing students in public education programs.
(D)Payment procedures and rates.
(E)Claims processing.
(2)In-person primary and preventive care, efficient and effective health care items and services, quality assurance, and promotion of public, environmental, and occupational health.
(3)Elimination of health care disparities.
(4)Nondiscrimination pursuant to Section 100631.
(5)Accessibility of health care items and services, including accessibility for people with disabilities and people with limited ability to speak or understand English.
(6)Providing health care items and services in a culturally, linguistically, and structurally competent manner.
(7)Prevention-oriented care.
(c)The board shall establish requirements and standards, to the extent authorized by federal law, by regulation, for replacing and merging with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the Affordable Care Act, and federally matched public health programs.
(d)A participating provider shall furnish information as required by the Department of Health Care Access and Information pursuant to Sections 100617 and 100641, and to Division 107 (commencing with Section 127000) of the Health and Safety Code, and permit examination of that information by the board as reasonably required for purposes of reviewing accessibility and utilization of health care items and services, quality assurance, cost containment, the making of payments, and statistical or other studies of the operation of CalCare or for protection and promotion of public, environmental, and occupational health.
(e)The board shall use the data furnished under this title to ensure that clinical practices meet the utilization, quality, and access standards of CalCare. The board shall not use a standard developed under this chapter for the purposes of establishing a payment incentive or adjustment under CalCare.
(f)To develop requirements and standards and making other policy determinations under this chapter, the board shall consult with representatives of members, health care providers, health care organizations, labor organizations representing health care employees, and other interested parties.
(g)The board shall coordinate with the Office of Health Equity, the Department of Health Care Access and Information, and the Department of Managed Health Care to do both of the following:
(1)Monitor participating providers for, and establish procedures related to, compliance with the requirements and standards established under this section.
(2)Establish programs, including special projects under Section 100677, to ensure or manage CalCare member access to in-person primary and preventive care, efficient and effective health care items and services, and quality care.
100661.(a)(1)As part of a health care practitioners duty to advocate for medically appropriate health care for their patients pursuant to Sections 510 and 2056 of the Business and Professions Code, a participating provider has a duty to act in the exclusive interest of the patient.
(2)The duty described in paragraph (1) applies to a health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare.
(b)Consistent with subdivision (a) and with Sections 510 and 2056 of the Business and Professions Code:
(1)An individuals treating physician, or other health care professional who is authorized to diagnose the individual in accordance with all applicable scope of practice and other license requirements and is treating the individual, is responsible for the determination of the medically necessary or appropriate care for the individual.
(2)A participating provider or health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare from a participating provider or other person participating in CalCare shall use reasonable care and diligence in safeguarding an individual under the care of the provider or professional and shall not impair an individuals treating physician or other health care provider treating the individual from advocating for medically necessary or appropriate care under this section.
(c)A health care provider or health care professional described in subdivision (a) violates the duty established under this section for any of the following:
(1)Having a pecuniary interest or relationship, including an interest or relationship disclosed under subdivision (d), that impairs the providers ability to provide medically necessary or appropriate care.
(2)Accepting a bonus, incentive payment, or compensation based on any of the following:
(A)A patients utilization of services.
(B)The financial results of another health care provider with which the participating provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship, or of a person that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(C)The financial results of an institutional provider, group practice, or person that contracts with, provides health care items or services under, or otherwise receives payment from CalCare.
(3)Having a board member, executive, or administrator that receives compensation from, owns stock or has other financial investments in, or serves as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(d)To evaluate and review compliance with this section, a participating provider shall report, at least annually, to the Department of Health Care Access and Information all of the following:
(1)A beneficial interest required to be disclosed to a patient pursuant to Section 654.2 of the Business and Professions Code.
(2)A membership, proprietary interest, coownership, or profit-sharing arrangement, required to be disclosed to a patient pursuant to Section 654.1 of the Business and Professions Code.
(3)A subcontract entered into that contains incentive plans that involve general payments, including capitation payments or shared risk agreements, that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions.
(4)Bonus or other incentive arrangements used in compensation agreements with another health care provider or an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(5)An offer, delivery, receipt, or acceptance of rebates, refunds, commission, preference, patronage dividend, discount, or other consideration for a referral made in exception to Section 650 of the Business and Professions Code.
(e)The board may adopt regulations as necessary to implement and enforce this section and may adopt regulations to expand reporting requirements under this section.
(f)For purposes of this section, person means an individual, partnership, corporation, limited liability company, or other organization, or any combination thereof, including a medical group practice, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer.
100662.(a)An individuals treating physician, nurse, or other health care professional, in implementing a patients medical or nursing care plan and in accordance with their scope of practice and licensure, may override health information technology or clinical practice guidelines, including standards and guidelines implemented by a participating provider through the use of health information technology, including electronic health record technology, clinical decision support technology, and computerized order entry programs.
(b)An override described in subdivision (a) shall, in the independent professional judgment of the treating physician, nurse, or other health care professional, meet all of the following requirements:
(1)The override is consistent with the treating physicians, nurses, or other health care professionals determination of medical necessity or appropriateness or nursing assessment.
(2)The override is in the best interest of the patient.
(3)The override is consistent with the patients wishes.
2.Health Equity100665.(a)There is hereby established, within CalCare, the Office of Health Equity. The Director of the Department of Health Care Access and Information shall be the director of the office and shall carry out all functions of that position, including enforcement.
(b)The office shall be responsible for coordination and collaboration across the programs and activities of CalCare and the California Health and Human Services Agency with respect to ensuring health equity under CalCare and other health programs of the California Health and Human Services Agency.
(c)The office shall do all of the following:
(1)Support the board through data collection and analysis of, and recommendations to address, all of the following:
(A)The disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, disability, sex, including gender identity and sexual orientation, geographic location, socioeconomic status, incarceration, housing status, and other population-based characteristics.
(B)Barriers to health, including barriers relating to income, education, housing, food insecurity, employment status, working conditions, and conditions related to the physical environment.
(C)Barriers to health care access, including lack of trust and awareness, lack of transportation, geography, hospital and service closures, lack of health care infrastructure and facilities, lack of health care professional staffing and recruitment, disparities in quality of care received, and disparities in utilization of care.
(D)Inequitable distribution of health care services, including health care professional shortage areas, medically underserved areas, medically underserved populations, and trends in hospital closures and service reductions.
(E)Discrimination in health care settings and the use of racially biased or other discriminatory practice guidelines, health care technologies, and algorithms.
(F)Increasing access to high-quality primary health care, particularly in medically underserved areas and for medically underserved populations
(2)Ensure that analysis and data collected under this section are made publicly available and allow for the analysis of cross-sectional information on peoples identities.
(3)Support the board through the development and coordination of programs and recommendations to enhance health equity in California, including programs and recommendations on all of the following:
(A)Improving the provision of culturally, linguistically, and structurally competent care.
(B)Increasing diversity in the health care workforce.
(C)Ensuring sufficient health care professionals and facilities to meet the health care needs across the state.
(D)Ensuring equitable access and distribution of health care professionals and facilities to meet the health care needs across the state.
(E)Recruitment and retention of a health care workforce that meets the cultural, linguistic, and other needs of Californians.
(F)Recruitment and retention of a health care workforce in rural and medically underserved areas.
(4)Develop, coordinate, and provide recommendations on programs that expand the number of primary health care providers and practitioners, including primary care physicians, registered nurses, and dentists, in the state.
(5)Develop, coordinate, and provide recommendations on targeted programs and resources for federally qualified health centers, rural health centers, community health centers, and other community-based organizations that provide primary care in the state.
(6)Conduct ongoing research and evaluation on health equity and access to primary care in California.
(7)Support the board and the CalCare Public Advisory Committee through data collection and analysis and recommendations to develop, propose, and review special projects under Section 100677.
(8)Adopt and promulgate regulations for the purpose of carrying out this chapter.
(9)Establish advisory or technical committees, as necessary.
(d)For purposes of implementing this section, including hiring staff and consultants, through the procurement authority and processes of the department, facilitating and conducting meetings, conducting research and analysis, and developing the required reports, the office may enter into exclusive or nonexclusive contracts on a bid or negotiated basis. Until January 1, 2026, contracts entered into or amended pursuant to this chapter are exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and are exempt from the review or approval of any division of the Department of General Services.
7.Funding1.Federal Health Programs and Funding100670.(a)(1)The board is authorized to and shall seek all federal waivers and other federal approvals and arrangements and submit state plan amendments as necessary to operate CalCare consistent with this title.
(2)The board is authorized to apply for a federal waiver or federal approval as necessary to receive funds to operate CalCare pursuant to paragraph (1), including a waiver under Section 18052 of Title 42 of the United States Code.
(3)The board shall apply for federal waivers or federal approval pursuant to paragraph (1) by January 1, 2026.
(b)(1)The board shall apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the Affordable Care Act, and any other federal programs or laws, as appropriate, that are necessary to enable all CalCare members to receive all benefits under CalCare through CalCare, to enable the state to implement this title, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the CalCare Trust Fund, created pursuant to Section 100675, and to use those funds for CalCare and other provisions under this title.
(2)To the fullest extent possible, the board shall negotiate arrangements with the federal government to ensure that federal payments are paid to CalCare in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs. To the extent any federal funding is not paid directly to CalCare, the state shall direct the funding and moneys to CalCare.
(3)The board may require members or applicants to provide information necessary for CalCare to comply with any waiver or arrangement under this title. Information provided by members to the board for the purposes of this subdivision shall not be used for any other purpose.
(4)The board may take any additional actions necessary to effectively implement CalCare to the maximum extent possible as an independent single-payer program consistent with this title. It is the intent of the Legislature to establish CalCare, to the fullest extent possible, as an independent agency.
(c)The board may take actions consistent with this article to enable CalCare to administer Medicare in California. CalCare shall be a provider of supplemental insurance coverage and shall provide premium assistance for drug coverage under Medicare Part D for eligible members of CalCare.
(d)The board may waive or modify the applicability of any provisions of this title relating to any federally matched public health program or Medicare, as necessary, to implement any waiver or arrangement under this section or to maximize the federal benefits to CalCare under this section.
(e)The board may apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare. Enrollment in a federally matched public health program or Medicare shall not cause a member to lose a health care item or service provided by CalCare or diminish any right the member would otherwise have.
(f)(1)Notwithstanding any other law, the board, by regulation, shall increase the income eligibility level, increase or eliminate the resource test for eligibility, simplify any procedural or documentation requirement for enrollment, and increase the benefits for any federally matched public health program and for any program in order to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(2)The board may act under this subdivision, upon a finding approved by the Director of Finance and the board that the action does all of the following:
(A)Will help to increase the number of members who are eligible for and enrolled in federally matched public health programs, or for any program to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(B)Will not diminish any individuals access to a health care item or service or right the individual would otherwise have.
(C)Is in the interest of CalCare.
(D)Does not require or has received any necessary federal waivers or approvals to ensure federal financial participation.
(g)To enable the board to apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare, the board may require that every member or applicant provide the information necessary to enable the board to determine whether the applicant is eligible for a federally matched public health program or for Medicare, or any program or benefit under Medicare.
(h)As a condition of continued eligibility for health care items and services under CalCare, a member who is eligible for benefits under Medicare shall enroll in Medicare, including Parts A, B, and D.
(i)The board shall provide premium assistance for all members enrolling in a Medicare Part D drug coverage plan under Section 1860D of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.), limited to the low-income benchmark premium amount established by the federal Centers for Medicare and Medicaid Services and any other amount the federal agency establishes under its de minimis premium policy, except that those payments made on behalf of members enrolled in a Medicare Advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to CalCare.
(j)If the board has reasonable grounds to believe that a member may be eligible for an income-related subsidy under Section 1860D-14 of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-114), the member shall provide, and authorize CalCare to obtain, any information or documentation required to establish the members eligibility for that subsidy. The board shall attempt to obtain as much of the information and documentation as possible from records that are available to it.
(k)The board shall make a reasonable effort to notify members of their obligations under this section. After a reasonable effort has been made to contact the member, the member shall be notified in writing that the member has 60 days to provide the required information. If the required information is not provided within the 60-day period, the members coverage under CalCare may be suspended until the issue is resolved. Information provided by a member to the board for the purposes of this section shall not be used for any other purpose.
(l)The board shall assume responsibility for all benefits and services paid for by the federal government with those funds.
2.CalCare Trust Fund100675.(a)The CalCare Trust Fund is hereby created in the State Treasury for the purposes of this title to be administered by the CalCare Board. Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title. Any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year may be carried forward to the next succeeding fiscal year.
(b)Notwithstanding any other law, moneys deposited in the fund shall not be loaned to, or borrowed by, any other special fund or the General Fund, a county general fund or any other county fund, or any other fund.
(c)The board shall establish and maintain a prudent reserve in the fund to enable it to respond to costs including those of an epidemic, pandemic, natural disaster, or other health emergency, or market-shift adjustments related to patient volume.
(d)The board or staff of the board shall not utilize any funds intended for the administrative and operational expenses of the board for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.
(e)Notwithstanding Section 16305.7, all interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.
(f)The fund shall consist of all of the following:
(1)All moneys obtained pursuant to legislation enacted as proposed under Section 100680.
(2)Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials for health care programs established under Medicare, any federally matched public health program, or the Affordable Care Act.
(3)The amounts paid by the State Department of Health Care Services that are equivalent to those amounts that are paid on behalf of residents of this state under Medicare, any federally matched public health program, or the Affordable Care Act for health benefits that are equivalent to health benefits covered under CalCare.
(4)Federal and state funds for purposes of the provision of services authorized under Title XX of the federal Social Security Act (42 U.S.C. Sec. 1397 et seq.) that would otherwise be covered under CalCare.
(5)State moneys that would otherwise be appropriated to any governmental agency, office, program, instrumentality, or institution that provides health care items or services for services and benefits covered under CalCare. Payments to the fund pursuant to this section shall be in an amount equal to the money appropriated for those purposes in the fiscal year beginning immediately preceding the effective date of this title.
(g)All federal moneys shall be placed into the CalCare Federal Funds Account, which is hereby created within the CalCare Trust Fund.
(h)Moneys in the CalCare Trust Fund shall only be used for the purposes established in this title.
(i)(1)Before the delivery of the fiscal analysis required pursuant to Section 100620:
(A)Moneys in the CalCare Trust fund Fund shall not be used for startup and administrative costs to implement Section 100612.
(B)Moneys in the CalCare Trust Fund may be used to design and commission the fiscal analysis required pursuant to Section 100620.
(2)After delivery of the fiscal analysis required pursuant to Section 100620, moneys in the CalCare Trust Fund may be used for startup and administrative costs to implement Section 100612.
100676.(a)The board annually shall prepare a budget for CalCare that specifies a budget for all expenditures to be made for covered health care items and services and shall establish allocations for each of the budget components under subdivision (b) that shall cover a three-year period.
(b)The CalCare budget shall consist of at least the following components:
(1)An operating budget.
(2)A capital expenditures budget.
(3)A special projects budget.
(4)Program standards activities.
(5)Health professional education expenditures.
(6)Health care workforce recruitment and retention expenditures.
(7)Administrative costs.
(8)Prevention and public health activities.
(c)The board shall allocate the funds received among the components described in subdivision (b) to ensure the following:
(1)The operating budget allows for participating providers to meet the health care needs of the population.
(2)A fair allocation to the special projects budget to meet the purposes described in subdivision (f) in a reasonable timeframe.
(3)A fair allocation for program standards activities.
(4)The health professional education expenditures component is sufficient to meet the need for covered health care items and services.
(d)The operating budget described in paragraph (1) of subdivision (b) shall be used for payments to providers for health care items and services furnished by participating providers under CalCare.
(e)The capital expenditures budget described in paragraph (2) of subdivision (b) shall be used for the construction or renovation of health care facilities, excluding congregate or segregated facilities for individuals with disabilities who receive long-term services and supports under CalCare, and other capital expenditures.
(f)The special projects budget described in paragraph (3) of subdivision (b) shall be used for the payment to not-for-profit or governmental entities pursuant to Section 100677.
(g)For up to five years following the date on which benefits first become available under CalCare, at least 1 percent of the budget shall be allocated to programs providing transition assistance pursuant to Section 100615.
(h)During the implementation period and for at least five years following the date on which benefits first become available under CalCare, up to 1 percent of the budget shall be allocated to programs providing health care workforce education, recruitment, and retention pursuant to Section 100686.
100677.(a)(1)The special projects budget described in paragraph (3) of subdivision (b) of Section 100676 shall be used for the payment to not-for-profit entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code or governmental entities for the construction or renovation of health care facilities, major equipment purchases, staffing in a rural or medically underserved area, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(2)To mitigate the impact of the payments on the availability and accessibility of health care services, the special projects budget may be used to increase payment to providers in a rural or medically underserved area.
(b)(1)An agency of the state, a city, a county, a city and county, or another political subdivision of the state or a not-for-profit entity that is a health facility pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code may submit an application to the board for payment from the special projects budget for a special project under this section.
(2)The board shall develop criteria to evaluate applications for payment from the special projects budget for special projects in consultation with the CalCare Public Advisory Committee, the Office of Health Equity, the California Health Facilities Financing Authority, the Department of Health Care Access and Information, the State Department of Health Care Services, the Department of Managed Health Care, the State Department of Public Health, and other relevant state agencies.
(3)The criteria to evaluate applications shall consider factors, including if the special project will support a health facility in a rural or medically underserved area, and if the special project will address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(4)The criteria to evaluate applications shall also be used for identification and monitoring of health facilities at risk of understaffing in rural or medically underserved areas and of populations experiencing health disparities.
(c)(1)The board may issue a request for applications for a special project paid under subdivision (b) in consultation with the Office of Health Equity.
(2)The CalCare Public Advisory Committee may develop and recommend the board issue a request for applications for a special project paid under subdivision (b).
(d)(1)An applicant for payment from the special projects budget shall provide the board with financial, demographic, and other information regarding the proposed health care service area as determined by the board, in a format determined by the board, to review an application to receive payment from the special projects budget for a special project.
(2)An applicant for payment from the special projects budget shall submit a plan to the board detailing the projected uses of the proposed payment and strategies proposed to address a health disparity or other qualifying need identified by the board.
(e)(1)The board shall determine the application process and methodology for approval and distribution of payments from the special projects budget.
(2)In reviewing a plan submitted by an applicant for payment from the special projects budget under this section, the board shall evaluate if there is a reasonable likelihood that it will address a health disparity or other qualifying need identified by the board.
(3)The board shall provide public notice of an application submitted under this section and post a copy of the applicants plan submitted under this section on its internet website.
(4)The board shall make its application process and methodology publicly accessible on its internet website.
(f)(1)Within 90 days of receipt of a complete application for a payment from the special projects budget for a special project, the board shall provide a preliminary report to the applicant of the boards initial review of the application and provide public notice of the preliminary report.
(2)The board shall provide the public the opportunity to provide written comment on a preliminary report of an application for payment from the special projects budget for a special project.
(3)Before the board approves an application for payment from the special projects budgets for a special project, the CalCare Public Advisory Committee shall conduct at least one public hearing to receive public input and comment on the application.
(4)The CalCare Public Advisory Committee shall provide a recommendation to the board on the approval of an application submitted to the board under this section.
(g)The board shall have the authority to determine service provision requirements or other conditions in approving, and for the duration of, special projects payments to health facilities or that support health facilities. In making its determination, the board shall consider the impact of any changes to the health facilities service delivery on access to medical care.
3.CalCare Financing100680.(a)It is the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. In developing the revenue plan, it is the intent of the Legislature to consult with appropriate officials and stakeholders.
(b)It is the intent of the Legislature to enact legislation that would require all state revenues from CalCare to be deposited in an account within the CalCare Trust Fund to be established and known as the CalCare Trust Fund Account.
8.Transition100685.(a)An individual who meets all of the following requirements shall be eligible to enroll as a member of CalCare during the implementation period:
(1)The individual meets the eligibility standards established by the board under Section 100630.
(2)The individual is 55 years of age or older, 18 years of age or younger, or is currently enrolled in Medicare or Medicaid during the implementation period.
(b)The board shall ensure that all persons enrolled, or who seek to enroll, in a health plan during the implementation period are protected from disruptions in their care during the implementation period, including continuity of care with current health care teams.
(c)(1)During the implementation period, a carrier shall not end coverage for a CalCare member until the end of the implementation period except as expressly agreed upon under the terms of the plan.
(2)During the implementation period, a carrier shall not impose any exclusion or limitation of coverage on the basis of a persons disability, complex medical need, or chronic condition.
(3)This subdivision applies to a carrier except as otherwise prohibited by federal law.
(d)The board shall consult with the Advisory Commission on Long-Term Services and Supports, communities and advocacy organizations of persons living with disabilities, and other patient advocacy organizations to ensure that CalCare coverage during the implementation period takes into account the continuity of care for persons with disabilities, complex medical needs, or chronic conditions.
(e)In the case of inpatient hospital services and extended care services during a continuous period of stay that began before the end of the implementation period, and that had not ended as of the end of the implementation date, the board shall provide for continuation of benefits under CalCare until the end of the period of stay.
(f)During the implementation period, the board shall establish and maintain procedures that, to the greatest extent possible, provide for the following:
(1)Automatic enrollment in CalCare of individuals who are eligible to enroll in CalCare during the implementation period.
(2)Automatic enrollment in CalCare of individuals who will become eligible to enroll in CalCare after the end of the implementation period.
(g)(1)During the implementation period, the board shall establish and maintain procedures for individuals who will become eligible to enroll in CalCare after the end of the implementation period to select a primary care provider under subdivision (e) of Section 100630.
(2)During the implementation period, the board, to the greatest extent possible, shall establish and maintain procedures for individuals who are currently members of an integrated health care delivery system to automatically select participating providers in the individuals integrated health care delivery system care team as their primary care provider upon enrollment in CalCare.
(h)A person who is eligible to receive CalCare benefits during the implementation period may opt to maintain coverage outside of CalCare, including private health care coverage or coverage offered through the California Health Benefit Exchange, until the end of the implementation period.
100686.(a)(1)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for programs to address health care workforce education, recruitment, and retention to meet health workforce demands under CalCare, including programs implemented during the implementation period.
(2)The board shall coordinate with the CalCare Public Advisory Committee, the Office of Health Equity, the Department of Health Care Access and Information, the Labor and Workforce Development Agency, the California Health and Human Services Agency, and health care professional licensing boards, including the Board of Registered Nursing, Medical Board of California, and Dental Board of California, to implement programs and policies related to health care workforce education, recruitment, and retention.
(b)The board shall establish a CalCare Health Workforce Working Group to provide input, including recommendations, to the board and Secretary of Labor and Workforce Development on issues related to health care workforce education, recruitment, and retention, including all of the following:
(1)Programs and measures to expand clinical education capacity at California community colleges providing associate degree programs in health professions, including through programs to ensure the fair and equitable distribution of clinical placement at clinical education sites among approved health professions education programs and through programs to recruit and retain clinical faculty.
(2)Data collection and analysis and recommendations on health workforce attrition from direct care positions, including on moral distress and moral injury, safe staffing, and gaps in active California health professions licensees and those working in direct care.
(3)Identification and prioritization of geographical areas or populations in the state with unmet primary care or other health care needs, including access and availability of family physicians, primary care clinics, and registered nurses.
(4)Programs and measures to retain health care workforces, including public loan repayment assistance programs, minimum safe staffing requirements, investments in personal protective equipment, and occupational safety and health programs.
(5)Programs and measures to support expansion of graduate medical education programs and assistance for medical residents.
(6)Career ladders into health professions for ancillary and allied health workers, including licensed vocational nurses, certified nursing assistants, medical technicians, behavioral health technicians, health navigators, and community health workers.
(7)Career technical education pathways toward an associate degree at a California community college in a health professions education program.
(8)Programs to address barriers to health professions, including student debt levels, tuition assistance, childcare or other support, and debt-free residency or mentorship programs.
(c)The board shall appoint the members of the CalCare Health Workforce Working Group. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the working group, the board shall aim for broad representation, including, at a minimum, all of the following:
(1)Representatives of health professions and other health care workers, including specialties for primary care and behavioral health, physicians, registered nurses, and ancillary services.
(2)Representatives of labor organizations representing health care workers.
(3)Representatives of California community colleges, graduate medical education and training programs, and nursing education programs.
(4)Representatives of consumer and patient groups.
(5)Representatives of health care providers, including hospitals, nonacute care providers, and medical groups.
(d)(1)Each appointed member of the CalCare Health Workforce Working Group shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(2)Working group members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the working group shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the working group members.
(3)Working group members shall receive reimbursement for travel and other actual costs.
(e)The working group shall meet at least four times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(f)The board shall consider input, including recommendations, from the working group, along with public comments, in the boards deliberation and decisionmaking.
9.Collective Negotiation by Health Care Providers with CalCare1.Definitions100690.For purposes of this chapter, the following definitions apply:
(a)(1)Health care provider means a person who is licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code and who is either of the following:
(A)An individual who practices that profession as a health care professional or as an independent contractor.
(B)An owner, officer, shareholder, or proprietor of a health care group practice that has elected to receive fee-for-service payments from CalCare pursuant to subdivision (d) of Section 100650.
(2)A health care provider licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code who practices as an employee of a health care provider is not a health care provider for purposes of this chapter.
(b)Health care providers representative means a third party that is authorized by a health care provider to negotiate on their behalf with CalCare over terms and conditions affecting those health care providers.
2. Authorized Collective Negotiation100691.(a)Health care providers may meet and communicate for the purpose of collectively negotiating with CalCare on any matter relating to CalCare fee-for-service rates of payment for health care items and services or procedures related to fee-for-service payment under CalCare.
(b)This chapter does not allow a strike of CalCare by health care providers related to the collective negotiations.
(c)This chapter does not allow or authorize terms or conditions that would impede the ability of CalCare to comply with applicable state or federal law.
3.Collective Negotiation Requirements100692.(a)Collective negotiation under this chapter shall meet all of the following requirements:
(1)A health care provider may communicate with other health care providers regarding the terms and conditions to be negotiated with CalCare.
(2)A health care provider may communicate with a health care providers representative.
(3)A health care providers representative is the only party authorized to negotiate with CalCare on behalf of the health care providers as a group.
(4)A health care provider can be bound by the terms and conditions negotiated by the health care providers representative.
(b)This chapter does not affect or limit the right of a health care provider or group of health care providers to collectively petition a governmental entity for a change in a law, rule, or regulation.
(c)This chapter does not affect or limit collective action or collective bargaining on the part of a health care provider with the health care providers employer or any other lawful collective action or collective bargaining.
100693.(a)Before engaging in collective negotiations with CalCare on behalf of health care providers, a health care providers representative shall file with the board, in the manner prescribed by the board, information identifying the representative, the representatives plan of operation, and the representatives procedures to ensure compliance with this chapter.
(b)A person who acts as the representative of negotiating parties under this chapter shall pay a fee to the board to act as a representative. The board, by regulation, shall set fees in amounts deemed reasonable and necessary to cover the costs incurred by the board in administering this chapter.
4.Prohibited Collective Action100694.(a)This chapter does not authorize competing health care providers to act in concert in response to a health care providers representatives discussions or negotiations with CalCare, except as authorized by other law.
(b)A health care providers representative shall not negotiate an agreement that excludes, limits the participation or reimbursement of, or otherwise limits the scope of services to be provided by a health care provider or group of health care providers with respect to the performance of services that are within the health care providers scope of practice, license, registration, or certificate.
10.Operative Date100695.(a)Notwithstanding any other law, this title, except for Chapter 1 (commencing with Section 100600), Chapter 2 (commencing with Section 100610), and Article 1 (commencing with Section 100670) of Chapter 7, shall not become operative until the date the Secretary of California Health and Human Services notifies the Secretary of the Senate and the Chief Clerk of the Assembly in writing that the secretary has determined that the CalCare Trust Fund has the revenues to fund the costs of implementing this title.
(b)The California Health and Human Services Agency shall publish a copy of the notice on its internet website.
(c)The Secretary of California Health and Human Services shall make a notification pursuant to subdivision (a).
SEC. 3.The provisions of this act are severable. If any provision of this act or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
SEC. 4.The Legislature finds and declares that Section 2 of this act, which adds Sections 100610, 100617, and 100619 to the Government Code, imposes a limitation on the publics 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 private, confidential, and proprietary information, it is necessary for that information to remain confidential.
(a)The Legislature finds and declares all of the following:
(1)Although the federal Patient Protection and Affordable Care Act (PPACA) brought many improvements in health care and health care coverage, PPACA still leaves many Californians without coverage or with inadequate coverage.
(2)Californians, as individuals, employers, and taxpayers, have experienced a rise in the cost of health care and health care coverage in recent years, including rising premiums, deductibles, and copayments, as well as restricted provider networks and high out-of-network charges.
(3)Businesses have also experienced increases in the costs of health care benefits for their employees, and many employers are shifting a larger share of the cost of coverage to their employees or dropping coverage entirely.
(4)Individuals often find that they are deprived of affordable care and choice because of decisions by health benefit plans guided by the plans economic needs rather than patients health care needs.
(5)To address the fiscal crisis facing the health care system and the state, and to ensure Californians get the health care they need, comprehensive health care coverage needs to be provided.
(6)Billions of dollars that could be spent on providing equal access to health care are wasted on administrative costs necessary in a multipayer health care system. Resources and costs spent on administration would be dramatically reduced in a single-payer system, allowing health care professionals and hospitals to focus on patient care instead.
(7)It is the intent of the Legislature to establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.
(b)(1)It is further the intent of the Legislature to establish the California Guaranteed Health Care for All program to provide universal health care coverage for every Californian, funded by broad-based revenue.
(2)It is the intent of the Legislature to work to obtain waivers and other approvals relating to Medi-Cal, the federal Childrens Health Insurance Program, Medicare, PPACA, and any other federal programs pertaining to the provision of health care so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the CalCare Trust Fund.
(3)Under those waivers and approvals, those funds would be used for health care coverage that provides health care benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums.
(4)Those programs would be replaced and merged into CalCare, which will operate as a true single-payer program.
(5)If any necessary waivers or approvals are not obtained, it is the intent of the Legislature that the state use state plan amendments and seek waivers and approvals to maximize, and make as seamless as possible, the use of funding from federally matched public health programs and other federal health programs in CalCare.
(6)Even if other programs, including Medi-Cal or Medicare, may contribute to paying for care, it is the goal of this act that the coverage be delivered by CalCare, and, as much as possible, that the multiple sources of funding be pooled with other CalCare program funds.
(7)It is the intent of the Legislature to provide universal health care coverage with greater benefits and access to providers than existing health coverage plans, including for Californians who primarily receive care through an integrated health care delivery system, that is free at the point of service and does not have deductibles, coinsurance, premiums, or other cost-sharing.
(c)This act does not create an employment benefit, nor does the act require, prohibit, or limit providing a health care employment benefit.
(d)(1)It is not the intent of the Legislature to change or impact in any way the role or authority of a licensing board or state agency that regulates the standards for or provision of health care and the standards for health care providers as established under current law, including the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code.
(2)This act would in no way authorize the CalCare Board, the California Guaranteed Health Care for All program, or the Secretary of California Health and Human Services to establish or revise licensure standards for health care professionals or providers.
(e)It is the intent of the Legislature that neither health information technology nor clinical practice guidelines limit the effective exercise of the professional judgment of physicians, registered nurses, and other licensed health care professionals. Physicians, registered nurses, and other licensed health care professionals shall be free to override health information technology and clinical practice guidelines if, in their professional judgment and in accordance with their scope of practice and licensure, it is in the best interest of the patient and consistent with the patients wishes.
(f)(1)It is the intent of the Legislature to prohibit CalCare, a state agency, a local agency, or a public employee acting under color of law from providing or disclosing to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(2)This act would also prohibit law enforcement agencies from using CalCares funds, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of any requirement that individuals register with the federal government or any federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Part 2 (commencing with Section 51) of Division 1 of the Civil Code).
(g)It is the further intent of the Legislature to address the high cost of prescription drugs and ensure they are affordable for patients.
SEC. 2.Title 23 (commencing with Section 100600) is added to the Government Code, to read:23.The California Guaranteed Health Care for All Act1.General Provisions100600.This title shall be known, and may be cited, as the California Guaranteed Health Care for All Act.
100601.There is hereby established in state government the California Guaranteed Health Care for All program, or CalCare, to be governed by the CalCare Board pursuant to Chapter 2 (commencing with Section 100610).
100602.For the purposes of this title, the following definitions apply:
(a)Activities of daily living means basic personal everyday activities including eating, toileting, grooming, dressing, bathing, and transferring.
(b)Advisory commission means the Advisory Commission on Long-Term Services and Supports established pursuant to Section 100614.
(c)Affordable Care Act or 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 amendments to, or regulations or guidance issued under, those acts.
(d)Allied health practitioner means a group of health professionals who apply their expertise to prevent disease transmission and diagnose, treat, and rehabilitate people of all ages and in all specialties, together with a range of technical and support staff, by delivering direct patient care, rehabilitation, treatment, diagnostics, and health improvement interventions to restore and maintain optimal physical, sensory, psychological, cognitive, and social functions. Examples include audiologists, occupational therapists, social workers, and radiographers.
(e)Board means the CalCare Board described in Section 100610.
(f)CalCare or California Guaranteed Health Care for All means the California Guaranteed Health Care for All program established in Section 100601.
(g)Capital expenditures means expenses for the purchase, lease, construction, or renovation of capital facilities, health information technology, artificial intelligence, and major equipment, including costs associated with state grants, loans, lines of credit, and lease-purchase arrangements.
(h)Carrier means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under subdivision (f) of Section 1345 of the Health and Safety Code, licensed by the Department of Managed Health Care.
(i)Committee means the CalCare Public Advisory Committee established pursuant to Section 100611.
(j)County organized health system means a health system implemented pursuant to Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code, and Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.
(k)Essential community provider means a provider, as defined in Section 156.235(c) of Title 45 of the Code of Federal Regulations, as published February 27, 2015, in the Federal Register (80 FR 10749), that serves predominantly low-income, medically underserved individuals and that is one of the following:
(1)A community clinic, as defined in subparagraph (A) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(2)A free clinic, as defined in subparagraph (B) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code.
(3)A federally qualified health center, as defined in Section 1395x(aa)(4) or Section 1396d(l)(2)(B) of Title 42 of the United States Code.
(4)A rural health clinic, as defined in Section 1395x(aa)(2) or 1396d(l)(1) of Title 42 of the United States Code.
(5)An Indian Health Service Facility, as defined in subdivision (v) of Section 2699.6500 of Title 10 of the California Code of Regulations.
(l)Federally matched public health program means the states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(m)Fund means the CalCare Trust Fund established pursuant to Article 2 (commencing with Section 100675) of Chapter 7.
(n)Global budget means the payment negotiated between an institutional provider and the board pursuant to Section 100651.
(o)Group practice means a professional corporation under the Moscone-Knox Professional Corporation Act (Part 4 (commencing with Section 13400) of Division 3 of Title 1 of the Corporations Code) that is a single corporation or partnership composed of licensed doctors of medicine, doctors of osteopathy, or other licensed health care professionals, and that provides health care items and services primarily directly through physicians or other health care professionals who are either employees or partners of the organization.
(p)Health care professional means a health care professional licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, or licensed pursuant to the Osteopathic Act or the Chiropractic Act, who, in accordance with the professionals scope of practice, may provide health care items and services under this title.
(q)Health care item or service means a health care item or service that is included as a benefit under CalCare.
(r)Health professional education expenditures means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities.
(s)Home- and community-based services means an integrated continuum of service options available locally for older individuals and functionally impaired persons who seek to maximize self-care and independent living in the home or a home-like environment, which includes the home- and community-based services that are available through Medi-Cal pursuant to the home- and community-based waiver program under Section 1915 of the federal Social Security Act (42 U.S.C. Sec. 1396n) as of January 1, 2019.
(t)Implementation period means the period under paragraph (6) of subdivision (e) of Section 100612 during which CalCare is subject to special eligibility and financing provisions until it is fully implemented under that section.
(u)Institutional provider means an entity that provides health care items and services and is licensed pursuant to any of the following:
(1)A health facility, as defined in Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)A clinic licensed pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code.
(3)A long-term health care facility, as defined in Section 1418 of the Health and Safety Code, or a program developed pursuant to paragraph (1) of subdivision (i) of Section 100612.
(4)A county medical facility licensed pursuant to Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code.
(5)A residential care facility for persons with chronic, life-threatening illness licensed pursuant to Chapter 3.01 (commencing with Section 1568.01) of Division 2 of the Health and Safety Code.
(6)An Alzheimers daycare resource center licensed pursuant to Chapter 3.1 (commencing with Section 1568.15) of Division 2 of the Health and Safety Code.
(7)A residential care facility for the elderly licensed pursuant to Chapter 3.2 (commencing with Section 1569) of Division 2 of the Health and Safety Code.
(8)A hospice licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code.
(9)A pediatric day health and respite care facility licensed pursuant to Chapter 8.6 (commencing with Section 1760) of Division 2 of the Health and Safety Code.
(10)A mental health care provider licensed pursuant to Division 4 (commencing with Section 4000) of the Welfare and Institutions Code.
(11)A federally qualified health center, as defined in Section 1395x(aa)(4) or 1396d(l)(2)(B) of Title 42 of the United States Code.
(v)Instrumental activities of daily living means activities related to living independently in the community, including meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
(w)Integrated health care delivery system has the same meaning as defined in paragraph (13) of subdivision (b) of Section 1182.14 of the Labor Code.
(x)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, including the entities established pursuant to Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96 of the Welfare and Institutions Code.
(y)Long-term services and supports means long-term care, treatment, maintenance, or services related to health conditions, injury, or age, that are needed to support the activities of daily living and the instrumental activities of daily living for a person with a disability, including all long-term services and supports as defined in Section 14186.1 of the Welfare and Institutions Code, home- and community-based services, additional services and supports identified by the board to support people with disabilities to live, work, and participate in their communities, and those as defined by the board.
(z)Medicaid or medical assistance means a program that is one of the following:
(1)The states Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(2)The federal Childrens Health Insurance Program under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(aa)Medically necessary or appropriate means the health care items, services, or supplies needed or appropriate to prevent, diagnose, or treat an illness, injury, condition, or disease, or its symptoms, and that meet accepted standards of medicine as determined by a patients treating physician or other individual health care professional who is treating the patient, and, according to that health care professionals scope of practice and licensure, is authorized to establish a medical diagnosis and has made an assessment of the patients condition.
(ab)Medicare means Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) and the programs thereunder.
(ac)Member means an individual who is enrolled in CalCare.
(ad)Out-of-state health care service means a health care item or service provided in person to a member while the member is temporarily, for no more than 90 days, and physically located out of the state under either of the following circumstances:
(1)It is medically necessary or appropriate that the health care item or service be provided while the member physically is out of the state.
(2)It is medically necessary or appropriate, and cannot be provided in the state, because the health care item or service can only be provided by a particular health care provider physically located out of the state.
(ae)Participating provider means an individual or entity that is a health care provider qualified under Section 100640 that has a participation agreement pursuant to Section 100641 in effect with the board to furnish health care items or services under CalCare.
(af)Prescription drugs means prescription drugs as defined in subdivision (n) of Section 130501 of the Health and Safety Code.
(ag)Resident means an individual whose primary place of abode is in this state, without regard to the individuals immigration status, who meets the California residence requirements adopted by the board pursuant to subdivision (k) of Section 100610. The board shall be guided by the principles and requirements set forth in the Medi-Cal program under Article 7 (commencing with Section 50320) of Chapter 2 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations.
(ah)Rural or medically underserved area has the same meaning as a health professional shortage area in Section 254e of Title 42 of the United States Code.
100603.This title does not preempt a city, county, or city and county from adopting additional health care coverage for residents in that city, county, or city and county that provides more protections and benefits to California residents than this title.
100604.To the extent any law is inconsistent with this title or the legislative intent of the California Guaranteed Health Care for All Act, this title shall apply and prevail, except when explicitly provided otherwise by this title.
2.Governance100610.(a)CalCare shall be governed by an executive board, known as the CalCare Board, consisting of nine voting members who are residents of California. The CalCare Board shall be an independent public entity not affiliated with an agency or department. Of the members of the board, five shall be appointed by the Governor, two shall be appointed by the Senate Committee on Rules, and two shall be appointed by the Speaker of the Assembly. The Secretary of California Health and Human Services or the secretarys designee shall serve as a nonvoting, ex officio member of the board.
(b)(1)A member of the board, other than an ex officio member, shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(2)Appointments by the Governor shall be subject to confirmation by the Senate. A member of the board may continue to serve until the appointment and qualification of the members successor. Vacancies shall be filled by appointment for the unexpired term. The board shall elect a chairperson on an annual basis.
(c)(1)Each person appointed to the board shall have demonstrated and acknowledged expertise in health care policy or delivery.
(2)Appointing authorities shall also consider the expertise of the other members of the board and attempt to make appointments so that the boards composition reflects a diversity of expertise in the various aspects of health care and the diversity of various regions within the state.
(3)Appointments to the board shall be made as follows:
(A)Two health care professionals who practice medicine. At least one shall be a practicing physician or medical doctor.
(B)One registered nurse.
(C)One public health professional.
(D)One mental health professional.
(E)One member with an institutional provider background.
(F)One representative of a not-for-profit organization that advocates for individuals who use health care in California
(G)One representative of a labor organization.
(H)One member of the committee established pursuant to Section 100611, who shall serve on a rotating basis to be determined by the committee.
(d)Each member of the board shall have the responsibility and duty to meet the requirements of this title and all applicable state and federal laws and regulations, to serve the public interest of the individuals, employers, and taxpayers seeking health care coverage through CalCare, and to ensure the operational well-being and fiscal solvency of CalCare.
(e)In making appointments to the board, the appointing authorities shall take into consideration the racial, ethnic, gender, and geographical diversity of the state so that the boards composition reflects the communities of California.
(f)(1)A member of the board or of the staff of the board shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health care professional, institutional provider, or group practice while serving on the board or on the staff of the board, except board members who are practicing health care professionals may be employed by an institutional provider or group practice. A member of the board or of the staff of the board shall not be a board member or an employee of a trade association of health professionals, institutional providers, or group practices while serving on the board or on the staff of the board. A member of the board or of the staff of the board may be a health care professional if that member does not have an ownership interest in an institutional provider or a professional health care practice.
(2)Notwithstanding Section 11009, a board member shall receive compensation for service on the board. A board member may receive a per diem and reimbursement for travel and other necessary expenses, as provided in Section 103 of the Business and Professions Code, while engaged in the performance of official duties of the board.
(g)A member of the board shall not make, participate in making, or in any way attempt to use the members official position to influence the making of a decision that the member knows, or has reason to know, will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on the member or a person in the members immediate family, or on either of the following:
(1)Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status aggregating two hundred fifty dollars ($250) or more in value provided to, received by, or promised to the member within 12 months before the decision is made.
(2)Any business entity in which the member is a director, officer, partner, trustee, employee, or holds any position of management.
(h)There shall not be liability in a private capacity on the part of the board or a member of the board, or an officer or employee of the board, for or on account of an act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this title or affairs related to this title.
(i)The board shall hire an executive director to organize, administer, and manage the operations of the board. The executive director shall be exempt from civil service and shall serve at the pleasure of the board.
(j)The board shall be subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2), except that the board may hold closed sessions when considering matters related to litigation, personnel, contracting, and provider rates.
(k)The board may adopt rules and regulations as necessary to implement and administer this title in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
100611.(a)The board shall convene a CalCare Public Advisory Committee to advise the board on all matters of policy for CalCare. The committee shall consist of members who are residents of California.
(b)Members of the committee shall be appointed by the board for a term of two years. These members may be reappointed for succeeding two-year terms.
(c)The members of the committee shall be as follows:
(1)Four health care professionals.
(2)One registered nurse.
(3)One representative of a licensed health facility.
(4)One representative of an essential community provider.
(5)One representative of a physician organization or medical group.
(6)One behavioral health provider.
(7)One dentist or oral care specialist.
(8)One representative of private hospitals.
(9)One representative of public hospitals.
(10)One individual who is enrolled in and uses health care items and services under CalCare.
(11)Two representatives of organizations that advocate for individuals who use health care in California, including at least one representative of an organization that advocates for the disabled community.
(12)Two representatives of organized labor, including at least one labor organization representing registered nurses.
(d)In convening the committee pursuant to this section, the board shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the social and geographic diversity of the state.
(e)Members of the committee shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies, and shall receive one hundred fifty dollars ($150) for each full day of attending meetings of the committee. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the committee during any particular 24-hour period.
(f)The committee shall meet at least once every quarter, and shall solicit input on agendas and topics set by the board. All meetings of the committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The committee shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)Committee members, or their assistants, clerks, or deputies, shall not use for personal benefit any information that is filed with, or obtained by, the committee and that is not generally available to the public.
100612.(a)The board shall have all powers and duties necessary to establish and implement CalCare. The board shall provide, under CalCare, comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state.
(b)The board shall, to the maximum extent possible, organize, administer, and market CalCare and services as a single-payer program under the name CalCare or any other name as the board determines, regardless of which law or source the definition of a benefit is found, including, on a voluntary basis, retiree health benefits. In implementing this title, the board shall avoid jeopardizing federal financial participation in the programs that are incorporated into CalCare and shall take care to promote public understanding and awareness of available benefits and programs.
(c)The board shall consider any matter to effectuate the provisions and purposes of this title. The board shall not have executive, administrative, or appointive duties except as otherwise provided by law.
(d)The board shall designate the executive director to employ necessary staff and authorize reasonable, necessary expenditures from the CalCare Trust Fund to pay program expenses and to administer CalCare. The executive director shall hire or designate another to hire staff, who shall not be exempt from civil service, to implement fully the purposes and intent of CalCare. The executive director, or the executive directors designee, shall give preference in hiring to all individuals displaced or unemployed as a direct result of the implementation of CalCare, including as set forth in Section 100615.
(e)The board shall do or delegate to the executive director all of the following:
(1)Determine goals, standards, guidelines, and priorities for CalCare.
(2)Annually assess projected revenues and expenditures and ensure the financial solvency of CalCare.
(3)Develop CalCares budget pursuant to Section 100676 to ensure adequate funding to meet the health care needs of the population, and review all budgets annually to ensure they address disparities in service availability and health care outcomes and for sufficiency of rates, fees, and prices to address disparities.
(4)Establish standards and criteria for the development and submission of provider operating and capital expenditure requests pursuant to Article 2 (commencing with Section 100650) of Chapter 5.
(5)Establish standards and criteria for the allocation of funds from the CalCare Trust Fund pursuant to Section 100676.
(6)Determine when individuals may begin enrolling in CalCare. There shall be an implementation period that begins on the date that individuals may begin enrolling in CalCare and ends on a date determined by the board.
(7)Establish an enrollment system that ensures all eligible California residents, including those who travel out of state, those who have disabilities that limit their mobility, hearing, vision, or mental or cognitive capacity, those who cannot read, and those who do not speak or write English, are aware of their right to health care and are formally enrolled in CalCare.
(8)Negotiate payment rates, set payment methodologies, and set prices involving aspects of CalCare and establish procedures thereto, including procedures for negotiating fee-for-service payment to certain participating providers pursuant to Chapter 8 (commencing with Section 100685).
(9)Oversee the establishment, as part of the administration of CalCare, of the committee pursuant to Section 100611.
(10)Implement policies to ensure that all Californians receive culturally, linguistically, and structurally competent care, pursuant to Chapter 6 (commencing with Section 100660), ensure that all disabled Californians receive care in accordance with the federal Americans with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) and Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. Sec. 794), and develop mechanisms and incentives to achieve these purposes and a means to monitor the effectiveness of efforts to achieve these purposes.
(11)Establish standards for mandatory reporting by participating providers and penalties for failure to report, including reporting of data pursuant to Section 100617 and to Section 100641.
(12)Implement policies to ensure that all residents of this state have access to medically appropriate, coordinated mental health services.
(13)Ensure the establishment of policies that support the public health.
(14)Meet regularly with the committee.
(15)Determine an appropriate level of, and provide support during the transition for, training and job placement for persons who are displaced from employment as a result of the initiation of CalCare pursuant to Section 100615.
(16)In consultation with the Department of Managed Health Care, oversee the establishment of a system for resolution of disputes pursuant to Section 100637 and a system for independent medical review pursuant to Section 100637.
(17)Establish and maintain an internet website that provides information to the public about CalCare that includes information that supports choice of providers and facilities and informs the public about meetings of the board and the committee.
(18)Establish a process that is accessible to all Californians for CalCare to receive the concerns, opinions, ideas, and recommendations of the public regarding all aspects of CalCare.
(19)(A)Annually prepare a written report on the implementation and performance of CalCare functions during the preceding fiscal year, that includes, at a minimum:
(i)The manner in which funds were expended.
(ii)The progress toward and achievement of the requirements of this title.
(iii)CalCares fiscal condition.
(iv)Recommendations for statutory changes.
(v)Receipt of payments from the federal government and other sources.
(vi)Whether current year goals and priorities have been met.
(vii)Future goals and priorities.
(B)The report shall be transmitted to the Legislature and the Governor, on or before October 1 of each year and at other times pursuant to this division, and shall be made available to the public on the internet website of CalCare.
(C)A report made to the Legislature pursuant to this subdivision shall be submitted pursuant to Section 9795.
(f)The board may do or delegate to the executive director all of the following:
(1)Negotiate and enter into any necessary contracts, including contracts with health care providers and health care professionals.
(2)Sue and be sued.
(3)Receive and accept gifts, grants, or donations of moneys from any agency of the federal government, any agency of the state, and any municipality, county, or other political subdivision of the state.
(4)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 by regulation.
(5)Share information with relevant state departments, consistent with the confidentiality provisions in this title, necessary for the administration of CalCare.
(g)(1)A carrier shall not offer benefits or cover health care items or services for which coverage is offered to individuals under CalCare.
(2)Notwithstanding paragraph (1), if otherwise authorized under state law, a carrier may offer benefits to cover health care items or services that are not offered to individuals under CalCare.
(3)This title does not prohibit a carrier from offering either of the following:
(A)Benefits to or for individuals, including their families, who are employed or self-employed in the state, but who are not residents of the state.
(B)Benefits during the implementation period to individuals who enrolled or may enroll as members of CalCare.
(4)Paragraph (1) applies to a carrier except as otherwise prohibited by federal law.
(h)After the end of the implementation period, a person shall not be a board member unless the person is a member of CalCare, except the ex officio member.
(i)No later than two years after the effective date of this section, the board shall develop proposals for the following:
(1)In consultation with the Advisory Committee on Public Employees Retirement System Health Benefits established under Section 100616, accommodating employer retiree health benefits for people who have been members of the Public Employees Retirement System, but live as retirees out of the state.
(2)Accommodating employer retiree health benefits for people who earned or accrued those benefits while residing in the state before the implementation of CalCare and live as retirees out of the state.
(j)The board shall develop a proposal for CalCare coverage of health care items and services currently covered under the workers compensation system, including whether and how to continue funding for those item and services under that system and how to incorporate experience rating.
100613.The board may contract with not-for-profit organizations to provide both of the following:
(a)Assistance to CalCare members with respect to selection of a participating provider, enrolling, obtaining health care items and services, disenrolling, and other matters relating to CalCare.
(b)Assistance to a health care provider providing, seeking, or considering whether to provide health care items and services under CalCare.
100614.(a)There is hereby established in state government an Advisory Commission on Long-Term Services and Supports, to advise the board on matters of policy related to long-term services and supports for CalCare.
(b)The advisory commission shall consist of eleven members who are residents of California. Of the members of the advisory commission, five shall be appointed by the Governor, three shall be appointed by the Senate Committee on Rules, and three shall be appointed by the Speaker of the Assembly. The members of the advisory commission shall include all of the following:
(1)At least two people with disabilities who use long-term services and supports.
(2)At least two older adults who use long-term services and supports.
(3)At least two providers of long-term services and supports, including one family attendant or family caregiver.
(4)At least one representative of a disability rights organization.
(5)At least one representative or member of a labor organization representing workers who provide long-term services and supports.
(6)At least one representative of a group representing seniors.
(7)At least one researcher or academic in long-term services and supports.
(c)In making appointments pursuant to this section, the Governor, the Senate Committee on Rules, and the Speaker of the Assembly shall make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the diversity of the population of people who use long-term services and supports, including their race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geographic location, and socioeconomic status.
(d)(1)A member of the advisory commission may continue to serve until the appointment and qualification of that members successor. Vacancies shall be filled by appointment for the unexpired term.
(2)Members of the advisory commission shall be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules shall be for a term of five years, and the initial appointment by the Speaker of the Assembly shall be for a term of two years. These members may be reappointed for succeeding four-year terms.
(3)Vacancies that occur shall be filled within 30 days after the occurrence of the vacancy, and shall be filled in the same manner in which the vacating member was initially selected or appointed. The Secretary of California Health and Human Services shall notify the appropriate appointing authority of any expected vacancies on the long-term services and supports advisory commission.
(e)Members of the advisory commission shall serve without compensation, but shall be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies. Members shall also receive one hundred fifty dollars ($150) for each full day of attending meetings of the advisory commission. For purposes of this section, full day of attending a meeting means presence at, and participation in, not less than 75 percent of the total meeting time of the advisory commission during any particular 24-hour period.
(f)The advisory commission shall meet at least six times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(g)The advisory commission shall elect a chairperson who shall serve for two years and who may be reelected for an additional two years.
(h)It is unlawful for the advisory commission members or any of their assistants, clerks, or deputies to use for personal benefit any information that is filed with, or obtained by, the advisory commission and that is not generally available to the public.
100615.(a)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for program assistance to individuals employed or previously employed in the fields of health insurance, health care service plans, or other third-party payments for health care, individuals providing services to health care providers to deal with third-party payers for health care, individuals who may be affected by and who may experience economic dislocation as a result of the implementation of this title, and individuals whose jobs may be or have been ended as a result of the implementation of CalCare, consistent with otherwise applicable law.
(b)Assistance described in subdivision (a) shall include job training and retraining, job placement, preferential hiring, wage replacement, retirement benefits, and education benefits.
100616.(a)The board shall establish an Advisory Committee on Public Employees Retirement System Health Benefits to provide input, including recommendations, to the board on matters of policy related to public employee retiree health benefits and CalCare, including all of the following:
(1)Processes to obtain approval of CalCare as a health benefits plan under public pension or retirement systems.
(2)Recommendations to the Legislature and Governor to provide tax or other accommodations for people who have accrued retiree health benefit contributions under public employees retirement systems.
(3)Recommendations to, and coordination with, public employee retirement system boards to fully integrate beneficiaries into CalCare.
(4)Processes to change or phase out health benefits under public employees retirement systems to fully integrate beneficiaries into CalCare.
(5)Federal approvals that may support transition of Medicare plans under public employees retirement systems to CalCare.
(b)(1)The board shall appoint the members of the advisory committee during the implementation period. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the advisory committee, the board shall aim for broad representation, including, at a minimum, the following representatives of public sector labor organizations, the Public Employees Retirement System, the State Teachers Retirement System, the University of California Retirement System, and locally administered public pension or retirement systems. At a minimum, one-half of the advisory committee members shall be representatives of public sector labor organizations.
(2)Each appointed member shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(3)Advisory committee members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the advisory committee shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the advisory committee members.
(4)Advisory committee members shall receive reimbursement for travel and other actual costs.
(c)The advisory committee shall meet at least four times per year in a place convenient to the public. All meetings of the advisory committee shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(d)The board shall consider input, including recommendations, from the advisory committee, along with public comments, in the boards deliberation and decisionmaking.
100617.(a)The board shall utilize the data collected pursuant to Chapter 1 (commencing with Section 128675) of Part 5 of Division 107 of the Health and Safety Code to assess patient outcomes and to review utilization of health care items and services paid for by CalCare.
(b)As applicable to the type of provider, the board shall require and enforce the collection and availability of all of the following data to promote transparency, assess quality of care, compare patient outcomes, and review utilization of health care items and services paid for by CalCare, which shall be reported to the board and, as applicable, the Department of Health Care Access and Information or the Medical Board of California:
(1)Inpatient discharge data, including severity of illness and risk of mortality, with respect to each discharge.
(2)Emergency department, ambulatory surgical center, and other outpatient department data, including cost data, charge data, length of stay, and patients unit of observation with respect to each individual receiving health care items and services.
(3)For hospitals and other providers receiving global budgets, annual financial data, including all of the following:
(A)Community benefit activities, including charity care, to which Section 501(r) of Title 26 of the United States Code applies, provided by the provider in dollar value at cost.
(B)Number of employees by employee classification or job title and by patient care unit or department.
(C)Number of hours worked by the employees in each patient care unit or department.
(D)Employee wage information by job title and patient care unit or department.
(E)Number of registered nurses per staffed bed by patient care unit or department.
(F)A description of all information technology, including health information technology and artificial intelligence, used by the provider and the dollar value of that information technology.
(G)Annual spending on information technology, including health information technology, artificial intelligence, purchases, upgrades, and maintenance.
(4)Risk-adjusted and raw outcome data, including:
(A)Risk-adjusted outcome reports for medical, surgical, and obstetric procedures selected by the Department of Health Care Access and Information pursuant to Sections 128745 to 128750, inclusive, of the Health and Safety Code.
(B)Any other risk-adjusted outcome reports that the board may require for medical, surgical, and obstetric procedures and conditions as it deems appropriate.
(5)A disclosure made by a provider as set forth in Article 6 (commencing with Section 650) of Chapter 1 of Division 2 of the Business and Professions Code.
(c)(1)The Medical Board of California shall collect data for the outpatient surgery settings that the Medical Board of California regulates that meets the Ambulatory Surgery Data Record requirements of Section 128737 of the Health and Safety Code, and shall submit that data to the CalCare board.
(2)The CalCare board shall make that data available as required pursuant to subdivision (d).
(d)The board shall make all disclosed data collected under this section publicly available and searchable through an internet website and through the Department of Health Care Access and Information public data sets.
(e)Consistent with state and federal privacy laws, the board shall make available data collected through CalCare to the Department of Health Care Access and Information and the California Health and Human Services Agency, consistent with this title and otherwise applicable law, to promote and protect public, environmental, and occupational health.
(f)Before full implementation of CalCare, and, for providers seeking to receive global budgets or salaried payments under Article 2 (commencing with Section 100650) of Chapter 5, as applicable, before the negotiation of initial payments, the board shall provide for the collection and availability of the following data:
(1)The number of patients served.
(2)The dollar value of the care provided, at cost, for all of the following categories of Department of Health Care Access and Information data items:
(A)Patients receiving charity care.
(B)Contractual adjustments of county and indigent programs, including traditional and managed care.
(C)Bad debts or any other unpaid charges for patient care that the provider sought, but was unable to collect.
(g)The board shall regularly analyze information reported under this section and shall establish rules and regulations to allow researchers, scholars, participating providers, and others to access and analyze data for purposes consistent with this title, without compromising patient privacy.
(h)(1)The board shall establish regulations for the collection and reporting of data to promote transparency, assess patient outcomes, and review utilization of services provided by physicians and other health care professionals, as applicable, and paid for by CalCare.
(2)In implementing this section, the board shall utilize data that is already being collected pursuant to other state or federal laws and regulations whenever possible.
(3)Data reporting required by participating providers under this section shall supplement the data collected by the Department of Health Care Access and Information and shall not modify or alter other reporting requirements to governmental agencies.
(i)The board shall not utilize quality or other review measures established under this section for the purposes of establishing payment methods to providers.
(j)The board may coordinate and cooperate with the Department of Health Care Access and Information or other health planning agencies of the state to implement the requirements of this section.
100618.(a)The board shall establish and use a process to enter into participation agreements with health care providers and other contracts with contractors. A contract entered into pursuant to this title shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of the Department of General Services. The board shall adopt a CalCare Contracting Manual incorporating procurement and contracting policies and procedures that shall be followed by CalCare. The policies and procedures in the manual shall be substantially similar to the provisions contained in the State Contracting Manual.
(b)The adoption, amendment, or repeal of a regulation by the board to implement this section, including the adoption of a manual pursuant to subdivision (a) and any procurement process conducted by CalCare in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
100619.(a)Notwithstanding any other law, CalCare, a state or local agency, or a public employee acting under color of law shall not provide or disclose to anyone, including the federal government, any personally identifiable information obtained, including a persons religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
(b)Notwithstanding any other law, law enforcement agencies shall not use CalCare moneys, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of a requirement that individuals register with the federal government or a federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act (Section 51 of the Civil Code).
100620.(a)On or before July 1, ____, the board shall conduct and deliver a fiscal analysis to determine both of the following:
(1)Whether or not CalCare may be implemented.
(2)If revenue is more likely than not to be sufficient to pay for program costs within eight years of CalCares implementation.
(b)The board may contract with one or more independent entities with the appropriate expertise or coordinate with other state agencies to conduct the fiscal analysis.
(c)The board shall deliver, and upon request present, the fiscal analysis to the Chair of the Senate Committee on Health, the Chair of the Assembly Committee on Health, the Chair of the Senate Committee on Appropriations, and the Chair of the Assembly Committee on Appropriations.
3.Eligibility and Enrollment100630.(a)Every resident of the state shall be eligible and entitled to enroll as a member of CalCare.
(b)(1)A member shall not be required to pay a fee, payment, or other charge for enrolling in or being a member of CalCare.
(2)A member shall not be required to pay a premium, copayment, coinsurance, deductible, or any other form of cost sharing for all covered benefits under CalCare.
(c)A college, university, or other institution of higher education in the state may purchase coverage under CalCare for a student, or a students dependent, who is not a resident of the state.
(d)An individual entitled to benefits through CalCare may obtain health care items and services from any institution, agency, or individual participating provider.
(e)The board shall establish a process for automatic CalCare enrollment at the time of birth in California.
100631.(a)All residents of this state, no matter what their sex, race, color, religion, ancestry, national origin, disability, age, previous or existing medical condition, genetic information, marital status, familial status, military or veteran status, sexual orientation, gender identity or expression, pregnancy, pregnancy-related medical condition, including termination of pregnancy, citizenship, primary language, or immigration status, are entitled to full and equal accommodations, advantages, facilities, privileges, or services in all health care providers participating in CalCare.
(b)Subdivision (a) prohibits a participating provider, or an entity conducting, administering, or funding a health program or activity pursuant to this title, from discriminating based upon the categories described in subdivision (a) in the provision, administration, or implementation of health care items and services through CalCare.
(c)Discrimination prohibited under this section includes the following:
(1)Exclusion of a person from participation in or denial of the benefits of CalCare, except as expressly authorized by this title for the purposes of enforcing eligibility standards in Section 100630.
(2)Reduction of a persons benefits.
(3)Any other discrimination by any participating provider or any entity conducting, administering, or funding a health program or activity pursuant to this title.
(d)Section 52 of the Civil Code shall apply to discrimination under this section.
(e)Except as otherwise provided in this section, a participating provider or entity is in violation of subdivision (b) if the complaining party demonstrates that any of the categories listed in subdivision (a) was a motivating factor for any health care practice, even if other factors also motivated the practice.
4.Benefits100635.(a)Individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to a participating provider for the health care items and services in subdivision (c), if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.
(b)The determination of medical necessity or appropriateness shall be made by the members treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards established in Chapter 6 (commencing with Section 100660), and by the board, and other laws of the state.
(c)Covered health care benefits for members include all of the following categories of health care items and services:
(1)Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services.
(2)Inpatient and outpatient health care professional services and other ambulatory patient services.
(3)Primary and preventive services, including chronic disease management.
(4)Prescription drugs, biological products, and all contraceptive items approved by the United States Food and Drug Administration.
(5)Medical devices, equipment, appliances, and assistive technology.
(6)Mental health and substance abuse treatment services, including inpatient and outpatient care.
(7)Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.
(8)Comprehensive reproductive care, including abortion, contraception, and assistive reproductive technology, maternity care, and newborn care.
(9)Pediatrics.
(10)Oral health, audiology, and vision services.
(11)Rehabilitative and habilitative services and devices, including inpatient and outpatient care.
(12)Emergency services and transportation.
(13)Early and periodic screening, diagnostic, and treatment services as defined in Section 1396d(r) of Title 42 of the United States Code.
(14)Comprehensive gender-affirming health care.
(15)Necessary transportation for health care items and services for persons with disabilities or who may qualify as low income.
(16)Long-term services and supports described in Section 100636, including long-term services and supports covered under Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code) or the federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.))
(17)Any additional health care items and services the board authorizes to be added to CalCare benefits.
(d)The categories of covered health care items and services under subdivision (c) include all the following:
(1)Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual.
(2)Child and adult immunizations.
(3)Hospice care.
(4)Care in a skilled nursing facility.
(5)Home health care, including health care provided in an assisted living facility.
(6)Prenatal and postnatal care.
(7)Podiatric care.
(8)Blood and blood products.
(9)Dialysis.
(10)Community-based adult services as defined under Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code as of January 1, 2021.
(11)Dietary and nutritional therapies determined appropriate by the board.
(12)Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture.
(13)Health care items and services previously covered by county integrated health and human services programs pursuant to Chapter 12.96 (commencing with Section 18990) and Chapter 12.991 (commencing with Section 18991) of Part 6 of Division 9 of the Welfare and Institutions Code.
(14)Health care items and services previously covered by a regional center for persons with developmental disabilities pursuant to Chapter 5 (commencing with Section 4620) of Division 4.5 of the Welfare and Institutions Code.
(15)Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers.
(e)Covered health care items and services under CalCare include all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:
(1)The federal Childrens Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
(2)Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(3)The federal Medicare program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(4)Health care service plans pursuant to 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).
(5)Health insurers, as defined in Section 106 of the Insurance Code, pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code.
(6)All essential health benefits mandated by the federal Patient Protection and Affordable Care Act as of January 1, 2017.
(f)Health care items and services covered under CalCare shall not be subject to prior authorization or a limitation applied through the use of step therapy protocols.
100636.(a)Subject to the other provisions of this title, individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this title, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:
(1)Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living.
(2)Is a disability, as defined in Section 12102(1)(A) of Title 42 of the United States Code, that substantially limits one or more of the members major life activities.
(b)The board shall adopt regulations that provide for the following:
(1)The determination of individual eligibility for long-term services and supports under this section.
(2)The assessment of the long-term services and supports needed for an eligible individual.
(3)The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program established in Title II or Title XVI of the federal Social Security Act to the long-term services and supports under this section.
(c)Long-term services and supports provided pursuant to this section shall do all of the following:
(1)Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting.
(2)Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care.
(3)Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the members maximum possible autonomy and the members maximum possible civic, social, and economic participation.
(4)Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization.
(5)Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipients type or level of disability, service need, or age.
(6)Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the members needs.
(7)Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity.
(8)Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions.
(9)Ensure that long-term services and supports provide recipients the option of self-direction of service, including under the Self-Directed Services Program described in Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code, from either the recipient or care coordinators of the recipients choosing.
(d)In developing regulations to implement this section, the board shall consult the advisory commission established pursuant to Section 100614.
100637.(a)(1)The board shall, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.
(2)In implementing this section, the board shall not remove or eliminate covered health care items and services under CalCare that are listed in this chapter.
(b)The board shall establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare.
(c)The board shall establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the Independent Medical Review System established in the Department of Managed Health Care pursuant to Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.
(d)For the purposes of this chapter:
(1)Coverage decision means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A coverage decision does not encompass a decision regarding a disputed health care item or service.
(2)Disputed health care item or service means a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision.
5.Delivery of Care1.Health Care Providers100640.(a)(1)A health care provider or entity is qualified to participate as a provider in CalCare if the health care provider furnishes health care items and services while the provider, or, if the provider is an entity, the individual health care professional of the entity furnishing the health care items and services, is physically present within the State of California, and if the provider meets all of the following:
(A)The provider or entity is a health care professional, group practice, or institutional health care provider licensed to practice in California.
(B)The provider or entity agrees to accept CalCare rates as payment in full for all covered health care items and services.
(C)The provider or entity has filed with the board a participation agreement described in Section 100641.
(D)The provider or entity is otherwise in good standing.
(2)The board shall establish and maintain procedures and standards for recognizing health care providers located out of the state for purposes of providing coverage under CalCare for members who require out-of-state health care services while the member is temporarily located out of the state.
(b)A provider or entity shall not be qualified to furnish health care items and services under CalCare if the provider or entity does not provide health care items or services directly to individuals, including the following:
(1)Entities or providers that contract with other entities or providers to provide health care items and services shall not be considered a qualified provider for those contracted items and services.
(2)Entities that are approved to coordinate care plans under the Medicare Advantage program established in Part C of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1851 et seq.) as of January 1, 2020, but do not directly provide health care items and services.
(c)A health care provider qualified to participate under this section may provide covered health care items or services under CalCare, as long as the health care provider is legally authorized to provide the health care item or service for the individual and under the circumstances involved.
(d)(1)The board shall establish and maintain procedures for members and individuals eligible to enroll in CalCare to enroll onsite at a participating provider.
(2)A participating provider shall accept onsite enrollment of members and eligible individuals under the procedures established pursuant to paragraph (1).
(e)The board shall establish and maintain procedures and standards for members to select a primary care provider, which may be an internist, a pediatrician, a physician who practices family medicine, a gynecologist, a physician who practices geriatric medicine, or, at the option of a member who has a chronic condition that requires specialty care, a specialist health care professional who regularly and continually provides treatment to the member for that condition, and other participating providers.
(f)A referral from a primary care provider is not required for a member to see a participating provider.
(g)A member may choose to receive health care items and services under CalCare from a participating provider, subject to the willingness or availability of the provider, and consistent with the provisions of this title relating to discrimination, and the appropriate clinically relevant circumstances and standards.
100641.(a)A health care provider shall enter into a participation agreement with the board to qualify as a participating provider under CalCare.
(b)A participation agreement between the board and a health care provider shall include provisions for at least the following, as applicable to each provider:
(1)Health care items and services to members shall be furnished by the provider without discrimination, as required by Section 100631. This paragraph does not require the provision of a type or class of health care items or services that are outside the scope of the providers normal practice.
(2)A charge shall not be made to a member for a covered health care item or service, other than for payment authorized by this title. Except as described in Section 100644, a contract shall not be entered into with a patient for a covered health care item or service.
(3)The provider shall follow the policies and procedures in the CalCare Contracting Manual established pursuant to Section 100618.
(4)The provider shall furnish information reasonably required by the board and shall meet the reporting requirements of Sections 100617 and 100661 for at least the following:
(A)Quality review by designated entities.
(B)Making payments, including the examination of records as necessary for the verification of information on which those payments are based.
(C)Statistical or other studies required for the implementation of this title.
(D)Other purposes specified by the board.
(5)If the provider is not an individual, the provider shall not employ or use an individual or other provider that has had a participation agreement terminated for cause to provide covered health care items and services.
(6)If the provider is paid on a fee-for-service basis for covered health care items and services, the provider shall submit bills and required supporting documentation relating to the provision of covered health care items or services within 30 days after the date of providing those items or services.
(7)The provider shall submit information and any other required supporting documentation reasonably required by the board on a quarterly basis that relates to the provision of covered health care items and services and describes health care items and services furnished with respect to specific individuals.
(8)(A)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall disclose the following to the board:
(i)Any case mix indexes, diagnosis coding software, procedure coding software, or other coding system utilized by the provider for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Any case mix indexes, diagnosis coding guidelines, procedure coding guidelines, or coding tip sheets used by the provider for the purposes of meeting payment or disclosure requirements under this title.
(B)If the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, the provider shall not do the following:
(i)Use proprietary case mix indexes, diagnosis coding software, procedure coding software, or other coding system for the purposes of meeting payment, global budget, or other disclosure requirements under this title.
(ii)Require another health care professional to apply case mix indexes, diagnosis coding software, procedure coding software, or other coding system in a manner that limits the clinical diagnosis, treatment process, or a treating health care professionals judgment in determining a diagnosis or treatment process, including the use of leading queries or prohibitions on using certain codes.
(iii)Provide financial incentives or disincentives to physicians, registered nurses, or other health care professionals for particular coding query results or code selections.
(iv)Use case mix indexes, diagnosis coding software, procedure coding software, or other coding system that make suggestions for higher severity diagnoses or higher cost procedure coding.
(9)The provider shall comply with the duty of patient advocacy and reporting requirements described in Section 100661.
(10)If the provider is not an individual, the provider shall ensure that a board member, executive, or administrator of the provider shall not receive compensation from, own stock or have other financial investments in, or receive services as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(11)If the provider is a not-for-profit hospital subject to Article 2 (commencing with Section 127340) of Chapter 2 of Part 2 of Division 107 of the Health and Safety Code, the hospital shall submit to the board the community benefits plan developed pursuant to Article 2 (commencing with Section 127340) of the Health and Safety Code.
(12)Health care items and services to members shall be furnished by a health care professional while the professional is physically present within the State of California.
(13)The provider shall not enter into risk-bearing, risk-sharing, or risk-shifting agreements with other health care providers or entities other than CalCare.
(c)This section does not limit the formation of group practices.
100642.(a)A participation agreement may be terminated with appropriate notice by the board for failure to meet the requirements of this title or may be terminated by a provider.
(b)A participating provider shall be provided notice and a reasonable opportunity to correct deficiencies before the board terminates an agreement, unless a more immediate termination is required for public safety or similar reasons.
(c)The procedures and penalties under the Medi-Cal program for fraud or abuse pursuant to Sections 14107, 14107.11, 14107.12, 14107.13, 14107.2, 14107.3, 14107.4, 14107.5, and 14108 of the Welfare and Institutions Code shall apply to an applicant or provider under CalCare.
(d)For purposes of this section:
(1)Applicant means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the board to participate as a provider in CalCare.
(2)Provider means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to CalCare program members.
100643.(a)A person shall not discharge or otherwise discriminate against an employee on account of the employee or a person acting pursuant to a request of the employee for any of the following:
(1)Notifying the board, executive director, or employees employer of an alleged violation of this title, including communications related to carrying out the employees job duties.
(2)Refusing to engage in a practice made unlawful by this title, if the employee has identified the alleged illegality to the employer.
(3)Providing, causing to be provided, or being about to provide or cause to be provided to the provider, the federal government, or the Attorney General information relating to a violation of, or an act or omission the provider or representative reasonably believes to be a violation of, this title.
(4)Testifying before or otherwise providing information relevant for a state or federal proceeding regarding this title or a proposed amendment to this title.
(5)Commencing, causing to be commenced, or being about to commence or cause to be commenced a proceeding under this title.
(6)Testifying or being about to testify in a proceeding.
(7)Assisting or participating, or being about to assist or participate, in a proceeding or other action to carry out the purposes of this title.
(8)Objecting to, or refusing to participate in, an activity, policy, practice, or assigned task that the employee or representative reasonably believes to be in violation of this title or any order, rule, regulation, standard, or ban under this title.
(b)An employee covered by this section who alleges discrimination by an employer in violation of subdivision (a) may bring an action governed by the rules and procedures, legal burdens of proof, and remedies applicable under the False Claims Act (Article 9 (commencing with Section 12650) of Chapter 6 of Part 2 of Division 3 of Title 2) or Section 12990, or an action against unfair competition pursuant to Chapter 5 (commencing with Section 17200) of Part 2 of Division 7 of the Business and Professions Code.
(c)(1)This section does not diminish the rights, privileges, or remedies of an employee under any other law, regulation, or collective bargaining agreement. The rights and remedies in this section shall not be waived by an agreement, policy, form, or condition of employment.
(2)This section does not preempt or diminish any other law or regulation against discrimination, demotion, discharge, suspension, threats, harassment, reprimand, retaliation, or any other manner of discrimination.
(d)For purposes of this section:
(1)Employer means a person engaged in profit or not-for-profit business or industry, including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees, and who is subject to liability for violating this title.
(2)Employee means an individual performing activities under this title on behalf of an employer.
100644.(a)This section shall be effective on the date the implementation period ends pursuant to paragraph (6) of subdivision (e) of Section 100612.
(b)(1)An institutional or other health care provider with a participation agreement in effect shall not bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is a covered benefit through CalCare.
(2)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is not a covered benefit through CalCare if the following requirements are met:
(A)The contract and provider meet the requirements specified in paragraphs (3) and (4).
(B)The health care item or service is not payable or available through CalCare.
(C)The provider does not receive reimbursement, directly or indirectly, from CalCare for the health care item or service, and does not receive an amount for the health care item or service from an organization that receives reimbursement, directly or indirectly, for the health care item or service from CalCare.
(3)(A)A contract described in paragraph (2) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the health care item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (2) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service.
(ii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iii)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(iv)The individual understands that the provider is providing services outside the scope of CalCare.
(4)A participating provider that enters into a contract described in paragraph (2) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the noncovered health care item or service, state that the provider will not submit a claim to CalCare for a noncovered health care item or service provided to a member, and be signed by the provider.
(5)If a provider signing an affidavit described in paragraph (4) knowingly and willfully submits a claim to CalCare for a noncovered health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract, all of the following apply:
(A)A contract described in paragraph (2) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(6)An institutional or other health care provider with a participation agreement in effect may bill or enter into a private contract with an individual ineligible for benefits under CalCare for a health care item or service. Consistent with Section 100619, the institutional or other health care provider shall report to the board, on an annual basis, aggregate information regarding services furnished to ineligible individuals.
(c)(1)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual eligible for benefits under CalCare for a health care item or service that is a covered benefit through CalCare only if the contract and provider meet the requirements specified in paragraphs (2) and (3).
(2)(A)A contract described in paragraph (1) shall be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the item or service is furnished pursuant to the contract, and shall not be entered into at a time when the individual is facing an emergency health care situation.
(B)A contract described in paragraph (1) shall clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
(i)The individual understands that the individual has the right to have the health care item or service provided by another provider for which payment would be made under CalCare.
(ii)The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service, even if the health care item or service is otherwise covered under CalCare.
(iii)The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service.
(iv)The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service.
(v)The individual understands that the provider is providing services outside the scope of CalCare.
(3)A provider that enters into a contract described in paragraph (1) shall have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. The affidavit shall identify the provider who is to furnish the health care item or service, state that the provider will not submit a claim to CalCare for a health care item or service provided to a member during a two-year period beginning on the date the affidavit was signed, and be signed by the provider.
(4)If a provider who signed an affidavit described in paragraph (3) knowingly and willfully submits a claim to CalCare for a health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract described in an affidavit signed pursuant to paragraph (3), all of the following apply:
(A)A contract described in paragraph (1) shall be void.
(B)A payment shall not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period shall be remitted to CalCare, plus interest.
(C)A payment received by the provider from the member, CalCare program, or other payer for a health care item or service furnished during the period described in subparagraph (B) shall be remitted to the payer, and damages shall be available to the payer pursuant to Section 3294 of the Civil Code.
(5)An institutional or other health care provider without a participation agreement in effect may bill or enter into a private contract with an individual for a health care item or service that is not a benefit under CalCare.
2.Payment for Health Care Items and Services100650.(a)The board shall adopt regulations regarding contracting for, and establishing payment methodologies for, covered health care items and services provided to members under CalCare by participating providers. All payment rates under CalCare shall be reasonable and reasonably related to all of the following:
(1)The cost of efficiently providing health care items and services.
(2)Ensuring availability and accessibility of CalCare health care services, including compliance with state requirements regarding network adequacy, timely access, and language access.
(3)Maintaining an optimal workforce and the health care facilities necessary to deliver quality, equitable health care.
(b)(1)Payment for health care items and services shall be considered payment in full.
(2)A participating provider shall not charge a rate in excess of the payment established through CalCare for a health care item or service furnished under CalCare and shall not solicit or accept payment from any member or third party for a health care item or service furnished under CalCare, except as provided under a federal program.
(3)This section does not preclude CalCare from acting as a primary or secondary payer in conjunction with another third-party payer when permitted by a federal program.
(c)Not later than the beginning of each fiscal quarter during which an institutional provider of care, including a hospital, skilled nursing facility, and chronic dialysis clinic, is to furnish health care items and services under CalCare, the board shall pay to each institutional provider a lump sum to cover all operating expenses under a global budget as set forth in Section 100651. An institutional provider receiving a global budget payment shall accept that payment as payment in full for all operating expenses for health care items and services furnished under CalCare, whether inpatient or outpatient, by the institutional provider.
(d)(1)A group practice, county organized health system, or local initiative may elect to be paid for health care items and services furnished under CalCare either on a fee-for-service basis under Section 100655 or on a salaried basis.
(2)A group practice, county organized health system, or local initiative that elects to be paid on a salaried basis shall negotiate salaried payment rates with the board annually, and the board shall pay the group practice, county organized health system, or local initiative at the beginning of each month.
(3)The board may determine whether a group practice, county organized health system, or local initiative may elect to be paid on an hourly or other time-based rate for certain health care items and services furnished under CalCare, including primary and preventive care.
(e)Health care items and services provided to members under CalCare by individual providers or any other providers not paid under subdivision (c) or (d) shall be paid for on a fee-for-service basis under Section 100655.
(f)Capital-related expenses for specifically identified capital expenditures incurred by participating providers shall meet the requirements under Section 100656.
(g)Payment methodologies and payment rates shall include a distinct component of reimbursement for direct and indirect costs incurred by the institutional provider for graduate medical education, as applicable.
(h)The board shall adopt, by regulation, payment methodologies and procedures for paying for out-of-state health care services.
(i)(1)This article does not regulate, interfere with, diminish, or abrogate a collective bargaining agreement, established employee rights, or the right, obligation, or authority of a collective bargaining representative under state or local law.
(2)This article does not compel, regulate, interfere with, or duplicate the provisions of an established training program that is operated under the terms of a collective bargaining agreement or unilaterally by an employer or bona fide labor union.
(j)The board shall determine the appropriate use and allocation of the special projects budget for the construction, renovation, or staffing of health care facilities in rural, underserved, or health professional or medical shortage areas, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
100651.(a)An institutional providers global budget shall be determined before the start of a fiscal year through negotiations between the provider and the board. The global budget shall be negotiated annually based on the payment factors described in subdivision (d).
(b)An institutional providers global budget shall be used only to cover operating expenses associated with direct care for patients for health care items and services covered under CalCare. An institutional providers global budget shall not be used for capital expenditures, and capital expenditures shall not be included in the global budget.
(c)The board, on a quarterly basis, shall review whether requirements of the institutional providers participation agreement and negotiated global budget have been performed and shall determine whether adjustment to the institutional providers payment is warranted.
(d)A payment negotiated pursuant to subdivision (a) shall take into account, with respect to each provider, all of the following:
(1)The historical volume of services provided for each health care item and service in the previous three-year period.
(2)The actual expenditures of a provider in the providers most recent Medicare cost report for each health care item and service, or other cost report that may otherwise be adopted by the board, compared to the following:
(A)The expenditures of other comparable institutional providers in the state.
(B)The normative payment rates established under the comparative payment rate systems pursuant to Section 100654, including permissible adjustments to the rates for the health care items and services.
(C)Projected changes in the volume and type of health care items and services to be furnished.
(D)Employee wages and compensation.
(E)The providers maximum capacity to provide health care items and services.
(F)Education and prevention programs.
(G)Health care workforce recruitment and retention programs, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(H)Permissible adjustments to the providers operating budget from the previous fiscal year due to factors including an increase in primary or specialty care access, efforts to decrease health care disparities in rural or medically underserved areas, a response to emergent conditions, and proposed changes to patient care programs at the institutional level.
(I)Any other factor determined appropriate by the board.
(3)In a rural or medically underserved area, the need to mitigate the impact of the availability and accessibility of health care services through increased global budget payment.
(e)A payment negotiated pursuant to subdivision (a) or payment methodology shall not do any of the following:
(1)Take into account capital expenditures of the provider or any other expenditure not directly associated with furnishing health care items and services under CalCare.
(2)Be used by a provider for capital expenditures or other expenditures associated with capital projects.
(3)Exceed the providers capacity to furnish health care items and services covered under CalCare.
(4)Be used to pay or otherwise compensate a board member, executive, or administrator of the institutional provider who has an interest or relationship prohibited under paragraph (10) of subdivision (b) of Section 100641 or paragraph (3) of subdivision (c) of Section 100661.
(5)Take into account relief pending appeal granted to a provider under Section 100653.
(f)The board may negotiate changes to an institutional providers global budget based on factors not prohibited under subdivision (e) or any other provision of this title.
(g)Subject to subdivision (i) of Section 100650, compensation costs for an employee, contractor employee, or subcontractor employee of an institutional provider receiving a global budget shall meet the compensation cap established in Section 4304(a)(16) of Title 41 of the United States Code and its implementing regulations, except that the board may establish one or more narrowly targeted exceptions for scientists, engineers, or other specialists upon a determination that those exceptions are needed to ensure CalCare continued access to needed skills and capabilities.
(h)A payment to an institutional provider pursuant to this section shall not allow a participating provider to retain revenue generated from outsourcing health care items and services covered under CalCare, unless that revenue was considered part of the global budget negotiation process. This subdivision shall apply to revenue from outsourcing health care items and services that were previously furnished by employees of the participating provider who were subject to a collective bargaining agreement.
(i)For the purposes of this section, operating expenses of a provider include the following:
(1)The costs associated with covered health care items and services under CalCare, including the following:
(A)Compensation for health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider.
(B)Pharmaceutical products administered by health care professionals at the institutional providers facility or facilities.
(C)Purchasing supplies.
(D)Maintenance of medical devices and health care technologies, including diagnostic testing equipment, except that health information technology that is not necessary to comply with data collection and reporting requirements under this title or otherwise required by law and artificial intelligence shall be considered capital expenditures, unless otherwise determined by the board.
(E)Incidental services necessary for safe patient care.
(F)Patient care, education, and preventive health programs, and necessary staff to implement those programs.
(G)Occupational health and safety programs and public health programs, and necessary staff to implement those programs for the continued education and health and safety of clinicians and other individuals employed by the institutional provider.
(H)Infectious disease response preparedness, including the maintenance of a one-year or 365-day stockpile of personal protective equipment, occupational testing and surveillance, and contact tracing.
(I)Recruitment, retention, and training of health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to Section 1276.4 of the Health and Safety Code.
(2)Administrative costs of the institutional provider.
100652.(a)The board shall consider a request for interim payment, filed by an institutional provider that is subject to the payments or global budget, based on the following:
(1)The overall financial condition of the institutional provider, including bankruptcy or financial solvency.
(2)Excessive risks to the ongoing operation of the institutional provider.
(3)Justifiable differences in costs among providers, including providing a service not available from other providers in the region, or the need for health care services in rural areas with a shortage of health professionals or medically underserved areas and populations.
(4)Factors that led to increased costs for the institutional provider that can reasonably be considered to be unanticipated and out of the control of the provider. Those factors may include:
(A)Natural disasters.
(B)Outbreaks of epidemics or infectious diseases.
(C)Unanticipated facility or equipment repairs or purchases.
(D)Significant and unanticipated increases in pharmaceutical or medical device prices.
(E)Public health emergencies.
(5)Changes in state or federal laws that result in a change in costs.
(6)Reasonable increases in labor costs, including salaries and benefits, and changes in collective bargaining agreements, prevailing wage, or local law.
(b)The board shall establish uniform written procedures under which it reviews requests for interim payment pursuant to subdivision (a), including procedures to provide immediate payment in the event of a public health emergency.
(c)On a quarterly basis, the board shall review the global budget and payments to institutional providers that are not-for-profit or governmental entities and may initiate an interim payment review under subdivision (b) based on the factors set forth in this section.
100653.(a)The board shall consider an appeal of payments, the global budget, or a determination of a request for interim payment, filed by an institutional provider that is subject to the payment or global budget.
(b)(1)The payments set and global budget negotiated by the board to be paid to the institutional provider shall stay in effect during the appeal process, subject to relief pending appeal under this subdivision.
(2)The board shall have the power to grant interim relief based on fairness. The board shall develop regulations governing interim relief. The board shall establish uniform written procedures for the submission, processing, and consideration of an interim relief appeal by an institutional provider. A decision on interim relief shall be granted within one month of the filing of an interim relief appeal. An institutional provider shall certify in its interim relief appeal that the request is made on the basis that the challenged amount is arbitrary and capricious, or that the institutional provider has experienced a bona fide emergency based on unanticipated costs or costs outside the control of the entity, including those described in paragraph (4) of subdivision (a) of Section 100652.
(c)(1)In accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2), the board may delegate the conduct of a hearing to an administrative law judge, who shall issue a proposed decision with findings of fact and conclusions of law.
(2)The administrative law judge may hold evidentiary hearings and shall issue a proposed decision with findings of fact and conclusions of law, including a recommended adjusted payment or global budget, within four months of the filing of the appeal.
(3)Within 30 days of receipt of the proposed decision by the administrative law judge, the board may approve, disapprove, or modify the decision, and shall issue a final decision for the appealing institutional provider.
(d)A final determination by the board shall be subject to judicial review pursuant to Section 1094.5 of the Code of Civil Procedure.
100654.(a)The board shall use existing Medicare prospective payment systems to establish and serve as the comparative payment rate system in global budget negotiations described in subparagraph (B) of paragraph (2) of subdivision (d) of Section 100651. The board shall update the comparative payment rate system annually.
(b)To develop the comparative payment rate system, the board shall use only the operating base payment rates under each Medicare prospective payment system with applicable adjustments.
(c)The comparative rate system shall not include value-based purchasing adjustments or capital expenses base payment rates that may be included in Medicare prospective payment systems.
(d)In the first year that global budget payments are available to institutional providers, and for purposes of selecting a comparative payment rate system used during initial global budget negotiations for an institutional provider, the board shall take into account the appropriate Medicare prospective payment system from the most recent year to determine what operating base payment the institutional provider would have been paid for covered health care items and services furnished the preceding year with applicable adjustments, excluding value-based purchasing adjustments, based on the prospective payment system.
100655.(a)The board shall engage in good faith negotiations with health care providers representatives under Chapter 8 (commencing with Section 100685) to determine rates of fee-for-service payments for health care items and services furnished under CalCare.
(b)There shall be a rebuttable presumption that the Medicare fee-for-service rates of reimbursement constitute reasonable fee-for-service payment rates. The fee schedule shall be updated annually.
(c)Payments to individual providers under this article shall not include payments to individual providers in salaried positions at institutional providers receiving global budgets under Section 100651 or individual health care professionals who are employed by or otherwise receive compensation or payment for health care items and services furnished under CalCare from group practices, county organized health systems, or local initiatives that receive payment under CalCare on a salaried basis.
(d)To establish the fee-for-service payment rates, the board shall ensure that the fee schedule compensates physicians and other health care professionals at a rate that reflects the value for health care items and services furnished.
(e)In a rural or medically underserved area, the board may mitigate the impact of the availability and accessibility of health care services through increased individual provider payment.
100656.(a)(1)The board shall adopt, by regulation, payment methodologies for the payment of capital expenditures for specifically identified capital projects incurred by not-for-profit or governmental entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.
(2)The board shall prioritize allocation of funding under this subdivision to projects that propose to use the funds to improve service in a rural or medically underserved area, or to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status. The board shall consider the impact of any prior reduction in services or facility closure by a not-for-profit or governmental entity as part of the application review process.
(3)For the purposes of funding capital expenditures under this section, health care facilities and governmental entities shall apply to the board in a time and manner specified by the board. All capital-related expenses generated by a capital project shall have received prior approval from the board to be paid under CalCare.
(b)Approval of an application for capital expenditures shall be based on achievement of the program standards described in Chapter 6 (commencing with Section 100660).
(c)The board shall not grant funding for capital expenditures for capital projects that are financed directly or indirectly through the diversion of private or other non-CalCare program funding that results in reductions in care to patients, including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability.
(d)A participating provider shall not use operating funds or payments from CalCare for the operating expenses associated with a capital asset that was not funded by CalCare without the approval of the board.
(e)A participating provider shall not do either of the following:
(1)Use funds from CalCare designated for operating expenses or payments for capital expenditures.
(2)Use funds from CalCare designated for capital expenditures or payments for operating expenses.
100657.(a)(1)A margin generated by a participating provider receiving a global budget under CalCare may be retained and used to meet the health care needs of CalCare members.
(2)A participating provider shall not retain a margin if that margin was generated through inappropriate limitations on access to health care, compromises in the quality of care, or actions that adversely affected or are likely to adversely affect the health of the persons receiving services from an institutional provider, group practice, or other participating provider under CalCare.
(3)The board shall evaluate the source of margin generation.
(b)A payment under CalCare, including provider payments for operating expenses or capital expenditures, shall not take into account, include a process for the funding of, or be used by a provider for any of the following:
(1)Marketing, which does not include education and prevention programs paid under a global budget.
(2)The profit or net revenue, or increasing the profit, net revenue, or financial result of the provider.
(3)An incentive payment, bonus, or compensation based on patient utilization of health care items or services or any financial measure applied with respect to the provider or a group practice or other entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(4)A bonus, incentive payment, or incentive adjustment from CalCare to a participating provider.
(5)A bonus, incentive payment, or compensation based on the financial results of any other health care provider with which the provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship.
(6)A bonus, incentive payment, or compensation based on the financial results of an integrated health care delivery system, group practice, or other provider.
(7)State political contributions.
(c)(1)The board shall establish and enforce penalties for violations of this section, consistent with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2).
(2)Penalty payments collected for violations of this section shall be remitted to the CalCare Trust Fund for use in CalCare.
100658.(a)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, and other relevant state agencies, negotiate prices to be paid for pharmaceuticals, medical supplies, medical technology, and medically necessary assistive equipment covered through CalCare. Negotiations by the board shall be on behalf of the entire CalCare program. A state agency shall cooperate to provide data and other information to the board.
(b)The board shall, in consultation with the Department of General Services, the Department of Health Care Services, the CalCare Public Advisory Committee, patient advocacy organizations, physicians, registered nurses, pharmacists, and other health care professionals, establish a prescription drug formulary system. To establish the prescription drug formulary system, the board shall do all of the following:
(1)Promote the use of generic and biosimilar medications.
(2)Consider the clinical efficacy of medications.
(3)Update the formulary frequently and allow health care professionals, other clinicians, and members to petition the board to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary.
(4)Consult with patient advocacy organizations, physicians, nurses, pharmacists, and other health care professionals to determine the clinical efficacy and need for the inclusion of specific medications in the formulary.
(c)The prescription drug formulary system shall not require a prior authorization determination for coverage under CalCare and shall not apply treatment limitations through the use of step therapy protocols.
(d)The board shall promulgate regulations regarding the use of off-formulary medications that allow for patient access.
6.Program Standards1.Standard of Care100660.CalCare shall establish a single standard of safe, therapeutic, and effective care for all residents of the state by the following means:
(a)The board shall establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:
(1)The scope, quality, and accessibility of health care items and services.
(2)Relations between participating providers and members.
(3)Relations between institutional providers, group practices, and individual health care organizations, including credentialing for participation in CalCare and clinical and admitting privileges, and terms, methods, and rates of payment.
(b)The board shall establish requirements and standards, by regulation, under CalCare that include provisions to promote all of the following:
(1)Simplification, transparency, uniformity, and fairness in the following:
(A)Health care provider credentialing for participation in CalCare.
(B)Health care provider clinical and admitting privileges in health care facilities.
(C)Clinical placement for educational purposes, including clinical placement for prelicensure registered nursing students without regard to degree type, that prioritizes nursing students in public education programs.
(D)Payment procedures and rates.
(E)Claims processing.
(2)In-person primary and preventive care, efficient and effective health care items and services, quality assurance, and promotion of public, environmental, and occupational health.
(3)Elimination of health care disparities.
(4)Nondiscrimination pursuant to Section 100631.
(5)Accessibility of health care items and services, including accessibility for people with disabilities and people with limited ability to speak or understand English.
(6)Providing health care items and services in a culturally, linguistically, and structurally competent manner.
(7)Prevention-oriented care.
(c)The board shall establish requirements and standards, to the extent authorized by federal law, by regulation, for replacing and merging with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the Affordable Care Act, and federally matched public health programs.
(d)A participating provider shall furnish information as required by the Department of Health Care Access and Information pursuant to Sections 100617 and 100641, and to Division 107 (commencing with Section 127000) of the Health and Safety Code, and permit examination of that information by the board as reasonably required for purposes of reviewing accessibility and utilization of health care items and services, quality assurance, cost containment, the making of payments, and statistical or other studies of the operation of CalCare or for protection and promotion of public, environmental, and occupational health.
(e)The board shall use the data furnished under this title to ensure that clinical practices meet the utilization, quality, and access standards of CalCare. The board shall not use a standard developed under this chapter for the purposes of establishing a payment incentive or adjustment under CalCare.
(f)To develop requirements and standards and making other policy determinations under this chapter, the board shall consult with representatives of members, health care providers, health care organizations, labor organizations representing health care employees, and other interested parties.
(g)The board shall coordinate with the Office of Health Equity, the Department of Health Care Access and Information, and the Department of Managed Health Care to do both of the following:
(1)Monitor participating providers for, and establish procedures related to, compliance with the requirements and standards established under this section.
(2)Establish programs, including special projects under Section 100677, to ensure or manage CalCare member access to in-person primary and preventive care, efficient and effective health care items and services, and quality care.
100661.(a)(1)As part of a health care practitioners duty to advocate for medically appropriate health care for their patients pursuant to Sections 510 and 2056 of the Business and Professions Code, a participating provider has a duty to act in the exclusive interest of the patient.
(2)The duty described in paragraph (1) applies to a health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare.
(b)Consistent with subdivision (a) and with Sections 510 and 2056 of the Business and Professions Code:
(1)An individuals treating physician, or other health care professional who is authorized to diagnose the individual in accordance with all applicable scope of practice and other license requirements and is treating the individual, is responsible for the determination of the medically necessary or appropriate care for the individual.
(2)A participating provider or health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare from a participating provider or other person participating in CalCare shall use reasonable care and diligence in safeguarding an individual under the care of the provider or professional and shall not impair an individuals treating physician or other health care provider treating the individual from advocating for medically necessary or appropriate care under this section.
(c)A health care provider or health care professional described in subdivision (a) violates the duty established under this section for any of the following:
(1)Having a pecuniary interest or relationship, including an interest or relationship disclosed under subdivision (d), that impairs the providers ability to provide medically necessary or appropriate care.
(2)Accepting a bonus, incentive payment, or compensation based on any of the following:
(A)A patients utilization of services.
(B)The financial results of another health care provider with which the participating provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship, or of a person that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(C)The financial results of an institutional provider, group practice, or person that contracts with, provides health care items or services under, or otherwise receives payment from CalCare.
(3)Having a board member, executive, or administrator that receives compensation from, owns stock or has other financial investments in, or serves as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(d)To evaluate and review compliance with this section, a participating provider shall report, at least annually, to the Department of Health Care Access and Information all of the following:
(1)A beneficial interest required to be disclosed to a patient pursuant to Section 654.2 of the Business and Professions Code.
(2)A membership, proprietary interest, coownership, or profit-sharing arrangement, required to be disclosed to a patient pursuant to Section 654.1 of the Business and Professions Code.
(3)A subcontract entered into that contains incentive plans that involve general payments, including capitation payments or shared risk agreements, that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions.
(4)Bonus or other incentive arrangements used in compensation agreements with another health care provider or an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
(5)An offer, delivery, receipt, or acceptance of rebates, refunds, commission, preference, patronage dividend, discount, or other consideration for a referral made in exception to Section 650 of the Business and Professions Code.
(e)The board may adopt regulations as necessary to implement and enforce this section and may adopt regulations to expand reporting requirements under this section.
(f)For purposes of this section, person means an individual, partnership, corporation, limited liability company, or other organization, or any combination thereof, including a medical group practice, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer.
100662.(a)An individuals treating physician, nurse, or other health care professional, in implementing a patients medical or nursing care plan and in accordance with their scope of practice and licensure, may override health information technology or clinical practice guidelines, including standards and guidelines implemented by a participating provider through the use of health information technology, including electronic health record technology, clinical decision support technology, and computerized order entry programs.
(b)An override described in subdivision (a) shall, in the independent professional judgment of the treating physician, nurse, or other health care professional, meet all of the following requirements:
(1)The override is consistent with the treating physicians, nurses, or other health care professionals determination of medical necessity or appropriateness or nursing assessment.
(2)The override is in the best interest of the patient.
(3)The override is consistent with the patients wishes.
2.Health Equity100665.(a)There is hereby established, within CalCare, the Office of Health Equity. The Director of the Department of Health Care Access and Information shall be the director of the office and shall carry out all functions of that position, including enforcement.
(b)The office shall be responsible for coordination and collaboration across the programs and activities of CalCare and the California Health and Human Services Agency with respect to ensuring health equity under CalCare and other health programs of the California Health and Human Services Agency.
(c)The office shall do all of the following:
(1)Support the board through data collection and analysis of, and recommendations to address, all of the following:
(A)The disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, disability, sex, including gender identity and sexual orientation, geographic location, socioeconomic status, incarceration, housing status, and other population-based characteristics.
(B)Barriers to health, including barriers relating to income, education, housing, food insecurity, employment status, working conditions, and conditions related to the physical environment.
(C)Barriers to health care access, including lack of trust and awareness, lack of transportation, geography, hospital and service closures, lack of health care infrastructure and facilities, lack of health care professional staffing and recruitment, disparities in quality of care received, and disparities in utilization of care.
(D)Inequitable distribution of health care services, including health care professional shortage areas, medically underserved areas, medically underserved populations, and trends in hospital closures and service reductions.
(E)Discrimination in health care settings and the use of racially biased or other discriminatory practice guidelines, health care technologies, and algorithms.
(F)Increasing access to high-quality primary health care, particularly in medically underserved areas and for medically underserved populations
(2)Ensure that analysis and data collected under this section are made publicly available and allow for the analysis of cross-sectional information on peoples identities.
(3)Support the board through the development and coordination of programs and recommendations to enhance health equity in California, including programs and recommendations on all of the following:
(A)Improving the provision of culturally, linguistically, and structurally competent care.
(B)Increasing diversity in the health care workforce.
(C)Ensuring sufficient health care professionals and facilities to meet the health care needs across the state.
(D)Ensuring equitable access and distribution of health care professionals and facilities to meet the health care needs across the state.
(E)Recruitment and retention of a health care workforce that meets the cultural, linguistic, and other needs of Californians.
(F)Recruitment and retention of a health care workforce in rural and medically underserved areas.
(4)Develop, coordinate, and provide recommendations on programs that expand the number of primary health care providers and practitioners, including primary care physicians, registered nurses, and dentists, in the state.
(5)Develop, coordinate, and provide recommendations on targeted programs and resources for federally qualified health centers, rural health centers, community health centers, and other community-based organizations that provide primary care in the state.
(6)Conduct ongoing research and evaluation on health equity and access to primary care in California.
(7)Support the board and the CalCare Public Advisory Committee through data collection and analysis and recommendations to develop, propose, and review special projects under Section 100677.
(8)Adopt and promulgate regulations for the purpose of carrying out this chapter.
(9)Establish advisory or technical committees, as necessary.
(d)For purposes of implementing this section, including hiring staff and consultants, through the procurement authority and processes of the department, facilitating and conducting meetings, conducting research and analysis, and developing the required reports, the office may enter into exclusive or nonexclusive contracts on a bid or negotiated basis. Until January 1, 2026, contracts entered into or amended pursuant to this chapter are exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and are exempt from the review or approval of any division of the Department of General Services.
7.Funding1.Federal Health Programs and Funding100670.(a)(1)The board is authorized to and shall seek all federal waivers and other federal approvals and arrangements and submit state plan amendments as necessary to operate CalCare consistent with this title.
(2)The board is authorized to apply for a federal waiver or federal approval as necessary to receive funds to operate CalCare pursuant to paragraph (1), including a waiver under Section 18052 of Title 42 of the United States Code.
(3)The board shall apply for federal waivers or federal approval pursuant to paragraph (1) by January 1, 2026.
(b)(1)The board shall apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the Affordable Care Act, and any other federal programs or laws, as appropriate, that are necessary to enable all CalCare members to receive all benefits under CalCare through CalCare, to enable the state to implement this title, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the CalCare Trust Fund, created pursuant to Section 100675, and to use those funds for CalCare and other provisions under this title.
(2)To the fullest extent possible, the board shall negotiate arrangements with the federal government to ensure that federal payments are paid to CalCare in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs. To the extent any federal funding is not paid directly to CalCare, the state shall direct the funding and moneys to CalCare.
(3)The board may require members or applicants to provide information necessary for CalCare to comply with any waiver or arrangement under this title. Information provided by members to the board for the purposes of this subdivision shall not be used for any other purpose.
(4)The board may take any additional actions necessary to effectively implement CalCare to the maximum extent possible as an independent single-payer program consistent with this title. It is the intent of the Legislature to establish CalCare, to the fullest extent possible, as an independent agency.
(c)The board may take actions consistent with this article to enable CalCare to administer Medicare in California. CalCare shall be a provider of supplemental insurance coverage and shall provide premium assistance for drug coverage under Medicare Part D for eligible members of CalCare.
(d)The board may waive or modify the applicability of any provisions of this title relating to any federally matched public health program or Medicare, as necessary, to implement any waiver or arrangement under this section or to maximize the federal benefits to CalCare under this section.
(e)The board may apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare. Enrollment in a federally matched public health program or Medicare shall not cause a member to lose a health care item or service provided by CalCare or diminish any right the member would otherwise have.
(f)(1)Notwithstanding any other law, the board, by regulation, shall increase the income eligibility level, increase or eliminate the resource test for eligibility, simplify any procedural or documentation requirement for enrollment, and increase the benefits for any federally matched public health program and for any program in order to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(2)The board may act under this subdivision, upon a finding approved by the Director of Finance and the board that the action does all of the following:
(A)Will help to increase the number of members who are eligible for and enrolled in federally matched public health programs, or for any program to reduce or eliminate an individuals coinsurance, cost-sharing, or premium obligations or increase an individuals eligibility for any federal financial support related to Medicare or the Affordable Care Act.
(B)Will not diminish any individuals access to a health care item or service or right the individual would otherwise have.
(C)Is in the interest of CalCare.
(D)Does not require or has received any necessary federal waivers or approvals to ensure federal financial participation.
(g)To enable the board to apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare, the board may require that every member or applicant provide the information necessary to enable the board to determine whether the applicant is eligible for a federally matched public health program or for Medicare, or any program or benefit under Medicare.
(h)As a condition of continued eligibility for health care items and services under CalCare, a member who is eligible for benefits under Medicare shall enroll in Medicare, including Parts A, B, and D.
(i)The board shall provide premium assistance for all members enrolling in a Medicare Part D drug coverage plan under Section 1860D of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.), limited to the low-income benchmark premium amount established by the federal Centers for Medicare and Medicaid Services and any other amount the federal agency establishes under its de minimis premium policy, except that those payments made on behalf of members enrolled in a Medicare Advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to CalCare.
(j)If the board has reasonable grounds to believe that a member may be eligible for an income-related subsidy under Section 1860D-14 of Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395w-114), the member shall provide, and authorize CalCare to obtain, any information or documentation required to establish the members eligibility for that subsidy. The board shall attempt to obtain as much of the information and documentation as possible from records that are available to it.
(k)The board shall make a reasonable effort to notify members of their obligations under this section. After a reasonable effort has been made to contact the member, the member shall be notified in writing that the member has 60 days to provide the required information. If the required information is not provided within the 60-day period, the members coverage under CalCare may be suspended until the issue is resolved. Information provided by a member to the board for the purposes of this section shall not be used for any other purpose.
(l)The board shall assume responsibility for all benefits and services paid for by the federal government with those funds.
2.CalCare Trust Fund100675.(a)The CalCare Trust Fund is hereby created in the State Treasury for the purposes of this title to be administered by the CalCare Board. Notwithstanding Section 13340, all moneys in the fund shall be continuously appropriated without regard to fiscal year for the purposes of this title. Any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year may be carried forward to the next succeeding fiscal year.
(b)Notwithstanding any other law, moneys deposited in the fund shall not be loaned to, or borrowed by, any other special fund or the General Fund, a county general fund or any other county fund, or any other fund.
(c)The board shall establish and maintain a prudent reserve in the fund to enable it to respond to costs including those of an epidemic, pandemic, natural disaster, or other health emergency, or market-shift adjustments related to patient volume.
(d)The board or staff of the board shall not utilize any funds intended for the administrative and operational expenses of the board for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.
(e)Notwithstanding Section 16305.7, all interest earned on the moneys that have been deposited into the fund shall be retained in the fund and used for purposes consistent with the fund.
(f)The fund shall consist of all of the following:
(1)All moneys obtained pursuant to legislation enacted as proposed under Section 100680.
(2)Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials for health care programs established under Medicare, any federally matched public health program, or the Affordable Care Act.
(3)The amounts paid by the State Department of Health Care Services that are equivalent to those amounts that are paid on behalf of residents of this state under Medicare, any federally matched public health program, or the Affordable Care Act for health benefits that are equivalent to health benefits covered under CalCare.
(4)Federal and state funds for purposes of the provision of services authorized under Title XX of the federal Social Security Act (42 U.S.C. Sec. 1397 et seq.) that would otherwise be covered under CalCare.
(5)State moneys that would otherwise be appropriated to any governmental agency, office, program, instrumentality, or institution that provides health care items or services for services and benefits covered under CalCare. Payments to the fund pursuant to this section shall be in an amount equal to the money appropriated for those purposes in the fiscal year beginning immediately preceding the effective date of this title.
(g)All federal moneys shall be placed into the CalCare Federal Funds Account, which is hereby created within the CalCare Trust Fund.
(h)Moneys in the CalCare Trust Fund shall only be used for the purposes established in this title.
(i)(1)Before the delivery of the fiscal analysis required pursuant to Section 100620:
(A)Moneys in the CalCare Trust fund shall not be used for startup and administrative costs to implement Section 100612.
(B)Moneys in the CalCare Trust Fund may be used to design and commission the fiscal analysis required pursuant to Section 100620.
(2)After delivery of the fiscal analysis required pursuant to Section 100620, moneys in the CalCare Trust Fund may be used for startup and administrative costs to implement Section 100612.
100676.(a)The board annually shall prepare a budget for CalCare that specifies a budget for all expenditures to be made for covered health care items and services and shall establish allocations for each of the budget components under subdivision (b) that shall cover a three-year period.
(b)The CalCare budget shall consist of at least the following components:
(1)An operating budget.
(2)A capital expenditures budget.
(3)A special projects budget.
(4)Program standards activities.
(5)Health professional education expenditures.
(6)Health care workforce recruitment and retention expenditures.
(7)Administrative costs.
(8)Prevention and public health activities.
(c)The board shall allocate the funds received among the components described in subdivision (b) to ensure the following:
(1)The operating budget allows for participating providers to meet the health care needs of the population.
(2)A fair allocation to the special projects budget to meet the purposes described in subdivision (f) in a reasonable timeframe.
(3)A fair allocation for program standards activities.
(4)The health professional education expenditures component is sufficient to meet the need for covered health care items and services.
(d)The operating budget described in paragraph (1) of subdivision (b) shall be used for payments to providers for health care items and services furnished by participating providers under CalCare.
(e)The capital expenditures budget described in paragraph (2) of subdivision (b) shall be used for the construction or renovation of health care facilities, excluding congregate or segregated facilities for individuals with disabilities who receive long-term services and supports under CalCare, and other capital expenditures.
(f)The special projects budget described in paragraph (3) of subdivision (b) shall be used for the payment to not-for-profit or governmental entities pursuant to Section 100677.
(g)For up to five years following the date on which benefits first become available under CalCare, at least 1 percent of the budget shall be allocated to programs providing transition assistance pursuant to Section 100615.
(h)During the implementation period and for at least five years following the date on which benefits first become available under CalCare, up to 1 percent of the budget shall be allocated to programs providing health care workforce education, recruitment, and retention pursuant to Section 100686.
100677.(a)(1)The special projects budget described in paragraph (3) of subdivision (b) of Section 100676 shall be used for the payment to not-for-profit entities that are health facilities pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code or governmental entities for the construction or renovation of health care facilities, major equipment purchases, staffing in a rural or medically underserved area, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(2)To mitigate the impact of the payments on the availability and accessibility of health care services, the special projects budget may be used to increase payment to providers in a rural or medically underserved area.
(b)(1)An agency of the state, a city, a county, a city and county, or another political subdivision of the state or a not-for-profit entity that is a health facility pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code may submit an application to the board for payment from the special projects budget for a special project under this section.
(2)The board shall develop criteria to evaluate applications for payment from the special projects budget for special projects in consultation with the CalCare Public Advisory Committee, the Office of Health Equity, the California Health Facilities Financing Authority, the Department of Health Care Access and Information, the State Department of Health Care Services, the Department of Managed Health Care, the State Department of Public Health, and other relevant state agencies.
(3)The criteria to evaluate applications shall consider factors, including if the special project will support a health facility in a rural or medically underserved area, and if the special project will address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
(4)The criteria to evaluate applications shall also be used for identification and monitoring of health facilities at risk of understaffing in rural or medically underserved areas and of populations experiencing health disparities.
(c)(1)The board may issue a request for applications for a special project paid under subdivision (b) in consultation with the Office of Health Equity.
(2)The CalCare Public Advisory Committee may develop and recommend the board issue a request for applications for a special project paid under subdivision (b).
(d)(1)An applicant for payment from the special projects budget shall provide the board with financial, demographic, and other information regarding the proposed health care service area as determined by the board, in a format determined by the board, to review an application to receive payment from the special projects budget for a special project.
(2)An applicant for payment from the special projects budget shall submit a plan to the board detailing the projected uses of the proposed payment and strategies proposed to address a health disparity or other qualifying need identified by the board.
(e)(1)The board shall determine the application process and methodology for approval and distribution of payments from the special projects budget.
(2)In reviewing a plan submitted by an applicant for payment from the special projects budget under this section, the board shall evaluate if there is a reasonable likelihood that it will address a health disparity or other qualifying need identified by the board.
(3)The board shall provide public notice of an application submitted under this section and post a copy of the applicants plan submitted under this section on its internet website.
(4)The board shall make its application process and methodology publicly accessible on its internet website.
(f)(1)Within 90 days of receipt of a complete application for a payment from the special projects budget for a special project, the board shall provide a preliminary report to the applicant of the boards initial review of the application and provide public notice of the preliminary report.
(2)The board shall provide the public the opportunity to provide written comment on a preliminary report of an application for payment from the special projects budget for a special project.
(3)Before the board approves an application for payment from the special projects budgets for a special project, the CalCare Public Advisory Committee shall conduct at least one public hearing to receive public input and comment on the application.
(4)The CalCare Public Advisory Committee shall provide a recommendation to the board on the approval of an application submitted to the board under this section.
(g)The board shall have the authority to determine service provision requirements or other conditions in approving, and for the duration of, special projects payments to health facilities or that support health facilities. In making its determination, the board shall consider the impact of any changes to the health facilities service delivery on access to medical care.
3.CalCare Financing100680.(a)It is the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. In developing the revenue plan, it is the intent of the Legislature to consult with appropriate officials and stakeholders.
(b)It is the intent of the Legislature to enact legislation that would require all state revenues from CalCare to be deposited in an account within the CalCare Trust Fund to be established and known as the CalCare Trust Fund Account.
8.Transition100685.(a)An individual who meets all of the following requirements shall be eligible to enroll as a member of CalCare during the implementation period:
(1)The individual meets the eligibility standards established by the board under Section 100630.
(2)The individual is 55 years of age or older, 18 years of age or younger, or is currently enrolled in Medicare or Medicaid during the implementation period.
(b)The board shall ensure that all persons enrolled, or who seek to enroll, in a health plan during the implementation period are protected from disruptions in their care during the implementation period, including continuity of care with current health care teams.
(c)(1)During the implementation period, a carrier shall not end coverage for a CalCare member until the end of the implementation period except as expressly agreed upon under the terms of the plan.
(2)During the implementation period, a carrier shall not impose any exclusion or limitation of coverage on the basis of a persons disability, complex medical need, or chronic condition.
(3)This subdivision applies to a carrier except as otherwise prohibited by federal law.
(d)The board shall consult with the Advisory Commission on Long-Term Services and Supports, communities and advocacy organizations of persons living with disabilities, and other patient advocacy organizations to ensure that CalCare coverage during the implementation period takes into account the continuity of care for persons with disabilities, complex medical needs, or chronic conditions.
(e)In the case of inpatient hospital services and extended care services during a continuous period of stay that began before the end of the implementation period, and that had not ended as of the end of the implementation date, the board shall provide for continuation of benefits under CalCare until the end of the period of stay.
(f)During the implementation period, the board shall establish and maintain procedures that, to the greatest extent possible, provide for the following:
(1)Automatic enrollment in CalCare of individuals who are eligible to enroll in CalCare during the implementation period.
(2)Automatic enrollment in CalCare of individuals who will become eligible to enroll in CalCare after the end of the implementation period.
(g)(1)During the implementation period, the board shall establish and maintain procedures for individuals who will become eligible to enroll in CalCare after the end of the implementation period to select a primary care provider under subdivision (e) of Section 100630.
(2)During the implementation period, the board, to the greatest extent possible, shall establish and maintain procedures for individuals who are currently members of an integrated health care delivery system to automatically select participating providers in the individuals integrated health care delivery system care team as their primary care provider upon enrollment in CalCare.
(h)A person who is eligible to receive CalCare benefits during the implementation period may opt to maintain coverage outside of CalCare, including private health care coverage or coverage offered through the California Health Benefit Exchange, until the end of the implementation period.
100686.(a)(1)The board shall provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for programs to address health care workforce education, recruitment, and retention to meet health workforce demands under CalCare, including programs implemented during the implementation period.
(2)The board shall coordinate with the CalCare Public Advisory Committee, the Office of Health Equity, the Department of Health Care Access and Information, the Labor and Workforce Development Agency, the California Health and Human Services Agency, and health care professional licensing boards, including the Board of Registered Nursing, Medical Board of California, and Dental Board of California, to implement programs and policies related to health care workforce education, recruitment, and retention.
(b)The board shall establish a CalCare Health Workforce Working Group to provide input, including recommendations, to the board and Secretary of Labor and Workforce Development on issues related to health care workforce education, recruitment, and retention, including all of the following:
(1)Programs and measures to expand clinical education capacity at California community colleges providing associate degree programs in health professions, including through programs to ensure the fair and equitable distribution of clinical placement at clinical education sites among approved health professions education programs and through programs to recruit and retain clinical faculty.
(2)Data collection and analysis and recommendations on health workforce attrition from direct care positions, including on moral distress and moral injury, safe staffing, and gaps in active California health professions licensees and those working in direct care.
(3)Identification and prioritization of geographical areas or populations in the state with unmet primary care or other health care needs, including access and availability of family physicians, primary care clinics, and registered nurses.
(4)Programs and measures to retain health care workforces, including public loan repayment assistance programs, minimum safe staffing requirements, investments in personal protective equipment, and occupational safety and health programs.
(5)Programs and measures to support expansion of graduate medical education programs and assistance for medical residents.
(6)Career ladders into health professions for ancillary and allied health workers, including licensed vocational nurses, certified nursing assistants, medical technicians, behavioral health technicians, health navigators, and community health workers.
(7)Career technical education pathways toward an associate degree at a California community college in a health professions education program.
(8)Programs to address barriers to health professions, including student debt levels, tuition assistance, childcare or other support, and debt-free residency or mentorship programs.
(c)The board shall appoint the members of the CalCare Health Workforce Working Group. Appointments shall be made by a majority vote of the voting members of the board. When appointing members to the working group, the board shall aim for broad representation, including, at a minimum, all of the following:
(1)Representatives of health professions and other health care workers, including specialties for primary care and behavioral health, physicians, registered nurses, and ancillary services.
(2)Representatives of labor organizations representing health care workers.
(3)Representatives of California community colleges, graduate medical education and training programs, and nursing education programs.
(4)Representatives of consumer and patient groups.
(5)Representatives of health care providers, including hospitals, nonacute care providers, and medical groups.
(d)(1)Each appointed member of the CalCare Health Workforce Working Group shall serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
(2)Working group members shall not have access to confidential, nonpublic information that is accessible to the board and office. Instead, the working group shall only have access to information that is publicly available. Neither the board nor the office shall disclose any confidential, nonpublic information to the working group members.
(3)Working group members shall receive reimbursement for travel and other actual costs.
(e)The working group shall meet at least four times per year in a place convenient to the public. All meetings of the advisory commission shall be open to the public, pursuant to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
(f)The board shall consider input, including recommendations, from the working group, along with public comments, in the boards deliberation and decisionmaking.
9.Collective Negotiation by Health Care Providers with CalCare1.Definitions100690.For purposes of this chapter, the following definitions apply:
(a)(1)Health care provider means a person who is licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code and who is either of the following:
(A)An individual who practices that profession as a health care professional or as an independent contractor.
(B)An owner, officer, shareholder, or proprietor of a health care group practice that has elected to receive fee-for-service payments from CalCare pursuant to subdivision (d) of Section 100650.
(2)A health care provider licensed, certified, registered, or authorized to practice a health care profession pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code who practices as an employee of a health care provider is not a health care provider for purposes of this chapter.
(b)Health care providers representative means a third party that is authorized by a health care provider to negotiate on their behalf with CalCare over terms and conditions affecting those health care providers.
2. Authorized Collective Negotiation100691.(a)Health care providers may meet and communicate for the purpose of collectively negotiating with CalCare on any matter relating to CalCare fee-for-service rates of payment for health care items and services or procedures related to fee-for-service payment under CalCare.
(b)This chapter does not allow a strike of CalCare by health care providers related to the collective negotiations.
(c)This chapter does not allow or authorize terms or conditions that would impede the ability of CalCare to comply with applicable state or federal law.
3.Collective Negotiation Requirements100692.(a)Collective negotiation under this chapter shall meet all of the following requirements:
(1)A health care provider may communicate with other health care providers regarding the terms and conditions to be negotiated with CalCare.
(2)A health care provider may communicate with a health care providers representative.
(3)A health care providers representative is the only party authorized to negotiate with CalCare on behalf of the health care providers as a group.
(4)A health care provider can be bound by the terms and conditions negotiated by the health care providers representative.
(b)This chapter does not affect or limit the right of a health care provider or group of health care providers to collectively petition a governmental entity for a change in a law, rule, or regulation.
(c)This chapter does not affect or limit collective action or collective bargaining on the part of a health care provider with the health care providers employer or any other lawful collective action or collective bargaining.
100693.(a)Before engaging in collective negotiations with CalCare on behalf of health care providers, a health care providers representative shall file with the board, in the manner prescribed by the board, information identifying the representative, the representatives plan of operation, and the representatives procedures to ensure compliance with this chapter.
(b)A person who acts as the representative of negotiating parties under this chapter shall pay a fee to the board to act as a representative. The board, by regulation, shall set fees in amounts deemed reasonable and necessary to cover the costs incurred by the board in administering this chapter.
4.Prohibited Collective Action100694.(a)This chapter does not authorize competing health care providers to act in concert in response to a health care providers representatives discussions or negotiations with CalCare, except as authorized by other law.
(b)A health care providers representative shall not negotiate an agreement that excludes, limits the participation or reimbursement of, or otherwise limits the scope of services to be provided by a health care provider or group of health care providers with respect to the performance of services that are within the health care providers scope of practice, license, registration, or certificate.
10.Operative Date100695.(a)Notwithstanding any other law, this title, except for Chapter 1 (commencing with Section 100600), Chapter 2 (commencing with Section 100610), and Article 1 (commencing with Section 100670) of Chapter 7, shall not become operative until the date the Secretary of California Health and Human Services notifies the Secretary of the Senate and the Chief Clerk of the Assembly in writing that the secretary has determined that the CalCare Trust Fund has the revenues to fund the costs of implementing this title.
(b)The California Health and Human Services Agency shall publish a copy of the notice on its internet website.
(c)The Secretary of California Health and Human Services shall make a notification pursuant to subdivision (a).
SEC. 3.The provisions of this act are severable. If any provision of this act or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
SEC. 4.The Legislature finds and declares that Section 2 of this act, which adds Sections 100610, 100617, and 100619 to the Government Code, imposes a limitation on the publics 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 private, confidential, and proprietary information, it is necessary for that information to remain confidential.
|
Date
|
Status
|
|---|---|
| May 16, 2024 | In committee: Held under submission. |
| May 16, 2024 | Joint Rule 62(a), file notice suspended. (Page 5215.) |
| May 15, 2024 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| May 1, 2024 | Re-referred to Com. on APPR. |
| Apr 30, 2024 | Read second time and amended. |
| Apr 29, 2024 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 9. Noes 4.) (April 23). |
| Apr 10, 2024 | Re-referred to Com. on HEALTH. |
| Apr 9, 2024 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 21, 2024 | Referred to Com. on HEALTH. |
| Feb 8, 2024 | From printer. May be heard in committee March 9. |
| Feb 7, 2024 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Apr 23, 2024 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Murrieta Wildomar Chamber of Commerce | ** Against | |
| Acclamation Insurance Management Services | ** Against | |
| Aclu California Action | ** Support | |
| African American Farmers of California | ** Against | |
| Agricultural Council Of California | ** Against | |
| Aids Healthcare Foundation | ** Support | |
| Alameda Chamber of Commerce | ** Against | |
| Alameda County Homeless Action Center | ** Support | |
| Alex Rechsteiner Painting | ** Support | |
| Alliance for Boys and Men of Color | ** Support | |
| Allied Managed Care | ** Against | |
| America'S Physician Groups | ** Against | |
| American Composites Manufacturers Association | ** Against | |
| American Petroleum and Convenience Store Association | ** Against | |
| American Pistachio Growers | ** Against | |
| American Property Casualty Insurance Association | ** Against | |
| Antelope Valley Chambers of Commerce | ** Against | |
| Asian Pacific Islanders for CalCare | ** Support | |
| Associated General Contractors | ** Against | |
| Associated General Contractors, San Diego | ** Against | |
| Association Of California Life & Health Insurance Companies | ** Against | |
| Bay Area Council | ** Against | |
| Black Lives Matter Los Angeles | ** Support | |
| Blue Shield Of California | ** Against | |
| Brea Chamber of Commerce | ** Against | |
| Building Owners and Managers Association of California | ** Against | |
| Business Council San Joaquin County | ** Against | |
| Butte County Health Care Coalition | ** Support | |
| Cal Red Berets | ** Support | |
| California Agents & Health Insurance Professionals | ** Against | |
| California Agricultural Aircraft Association | ** Against | |
| California Alliance For Retired Americans | ** Support | |
| California Apple Commission | ** Against | |
| California Asian Pacific Chamber Of Commerce | ** Against | |
| California Association Of Health Plans | ** Against | |
| California Association Of Highway Patrolmen | ** Against | |
| California Association Of Winegrape Growers | ** Against | |
| California Attractions And Parks Association | ** Against | |
| California Beer and Beverage Distributors | ** Against | |
| California Blueberry Association | ** Against | |
| California Blueberry Commission | ** Against | |
| California Builders Alliance | ** Against | |
| California Building Industry Association | ** Against | |
| California Business Properties Association | ** Against | |
| California Business Roundtable | ** Against | |
| California Cable and Telecommunications Association | ** Against | |
| California Cattlemen'S Association | ** Against | |
| California Chamber Of Commerce | * Against | Apr 23, 2024 |
| California Children'S Hospital Association | ** Against | |
| California Conference Of Machinists | ** Support | |
| California Correctional Peace Officers Association Benefit Trust | ** Against | |
| California Cotton Ginners and Growers Association | ** Against | |
| California Dental Association | ** Against | |
| California Faculty Association | ** Support | |
| California Federation of Interpreters | ** Support | |
| California Federation of Teachers, AFL-CIO | ** Support | |
| California Financial Services Association | ** Against | |
| California Fresh Fruit Association | ** Against | |
| California Fuels And Convenience Alliance | ** Against | |
| California Hispanic Chamber Of Commerce | ** Against | |
| California Hospital Association | ** Against | |
| California Immigrant Policy Center | ** Support | |
| California Independent Petroleum Association | ** Against | |
| California Labor Federation, Afl-Cio | ** Support | |
| California Land Title Association | ** Against | |
| California Landscape Contractor'S Association | ** Against | |
| California Landscape Contractors Association | ** Against | |
| California League of Food Producers | ** Against | |
| California Lodging Industry Association | ** Against | |
| California Manufacturers & Technology Association | ** Against | |
| California Medical Association | ** Against | |
| California New Car Dealers Association | ** Against | |
| California Nurses Association | * Support | Apr 23, 2024 |
| California OneCare | ** Support | |
| California Pan - Ethnic Health Network | ** Support | |
| California Pool & Spa Association | ** Against | |
| California Retailers Association | ** Against | |
| California Rice Commission | ** Against | |
| California School Employees Association | ** Support | |
| California State Northridge Young Democratic Socialists of America | ** Support | |
| California Strawberry Commission | ** Against | |
| California Taxpayers Association | ** Against | |
| California Teachers Association | * Support | Apr 23, 2024 |
| California Walnut Commission | ** Against | |
| California Women for Agriculture | ** Against | |
| Can Manufacturers Institute | ** Against | |
| Carlsbad Chamber of Commerce | ** Against | |
| Cemetery and Mortuary Association of California | ** Against | |
| Chino Valley Chamber of Commerce | ** Against | |
| Cigna | ** Against | |
| cleanearth4kids.org | ** Support | |
| Coalition of Small and Disabled Veteran Businesses | ** Against | |
| Coalition to Abolish Slavery and Trafficking | ** Support | |
| Community Health Councils | ** Support | |
| Conference of California Bar Associations | ** Support | |
| Construction Employers' Association | ** Against | |
| Corona Chamber of Commerce | ** Against | |
| Council Member Mateo Bedolla, City of Tracy | ** Support | |
| County of Santa Clara | ** Support | |
| Culver City Democratic Club | ** Support | |
| Dairy Institute Of California | ** Against | |
| Danville Area Chamber of Commerce | ** Against | |
| Democratic Socialists of America - San Luis Obispo | ** Support | |
| Department of California Marine Corps League | ** Against | |
| DSA-santa Barbara | ** Support | |
| East Valley Indivisibles | ** Support | |
| Educators for Single-payer | ** Support | |
| El Dorado County Chamber of Commerce | ** Against | |
| El Dorado Hills Chamber of Commerce | ** Against | |
| ELEVANCE HEALTH | ** Against | |
| Elk Grove Chamber Of Commerce | ** Against | |
| Family Business Association of California | ** Against | |
| Federation of Retired Union Members | ** Support | |
| Feel the Bern Democratic Club, Los Angeles | ** Support | |
| Feel the Bern San Fernando Valley Democratic Club | ** Support | |
| Flasher Barricade Association | ** Against | |
| Focus Strategies | ** Support | |
| Folsom Chamber Of Commerce | ** Against | |
| Fontana Chamber of Commerce | ** Against | |
| Fountain Valley Chamber of Commerce | ** Against | |
| Fresno Chamber of Commerce | ** Against | |
| Garden Grove Chamber Of Commerce | ** Against | |
| Gateway Chambers Alliance | ** Against | |
| Gilroy Chamber of Commerce | ** Against | |
| Gray Panthers of San Francisco | ** Support | |
| Greater Coachella Valley Chamber of Commerce | ** Against | |
| Greater Conejo Valley Chamber of Commerce | ** Against | |
| Greater Grass Valley Chamber of Commerce | ** Against | |
| Greater High Desert Chamber of Commerce | ** Against | |
| Greater Riverside Chambers of Commerce | ** Against | |
| Greater San Fernando Valley Chamber of Commerce | ** Against | |
| Greater Stockton Chamber of Commerce | ** Against | |
| Green Party of California | ** Support | |
| Green Party of Santa Clara County CA | ** Support | |
| Health Access California | ** Support | |
| Health Care 4 US | ** Support | |
| Health Care for All California | ** Support | |
| Health Net | ** Against | |
| Healthy California Now | ** Support | |
| Hire Survivors Hollywood | ** Support | |
| hollywood chamber of commerce | ** Against | |
| Hollywood4CalCare | ** Support | |
| Holy Faith Episcopal Church | ** Support | |
| Housing Contractors Of California | ** Against | |
| human agenda | ** Support | |
| Humboldt Progressive Democrats | ** Support | |
| Imperial Valley Regional Chamber of Commerce | ** Against | |
| Independent Lodging Industry Association. | ** Against | |
| Indivisible Ca: Statestrong | ** Support | |
| Indivisible Sacramento | ** Support | |
| Indivisible West Side Los Angeles | ** Support | |
| Initiate Justice Action | ** Support | |
| Inland Equity Partnership | ** Support | |
| Innovating Commerce Serving Communities | ** Against | |
| International Association of Machinists & Aerospace Workers Local Lodge 1484 | ** Support | |
| Iranian American Democrats of California | ** Support | |
| Kaiser Permanente | ** Against | |
| Katharine Gale Consulting | ** Support | |
| LA Cañada Flintridge Chamber of Commerce and Community Association | ** Against | |
| Labor Today International, INC. | ** Support | |
| Laguna Nigel Chamber of Commerce | ** Against | |
| lincoln area chamber of commerce | ** Against | |
| Long Beach Area Chamber of Commerce | ** Against | |
| Long Beach Gray Panthers | ** Support | |
| Los Angeles Area Chamber Of Commerce | ** Against | |
| Mammoth Lakes Chamber of Commerce | ** Against | |
| Manhattan Beach Chamber Of Commerce | ** Against | |
| Manteca Chamber of Commerce | ** Against | |
| Metal Finishing Association Of Northern California | ** Against | |
| Metal Finishing Association Of Southern California | ** Against | |
| Midnight Books | ** Support | |
| Mission Viejo Chamber of Commerce | ** Against | |
| Naiop California | ** Against | |
| National Electrical Contractors Association | ** Against | |
| National Federation Of Independent Business | ** Against | |
| Newport Beach Chamber of Commerce | ** Against | |
| Nisei Farmers League | ** Against | |
| Norcal Resist | ** Support | |
| North San Diego Business Chamber | ** Against | |
| Norwalk Chamber Of Commerce | ** Against | |
| Oakland Education Association | * Support | Apr 23, 2024 |
| Oceanside Chamber of Commerce | ** Against | |
| Olive Growers Council of California | ** Against | |
| Orange County Business Council | ** Against | |
| Palos Verdes Peninsula Chamber Of Commerce | ** Against | |
| Parivar Bay Area | ** Support | |
| Paso Robles & Templeton Chamber of Commerce | ** Against | |
| Peace and Freedom Party of California | ** Support | |
| Peace Officers Research Association Of California | ** Against | |
| Peninsula DSA | ** Support | |
| Physicians for A National Health Program -- Bay Area Chapter | ** Support | |
| Pleasanton Chamber of Commerce | ** Against | |
| Pride At Work South Bay Chapter | ** Support | |
| Rancho Cordova Area Chamber of Commerce | ** Against | |
| Redondo Beach Chamber of Commerce | ** Against | |
| Rocklin Area Chamber of Commerce | ** Against | |
| Roseville Area Chamber Of Commerce | ** Against | |
| Sacramento Black Chamber Of Commerce | ** Against | |
| Sacramento Democratic Socialists of America | ** Support | |
| Sacramento Regional Builders Exchange | ** Against | |
| Sacramento; City Of | ** Support | |
| San Diego Regional Chamber Of Commerce | ** Against | |
| San Diego Snahp Chapter | ** Support | |
| San Gabriel Valle Progressives | ** Support | |
| San Gabriel Valley Neighbors for Peace and Justice | ** Support | |
| San Juan Capistrano Chamber of Commerce | ** Against | |
| San Mateo Area Chamber of Commerce | ** Against | |
| San Pedro Chamber of Commerce | ** Against | |
| San Ramon Chamber of Commerce | ** Against | |
| Santa Ana Chamber of Commerce | ** Against | |
| Santa Clara County Single Payer Health Care Coalition | ** Support | |
| Santa Cruz for Bernie | ** Support | |
| Santa Maria Valley Chamber of Commerce | ** Against | |
| Santa Monica Democratic Club | ** Support | |
| Shasta County Of | ** Against | |
| Shingle Springs/cameron Park Chamber of Commerce | ** Against | |
| Silicon Valley Leadership Group | ** Against | |
| Simi Valley Chamber of Commerce | ** Against | |
| Socialists for CalCare | ** Support | |
| South Bay Association of Chambers of Commerce | ** Against | |
| South Bay Community Land Trust | ** Support | |
| South Bay Indigenous Solidarity | ** Support | |
| South Bay Progressive Alliance | ** Support | |
| Southern Alameda County Progressive Democrats | ** Support | |
| Southwest California Legislative Council | ** Against | |
| Stanislaus County Democratic Central Committee | ** Support | |
| TechEquity Collaborative | ** Support | |
| Thai Community Development Center | ** Support | |
| The National Tai Chi Chuan Association | ** Support | |
| Therapists for Single Payer | ** Support | |
| Torrance Area Chamber of Commerce | ** Against | |
| Trade Show Temps | ** Support | |
| Tulare Chamber of Commerce | ** Against | |
| UNITE HERE Local 11 | ** Support | |
| UNITE-HERE, AFL-CIO | ** Support | |
| United Chamber Advocacy Network | ** Against | |
| United Contractors | ** Against | |
| United Democrats of Southern Solano County | ** Support | |
| Vacaville Chamber of Commerce | ** Against | |
| VALLEY INDUSTRY AND COMMERCE ASSOCIATION | ** Against | |
| Ventura Chamber of Commerce | ** Against | |
| Walnut Creek Chamber of Commerce & Visitors Bureau | ** Against | |
| Waste Management | ** Against | |
| West Coast Lumber & Building Material Association | ** Against | |
| West Hollywood Chamber of Commerce | ** Against | |
| West Ventura County Business Alliance | ** Against | |
| Western Agricultural Processors Association | ** Against | |
| Western Center on Law & Poverty, INC. | ** Support | |
| Western Growers Association | ** Against | |
| Western Manufactured Housing Communities Association | ** Against | |
| Western Plant Health Association | ** Against | |
| White People 4 Black Lives | ** Support | |
| Whittier Area Chamber of Commerce | ** Against | |
| Word & Brown | ** Against | |
| Yuba Sutter Chamber of Commerce | ** Against |
Date of Hearing: May 15, 2024
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Buffy Wicks, Chair
ABPCA Bill Id:AB 2200
Author:(Kalra) – As Amended Ver:April 30, 2024
Policy Committee: | Health | Vote: | 9 - 4 |
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Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill establishes the policy framework for the California Guaranteed Health Care for All program, or CalCare, a health care service plan, to provide comprehensive, universal, single-payer health care coverage and a health care cost control system for all residents of the state.
FISCAL EFFECT:
No cost estimates are available for this bill. Analyses of previous universal health care bills have suggested costs in the hundreds of billions of dollars, but lower than overall spending under the existing system. For example, the University of Massachusetts, Amherst, Political Economy Research Institute (PERI) conducted an economic analysis of SB 562 (Lara), of the 2017-18 Legislative Session. The authors of the PERI study estimated that implementation of SB 562, could reduce overall costs of providing full health care coverage to all Californians by about 18% relative to spending under the existing system. The PERI analysis suggested that although SB 562’s single-payer system would be expensive, its cost in taxes would ultimately be lower than what Californians were paying to private insurers. “The overall annual costs of this single-payer system for California would be $331 billion as of 2017,” equivalent to $392 billion in 2024 dollars (based on health care inflation rates from 2018 through 2024).
More recently, the Healthy California for All Commission (Commission), in its report, “Key Design Considerations for Unified Health Care Financing System in California, Final Report, April 2022,” (report) provides estimates for changes in health spending for different scenarios and design decisions, all predicated on the state being able to achieve the necessary federal and state-level approvals. Variables in spending estimates were:
- Cost sharing – options considered no cost sharing or income-related cost sharing.
- Use of intermediaries – options were:
- No intermediaries - the unified financing (UF) authority would make direct payments to hospitals and health care providers.
- Californians would be required to enroll in a health plan or health system, and the UF authority would make payments to, the health plan or system.
- Long term services and supports (LTSS) – expanded LTSS or status quo, with a continuation of Medi-Cal coverage for LTSS, including nursing home care and in-home supportive services.
The analysis estimated that with no changes, total health care spending would be $517 billion in 2022. The following are example scenarios and associated total spending estimates:
- No cost sharing, direct payments to providers, and no LTSS expansion: $501 billion ($16 billion savings over status quo).
- Income-related cost sharing, no LTSS expansion: $482 billion ($35 billion savings compared to status quo).
- Income-related cost sharing, LTSS expansion: $508 billion ($9 billion savings compared to status quo).
- Including an intermediary increases estimated spending for the above scenarios by $4 billion to $5 billion.
COMMENTS:
- Purpose. This bill is sponsored by the California Nurses Association. According to the author:
Today’s U.S. health care system is a complex, fragmented multi-payer system that leaves wide gaps in coverage and access to care, poses significant issues of affordability, and has growing health disparities. Despite health care spending in the U.S. far exceeding other high-income, industrialized countries that offer a publicly financed single-payer system, we consistently report worse health outcomes and disparities among vulnerable populations.
AB 2200, the California Guaranteed Health Care for All Act, will begin the process of creating a universal single-payer system of health care for every California resident. AB 2200 would enact a comprehensive framework of governance, benefits, program standards, and health care cost controls, and will allow California to begin consolidating existing health care programs, obtain necessary federal waivers and determine any future public financing. Also known as CalCare, this is a meaningful step towards building a transformative and equitable health care payment system that will guarantee comprehensive health care and achieve health care justice for all.
We cannot afford to let our health care status quo persist and CalCare would actually save money. The Healthy California for All Commission found that under a single-payer model California would save between $32 billion to $213 billion over 10 years compared to our current system. With a single-payer system, these savings will be redirected to patients and allow the state to make strategic investments in our health care to improve access to care and dismantle health inequities.
By guaranteeing health care for all Californians and establishing a payment system that eliminates waste and aligns reimbursements with the actual cost of care, we can make tremendous progress on health care as a human right. Transforming our complex, inequitable health care system will not be easy and will not happen overnight. AB 2200 is the first necessary step that will lay the policy foundation for single-payer so the state can submit federal waivers and determine a just financing plan that puts the health of California before profits.
- Background. SB 104 (Committee on Budget and Fiscal Review), Chapter 67, Statutes of 2019, established the Commission and charged it with developing a plan that includes options for advancing progress toward a health care delivery system in California that provides coverage and access through a unified financing system, including, but not limited to, a single-payer financing system, for all Californians. The Commission’s report was the final deliverable required by SB 104. The report provided an endorsement of a rationale for a system of unified health care financing that is accessible, affordable, equitable, high-quality and universal, among other things.
- UC Labor Center Analysis. A presentation made to the Healthy California for All Commission by the UC Labor Center on November 17, 2021, asserted that by 2031, total health spending in California was projected to grow by $158 billion in 2021 dollars. Under the current system, the 2022 estimate for health care expenditures in California would be $517 billion, broken down as follows: employer and household spending at $222 billion, federal spending at $204 billion, state and local spending at $45 billion and other spending at $45 billion. According to this presentation, California would need to replace the $222 billion of employer and household spending. However, the presentation also pointed out that there would be substantial savings related to administrative overhead, significant drug cost reductions and reduced provider payments reflecting billing- and insurance-related savings for providers but otherwise assumed that doctors, hospitals and other providers would be paid, in aggregate, what they are currently paid. Additionally, under unified financing, there would be increased use of services associated with the expansion of coverage and reduction in consumer cost-sharing. Reduced health spending growth could be achieved by various means, including payment reforms, systems accountability and care coordination. The estimate indicated that the $222 billion in employer and household spending could be replaced by $207 billion in more progressive financing under a single-payer scenario with no cost sharing and no expansion of LTSS. Under an assumption with no cost sharing and with LTSS expansion, the estimate indicates California would need to raise $233 billion.
- Prior Legislation. Since 2007, five single-payer bills have been introduced:
- AB 1400 (Kalra), of the 2021-22 Legislative Session, died on third reading.
- SB 562 (Lara), of the 2017-18 Legislative Session, died in Assembly Rules Committee.
- SB 810 (Leno), of the 2011-12 Legislative Session, failed passage on the Senate Floor.
- SB 810 (Leno), of the 2009-10 Legislative Session, was not taken up on the Assembly Floor.
- SB 840 (Kuehl), of the 2007-08 Legislative Session, was vetoed by Governor Schwarzenegger, who cited a Legislative Analyst's Office analysis that estimated the bill to cost $210 billion in its first full year of implementation and cause annual shortfalls of $42 billion.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: April 23, 2024
ASSEMBLY COMMITTEE ON HEALTH
Mia Bonta, Chair
ABPCA Bill Id:AB 2200
Author:(Kalra) – As Amended Ver:April 9, 2024
SUBJECT: Guaranteed Health Care for All.
SUMMARY: Creates the California Guaranteed Health Care for All Act. Establishes in state government the California Guaranteed Health Care for All program, or CalCare, to be governed by the CalCare Board (board). Specifies that every state resident is eligible and entitled to enroll as a CalCare member. Prohibits a member from being required to pay a fee, payment, or other charge for enrolling in or being a CalCare member. Entitles individuals enrolled for CalCare benefits to have payments made by CalCare to a participating provider for the health care items and services if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition. Provides that a health care provider or entity is qualified to participate as a CalCare provider, as specified. Requires the CalCare board to adopt regulations regarding contracting for, and establishing payment methodologies for, covered health care items and services. Requires CalCare to establish a single standard of care, therapeutic, and effective care for all state residents. Establishes an Office of Health Equity (Office) within CalCare. Authorizes the CalCare board to seek all federal waivers and other federal approvals and arrangements and submit state plan amendments as necessary to operate CalCare. Creates the CalCare Trust Fund and requires the CalCare board to annually prepare a budget that specifies a budget for all expenditures to be made for covered health care items and services. Specifies the intent of the Legislature to enact legislation that would develop a revenue plan, taking into considerations anticipated federal revenue available for CalCare. Specifically, this bill:
Governance
- Requires CalCare to be governed by an executive board, known as the CalCare board, consisting of nine voting members who are residents of California. Requires the board to be an independent public entity not affiliated with an agency or department. Requires, of the members of the board, five to be appointed by the Governor, two to be appointed by the Senate Committee on Rules, and two to be appointed by the Speaker of the Assembly. Requires the Secretary of the California Health and Human Services Agency (CHHSA) or the Secretary’s designee to serve as a nonvoting, ex officio member of the board.
- Requires a member of the board, other than an ex officio member, to be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules to be for a term of five years, and the initial appointment by the Speaker of the Assembly to be for a term of two years. Allows these members to be reappointed for succeeding four-year terms.
- Requires appointments by the Governor to be subject to confirmation by the Senate. Allows a member of the board to continue to serve until the appointment and qualification of the member’s successor. Requires vacancies to be filled by appointment for the unexpired term. Requires the board to elect a chairperson on an annual basis.
- Requires each person appointed to the board to have demonstrated and acknowledged expertise in health care policy or delivery. Requires appointing authorities to also consider the expertise of the other members of the board and attempt to make appointments so that the board’s composition reflects a diversity of expertise in the various aspects of health care and the diversity of various regions within the state.
- Requires appointments to the board to be made as follows:
- Two health care professionals who practice medicine. At least one to be a practicing physician or medical doctor;
- One registered nurse;
- One public health professional;
- One mental health professional;
- One member with an institutional provider background;
- One representative of a not-for-profit organization that advocates for individuals who use health care in California;
- One representative of a labor organization; and,
- One member of the committee under 15) below to serve on a rotating basis to be determined by the committee.
- Requires each member of the board to have the responsibility and duty to meet the requirements of this bill and all applicable state and federal laws and regulations, to serve the public interest of the individuals, employers, and taxpayers seeking health care coverage through CalCare, and to ensure the operational well-being and fiscal solvency of CalCare.
- Requires the appointment authorities to, in making appointments to the board, take into consideration the racial, ethnic, gender, and geographical diversity of the state so that the board’s composition reflects the communities of California.
- Prohibits a member of the board or of the staff of the board from being employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health care professional, institutional provider, or group practice while serving on the board or on the staff of the board, except board members who are practicing health care professionals may be employed by an institutional provider or group practice. Prohibits a member of the board or of the staff of the board from being a board member or an employee of a trade association of health professionals, institutional providers, or group practices while serving on the board or on the staff of the board. Allows a member of the board or of the staff of the board to be a health care professional if that member does not have an ownership interest in an institutional provider or a professional health care practice.
- Specifies a board member is to receive compensation for service on the board. Authorizes a board member to receive a per diem and reimbursement for travel and other necessary expenses while engaged in the performance of official duties of the board.
- Prohibits a member of the board from making, participate in making, or in any way attempting to use the member’s official position to influence the making of a decision that the member knows, or has reason to know, will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on the member or a person in the member’s immediate family, or on either of the following:
- Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status aggregating two hundred fifty dollars ($250) or more in value provided to, received by, or promised to the member within 12 months before the decision is made; or,
- Any business entity in which the member is a director, officer, partner, trustee, employee, or holds any position of management.
- Prohibits liability in a private capacity on the part of the board or a member of the board, or an officer or employee of the board, for or on account of an act performed or obligation entered into in an official capacity, when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this title or affairs related to this bill.
- Requires the board to hire an executive director to organize, administer, and manage the operations of the board. Exempts the executive director from civil service and serves at the pleasure of the board.
- Subjects the board to the Bagley-Keene Open Meeting Act, except authorizes the board to hold closed sessions when considering matters related to litigation, personnel, contracting, and provider rates.
- Authorizes the board to adopt rules and regulations as necessary to implement and administer this title in accordance with the Administrative Procedure Act.
- Requires the board to convene a CalCare Public Advisory Committee (committee) to advise the board on all matters of policy for CalCare. Requires the committee to consist of members who are residents of California.
- Requires members of the committee to be appointed by the board for a term of two years. Allows for reappointment for succeeding two-year terms.
- Requires committee members to be as follows:
- Four health care professionals;
- One registered nurse;
- One representative of a licensed health facility;
- One representative of an essential community provider;
- One representative of a physician organization or medical group;
- One behavioral health provider;
- One dentist or oral care specialist;
- One representative of private hospitals;
- One representative of public hospitals;
- One individual who is enrolled in and uses health care items and services under CalCare;
- Two representatives of organizations that advocate for individuals who use health care in California, including at least one representative of an organization that advocates for the disabled community; and,
- Two representatives of organized labor, including at least one labor organization representing registered nurses.
- Requires the board to, in convening the committee, make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the social and geographic diversity of the state.
- Requires committee members to serve without compensation, but to be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies, and to receive one hundred fifty dollars ($150) for each full day of attending meetings of the committee. Defines full day of attending a meeting to mean presence at, and participation in, not less than 75% of the total meeting time of the committee during any particular 24-hour period.
- Requires the committee to meet at least once every quarter, and to solicit input on agendas and topics set by the board. Requires all meetings of the committee to be open to the public, pursuant to the Bagley-Keene Open Meeting Act.
- Requires the committee to elect a chairperson to serve for two years and to be reelected for an additional two years.
- Prohibits committee members, or their assistants, clerks, or deputies, from using for personal benefit any information that is filed with, or obtained by, the committee and that is not generally available to the public.
- Requires the board to have all powers and duties necessary to establish and implement CalCare. Requires the board to provide, under CalCare, comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state.
- Requires the board, to the maximum extent possible, to organize, administer, and market CalCare and services as a single-payer program under the name “CalCare” or any other name as the board determines, regardless of which law or source the definition of a benefit is found, including, on a voluntary basis, retiree health benefits. Requires the board to, in implementing this bill, avoid jeopardizing federal financial participation in the programs that are incorporated into CalCare and to take care to promote public understanding and awareness of available benefits and programs.
- Requires the board to consider any matter to effectuate the provisions and purposes of this bill. Prohibits the board from having executive, administrative, or appointive duties except as otherwise provided by law.
- Requires the board to designate the executive director to employ necessary staff and authorize reasonable, necessary expenditures from the CalCare Trust Fund to pay program expenses and to administer CalCare. Requires the executive director to hire or designate another to hire staff, as specified. Requires the executive director, or the executive director’s designee, to give preference in hiring to all individuals displaced or unemployed as a direct result of the implementation of CalCare, including as set forth in 42) below.
- Requires the board to do or delegate to the executive director all of the following:
- Determine goals, standards, guidelines, and priorities for CalCare;
- Annually assess projected revenues and expenditures and ensure the financial solvency of CalCare;
- Develop CalCare’s budget pursuant to 231) below to ensure adequate funding to meet the health care needs of the population, and review all budgets annually to ensure they address disparities in service availability and health care outcomes and for sufficiency of rates, fees, and prices to address disparities;
- Establish standards and criteria for the development and submission of provider operating and capital expenditure requests pursuant to 133) below;
- Establish standards and criteria for the allocation of funds from the CalCare Trust Fund 230) below;
- Determine when individuals may begin enrolling in CalCare. Requires an implementation period that begins on the date that individuals may begin enrolling in CalCare and ends on a date determined by the board;
- Establish an enrollment system that ensures all eligible California residents, including those who travel out of state, those who have disabilities that limit their mobility, hearing, vision, or mental or cognitive capacity, those who cannot read, and those who do not speak or write English, are aware of their right to health care and are formally enrolled in CalCare;
- Negotiate payment rates, set payment methodologies, and set prices involving aspects of CalCare and establish procedures thereto, including procedures for negotiating fee-for-service (FFS) payment to certain participating providers pursuant 260) below;
- Oversee the establishment, as part of the administration of CalCare, of the committee pursuant to 15) above;
- Implement policies to ensure that all Californians receive culturally, linguistically, and structurally competent care, pursuant 191) below to, ensure that all disabled Californians receive care in accordance with the federal Americans with Disabilities Act and the federal Rehabilitation Act of 1973, and develop mechanisms and incentives to achieve these purposes and a means to monitor the effectiveness of efforts to achieve these purposes;
- Establish standards for mandatory reporting by participating providers and penalties for failure to report, including reporting of data pursuant to 47) below and to 100) below;
- Implement policies to ensure that all residents of this state have access to medically appropriate, coordinated mental health services;
- Ensure the establishment of policies that support the public health;
- Meet regularly with the committee;
- Determine an appropriate level of, and provide support during the transition for, training and job placement for persons who are displaced from employment as a result of the initiation of CalCare pursuant to 42) below;
- In consultation with the Department of Managed Health Care (DMHC), oversee the establishment of a system for resolution of disputes and a system for independent medical review (IMR) pursuant to 90) below;
- Establish and maintain an internet website that provides information to the public about CalCare that includes information that supports choice of providers and facilities and informs the public about meetings of the board and the committee;
- Establish a process that is accessible to all Californians for CalCare to receive the concerns, opinions, ideas, and recommendations of the public regarding all aspects of CalCare; and,
- Annually prepare a written report on the implementation and performance of CalCare functions during the preceding fiscal year, that includes, at a minimum:
- The manner in which funds were expended;
- The progress toward and achievement of the requirements of this title;
- CalCare’s fiscal condition;
- Recommendations for statutory changes;
- Receipt of payments from the federal government and other sources;
- Whether current year goals and priorities have been met;
- Future goals and priorities; and,
- Requires the report to be transmitted to the Legislature and the Governor, on or before October 1 of each year and to be made available to the public on the internet website of CalCare, as specified.
- Allows the board to do or delegate to the executive director all of the following:
- Negotiate and enter into any necessary contracts, including contracts with health care providers and health care professionals;
- Sue and be sued;
- Receive and accept gifts, grants, or donations of moneys from any agency of the federal government, any agency of the state, and any municipality, county, or other political subdivision of the state;
- 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 by regulation; and,
- Share information with relevant state departments, consistent with the confidentiality provisions in this title, necessary for the administration of CalCare.
- Prohibits a carrier from offering benefits or cover health care items or services for which coverage is offered to individuals under CalCare. Allows a carrier to offer benefits to cover health care items or services that are not offered to individuals under CalCare.
- Allows a carrier to offer either of the following:
- Benefits to or for individuals, including their families, who are employed or self-employed in the state, but who are not residents of the state. Applies to a carrier except as otherwise prohibited by federal law; or,
- Benefits during the implementation period to individuals who enrolled or may enroll as members of CalCare.
- Prohibits a person from being a board a member unless the person is a member of CalCare, except the ex officio member, after the end of the implementation period.
- Requires board, no later than two years after the effective date of this bill, to develop proposals for the following:
- In consultation with the Advisory Committee on Public Employees’ Retirement System Health Benefits established under 43) below, accommodating employer retiree health benefits for people who have been members of the Public Employees’ Retirement System, but live as retirees out of the state; and,
- Accommodating employer retiree health benefits for people who earned or accrued those benefits while residing in the state before the implementation of CalCare and live as retirees out of the state.
- Requires the board to develop a proposal for CalCare coverage of health care items and services currently covered under the workers’ compensation system, including whether and how to continue funding for those item and services under that system and how to incorporate experience rating.
- Authorizes the board to contract with not-for-profit organizations to provide both of the following:
- Assistance to CalCare members with respect to selection of a participating provider, enrolling, obtaining health care items and services, disenrolling, and other matters relating to CalCare; and,
- Assistance to a health care provider providing, seeking, or considering whether to provide health care items and services under CalCare.
- Establishes in state government an Advisory Commission on Long-Term Services and Supports (commission), to advise the board on matters of policy related to long-term services and supports for CalCare.
- Requires the advisory commission to consist of eleven members who are residents of California. Requires, of the members of the advisory commission, five to be appointed by the Governor, three to be appointed by the Senate Committee on Rules, and three to be appointed by the Speaker of the Assembly. Requires the members of the advisory commission to include all of the following:
- At least two people with disabilities who use long-term services and supports;
- At least two older adults who use long-term services and supports;
- At least two providers of long-term services and supports, including one family attendant or family caregiver;
- At least one representative of a disability rights organization;
- At least one representative or member of a labor organization representing workers who provide long-term services and supports;
- At least one representative of a group representing seniors; and,
- At least one researcher or academic in long-term services and supports.
- Requires, in making appointments pursuant to 36) above, the Governor, the Senate Committee on Rules, and the Speaker of the Assembly to make good faith efforts to ensure that their appointments, as a whole, reflect, to the greatest extent feasible, the diversity of the population of people who use long-term services and supports, including their race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geographic location, and socioeconomic status.
- Allows a member of the advisory commission to continue to serve until the appointment and qualification of that member’s successor. Requires vacancies to be filled by appointment for the unexpired term. Requires members of the advisory commission to be appointed for a term of four years, except that the initial appointment by the Senate Committee on Rules to be for a term of five years, and the initial appointment by the Speaker of the Assembly to be for a term of two years. Allows these members to be reappointed for succeeding four-year terms.
- Requires vacancies that occur to be filled within 30 days after the occurrence of the vacancy, and to be filled in the same manner in which the vacating member was initially selected or appointed. Requires the CHHSA Secretary to notify the appropriate appointing authority of any expected vacancies on the long-term services and supports advisory commission.
- Requires members of the advisory commission to serve without compensation, but to be reimbursed for actual and necessary expenses incurred in the performance of their duties to the extent that reimbursement for those expenses is not otherwise provided or payable by another public agency or agencies. Requires members to also receive one hundred fifty dollars ($150) for each full day of attending meetings of the advisory commission. Defines full day of attending a meeting to mean presence at, and participation in, not less than 75% of the total meeting time of the advisory commission during any particular 24-hour period.
- Requires the advisory commission to meet at least six times per year in a place convenient to the public. Requires all meetings of the advisory commission to be open to the public, pursuant to the Bagley-Keene Open Meeting Act. Requires the advisory commission to elect a chairperson who shall serve for two years and who may be reelected for an additional two years. Prohibits the advisory commission members or any of their assistants, clerks, or deputies from using for personal benefit any information that is filed with, or obtained by, the advisory commission and that is not generally available to the public.
- Requires the board to provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for program assistance to individuals employed or previously employed in the fields of health insurance, health care service plans, or other third-party payments for health care, individuals providing services to health care providers to deal with third-party payers for health care, individuals who may be affected by and who may experience economic dislocation as a result of the implementation of this bill, and individuals whose jobs may be or have been ended as a result of the implementation of CalCare, consistent with otherwise applicable law. Specifies assistance described to include job training and retraining, job placement, preferential hiring, wage replacement, retirement benefits, and education benefits.
- Requires the board to establish an Advisory Committee on Public Employees’ Retirement System Health Benefits to provide input, including recommendations, to the board on matters of policy related to public employee retiree health benefits and CalCare, including all of the following:
- Processes to obtain approval of CalCare as a health benefits plan under public pension or retirement systems;
- Recommendations to the Legislature and Governor to provide tax or other accommodations for people who have accrued retiree health benefit contributions under public employees’ retirement systems;
- Recommendations to, and coordination with, public employee retirement system boards to fully integrate beneficiaries into CalCare;
- Processes to change or phase out health benefits under public employees’ retirement systems to fully integrate beneficiaries into CalCare; and,
- Federal approvals that may support transition of Medicare plans under public employees’ retirement systems to CalCare.
- Requires the board to appoint the members of the advisory committee during the implementation period. Requires appointments to be made by a majority vote of the voting members of the board. Requires the board to aim for broad representation, including, at a minimum, the following representatives of public sector labor organizations, the Public Employees’ Retirement System, the State Teachers’ Retirement System, the University of California Retirement System, and locally administered public pension or retirement systems when appointing members to the advisory committee. Requires one-half of the committee members, at a minimum, to be representatives of public sector labor organizations.
- Requires each appointed member to serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
- Prohibits advisory committee members from having access to confidential, nonpublic information that is accessible to the board and office. Requires instead, the advisory committee to only have access to information that is publicly available. Neither the board nor the office to disclose any confidential, nonpublic information to the advisory committee members. Requires advisory committee members to receive reimbursement for travel and other actual costs. Requires the advisory committee to meet at least four times per year in a place convenient to the public. Subjects all meetings of the advisory committee to be open to the public, pursuant to the Bagley-Keene Open Meeting Act. Requires the board to consider input, including recommendations, from the advisory committee, along with public comments, in the board’s deliberation and decisionmaking.
- Requires the board to utilize the data collected pursuant to the existing Health Data and Advisory Council Consolidation Act to assess patient outcomes and to review utilization of health care items and services paid for by CalCare.
- Provides that the board require and enforce the collection and availability of all of the following data to promote transparency, assess quality of care, compare patient outcomes, and review utilization of health care items and services paid for by CalCare, As applicable to the type of provider, which shall be reported to the board and, as applicable, the Department of Health Care Access and Information (HCAI) or the Medical Board of California (MBC):
- Inpatient discharge data, including severity of illness and risk of mortality, with respect to each discharge;
- Emergency department, ambulatory surgical center, and other outpatient department data, including cost data, charge data, length of stay, and patients’ unit of observation with respect to each individual receiving health care items and services;
- For hospitals and other providers receiving global budgets, annual financial data, including all of the following:
- Community benefit activities, including charity care, as specified, provided by the provider in dollar value at cost;
- Number of employees by employee classification or job title and by patient care unit or department;
- Number of hours worked by the employees in each patient care unit or department;
- Employee wage information by job title and patient care unit or department;
- Number of registered nurses per staffed bed by patient care unit or department;
- A description of all information technology, including health information technology and artificial intelligence, used by the provider and the dollar value of that information technology; and,
- Annual spending on information technology, including health information technology, artificial intelligence, purchases, upgrades, and maintenance.
- Risk-adjusted and raw outcome data, including:
- Risk-adjusted outcome reports for medical, surgical, and obstetric procedures selected by the HCAI pursuant existing law; and,
- Any other risk-adjusted outcome reports that the board may require for medical, surgical, and obstetric procedures and conditions as it deems appropriate, and,
- A disclosure made by a provider of unearned rebates, refunds, and discounts pursuant to existing law.
- Requires the MBC to collect data for the outpatient surgery settings that the MBC regulates that meets the Ambulatory Surgery Data Record requirements of existing law, and to submit that data to the CalCare board.
- Requires the board to make that data available as required under 51) below.
- Requires the board to make all disclosed data collected publicly available and searchable through an internet website and through the HCAI public data sets.
- Requires the board to make available data collected through CalCare to the HCAI and the CHHSA, consistent with this bill and otherwise applicable law, to promote and protect public, environmental, and occupational health consistent with state and federal privacy laws.
- Requires the board to, before full implementation of CalCare, and, for providers seeking to receive global budgets or salaried payments under 133) below, as applicable, before the negotiation of initial payments, the board provide for the collection and availability of the following data:
- The number of patients served;
- The dollar value of the care provided, at cost, for all of the following categories of HCAI data items:
- Patients receiving charity care;
- Contractual adjustments of county and indigent programs, including traditional and managed care; and,
- Bad debts or any other unpaid charges for patient care that the provider sought, but was unable to collect.
- Requires the board to regularly analyze information reported under this section and to establish rules and regulations to allow researchers, scholars, participating providers, and others to access and analyze data for purposes consistent with this bill, without compromising patient privacy.
- Requires the board to establish regulations for the collection and reporting of data to promote transparency, assess patient outcomes, and review utilization of services provided by physicians and other health care professionals, as applicable, and paid for by CalCare.
- Requires the board to, in implementing 47) above, utilize data that is already being collected pursuant to other state or federal laws and regulations whenever possible.
- Provides that data reporting required by participating providers under 47) above to supplement the data collected by the HCAI and prohibits modifying or altering other reporting requirements to governmental agencies.
- Prohibits the board from utilizing quality or other review measures established under 47) above for the purposes of establishing payment methods to providers.
- Allows the board to coordinate and cooperate with the HCAI or other health planning agencies of the state to implement the requirements of 47) above.
- Requires the board to establish and use a process to enter into participation agreements with health care providers and other contracts with contractors. Exempts contract entered into pursuant to this bill from the Public Contract Code, and from the review or approval of the Department of General Services (DGS). Requires the board to adopt a CalCare Contracting Manual incorporating procurement and contracting policies and procedures to be followed by CalCare. Requires the policies and procedures in the manual to be substantially similar to the provisions contained in the State Contracting Manual.
- Provides that the adoption, amendment, or repeal of a regulation by the board to implement 60) above, including the adoption of a manual and any procurement process conducted by CalCare in accordance with the manual, is exempt from the rulemaking provisions of the Administrative Procedure Act.
- Prohibits CalCare, a state or local agency, or a public employee acting under color of law from providing or disclosing to anyone, including the federal government, any personally identifiable information obtained, including a person’s religious beliefs, practices, or affiliation, national origin, ethnicity, or immigration status, for law enforcement or immigration purposes.
- Prohibits law enforcement agencies from using CalCare moneys, facilities, property, equipment, or personnel to investigate, enforce, or assist in the investigation or enforcement of a criminal, civil, or administrative violation or warrant for a violation of a requirement that individuals register with the federal government or a federal agency based on religion, national origin, ethnicity, immigration status, or other protected category as recognized in the Unruh Civil Rights Act.
- Requires the board to, on or before July 1, ____, conduct and deliver a fiscal analysis to determine both of the following:
- Whether or not CalCare may be implemented; and,
- If revenue is more likely than not to be sufficient to pay for program costs within eight years of CalCare’s implementation.
- Authorizes the board to contract with one or more independent entities with the appropriate expertise or coordinate with other state agencies to conduct the fiscal analysis.
- Requires the board deliver, and upon request present, the fiscal analysis to the Chair of the Senate Committee on Health, the Chair of the Assembly Committee on Health, the Chair of the Senate Committee on Appropriations, and the Chair of the Assembly Committee on Appropriations.
Eligibility and Enrollment
- Provides that every resident of the state be eligible and entitled to enroll as a member of CalCare.
- Prohibits a member from being required to pay a fee, payment, or other charge for enrolling in or being a member of CalCare.
- Prohibits a member from being required to pay a premium, copayment, coinsurance, deductible, or any other form of cost sharing for all covered benefits under CalCare.
- Authorizes a college, university, or other institution of higher education in the state to purchase coverage under CalCare for a student, or a student’s dependent, who is not a resident of the state.
- Allows an individual entitled to benefits through CalCare to obtain health care items and services from any institution, agency, or individual participating provider.
- Requires the board to establish a process for automatic CalCare enrollment at the time of birth in California.
- Provides that all residents of this state, no matter what their sex, race, color, religion, ancestry, national origin, disability, age, previous or existing medical condition, genetic information, marital status, familial status, military or veteran status, sexual orientation, gender identity or expression, pregnancy, pregnancy-related medical condition, including termination of pregnancy, citizenship, primary language, or immigration status, are entitled to full and equal accommodations, advantages, facilities, privileges, or services in all health care providers participating in CalCare.
- Prohibits a participating provider, or an entity conducting, administering, or funding a health program or activity pursuant to this bill, from discriminating based upon the categories described in 73) above in the provision, administration, or implementation of health care items and services through CalCare. Includes the following:
- Exclusion of a person from participation in or denial of the benefits of CalCare, except as expressly authorized by this title for the purposes of enforcing eligibility standards in 67) above;
- Reduction of a person’s benefits; and,
- Any other discrimination by any participating provider or any entity conducting, administering, or funding a health program or activity pursuant to this bill.
- Applies personal rights penalties in existing law for the actual damages, any amount that may be determined by a jury, or a court sitting without a jury, up to a maximum of three times the amount of actual damage but in no case less than four thousand dollars ($4,000), and any attorney’s fees that may be determined by the court in addition thereto, suffered by any person denied the rights, as specified.
- Specifies that a participating provider or entity is in violation of 74) above if the complaining party demonstrates that any of the categories listed in 73) above was a motivating factor for any health care practice, even if other factors also motivated the practice.
Benefits
- Entitles individuals enrolled for benefits under CalCare to have payment made by CalCare to a participating provider for the health care items and services in 79) below, if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.
- Requires the determination of medical necessity or appropriateness to be made by the member’s treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards, as established, and by the board, and other laws of the state.
- Specifies covered health care benefits for members to include all of the following categories of health care items and services:
- Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services;
- Inpatient and outpatient health care professional services and other ambulatory patient services;
- Primary and preventive services, including chronic disease management;
- Prescription drugs, biological products, and all contraceptive items approved by the United States Food and Drug Administration;
- Medical devices, equipment, appliances, and assistive technology;
- Mental health and substance abuse treatment services, including inpatient and outpatient care;
- Diagnostic imaging, laboratory services, and other diagnostic and evaluative services;
- Comprehensive reproductive care, including abortion, contraception, and assistive reproductive technology, maternity care, and newborn care;
- Pediatrics;
- Oral health, audiology, and vision services;
- Rehabilitative and habilitative services and devices, including inpatient and outpatient care;
- Emergency services and transportation;
- Early and periodic screening, diagnostic, and treatment services as defined in federal law;
- Comprehensive gender-affirming health care;
- Necessary transportation for health care items and services for persons with disabilities or who may qualify as low income;
- Long-term services and supports described in Section 100636, including long-term services and supports covered under Medi-Cal or the federal Children’s Health Insurance Program (CHIP);
- Care coordination; and,
- Any additional health care items and services the board authorizes to be added to CalCare benefits.
- Includes all the following under the categories of covered health care items and services of 79) above:
- Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual;
- Child and adult immunizations;
- Hospice care;
- Care in a skilled nursing facility;
- Home health care, including health care provided in an assisted living facility;
- Prenatal and postnatal care;
- Podiatric care;
- Blood and blood products;
- Dialysis;
- Community-based adult services as defined;
- Dietary and nutritional therapies determined appropriate by the board;
- Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture;
- Health care items and services previously covered by county integrated health and human services programs;
- Health care items and services previously covered by a regional center for persons with developmental disabilities; and,
- Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers.
- Includes all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:
- CHIP;
- Medi-Cal;
- The federal Medicare program;
- Health care service plans pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (KKA);
- Health insurers, as defined in the Insurance Code; and,
- All essential health benefits (EHBs) mandated by the federal Patient Protection and Affordable Care Act (ACA) as of January 1, 2017.
- Prohibits health care items and services covered under CalCare from being subject to prior authorization or a limitation applied through the use of step therapy protocols.
- Entitles individuals enrolled for benefits under CalCare to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this bill, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:
- Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living; or,
- Is a disability, as defined in federal law, that substantially limits one or more of the member’s major life activities.
- Requires the board to adopt regulations that provide for the following:
- The determination of individual eligibility for long-term services and supports under 83) above;
- The assessment of the long-term services and supports needed for an eligible individual; or,
- The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program to the long-term services and supports under 83) above.
- Requires long-term services and supports provided in 83) above to do all of the following:
- Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting;
- Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care;
- Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the member’s maximum possible autonomy and the member’s maximum possible civic, social, and economic participation;
- Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization;
- Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipient’s type or level of disability, service need, or age;
- Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the member’s needs;
- Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity;
- Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions; and,
- Ensure that long-term services and supports provide recipients the option of self-direction of service, as specified, from either the recipient or care coordinators of the recipient’s choosing.
- Requires the board to consult the advisory commission established in 35) in developing regulations to implement 84) above.
- Requires the board to, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.
- Prohibits the board from removing or eliminating covered health care items and services under CalCare as listed in this bill.
- Requires the board to establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare.
- Requires the board to establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the IMR System established in DMHC. Defines the following:
- Coverage decision as the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A “coverage decision” does not encompass a decision regarding a disputed health care item or service; and,
- Disputed health care item or service as a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision.
Health Care Delivery
- Qualifies a health care provider or entity to participate as a provider in CalCare if the health care provider furnishes health care items and services while the provider, or, if the provider is an entity, the individual health care professional of the entity furnishing the health care items and services, is physically present within the State of California, and if the provider meets all of the following:
- The provider or entity is a health care professional, group practice, or institutional health care provider licensed to practice in California;
- The provider or entity agrees to accept CalCare rates as payment in full for all covered health care items and services;
- The provider or entity has filed with the board a participation agreement described in x) below; and,
- The provider or entity is otherwise in good standing.
- Requires the board to establish and maintain procedures and standards for recognizing health care providers located out of the state for purposes of providing coverage under CalCare for members who require out-of-state health care services while the member is temporarily located out of the state.
- Prohibits a provider or entity from being qualified to furnish health care items and services under CalCare if the provider or entity does not provide health care items or services directly to individuals, including the following:
- Entities or providers that contract with other entities or providers to provide health care items and services. Prohibits these entities or providers from being considered a qualified provider for those contracted items and services.
- Entities that are approved to coordinate care plans under the Medicare Advantage program as of January 1, 2020, but do not directly provide health care items and services.
- Authorizes a health care provider qualified to participate to provide covered health care items or services under CalCare, as long as the health care provider is legally authorized to provide the health care item or service for the individual and under the circumstances involved.
- Requires the board to establish and maintain procedures for members and individuals eligible to enroll in CalCare to enroll onsite at a participating provider.
- Requires a participating provider to accept onsite enrollment of members and eligible individuals under the procedures established.
- Requires the board to establish and maintain procedures and standards for members to select a primary care provider, which may be an internist, a pediatrician, a physician who practices family medicine, a gynecologist, a physician who practices geriatric medicine, or, at the option of a member who has a chronic condition that requires specialty care, a specialist health care professional who regularly and continually provides treatment to the member for that condition, and other participating providers.
- Provides that a referral from a primary care provider is not required for a member to see a participating provider.
- Allows a member to choose to receive health care items and services under CalCare from a participating provider, subject to the willingness or availability of the provider, and consistent with the provisions of this title relating to discrimination, and the appropriate clinically relevant circumstances and standards.
- Requires a health care provider to enter into a participation agreement with the board to qualify as a participating provider under CalCare.
- Requires a participation agreement between the board and a health care provider to include provisions for at least the following, as applicable to each provider:
- Health care items and services to members to be furnished by the provider without discrimination, as required by 69) above. Prohibits the provision of a type or class of health care items or services that are outside the scope of the provider’s normal practice.
- Prohibits a charge to be made to a member for a covered health care item or service, other than for payment authorized by this title. Provides that, except as described in 119) below, a contract not be entered into with a patient for a covered health care item or service.
- Requires the provider to follow the policies and procedures in the CalCare Contracting Manual established 61) above.
- Requires the provider to furnish information reasonably required by the board and shall meet the reporting requirements of 47) above and 193 below for at least the following:
- Quality review by designated entities.
- Making payments, including the examination of records as necessary for the verification of information on which those payments are based.
- Statistical or other studies required for the implementation of this bill.
- Other purposes specified by the board.
- Prohibits the provider from employing or using an individual or other provider that has had a participation agreement terminated for cause to provide covered health care items and services if the provider is not an individual.
- Requires the provider to submit bills and required supporting documentation relating to the provision of covered health care items or services within 30 days after the date of providing those items or services if the provider is paid on a FFS basis for covered health care items and services.
- Requires the provider to submit information and any other required supporting documentation reasonably required by the board on a quarterly basis that relates to the provision of covered health care items and services and describes health care items and services furnished with respect to specific individuals.
- Requires the provider to, if the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, disclose the following to the board:
- Any case mix indexes, diagnosis coding software, procedure coding software, or other coding system utilized by the provider for the purposes of meeting payment, global budget, or other disclosure requirements under this bill; and,
- Any case mix indexes, diagnosis coding guidelines, procedure coding guidelines, or coding tip sheets used by the provider for the purposes of meeting payment or disclosure requirements under this bill.
- Prohibits the provider from, if the provider receives payment based on provider data on diagnosis-related coding, procedure coding, or other coding system or data, doing the following:
- Use proprietary case mix indexes, diagnosis coding software, procedure coding software, or other coding system for the purposes of meeting payment, global budget, or other disclosure requirements under this bill;
- Require another health care professional to apply case mix indexes, diagnosis coding software, procedure coding software, or other coding system in a manner that limits the clinical diagnosis, treatment process, or a treating health care professional’s judgment in determining a diagnosis or treatment process, including the use of leading queries or prohibitions on using certain codes;
- Provide financial incentives or disincentives to physicians, registered nurses, or other health care professionals for particular coding query results or code selections; and,
- Use case mix indexes, diagnosis coding software, procedure coding software, or other coding system that make suggestions for higher severity diagnoses or higher cost procedure coding.
- Requires the provider to comply with the duty of patient advocacy and reporting requirements described in 192) below.
- Provides that if the provider is not an individual, the provider to ensure that a board member, executive, or administrator of the provider is not receiving compensation from, own stock or have other financial investments in, or receive services as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
- Provides that if the provider is a not-for-profit hospital, as specified, the hospital to submit to the board the community benefits plan developed pursuant existing law.
- Requires health care items and services to members to be furnished by a health care professional while the professional is physically present within the State of California.
- Prohibits the provider from entering into risk-bearing, risk-sharing, or risk-shifting agreements with other health care providers or entities other than CalCare.
- Does not limit the formation of group practices.
- Authorizes a participation agreement to be terminated with appropriate notice by the board for failure to meet the requirements of this bill or may be terminated by a provider.
- Requires a participating provider to be provided notice and a reasonable opportunity to correct deficiencies before the board terminates an agreement, unless a more immediate termination is required for public safety or similar reasons.
- Requires the procedures and penalties under the Medi-Cal program for fraud or abuse pursuant existing law to apply to an applicant or provider under CalCare. Defines the following:
- Applicant as an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the board to participate as a provider in CalCare; and,
- Provider as an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to CalCare program members.
- Prohibits a person from discharging or otherwise discriminating against an employee on account of the employee or a person acting pursuant to a request of the employee for any of the following:
- Notifying the board, executive director, or employee’s employer of an alleged violation of this bill, including communications related to carrying out the employee’s job duties;
- Refusing to engage in a practice made unlawful by this title, if the employee has identified the alleged illegality to the employer;
- Providing, causing to be provided, or being about to provide or cause to be provided to the provider, the federal government, or the Attorney General information relating to a violation of, or an act or omission the provider or representative reasonably believes to be a violation of, this bill;
- Testifying before or otherwise providing information relevant for a state or federal proceeding regarding this bill or a proposed amendment to this bill;
- Commencing, causing to be commenced, or being about to commence or cause to be commenced a proceeding under this bill;
- Testifying or being about to testify in a proceeding;
- Assisting or participating, or being about to assist or participate, in a proceeding or other action to carry out the purposes of this bill; and,
- Objecting to, or refusing to participate in, an activity, policy, practice, or assigned task that the employee or representative reasonably believes to be in violation of this bill or any order, rule, regulation, standard, or ban under this bill.
- Allows an employee covered by this section who alleges discrimination by an employer in violation to 117) above to bring an action governed by the rules and procedures, legal burdens of proof, and remedies applicable under the False Claims Act, or an action against unfair competition, as specified.
- Prohibits the rights and remedies in 118) above from being waived by an agreement, policy, form, or condition of employment or preempting or diminishing any other law or regulation against discrimination, demotion, discharge, suspension, threats, harassment, reprimand, retaliation, or any other manner of discrimination. Defines the following:
- Employer as a person engaged in profit or not-for-profit business or industry, including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees, and who is subject to liability for violating this bill; and,
- Employee as an individual performing activities under this bill on behalf of an employer.
- Prohibits an institutional or other health care provider with a participation agreement in effect from billing or entering into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is a covered benefit through CalCare.
- Allows an institutional or other health care provider with a participation agreement in effect to bill or enter into a private contract with an individual eligible for benefits through CalCare for a health care item or service that is not a covered benefit through CalCare if the following requirements are met:
- The contract and provider meet the requirements specified in 122) and 124) below;
- The health care item or service is not payable or available through CalCare; and,
- The provider does not receive reimbursement, directly or indirectly, from CalCare for the health care item or service, and does not receive an amount for the health care item or service from an organization that receives reimbursement, directly or indirectly, for the health care item or service from CalCare.
- Requires a contract described in 121) above to be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the health care item or service is furnished pursuant to the contract, and to not be entered into at a time when the individual is facing an emergency health care situation.
- Requires a contract described in 121) above to clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
- Prohibits the individual from submitting a claim or request that the provider submit a claim to CalCare for the health care item or service;
- The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service;
- The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service; and,
- The individual understands that the provider is providing services outside the scope of CalCare.
- Requires a participating provider that enters into a contract described in 120) above to have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, to be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. Requires the affidavit to identify the provider who is to furnish the noncovered health care item or service, state that the provider will not submit a claim to CalCare for a noncovered health care item or service provided to a member, and be signed by the provider.
- Requires all of the following to apply if a provider signing an affidavit described in 124) above knowingly and willfully submits a claim to CalCare for a noncovered health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract:
- A contract described 120) to be void;
- A payment to not be made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period to be remitted to CalCare, plus interest; and,
- A payment received by the provider from the member, CalCare, or other payer for a health care item or service furnished during the period described in 125)b) above to be remitted to the payer, and damages to be available to the payer pursuant to existing law.
- Allows an institutional or other health care provider with a participation agreement in effect to bill or enter into a private contract with an individual ineligible for benefits under CalCare for a health care item or service. Requires the institutional or other health care provider to report to the board, on an annual basis, aggregate information regarding services furnished to ineligible individuals consistent with 63) above.
- Allows an institutional or other health care provider without a participation agreement in effect to bill or enter into a private contract with an individual eligible for benefits under CalCare for a health care item or service that is a covered benefit through CalCare only if the contract and provider meet the requirements specified in 128) and 129) below.
- Requires a contract described in 127) above to be in writing and signed by the individual, or authorized representative of the individual, receiving the health care item or service before the item or service is furnished pursuant to the contract, and to not be entered into at a time when the individual is facing an emergency health care situation.
- Requires a contract described in 127) above to clearly indicate to the individual receiving the health care item or service that by signing the contract, the individual agrees to all of the following:
- The individual understands that the individual has the right to have the health care item or service provided by another provider for which payment would be made under CalCare;
- The individual shall not submit a claim or request that the provider submit a claim to CalCare for the health care item or service, even if the health care item or service is otherwise covered under CalCare;
- The individual is responsible for payment of the health care item or service and understands that reimbursement shall not be provided under CalCare for the health care item or service;
- The individual understands that the limits under CalCare do not apply to amounts that may be charged for the health care item or service; and,
- The individual understands that the provider is providing services outside the scope of CalCare.
- Requires a provider that enters into a contract described in 127) above to have in effect, during the period a health care item or service is to be provided pursuant to the contract, an affidavit, which shall be filed with the board no later than 10 days after the first contract to which the affidavit applies is entered into. Requires the affidavit to identify the provider who is to furnish the health care item or service, state that the provider will not submit a claim to CalCare for a health care item or service provided to a member during a two-year period beginning on the date the affidavit was signed, and be signed by the provider.
- Requires all of the following apply if a provider who signed an affidavit described in 130) above knowingly and willfully submits a claim to CalCare for a health care item or service or receives reimbursement or an amount for a health care item or service provided pursuant to a private contract described in an affidavit signed:
- A contract described in 127) above to be void;
- Prohibits a payment from being made under CalCare for a health care item or service furnished by the provider during the two-year period beginning on the date the affidavit was signed or the date the claim was submitted, whichever is later. A payment made by CalCare to the provider during that two-year period be remitted to CalCare, plus interest; and,
- A payment received by the provider from the member, CalCare program, or other payer for a health care item or service furnished during the period described in 131) b) to be remitted to the payer, and damages to be available to the payer pursuant to existing law.
- Allows an institutional or other health care provider without a participation agreement in effect to bill or enter into a private contract with an individual for a health care item or service that is not a benefit under CalCare.
Payment for Health Care Items and Services
- Requires the board to adopt regulations regarding contracting for, and establishing payment methodologies for, covered health care items and services provided to members under CalCare by participating providers. Requires all payment rates under CalCare to be reasonable and reasonably related to all of the following:
- The cost of efficiently providing health care items and services;
- Ensuring availability and accessibility of CalCare health care services, including compliance with state requirements regarding network adequacy, timely access, and language access; and,
- Maintaining an optimal workforce and the health care facilities necessary to deliver quality, equitable health care.
- Requires payment for health care items and services to be considered payment in full.
- Prohibits a participating provider from charging a rate in excess of the payment established through CalCare for a health care item or service furnished under CalCare and from soliciting or accepting payment from any member or third party for a health care item or service furnished under CalCare, except as provided under a federal program.
- Does not preclude CalCare from acting as a primary or secondary payer in conjunction with another third-party payer when permitted by a federal program.
- Requires the board to pay to each institutional provider a lump sum to cover all operating expenses under a global budget as set forth in 147) below. Requires an institutional provider receiving a global budget payment to accept that payment as payment in full for all operating expenses for health care items and services furnished under CalCare, whether inpatient or outpatient, by the institutional provider, no later than the beginning of each fiscal quarter during which an institutional provider of care, including a hospital, skilled nursing facility, and chronic dialysis clinic, is to furnish health care items and services under CalCare.
- Allows a group practice, county organized health system, or local initiative to elect to be paid for health care items and services furnished under CalCare either on a FFS basis under 169) below or on a salaried basis.
- Requires a group practice, county organized health system, or local initiative that elects to be paid on a salaried basis to negotiate salaried payment rates with the board annually, and requires the board to pay the group practice, county organized health system, or local initiative at the beginning of each month.
- Allows the board to determine whether a group practice, county organized health system, or local initiative may elect to be paid on an hourly or other time-based rate for certain health care items and services furnished under CalCare, including primary and preventive care and care coordination.
- Requires health care items and services provided to members under CalCare by individual providers or any other providers not paid under 137) or 138) above to be paid for on a FFS basis under 169) below.
- Requires capital-related expenses for specifically identified capital expenditures incurred by participating providers to meet the requirements under 174) below.
- Requires payment methodologies and payment rates to include a distinct component of reimbursement for direct and indirect costs incurred by the institutional provider for graduate medical education, as applicable.
- Requires the board to adopt, by regulation, payment methodologies and procedures for paying for out-of-state health care services.
- Specifies that this bill does not regulate, interfere with, diminish, or abrogate a collective bargaining agreement, established employee rights, or the right, obligation, or authority of a collective bargaining representative under state or local law; nor does it not compel, regulate, interfere with, or duplicate the provisions of an established training program that is operated under the terms of a collective bargaining agreement or unilaterally by an employer or bona fide labor union.
- Requires the board to determine the appropriate use and allocation of the special projects budget for the construction, renovation, or staffing of health care facilities in rural, underserved, or health professional or medical shortage areas, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
- Requires an institutional provider’s global budget to be determined before the start of a fiscal year through negotiations between the provider and the board. Requires the global budget to be negotiated annually based on the payment factors described in 150) below.
- Requires an institutional provider’s global budget to be used only to cover operating expenses associated with direct care for patients for health care items and services covered under CalCare. Prohibits an institutional provider’s global budget from being used for capital expenditures, and capital expenditures and being included in the global budget.
- Requires the board, on a quarterly basis, to review whether requirements of the institutional provider’s participation agreement and negotiated global budget have been performed and to determine whether adjustment to the institutional provider’s payment is warranted.
- Requires a payment negotiated pursuant to 147) above to take into account, with respect to each provider, all of the following:
- The historical volume of services provided for each health care item and service in the previous three-year period;
- The actual expenditures of a provider in the provider’s most recent Medicare cost report for each health care item and service, or other cost report that may otherwise be adopted by the board, compared to the following:
- The expenditures of other comparable institutional providers in the state;
- The normative payment rates established under the comparative payment rate systems pursuant to 165) below, including permissible adjustments to the rates for the health care items and services;
- Projected changes in the volume and type of health care items and services to be furnished;
- Employee wages and compensation;
- The provider’s maximum capacity to provide health care items and services;
- Education and prevention programs;
- Health care workforce recruitment and retention programs, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to existing law;
- Permissible adjustments to the provider’s operating budget from the previous fiscal year due to factors including an increase in primary or specialty care access, efforts to decrease health care disparities in rural or medically underserved areas, a response to emergent conditions, and proposed changes to patient care programs at the institutional level; and,
- Any other factor determined appropriate by the board; and,
- In a rural or medically underserved area, the need to mitigate the impact of the availability and accessibility of health care services through increased global budget payment.
- Prohibits a payment negotiated pursuant to 147) above or payment methodology from doing any of the following:
- Take into account capital expenditures of the provider or any other expenditure not directly associated with furnishing health care items and services under CalCare;
- Be used by a provider for capital expenditures or other expenditures associated with capital projects;
- Exceed the provider’s capacity to furnish health care items and services covered under CalCare;
- Be used to pay or otherwise compensate a board member, executive, or administrator of the institutional provider who has an interest or relationship prohibited under 100) above or 192) below; and,
- Take into account relief pending appeal granted to a provider under 158) above.
- Allows the board to negotiate changes to an institutional provider’s global budget based on factors not prohibited under this bill.
- Requires compensation costs for an employee, contractor employee, or subcontractor employee of an institutional provider receiving a global budget to meet the compensation cap established federal law and its implementing regulations, except that the board may establish one or more narrowly targeted exceptions for scientists, engineers, or other specialists upon a determination that those exceptions are needed to ensure CalCare continued access to needed skills and capabilities.
- Prohibits payment to an institutional provider from allowing a participating provider to retain revenue generated from outsourcing health care items and services covered under CalCare, unless that revenue was considered part of the global budget negotiation process. Requires payment to apply to revenue from outsourcing health care items and services that were previously furnished by employees of the participating provider who were subject to a collective bargaining agreement. Defines “operating expenses” of a provider to include the following:
- The costs associated with covered health care items and services under CalCare, including the following:
- Compensation for health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider;
- Pharmaceutical products administered by health care professionals at the institutional provider’s facility or facilities;
- Purchasing supplies;
- Maintenance of medical devices and health care technologies, including diagnostic testing equipment, except that health information technology that is not necessary to comply with data collection and reporting requirements under this title or otherwise required by law and artificial intelligence shall be considered capital expenditures, unless otherwise determined by the board;
- Incidental services necessary for safe patient care;
- Patient care, education, and preventive health programs, and necessary staff to implement those programs;
- Occupational health and safety programs and public health programs, and necessary staff to implement those programs for the continued education and health and safety of clinicians and other individuals employed by the institutional provider;
- Infectious disease response preparedness, including the maintenance of a one-year or 365-day stockpile of personal protective equipment, occupational testing and surveillance, and contact tracing; and,
- Recruitment, retention, and training of health care professionals, ancillary staff, and services employed or otherwise paid by an institutional provider, including programs to maintain optimal staffing levels of health care workers as established by the board and to maintain mandatory minimum safe registered nurse-to-patient ratio regulations adopted pursuant to existing law; and,
- Administrative costs of the institutional provider.
- The costs associated with covered health care items and services under CalCare, including the following:
- Requires the board to consider a request for interim payment, filed by an institutional provider that is subject to the payments or global budget, based on the following:
- The overall financial condition of the institutional provider, including bankruptcy or financial solvency;
- Excessive risks to the ongoing operation of the institutional provider;
- Justifiable differences in costs among providers, including providing a service not available from other providers in the region, or the need for health care services in rural areas with a shortage of health professionals or medically underserved areas and populations;
- Factors that led to increased costs for the institutional provider that can reasonably be considered to be unanticipated and out of the control of the provider. Those factors may include:
- Natural disasters;
- Outbreaks of epidemics or infectious diseases;
- Unanticipated facility or equipment repairs or purchases;
- Significant and unanticipated increases in pharmaceutical or medical device prices; and,
- Public health emergencies.
- Changes in state or federal laws that result in a change in costs; and,
- Reasonable increases in labor costs, including salaries and benefits, and changes in collective bargaining agreements, prevailing wage, or local law.
- Requires the board to establish uniform written procedures under which it reviews requests for interim payment pursuant to 155) above, including procedures to provide immediate payment in the event of a public health emergency.
- Requires the board, to, on a quarterly basis, review the global budget and payments to institutional providers that are not-for-profit or governmental entities and may initiate an interim payment review under 155) above.
- Requires the board to consider an appeal of payments, the global budget, or a determination of a request for interim payment, filed by an institutional provider that is subject to the payment or global budget.
- Requires the payments set and global budget negotiated by the board to be paid to the institutional provider to stay in effect during the appeal process, subject to relief pending appeal under this subdivision.
- Requires the board to have the power to grant interim relief based on fairness. Requires the board to develop regulations governing interim relief. Requires the board to establish uniform written procedures for the submission, processing, and consideration of an interim relief appeal by an institutional provider. Requires a decision on interim relief to be granted within one month of the filing of an interim relief appeal. Requires an institutional provider to certify in its interim relief appeal that the request is made on the basis that the challenged amount is arbitrary and capricious, or that the institutional provider has experienced a bona fide emergency based on unanticipated costs or costs outside the control of the entity, including those described 155) above.
- Allows the board to delegate the conduct of a hearing to an administrative law judge, to issue a proposed decision with findings of fact and conclusions of law.
- Authorizes the administrative law judge to hold evidentiary hearings and to issue a proposed decision with findings of fact and conclusions of law, including a recommended adjusted payment or global budget, within four months of the filing of the appeal.
- Allows the board to, within 30 days of receipt of the proposed decision by the administrative law judge, approve, disapprove, or modify the decision, and to issue a final decision for the appealing institutional provider.
- Requires a final determination by the board to be subject to judicial review pursuant to existing law.
- Requires the board to use existing Medicare prospective payment systems to establish and serve as the comparative payment rate system in global budget negotiations described in 150) above. Requires the board to update the comparative payment rate system annually.
- Requires the board to use only the operating base payment rates under each Medicare prospective payment system with applicable adjustments to develop the comparative payment rate system.
- Prohibits the comparative rate system from including value-based purchasing adjustments or capital expenses base payment rates that may be included in Medicare prospective payment systems.
- Requires the board to take into account the appropriate Medicare prospective payment system from the most recent year to determine what operating base payment the institutional provider would have been paid for covered health care items and services furnished the preceding year with applicable adjustments, excluding value-based purchasing adjustments, based on the prospective payment system, in the first year that global budget payments are available to institutional providers, and for purposes of selecting a comparative payment rate system used during initial global budget negotiations for an institutional provider.
- Requires the board to engage in good faith negotiations with health care providers’ representatives under 260) below to determine rates of FFS payments for health care items and services furnished under CalCare.
- Provides for a rebuttable presumption that the Medicare FFS rates of reimbursement constitute reasonable FFS payment rates. Requires the fee schedule to be updated annually.
- Prohibits payments to individual providers under this article from including payments to individual providers in salaried positions at institutional providers receiving global budgets under 147) above or individual health care professionals who are employed by or otherwise receive compensation or payment for health care items and services furnished under CalCare from group practices, county organized health systems, or local initiatives that receive payment under CalCare on a salaried basis.
- Requires the board to ensure that the fee schedule compensates physicians and other health care professionals at a rate that reflects the value for health care items and services furnished to establish the FFS payment rates.
- Allows the board to mitigate the impact of the availability and accessibility of health care services through increased individual provider payment in a rural or medically underserved area.
- Requires the board to adopt, by regulation, payment methodologies for the payment of capital expenditures for specifically identified capital projects incurred by not-for-profit or governmental entities that are health facilities pursuant existing law.
- Requires the board to prioritize allocation of funding under 174) above to projects that propose to use the funds to improve service in a rural or medically underserved area, or to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status. Requires the board to consider the impact of any prior reduction in services or facility closure by a not-for-profit or governmental entity as part of the application review process.
- Requires health care facilities and governmental entities to apply to the board in a time and manner specified by the board for the purposes of funding capital expenditures 174) above. Requires all capital-related expenses generated by a capital project to have received prior approval from the board to be paid under CalCare.
- Requires approval of an application for capital expenditures to be based on achievement of the program standards described in 191) below.
- Prohibits the board from granting funding for capital expenditures for capital projects that are financed directly or indirectly through the diversion of private or other non-CalCare program funding that results in reductions in care to patients, including reductions in registered nursing staffing patterns and changes in emergency room or primary care services or availability.
- Prohibits a participating provider from using operating funds or payments from CalCare for the operating expenses associated with a capital asset that was not funded by CalCare without the approval of the board.
- Prohibits a participating provider from doing either of the following:
- Use funds from CalCare designated for operating expenses or payments for capital expenditures; or,
- Use funds from CalCare designated for capital expenditures or payments for operating expenses.
- Allows a margin generated by a participating provider receiving a global budget under CalCare to be retained and used to meet the health care needs of CalCare members.
- Prohibits a participating provider from retaining a margin if that margin was generated through inappropriate limitations on access to health care, compromises in the quality of care, or actions that adversely affected or are likely to adversely affect the health of the persons receiving services from an institutional provider, group practice, or other participating provider under CalCare.
- Requires the board to evaluate the source of margin generation.
- Prohibits a payment under CalCare, including provider payments for operating expenses or capital expenditures, taking into account, include a process for the funding of, or be used by a provider for any of the following:
- Marketing, which does not include education and prevention programs paid under a global budget;
- The profit or net revenue, or increasing the profit, net revenue, or financial result of the provider;
- An incentive payment, bonus, or compensation based on patient utilization of health care items or services or any financial measure applied with respect to the provider or a group practice or other entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider;
- A bonus, incentive payment, or incentive adjustment from CalCare to a participating provider;
- A bonus, incentive payment, or compensation based on the financial results of any other health care provider with which the provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship;
- A bonus, incentive payment, or compensation based on the financial results of an integrated health care delivery system, group practice, or other provider; or,
- State political contributions.
- Requires the board to establish and enforce penalties for violations of 180) above, consistent with the Administrative Procedure Act.
- Requires penalty payments collected for violations of 180) above to be remitted to the CalCare Trust Fund for use in CalCare.
- Requires the board to, in consultation with the DGS, the Department of Health Care Services (DHCS), and other relevant state agencies, negotiate prices to be paid for pharmaceuticals, medical supplies, medical technology, and medically necessary assistive equipment covered through CalCare. Requires negotiations by the board to be on behalf of the entire CalCare program. Requires a state agency to cooperate to provide data and other information to the board.
- Requires the board to, in consultation with the DGS, the DHCS, the CalCare Public Advisory Committee, patient advocacy organizations, physicians, registered nurses, pharmacists, and other health care professionals, establish a prescription drug formulary system. Requires the board to do all of the following:
- Promote the use of generic and biosimilar medications;
- Consider the clinical efficacy of medications;
- Update the formulary frequently and allow health care professionals, other clinicians, and members to petition the board to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary; and,
- Consult with patient advocacy organizations, physicians, nurses, pharmacists, and other health care professionals to determine the clinical efficacy and need for the inclusion of specific medications in the formulary.
- Prohibits the prescription drug formulary system from requiring a prior authorization determination for coverage under CalCare and from applying treatment limitations through the use of step therapy protocols.
- Requires the board to promulgate regulations regarding the use of off-formulary medications that allow for patient access.
Program Standards
- Requires CalCare to establish a single standard of safe, therapeutic, and effective care for all residents of the state by the following means:
- The board to establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:
- The scope, quality, and accessibility of health care items and services;
- Relations between participating providers and members; and,
- Relations between institutional providers, group practices, and individual health care organizations, including credentialing for participation in CalCare and clinical and admitting privileges, and terms, methods, and rates of payment.
- The board to establish requirements and standards, by regulation, under CalCare that include provisions to promote all of the following:
- Simplification, transparency, uniformity, and fairness in the following:
- Health care provider credentialing for participation in CalCare;
- Health care provider clinical and admitting privileges in health care facilities;
- Clinical placement for educational purposes, including clinical placement for prelicensure registered nursing students without regard to degree type, that prioritizes nursing students in public education programs;
- Payment procedures and rates; and,
- Claims processing.
- In-person primary and preventive care, efficient and effective health care items and services, quality assurance, and promotion of public, environmental, and occupational health;
- Elimination of health care disparities;
- Nondiscrimination pursuant to x) above Section 100631;
- Accessibility of health care items and services, including accessibility for people with disabilities and people with limited ability to speak or understand English;
- Providing health care items and services in a culturally, linguistically, and structurally competent manner; and,
- Prevention-oriented care.
- Simplification, transparency, uniformity, and fairness in the following:
- The board to establish requirements and standards, to the extent authorized by federal law, by regulation, for replacing and merging with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the ACA, and federally matched public health programs;
- A participating provider to furnish information as required by HCAI pursuant to 47) above) and 100) above, and to existing law, and permit examination of that information by the board as reasonably required for purposes of reviewing accessibility and utilization of health care items and services, quality assurance, cost containment, the making of payments, and statistical or other studies of the operation of CalCare or for protection and promotion of public, environmental, and occupational health;
- The board to use the data furnished under this title to ensure that clinical practices meet the utilization, quality, and access standards of CalCare. The board to not use a standard developed under 191) above for the purposes of establishing a payment incentive or adjustment under CalCare;
- To develop requirements and standards and making other policy determinations under this chapter, the board to consult with representatives of members, health care providers, health care organizations, labor organizations representing health care employees, and other interested parties; and,
- The board to coordinate with the Office, HCAI, and DMHC to do both of the following:
- Monitor participating providers for, and establish procedures related to, compliance with the requirements and standards established under this section; and,
- Establish programs, including special projects under 239) below, to ensure or manage CalCare member access to in-person primary and preventive care, efficient and effective health care items and services, and quality care.
- The board to establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:
- Provides that a participating provider has a duty to act in the exclusive interest of the patient as part of a health care practitioner’s duty to advocate for medically appropriate health care for their patients pursuant to existing law. Applies to a health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare.
- Specifies that an individual’s treating physician, or other health care professional who is authorized to diagnose the individual in accordance with all applicable scope of practice and other license requirements and is treating the individual, is responsible for the determination of the medically necessary or appropriate care for the individual; and, a participating provider or health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare from a participating provider or other person participating in CalCare to use reasonable care and diligence in safeguarding an individual under the care of the provider or professional and shall not impair an individual’s treating physician or other health care provider treating the individual from advocating for medically necessary or appropriate care under this section.
- Provides that a health care provider or health care professional violates the duty under 192) above, for any of the following:
- Having a pecuniary interest or relationship, including an interest or relationship disclosed under 195) below, that impairs the provider’s ability to provide medically necessary or appropriate care;
- Accepting a bonus, incentive payment, or compensation based on any of the following:
- A patient’s utilization of services;
- The financial results of another health care provider with which the participating provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship, or of a person that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider; and,
- The financial results of an institutional provider, group practice, or person that contracts with, provides health care items or services under, or otherwise receives payment from CalCare; and,
- Having a board member, executive, or administrator that receives compensation from, owns stock or has other financial investments in, or serves as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.
- Requires a participating provider to report, at least annually, to HCAI all of the following:
- A beneficial interest required to be disclosed to a patient pursuant existing law;
- A membership, proprietary interest, coownership, or profit-sharing arrangement, required to be disclosed to a patient pursuant to existing law;
- A subcontract entered into that contains incentive plans that involve general payments, including capitation payments or shared risk agreements, that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions;
- Bonus or other incentive arrangements used in compensation agreements with another health care provider or an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider; and,
- An offer, delivery, receipt, or acceptance of rebates, refunds, commission, preference, patronage dividend, discount, or other consideration for a referral made in exception to existing law.
- Allows the board to adopt regulations as necessary to implement and enforce this section and to adopt regulations to expand reporting requirements under this bill. Defines person to mean an individual, partnership, corporation, limited liability company, or other organization, or any combination thereof, including a medical group practice, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer.
- Allows an individual’s treating physician, nurse, or other health care professional, in implementing a patient’s medical or nursing care plan and in accordance with their scope of practice and licensure, to override health information technology or clinical practice guidelines, including standards and guidelines implemented by a participating provider through the use of health information technology, including electronic health record technology, clinical decision support technology, and computerized order entry programs.
- Requires an override described in 197) above to, in the independent professional judgment of the treating physician, nurse, or other health care professional, meet all of the following requirements:
- The override is consistent with the treating physician’s, nurse’s, or other health care professional’s determination of medical necessity or appropriateness or nursing assessment;
- The override is in the best interest of the patient; and,
- The override is consistent with the patient’s wishes.
- Establishes, within CalCare, the Office. Requires the HCAI Director to be the director of the office and to carry out all functions of that position, including enforcement.
- Requires the office to be responsible for coordination and collaboration across the programs and activities of CalCare and the CHHSA with respect to ensuring health equity under CalCare and other health programs of the CHHSA.
- Requires the office to do all of the following:
- Support the board through data collection and analysis of, and recommendations to address, all of the following:
- The disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, disability, sex, including gender identity and sexual orientation, geographic location, socioeconomic status, incarceration, housing status, and other population-based characteristics;
- Barriers to health, including barriers relating to income, education, housing, food insecurity, employment status, working conditions, and conditions related to the physical environment;
- Barriers to health care access, including lack of trust and awareness, lack of transportation, geography, hospital and service closures, lack of health care infrastructure and facilities, lack of health care professional staffing and recruitment, disparities in quality of care received, and disparities in utilization of care;
- Inequitable distribution of health care services, including health care professional shortage areas, medically underserved areas, medically underserved populations, and trends in hospital closures and service reductions;
- Discrimination in health care settings and the use of racially biased or other discriminatory practice guidelines, health care technologies, and algorithms; and,
- Increasing access to high-quality primary health care, particularly in medically underserved areas and for medically underserved populations;
- Ensure that analysis and data collected are made publicly available and allow for the analysis of cross-sectional information on people’s identities;
- Support the board through the development and coordination of programs and recommendations to enhance health equity in California, including programs and recommendations on all of the following:
- Improving the provision of culturally, linguistically, and structurally competent care;
- Increasing diversity in the health care workforce;
- Ensuring sufficient health care professionals and facilities to meet the health care needs across the state;
- Ensuring equitable access and distribution of health care professionals and facilities to meet the health care needs across the state;
- Recruitment and retention of a health care workforce that meets the cultural, linguistic, and other needs of Californians; and,
- Recruitment and retention of a health care workforce in rural and medically underserved areas.
- Develop, coordinate, and provide recommendations on programs that expand the number of primary health care providers and practitioners, including primary care physicians, registered nurses, and dentists, in the state;
- Develop, coordinate, and provide recommendations on targeted programs and resources for federally qualified health centers, rural health centers, community health centers, and other community-based organizations that provide primary care in the state;
- Conduct ongoing research and evaluation on health equity and access to primary care in California;
- Support the board and the CalCare Public Advisory Committee through data collection and analysis and recommendations to develop, propose, and review special projects under x) below Section 100677;
- Adopt and promulgate regulations for the purpose of carrying out 199) above; and,
- Establish advisory or technical committees, as necessary.
- Support the board through data collection and analysis of, and recommendations to address, all of the following:
- Allows the office to enter into exclusive or nonexclusive contracts on a bid or negotiated basis for purposes of implementing 199) above, including hiring staff and consultants, through the procurement authority and processes of HCAI, facilitating and conducting meetings, conducting research and analysis, and developing the required reports. Exempts, until January 1, 2026, contracts entered into or amended from the Public Contract Code, and the State Administrative Manual, from the review or approval of any division of DGS.
Federal Health Programs and Funding
- Authorizes the board to seek all federal waivers and other federal approvals and arrangements and submit state plan amendments as necessary to operate CalCare consistent with this bill.
- Authorizes the board to apply for a federal waiver or federal approval as necessary to receive funds to operate CalCare pursuant 203) above, including a waiver under Section 18052 of Title 42 of the United States Code.
- Requires the board to apply for federal waivers or federal approval pursuant to 203) above by January 1, 2026.
- Requires the board to apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the ACA, and any other federal programs or laws, as appropriate, that are necessary to enable all CalCare members to receive all benefits under CalCare through CalCare, to enable the state to implement this bill, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the CalCare Trust Fund, created pursuant to 221) below, and to use those funds for CalCare and other provisions under this bill.
- Requires the board to, to the fullest extent possible, negotiate arrangements with the federal government to ensure that federal payments are paid to CalCare in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs. Requires the state to direct the funding and moneys to CalCare to the extent any federal funding is not paid directly to CalCare.
- Allows the board to require members or applicants to provide information necessary for CalCare to comply with any waiver or arrangement under this bill. Prohibits information provided by members to the board for the purposes of 206) above from being used for any other purpose.
- Allows the board to take any additional actions necessary to effectively implement CalCare to the maximum extent possible as an independent single-payer program consistent with this bill. States the intent of the Legislature to establish CalCare, to the fullest extent possible, as an independent agency.
- Allows the board to take actions consistent with 203) above to enable CalCare to administer Medicare in California. Requires CalCare to be a provider of supplemental insurance coverage and to provide premium assistance for drug coverage under Medicare Part D for eligible members of CalCare.
- Allows the board to waive or modify the applicability of any provisions of this title relating to any federally matched public health program or Medicare, as necessary, to implement any waiver or arrangement under 203) above or to maximize the federal benefits to CalCare under this bill.
- Allows the board to apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare. Prohibits enrollment in a federally matched public health program or Medicare from causing a member to lose a health care item or service provided by CalCare or diminish any right the member would otherwise have.
- Requires the board, by regulation, to increase the income eligibility level, increase or eliminate the resource test for eligibility, simplify any procedural or documentation requirement for enrollment, and increase the benefits for any federally matched public health program and for any program in order to reduce or eliminate an individual’s coinsurance, cost-sharing, or premium obligations or increase an individual’s eligibility for any federal financial support related to Medicare or the ACA.
- Authorizes the board to act under this 213) above, upon a finding approved by the Director of Finance and the board that the action does all of the following:
- Will help to increase the number of members who are eligible for and enrolled in federally matched public health programs, or for any program to reduce or eliminate an individual’s coinsurance, cost-sharing, or premium obligations or increase an individual’s eligibility for any federal financial support related to Medicare or the ACA;
- Will not diminish any individual’s access to a health care item or service or right the individual would otherwise have;
- Is in the interest of CalCare; and,
- Does not require or has received any necessary federal waivers or approvals to ensure federal financial participation.
- Allows the board to require that every member or applicant provide the information necessary to enable the board to determine whether the applicant is eligible for a federally matched public health program or for Medicare, or any program or benefit under Medicare to enable the board to apply for coverage for, and enroll, any eligible member under any federally matched public health program or Medicare.
- Requires a member who is eligible for benefits under Medicare to enroll in Medicare, including Parts A, B, and D, as a condition of continued eligibility for health care items and services under CalCare.
- Requires the board to provide premium assistance for all members enrolling in a Medicare Part D drug coverage plan under federal law, limited to the low-income benchmark premium amount established by the federal Centers for Medicare and Medicaid Services (CMS) and any other amount the federal agency establishes under its de minimis premium policy, except that those payments made on behalf of members enrolled in a Medicare Advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to CalCare.
- Requires the member to provide, and authorize CalCare to obtain, any information or documentation required to establish the member’s eligibility for that subsidy if the board has reasonable grounds to believe that a member may be eligible for an income-related subsidy under federal law. Requires the board to attempt to obtain as much of the information and documentation as possible from records that are available to it.
- Requires the board to make a reasonable effort to notify members of their obligations under 218) above. Requires the member to be notified in writing that the member has 60 days to provide the required information after a reasonable effort has been made to contact the member. Allows the member’s coverage under CalCare to be suspended until the issue is resolved if the required information is not provided within the 60-day period. Prohibits information provided by a member to the board for the purposes of 218) above from being used for any other purpose.
- Requires the board to assume responsibility for all benefits and services paid for by the federal government with those funds.
- Creates the CalCare Trust Fund in the State Treasury for the purposes of this bill to be administered by the CalCare Board. Requires all moneys in the fund to be continuously appropriated without regard to fiscal year for the purposes of this bill. Allows any moneys in the fund that are unexpended or unencumbered at the end of a fiscal year to be carried forward to the next succeeding fiscal year.
- Prohibits moneys deposited in the fund from being loaned to, or borrowed by, any other special fund or the General Fund, a county general fund or any other county fund, or any other fund.
- Requires the board to establish and maintain a prudent reserve in the fund to enable it to respond to costs including those of an epidemic, pandemic, natural disaster, or other health emergency, or market-shift adjustments related to patient volume.
- Prohibits the board or staff of the board from utilizing any funds intended for the administrative and operational expenses of the board for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or state legislative or regulatory modifications.
- Requires all interest earned on the moneys that have been deposited into the fund to be retained in the fund and used for purposes consistent with the fund.
- Requires the fund to consist of all of the following:
- All moneys obtained pursuant to legislation enacted as proposed under 258) below;
- Federal payments received as a result of any waiver of requirements granted or other arrangements agreed to by the United States Secretary of Health and Human Services or other appropriate federal officials for health care programs established under Medicare, any federally matched public health program, or the ACA;
- The amounts paid by the DHCS that are equivalent to those amounts that are paid on behalf of residents of this state under Medicare, any federally matched public health program, or the ACA for health benefits that are equivalent to health benefits covered under CalCare;
- Federal and state funds for purposes of the provision of services authorized under federal law that would otherwise be covered under CalCare; and,
- State moneys that would otherwise be appropriated to any governmental agency, office, program, instrumentality, or institution that provides health care items or services for services and benefits covered under CalCare. Requires payments to the fund pursuant to 221) above to be in an amount equal to the money appropriated for those purposes in the fiscal year beginning immediately preceding the effective date of this bill.
- Requires all federal moneys to be placed into the CalCare Federal Funds Account, which is hereby created within the CalCare Trust Fund.
- Requires moneys in the CalCare Trust Fund to only be used for the purposes established in this bill.
- Requires, before the delivery of the fiscal analysis required pursuant to 65) above:
- Moneys in the CalCare Trust fund to not be used for startup and administrative costs to implement 23) above; and,
- Moneys in the CalCare Trust Fund to be used to design and commission the fiscal analysis required pursuant to 65) above.
- Allows moneys in the CalCare Trust Fund to be used for startup and administrative costs to implement 23) above after delivery of the fiscal analysis required pursuant to 65) above.
- Requires the board annually to prepare a budget for CalCare that specifies a budget for all expenditures to be made for covered health care items and services and to establish allocations for each of the budget components under 232) below that cover a three-year period.
- Requires the CalCare budget to consist of at least the following components:
- An operating budget;
- A capital expenditures budget;
- A special projects budget;
- Program standards activities;
- Health professional education expenditures;
- Health care workforce recruitment and retention expenditures;
- Administrative costs; and,
- Prevention and public health activities.
- Requires the board to allocate the funds received among the components described in 232) above to ensure the following:
- The operating budget allows for participating providers to meet the health care needs of the population;
- A fair allocation to the special projects budget to meet the purposes described in a reasonable timeframe;
- A fair allocation for program standards activities; and,
- The health professional education expenditures component is sufficient to meet the need for covered health care items and services.
- Specifies the operating budget described in 232) above to be used for payments to providers for health care items and services furnished by participating providers under CalCare.
- Requires the capital expenditures budget described in 232) above to be used for the construction or renovation of health care facilities, excluding congregate or segregated facilities for individuals with disabilities who receive long-term services and supports under CalCare, and other capital expenditures.
- Specifies the special projects budget described in 232) above to be used for the payment to not-for-profit or governmental entities pursuant to 239) below.
- Requires at least 1% of the budget to be allocated to programs providing transition assistance pursuant to 42) above for up to five years following the date on which benefits first become available under CalCare.
- Requires up to 1% of the budget to be allocated to programs providing health care workforce education, recruitment, and retention pursuant to 271) below during the implementation period and for at least five years following the date on which benefits first become available under CalCare.
- Requires the special projects budget described in 232) above to be used for the payment to not-for-profit entities that are health facilities pursuant to existing law or governmental entities for the construction or renovation of health care facilities, major equipment purchases, staffing in a rural or medically underserved area, and to address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
- Authorizes the special projects budget to be used to increase payment to providers in a rural or medically underserved area to mitigate the impact of the payments on the availability and accessibility of health care services.
- Authorizes an agency of the state, a city, a county, a city and county, or another political subdivision of the state or a not-for-profit entity that is a health facility pursuant to existing law to submit an application to the board for payment from the special projects budget for a special project under 239) above.
- Requires the board to develop criteria to evaluate applications for payment from the special projects budget for special projects in consultation with the CalCare Public Advisory Committee, the office, the California Health Facilities Financing Authority, HCAI, DHCS, DMHC, the Department of Public Health (DPH), and other relevant state agencies.
- Requires the criteria to evaluate applications to consider factors, including if the special project will support a health facility in a rural or medically underserved area, and if the special project will address health disparities, including those based on race, ethnicity, national origin, primary language use, age, disability, sex, including gender identity and sexual orientation, geography, and socioeconomic status.
- Requires the criteria to evaluate applications to also be used for identification and monitoring of health facilities at risk of understaffing in rural or medically underserved areas and of populations experiencing health disparities.
- Authorizes the board to issue a request for applications for a special project paid under 241) above in consultation with the office.
- Allows the CalCare Public Advisory Committee to develop and recommend the board issue a request for applications for a special project paid under 241) above.
- Requires an applicant for payment from the special projects budget to provide the board with financial, demographic, and other information regarding the proposed health care service area as determined by the board, in a format determined by the board, to review an application to receive payment from the special projects budget for a special project.
- Requires an applicant for payment from the special projects budget to submit a plan to the board detailing the projected uses of the proposed payment and strategies proposed to address a health disparity or other qualifying need identified by the board.
- Requires the board to determine the application process and methodology for approval and distribution of payments from the special projects budget.
- Requires the board to evaluate if there is a reasonable likelihood that it will address a health disparity or other qualifying need identified by the board in reviewing a plan submitted by an applicant for payment from the special projects budget under 239) above.
- Requires the board to provide public notice of an application submitted under 239) above and post a copy of the applicant’s plan submitted on its internet website.
- Requires the board to make its application process and methodology publicly accessible on its internet website.
- Requires the board to provide a preliminary report to the applicant of the board’s initial review of the application and provide public notice of the preliminary report within 90 days of receipt of a complete application for a payment from the special projects budget for a special project.
- Requires the board to provide the public the opportunity to provide written comment on a preliminary report of an application for payment from the special projects budget for a special project.
- Requires the CalCare Public Advisory Committee to conduct at least one public hearing to receive public input and comment on the application before the board approves an application for payment from the special projects budgets for a special project.
- Requires the CalCare Public Advisory Committee to provide a recommendation to the board on the approval of an application submitted to the board.
- Requires the board to have the authority to determine service provision requirements or other conditions in approving, and for the duration of, special projects payments to health facilities or that support health facilities. Requires the board to consider the impact of any changes to the health facilities service delivery on access to medical care in making its determination.
- States the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for CalCare. Specifies the intent of the Legislature to consult with appropriate officials and stakeholders in developing the revenue plan.
- State the intent of the Legislature to enact legislation that would require all state revenues from CalCare to be deposited in an account within the CalCare Trust Fund to be established and known as the CalCare Trust Fund Account.
Transition
- Allows an individual who meets all of the following to be eligible to enroll as a member of CalCare during the implementation period:
- The individual meets the eligibility standards established by the board under 67) above; and,
- The individual is 55 years of age or older, 18 years of age or younger, or is currently enrolled in Medicare or Medicaid during the implementation period.
- Requires the board to ensure that all persons enrolled, or who seek to enroll, in a health plan during the implementation period are protected from disruptions in their care during the implementation period, including continuity of care with current health care teams.
- Prohibits a carrier, during the implementation period, from ending coverage for a CalCare member until the end of the implementation period except as expressly agreed upon under the terms of the plan.
- Prohibits a carrier from imposing any exclusion or limitation of coverage on the basis of a person’s disability, complex medical need, or chronic condition during the implementation period.
- Applies to a carrier except as otherwise prohibited by federal law.
- Requires the board to consult with the Advisory Commission on Long-Term Services and Supports, communities and advocacy organizations of persons living with disabilities, and other patient advocacy organizations to ensure that CalCare coverage during the implementation period takes into account the continuity of care for persons with disabilities, complex medical needs, or chronic conditions.
- Require the board to provide for continuation of benefits under CalCare until the end of the period of stay in the case of inpatient hospital services and extended care services during a continuous period of stay that began before the end of the implementation period, and that had not ended as of the end of the implementation date.
- Requires the board to, during the implementation period, establish and maintain procedures that, to the greatest extent possible, provide for the following:
- Automatic enrollment in CalCare of individuals who are eligible to enroll in CalCare during the implementation period; and,
- Automatic enrollment in CalCare of individuals who will become eligible to enroll in CalCare after the end of the implementation period.
- Requires the board to, during the implementation period, establish and maintain procedures for individuals who will become eligible to enroll in CalCare after the end of the implementation period to select a primary care provider under 68) above.
- Requires the board to, during the implementation period to the greatest extent possible, establish and maintain procedures for individuals who are currently members of an integrated health care delivery system to automatically select participating providers in the individual’s integrated health care delivery system care team as their primary care provider upon enrollment in CalCare.
- Allows a person who is eligible to receive CalCare benefits during the implementation period to opt to maintain coverage outside of CalCare, including private health care coverage or coverage offered through the California Health Benefit Exchange, until the end of the implementation period.
- Requires the board to provide funds from the CalCare Trust Fund or funds otherwise appropriated for this purpose to the Secretary of Labor and Workforce Development for programs to address health care workforce education, recruitment, and retention to meet health workforce demands under CalCare, including programs implemented during the implementation period.
- Requires the board to coordinate with the CalCare Public Advisory Committee, the office, HCAI, the Labor and Workforce Development Agency, CHHSA, and health care professional licensing boards, including the Board of Registered Nursing, MBC, and Dental Board of California, to implement programs and policies related to health care workforce education, recruitment, and retention.
- Requires the board to establish a CalCare Health Workforce Working Group to provide input, including recommendations, to the board and Secretary of Labor and Workforce Development on issues related to health care workforce education, recruitment, and retention, including all of the following:
- Programs and measures to expand clinical education capacity at California community colleges providing associate degree programs in health professions, including through programs to ensure the fair and equitable distribution of clinical placement at clinical education sites among approved health professions education programs and through programs to recruit and retain clinical faculty;
- Data collection and analysis and recommendations on health workforce attrition from direct care positions, including on moral distress and moral injury, safe staffing, and gaps in active California health professions licensees and those working in direct care;
- Identification and prioritization of geographical areas or populations in the state with unmet primary care or other health care needs, including access and availability of family physicians, primary care clinics, and registered nurses;
- Programs and measures to retain health care workforces, including public loan repayment assistance programs, minimum safe staffing requirements, investments in personal protective equipment, and occupational safety and health programs;
- Programs and measures to support expansion of graduate medical education programs and assistance for medical residents;
- Career ladders into health professions for ancillary and allied health workers, including licensed vocational nurses, certified nursing assistants, medical technicians, behavioral health technicians, health navigators, and community health workers;
- Career technical education pathways toward an associate degree at a California community college in a health professions education program; and,
- Programs to address barriers to health professions, including student debt levels, tuition assistance, childcare or other support, and debt-free residency or mentorship programs.
- Requires the board to appoint the members of the CalCare Health Workforce Working Group. Requires appointments to be made by a majority vote of the voting members of the board. Requires the board to, when appointing members to the working group, aim for broad representation, including, at a minimum, all of the following:
- Representatives of health professions and other health care workers, including specialties for primary care and behavioral health, physicians, registered nurses, and ancillary services;
- Representatives of labor organizations representing health care workers; Representatives of California community colleges, graduate medical education and training programs, and nursing education programs;
- Representatives of consumer and patient groups; and,
- Representatives of health care providers, including hospitals, nonacute care providers, and medical groups.
- Requires each appointed member of the CalCare Health Workforce Working Group to serve at the discretion of the board and may be removed at any time by a majority vote of the voting members of the board.
- Prohibits working group members from having access to confidential, nonpublic information that is accessible to the board and office. Requires, instead, the working group to only have access to information that is publicly available. Specifies that neither the board nor the office disclose any confidential, nonpublic information to the working group members.
- Requires the working group members receive reimbursement for travel and other actual costs.
- Requires the working group to meet at least four times per year in a place convenient to the public and all meetings of the advisory commission to be open to the public, pursuant to the Bagley-Keene Open Meeting Act.
- Requires the board to consider input, including recommendations, from the working group, along with public comments, in the board’s deliberation and decisionmaking.
Collective Negotiation by Health Care Providers with CalCare
- Authorizes health care providers to meet and communicate for the purpose of collectively negotiating with CalCare on any matter relating to CalCare FFS rates of payment for health care items and services or procedures related to FFS payment under CalCare.
- Provides that collective negotiations does not allow a strike of CalCare by health care providers.
- Provides that collective negotiations does not allow or authorize terms or conditions that would impede the ability of CalCare to comply with applicable state or federal law.
- Requires collective negotiation to meet all of the following requirements:
- A health care provider may communicate with other health care providers regarding the terms and conditions to be negotiated with CalCare;
- A health care provider may communicate with a health care provider’s representative;
- A health care provider’s representative is the only party authorized to negotiate with CalCare on behalf of the health care providers as a group; and,
- A health care provider can be bound by the terms and conditions negotiated by the health care provider’s representative.
- Specifies that collective negotiations does not affect or limit the right of a health care provider or group of health care providers to collectively petition a governmental entity for a change in a law, rule, or regulation.
- Specifies that collective negotiations does not affect or limit collective action or collective bargaining on the part of a health care provider with the health care provider’s employer or any other lawful collective action or collective bargaining.
- Requires a health care provider’s representative to file with the board, in the manner prescribed by the board, information identifying the representative, the representative’s plan of operation, and the representative’s procedures to ensure compliance before engaging in collective negotiations with CalCare on behalf of health care providers.
- Requires a person who acts as the representative of negotiating parties to pay a fee to the board to act as a representative. Requires the board, by regulation, to set fees in amounts deemed reasonable and necessary to cover the costs incurred by the board.
- Specifies that collective negotiation does not authorize competing health care providers to act in concert in response to a health care provider’s representative’s discussions or negotiations with CalCare, except as authorized by other law.
- Prohibits a health care provider’s representative from negotiating an agreement that excludes, limits the participation or reimbursement of, or otherwise limits the scope of services to be provided by a health care provider or group of health care providers with respect to the performance of services that are within the health care provider’s scope of practice, license, registration, or certificate.
- Applies the definitions to 280) to 289) above:
- Health care provider as a person who is licensed, certified, registered, or authorized to practice a health care profession pursuant to existing law and who is either of the following:
- An individual who practices that profession as a health care professional or as an independent contractor; or,
- An owner, officer, shareholder, or proprietor of a health care group practice that has elected to receive FFS payments from CalCare pursuant to 133) above.
- A health care provider licensed, certified, registered, or authorized to practice a health care profession pursuant to existing who practices as an employee of a health care provider is not a health care provider for purposes of this chapter.
- Health care provider’s representative as a third party that is authorized by a health care provider to negotiate on their behalf with CalCare over terms and conditions affecting those health care providers.
- Health care provider as a person who is licensed, certified, registered, or authorized to practice a health care profession pursuant to existing law and who is either of the following:
Operative Date
- Prohibits CalCare from being operative until the date the CHHSA Secretary notifies the Secretary of the Senate and the Chief Clerk of the Assembly in writing that the secretary has determined that the CalCare Trust Fund has the revenues to fund the costs of implementing this bill.
- Requires the CHHSA to publish a copy of the notice on its internet website.
- Requires the CHHSA Secretary to make a notification pursuant to 291) above.
- Includes severability clause that if any provision of this bill or its application is held invalid, that invalidity not affect other provisions or applications that can be given effect without the invalid provision or application.
- Makes findings and declarations that specified sections of this bill 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 the California Constitution; and, to demonstrate the interest protected by this limitation and the need for protecting that interest, it is necessary for that information to remain confidential. In order to protect private, confidential, and proprietary information.
Definitions
- Defines the following:
- Activities of daily living as basic personal everyday activities including eating, toileting, grooming, dressing, bathing, and transferring
- Advisory commission as the Advisory Commission on Long-Term Services and Supports;
- The ACA as the federal Patient Protection and Affordable Care Act, and any amendments to, or regulations or guidance issued under, those acts;
- Allied health practitioner as a group of health professionals who apply their expertise to prevent disease transmission and diagnose, treat, and rehabilitate people of all ages and in all specialties, together with a range of technical and support staff, by delivering direct patient care, rehabilitation, treatment, diagnostics, and health improvement interventions to restore and maintain optimal physical, sensory, psychological, cognitive, and social functions. Includes audiologists, occupational therapists, social workers, and radiographers;
- Board as the CalCare Board;
- CalCare or “California Guaranteed Health Care for All” means the California Guaranteed Health Care for All program;
- Capital expenditures as expenses for the purchase, lease, construction, or renovation of capital facilities, health information technology, artificial intelligence, and major equipment, including costs associated with state grants, loans, lines of credit, and lease-purchase arrangements;
- Carrier as either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan, as defined under existing law, licensed by the DMHC;
- Committee as the CalCare Public Advisory Committee;
- County organized health system as a health system implemented pursuant to existing law;
- Essential community provider as a provider, as defined in federal law, that serves predominantly low-income, medically underserved individuals and that is one of the following:
- A community clinic, as defined;
- A free clinic, as defined;
- A federally qualified health center, as defined;
- A rural health clinic, as defined; and,
- An Indian Health Service Facility, as defined;
- Federally matched public health program as the state’s Medi-Cal program and the federal CHIP under federal law;
- Fund as the CalCare Trust Fund;
- Global budget as the payment negotiated between an institutional provider and the board under 147) above;
- Group practice as professional corporation under existing law that is a single corporation or partnership composed of licensed doctors of medicine, doctors of osteopathy, or other licensed health care professionals, and that provides health care items and services primarily directly through physicians or other health care professionals who are either employees or partners of the organization;
- Health care professional as a health care professional licensed pursuant existing law, who, in accordance with the professional’s scope of practice, may provide health care items and services under this title;
- Health care item or service as a health care item or service that is included as a benefit under CalCare;
- Health professional education expenditures as expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities;
- Home- and community-based services as an integrated continuum of service options available locally for older individuals and functionally impaired persons who seek to maximize self-care and independent living in the home or a home-like environment, which includes the home- and community-based services that are available through Medi-Cal pursuant to the home- and community-based waiver program under federal law;
- Implementation period as the period under 23) above is subject to special eligibility and financing provisions until it is fully implemented under that section;
- Institutional provider as an entity that provides health care items and services and is licensed pursuant to any of the following (as defined and licensed under existing law):
- A health facility;
- A clinic;
- A long-term health care facility;
- A county medical facility;
- A residential care facility for persons with chronic, life-threatening illness;
- An Alzheimer’s daycare resource center;
- A residential care facility for the elderly;
- A hospice;
- A pediatric day health and respite care facility;
- A mental health care provider; and,
- A federally qualified health center.
- Instrumental activities of daily living as activities related to living independently in the community, including meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community;
- Integrated health care delivery system;
- Local initiative as 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, including the entities established in existing law;
- Long-term services and supports as long-term care, treatment, maintenance, or services related to health conditions, injury, or age, that are needed to support the activities of daily living and the instrumental activities of daily living for a person with a disability, including all long-term services and supports as defined, home- and community-based services, additional services and supports identified by the board to support people with disabilities to live, work, and participate in their communities, and those as defined by the board;
- Medicaid or medical assistance as a program that is one of the following:
- The state’s Medi-Cal program under Title XIX of the federal Social Security Act; or,
- The federal CHIP under Title XXI of the federal Social Security Act;
- Medically necessary or appropriate as the health care items, services, or supplies needed or appropriate to prevent, diagnose, or treat an illness, injury, condition, or disease, or its symptoms, and that meet accepted standards of medicine as determined by a patient’s treating physician or other individual health care professional who is treating the patient, and, according to that health care professional’s scope of practice and licensure, is authorized to establish a medical diagnosis and has made an assessment of the patient’s condition;
- Medicare as Title XVIII of the federal Social Security Act and the programs thereunder;
- Member as an individual who is enrolled in CalCare;
- Out-of-state health care service as a health care item or service provided in person to a member while the member is temporarily, for no more than 90 days, and physically located out of the state under either of the following circumstances:
- It is medically necessary or appropriate that the health care item or service be provided while the member physically is out of the state; or,
- It is medically necessary or appropriate, and cannot be provided in the state, because the health care item or service can only be provided by a particular health care provider physically located out of the state;
- Participating provider as an individual or entity that is a health care provider qualified under 91) that has a participation agreement pursuant to 100) above in effect with the board to furnish health care items or services under CalCare;
- Prescription drugs as prescription drugs as defined in existing law;
- Resident as an individual whose primary place of abode is in this state, without regard to the individual’s immigration status, who meets the California residence requirements adopted by the board pursuant to 1) above. Requires the board to be guided by the principles and requirements set forth in the Medi-Cal program; and,
- Rural or medically underserved area as the same meaning as a “health professional shortage area” in federal law.
- Prohibits this bill from preempting a city, county, or city and county from adopting additional health care coverage for residents in that city, county, or city and county that provides more protections and benefits to California residents than this bill.
- Specifies that to the extent any law is inconsistent with this bill or the legislative intent of the California Guaranteed Health Care for All Act, this bill apply and prevail, except when explicitly provided otherwise by this bill.
- Makes various findings and declarations including the following:
- To establish the California Guaranteed Health Care for All program to provide universal health care coverage for every Californian, funded by broad-based revenue;
- To work to obtain waivers and other approvals relating to Medi-Cal, the federal CHIP, Medicare, the ACA, and any other federal programs pertaining to the provision of health care so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the CalCare Trust Fund;
- Under those waivers and approvals, those funds would be used for health care coverage that provides health care benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums;
- Those programs would be replaced and merged into CalCare, which will operate as a true single-payer program;
- If any necessary waivers or approvals are not obtained, it is the intent of the Legislature that the state use state plan amendments and seek waivers and approvals to maximize, and make as seamless as possible, the use of funding from federally matched public health programs and other federal health programs in CalCare;
- Even if other programs, including Medi-Cal or Medicare, may contribute to paying for care, it is the goal of this act that the coverage be delivered by CalCare, and, as much as possible, that the multiple sources of funding be pooled with other CalCare program funds; and,
- It is the intent of the Legislature to provide universal health care coverage with greater benefits and access to providers than existing health coverage plans, including for Californians who primarily receive care through an integrated health care delivery system, that is free at the point of service and does not have deductibles, coinsurance, premiums, or other cost-sharing.
EXISTING FEDERAL LAW:
- Establishes the Medicaid program to enable each state to furnish medical assistance on behalf of individuals whose income and resources are insufficient to meet the costs of necessary medical services. Requires states to submit a state plan for medical assistance describing the coverage of mandatory and optional populations and benefits. [42 United States Code (USC) §1396, et seq.]
- Establishes CHIP to allow states to provide free or low-cost health coverage to low-income children and pregnant women whose income is too high for Medicaid coverage. Requires states to submit a state child health plan in order to receive payment for health coverage under CHIP. [42 USC §1397aa, et seq.]
- Authorizes the Department of Health and Human Services (DHHS) Secretary to waive Medicaid state plan requirements (with the exception of citizenship and requirements of another agency) to the extent necessary to carry out a demonstration or experimental project furthering the goals of the program. [42 USC §1315]
- Establishes state health insurance exchanges through the ACA to sell qualified health plans (QHPs) with standard benefit designs to eligible individuals with or without premium assistance and cost sharing reductions. Limits eligibility for premium assistance and cost-sharing reductions to individuals who earn between 100-400% of the federal poverty level (FPL) or 100-250% FPL respectively and who do not have minimum essential coverage (MEC), are lawfully present and are not incarcerated. [42 USC §18031 et seq.; 26 CFR §1.36B-2.]
- Authorizes waivers for state innovation under which states can seek federal approval to waive major provisions of the ACA, including the requirement for Exchanges, QHPs, premium tax credits and cost-sharing reductions, the individual mandate and the employer responsibility requirement, provided federal requirements for comprehensive benefits, affordability, and comparable coverage are met and the state proposal does not increase the federal deficit. [42 USC §18052]
- Establishes, pursuant to federal law, the Medicare program, which provides coverage for seniors and certain persons with disabilities. Authorizes the federal Secretary of DHHS, to develop and engage in experiments and demonstration projects for specified purposes, either directly or through grants to public or private agencies, institutions, and organizations or contracts with public or private agencies, institutions, and organizations. [42 USC §1395, et seq.; §1395b-1]
- Creates within CMS a Center for Medicare and Medicaid Innovation (CMMI), the purpose of which is to test innovative payment and service delivery models to reduce program expenditures under Medicare and Medicaid while preserving or enhancing the quality of care furnished to individuals under those programs. [42 USC §1315a]
- Penalizes employers with 50 or more full time or full-time equivalent employees who do not offer MEC to their employees. [26 USC §4980H]
EXISTING STATE LAW:
- Designates HCAI as the state agency that collects health facility data for use by all state agencies, including various financial data reports. [Health and Safety Code (HSC) §128730, et seq.]
- Requires HCAI to convene a Health Care Equity Measures Advisory Committee (Advisory Committee) to assist and advise the HCAI Director in reviewing and amending the appropriate measures that align with the health equity measures developed by CMS at the hospital-, hospital system-, and integrated system-level related to access, quality, and outcomes, including any relevant Agency for Healthcare Research and Quality’s Quality Indicators, that hospitals are required to report in their annual equity reports. [HSC § 127372]
- Requires hospitals to prepare an annual equity report. Requires the annual equity report to include an analysis of health status and access to care disparities for patients on the basis of age, sex, race, ethnicity, language, disability status, sexual orientation, gender identity, and payor. [Id]
- Requires a hospital to annually submit the equity report to HCAI. Requires a hospital to annually post the equity report on its website, as specified. Requires data and information included in annual equity reports to be reported to the extent information is available and disclosed in a manner that protects the personal information of patients pursuant to state and federal privacy laws. [HSC § 127373]
- Provides HCAI the authority to establish the Health Care Payments Data Program to collect health care data from health plans, health insurers, government agencies and others. [Health and Safety Code (HSC) §8.5]
- Establishes the Office of Health Care Affordability (OHCA) within HCAI. Identifies OHCAs three primary responsibilities: managing spending targets, monitoring system performance, and assessing market consolidation. Requires OHCA to collect, analyze, and publicly report data on total health care expenditures, and enforce spending targets set by a Health Care Affordability Board. [HSC §127501]
- Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [Welfare and Institutions Code § 14000, et seq.]
- Establishes the DMHC to regulate health plans under the KKA. [HSC §1340, et seq.]
- Establishes as California’s EHBs benchmark under the ACA, the Kaiser Small Group Health Maintenance Organization, existing California health insurance mandates, and the 10 ACA mandated benefits, including prescription drug coverage. [HSC §1367.005]
- Requires the criteria or guidelines used by health plans and insurers, or any entities with which plans or insurers contract for utilization review or utilization management functions, to determine whether to authorize, modify, or deny health care services to:
- Be developed with involvement from actively practicing health care providers;
- Be consistent with sound clinical principles and processes;
- Be evaluated, and updated if necessary, at least annually;
- If used as the basis of a decision to modify, delay, or deny services in a specified case under review, be disclosed to the provider and the enrollee or insured in that specified case; and,
- Be available to the public upon request. [HSC §1363.5]
- Requires reviews, for purposes of IMR, to determine whether the disputed health care service was medically necessary based on the specific medical needs of the enrollee and any of the following:
- Peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service;
- Nationally recognized professional standards;
- Expert opinion;
- Generally accepted standards of medical practice; or,
- Treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious. [HSC §1374.33]
- Requires health plans to demonstrate that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management. [HSC §1367]
- Requires, if a health plan that provides coverage for prescription drugs or a contracted physicians group fails to respond to prior authorization, or step therapy exception request, as specified, within 72 hours for nonurgent requests, and within 24 hours if exigent circumstances exist, upon the receipt of a completed request form, the request is deemed granted. [HSC §1367.241]
- Establishes Covered California (or Exchange) as an independent entity in state government not affiliated with any state agency or department, governed by a five-member board. Requires the Covered California Executive Board to establish and use a competitive process to select participating carriers and other contractors, and to make health insurance available to individuals and small businesses as authorized under the ACA. [Government Code (GOV) §100500 -100522]
- Creates the Affordability Fund to be utilized, in addition to any other appropriations made by the Legislature for the same purpose, for the purpose of health care affordability programs operated by Covered California. [GOV §100520.5]
- Requires Covered California to develop options for providing cost sharing reduction subsidies to reduce cost sharing for low- and middle-income Californians. Requires the options to be reported to the Legislature, Governor, and the Healthy California for All Commission (HCFA) on or before January 1, 2022, for consideration in the 2022–23 budget process. [GOV §100520.5]
- Requires, under the Minimum Essential Coverage (MEC) Individual Mandate (state mandate requiring health coverage), for each month beginning on or after January 1, 2020, a California resident to be enrolled in and maintain MEC for that month, and for any person who qualifies as a spouse or dependent of the resident except as provided below:
- An individual who has in effect a certificate of exemption for hardship or religious conscience issued by Covered California for that month;
- An individual who is a member of a health care sharing ministry, as specified for that month;
- An individual who is incarcerated for that month, other than incarceration pending the disposition of charges;
- An individual who is not a citizen or national of the US and is not lawfully present in the US for that month;
- An individual who is a member of an Indian tribe, as defined, during that month;
- An individual for whom that month occurs during a period living abroad, as described;
- An individual who is a bona fide resident of a possession of the U.S., as specified;
- An individual who is a bona fide resident of another state for that month; and,
- An individual who is enrolled in limited or restricted scope coverage under the Medi-Cal program or another health care coverage program administered by and determined to be substantially similar to limited or restricted scope coverage by DHCS for that month. [GOV §100705]
- Requires an Individual Shared Responsibility Penalty to be imposed for failure to meet the requirement of the MEC Individual Mandate. [GOV §100705]
- Establishes the HCFA as an independent body to develop a plan that includes options for advancing progress toward achieving a health care delivery system in California that provides coverage and access through a unified financing system, including, but not limited to, a single-payer financing system, for all Californians. Requires the HCFA to submit a report to the Legislature and Governor by February 1, 2021, that that includes options for key design considerations for a unified financing system, including, but not limited to, a single-payer financing system. [HSC §1002, repealed on Jan. 1, 2022 by HSC §1005]
- Requires all meetings to be conducted in the open of multimember state bodies that are created by statute. [GOV §11120, 11121]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, today’s U.S. health care system is a complex, fragmented multi-payer system that leaves wide gaps in coverage and access to care, poses significant issues of affordability, and has growing health disparities. Despite health care spending in the U.S. far exceeding other high-income, industrialized countries that offer a publicly financed single-payer system, we consistently report worse health outcomes and disparities among vulnerable populations. CalCare will begin the process of creating a universal single-payer system of health care for every California resident. This bill would enact a comprehensive framework of governance, benefits, program standards, and health care cost controls, and will allow California to begin consolidating existing health care programs, obtain necessary federal waivers and determine any future public financing. Also known as CalCare, this is a meaningful step towards building a transformative and equitable health care payment system that will guarantee comprehensive health care and achieve health care justice for all. The author states that we cannot afford to let our health care status quo persist and CalCare would actually save money. The HCFA found that under a single-payer model, California will save between $32 billion to $213 billion over 10 years compared to the current system. With a single-payer system, these savings will be redirected to patients and allow the state to make strategic investments in our health care to improve access to care and dismantle health inequities. By guaranteeing health care for all Californians and establishing a payment system that eliminates waste and aligns reimbursements with the actual cost of care, we can make tremendous progress on health care as a human right. Transforming our complex, inequitable health care system will not be easy and will not happen overnight. The author concludes that this bill is the first necessary step that will lay the policy foundation for single-payer so the state can submit federal waivers and determine a just financing plan that puts the health of California before profits.
- California Health Insurance Coverage. In 2022, according to the California Health Care Foundation (CHCF), California health insurers covered 35.9 million enrollees. Of those, 14.1 million were commercial enrollees, 16.1 million were public managed care enrollees, and 5.8 million were enrolled through administrative services only arrangements for self-insured employers.
- California’s regulation of health insurance. The business of health insurance in California is subject to a complex patchwork of federal and state regulations. Different rules apply depending on whether insurance coverage is purchased directly by individuals or on behalf of a group, as in job-based health insurance.
In California, regulation and oversight of fully insured employee health benefit plans is split between two state departments, the DMHC and the California Department of Insurance (CDI). DMHC primarily regulates health maintenance organizations (HMOs), but also has jurisdiction over some preferred provider organization (PPO) plans. CDI has jurisdiction over all other types of health insurance, including plans that offer traditional health insurance products, such as indemnity plans, and some PPO plans.
There are essentially three relevant regulatory frameworks for health insurance state regulation by DMHC, by CDI, and regulation of self-insured employee health benefit plans by the federal Department of Labor. - Uninsured. California’s implementation of the ACA significantly reduced the number of uninsured in the state. In 2012, there were 6.5 million Californians who were uninsured. Recently, the state has undertaken additional initiatives to extend health care coverage to more Californians. Between 2016 and 2020, the state expanded comprehensive Medi-Cal coverage to include income-eligible undocumented residents who are under the age of 26. Beginning in May 2022, the state further expanded eligibility for comprehensive Medi-Cal coverage to income-eligible undocumented residents over the age of 49. As part of the 2022-23 Budget Act, the Legislature approved expanding eligibility to income-eligible undocumented residents between the ages of 26 through 49 beginning no later than January 1, 2024. At full implementation, over 700,000 undocumented residents between the ages of 26 through 49 are expected to enroll in comprehensive Medi-Cal.
According to a March 2023 Policy Brief by the University of California Los Angeles Center for Health Policy Research and University of California Berkeley Labor Center (Labor Center) entitled “California’s Uninsured in 2024: Medi-Cal Expands to all low-income adults but half a million undocumented Californians lack affordable coverage options,” after the January 1, 2024 Medi-Cal expansion, California’s uninsured population will decrease to a record low of 2.57 million under the age of 65. Close to one million undocumented Californians will have gained access to Medi-Cal through the expansions to children, young adults, older adults and now adults ages 26 to 49. The policy brief specifies that out of the 2.57 million uninsured: 230,000 are eligible for Covered California coverage above the 400% FPL; 540,000 are eligible for Covered California coverage under the 400% FPL; 570,000 are eligible for employer coverage; 710,000 are eligible for Medi-Cal and 520,000 are undocumented and not eligible for Medi-Cal or Covered California, and without an offer of employer coverage. Californians who are low-income, Latinos, or adults age 19 to 49 are more likely to be uninsured.
According to the Labor Center, undocumented Californians will continue to be excluded from Covered California under federal policy and are currently excluded from purchasing coverage through Covered California and from receiving ACA subsidies that help make coverage more affordable for other Californians. Despite the lack of financial help, the Labor Center projects 110,000 undocumented Californians will pay the full cost of individual market coverage. While others enroll in employer coverage, undocumented workers are offered affordable employer coverage at a lower rate than their counterparts with citizenship or documentation. According to the Labor Center, the health coverage needs of this group warrant particular attention because they remain categorically excluded from enrolling in Covered California and cannot receive federal subsidies to make coverage more affordable.
- Health care spending. According to OHCA, health care spending in California reached $10,299 per capita and $405 billion overall in 2020, up 30% from 2015. Californians with job-based coverage are facing higher out-of-pocket costs, with the share of workers with a large deductible ($1,000 or more) increasing from 6% in 2006 to 54% in 2020. For the third consecutive year, the 2022 CHCF California Health Policy Survey found that half of Californians (49%) – and fully two-thirds of those with lower incomes (under 200% of the federal poverty level) – reported skipping or delaying at least one kind of health care due to cost in the past 12 months. Among those who reported skipping or delaying care due to cost, about half reported that their conditions worsened as a result. OHCA states that to create a sustainable health care system, the rate of health care spending needs to align with a target percentage, such as the statewide economic growth rate. An analysis of health care spending in California identified a range of contributors to high health care costs, including overtreatment and administrative complexity, and estimated that California could save between $58 and $73 billion per year by eliminating waste and improving efficiency.
- Affordability concerns. According to the Labor Center, since 2008, premiums for job-based family health coverage in California have grown by 49% on average; but real median wages have remained stagnant. For example, single coverage premiums averaged $8,712 per year in 2018, equivalent to $4 per hour for someone working 40 hours per week and for family coverage, the average annual premium was $20,843 which is equivalent to $10 per hour work for a full-time worker, which is $2 less per hour than the current $12 minimum wage for employers with more than 25 employees. In addition to premium costs, consumers are also facing higher out-of-pocket spending.
For most people with job-based coverage, the largest health-related expenditure in any given year will be the cost of premiums. The total premium cost is usually split between the employer and the worker; on average in 2022 California workers paid 30% of the cost of family coverage and employers paid 70%. Despite this nominal division of costs, economic theory posits that workers pay the entire cost of premiums in forgone wages, and in practice the entire cost of coverage is included when calculating workers’ total compensation. As health care premiums have increased, so has the amount workers’ pay for their coverage. Not only has the dollar amount increased, but employers have also increased the premium share paid by workers. In 2002, California workers in the private sector paid 15% of the cost of single premiums ($446 on average) and 24% of the cost of family premiums ($4,193 on average). In 2022, private-sector workers paid both higher amounts and a higher share of the premium: an average of 19% of the cost of single coverage ($1,448) and 30% of the cost of family premiums ($6,755).
- OHCA. In 2022, the California Health Care Quality and Affordability Act (SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022) established OHCA within HCAI. Recognizing that health care affordability has reached a crisis point as health care costs continue to grow, OHCA’s enabling statute emphasizes that it is in the public interest that all Californians receive health care that is accessible, affordable, equitable, high-quality, and universal. OHCA will collect, analyze, and publicly report data on total health care expenditures, and enforce spending targets set by a new Health Care Affordability Board. To ensure a balanced approach to slow spending growth, OHCA will monitor system performance by measuring quality, equity, adoption of alternative payment models, investment in primary care and behavioral health, and workforce stability. Through cost and market impact reviews, OHCA will analyze transactions that are likely to significantly impact on market competition, the state’s ability to meet targets, or affordability for consumers and purchasers. Based on results of the review, OHCA will then coordinate with other state agencies to address consolidation as appropriate.
- California’s Recent Attempts to Enact Single Payer.
- Background on the Creation of the HCFA. On August 23, 2017, Speaker Rendon created the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage (Select Committee) to hold hearings to develop plans for achieving universal health care in California, in part as a response to SB 562 (Lara) of 2017. SB 562 would have created a universal health care system in California. The Select Committee held six days of hearings on various topics including cost containment efforts, achieving better access and greater value in California’s health care system, implementation considerations and options for universal coverage. The Select Committee also published a report and included recommendations for achieving universal coverage in California.
AB 1810 (Committee on Budget), Chapter 34, Statutes of 2018, established the Council on Health Care Delivery Systems (Council) as an independent body to develop a plan that includes options for advancing progress toward achieving a health care delivery system that provides coverage and access through a unified financing (UF) system for all Californians, based on one of the Select Committee’s recommendations. AB 1810 was subsequently amended by SB 104 (Committee on Budget), Chapter 67, Statutes of 2019, and renamed the Council into the HCFA and charged HCFA with developing a plan that includes options for advancing progress toward achieving a health care delivery system in California that provides coverage and access through a UF system, including, but not limited to, a single-payer financing system, for all Californians. SB 104 required the HCFA to submit a report to the Legislature and the Governor with, among other things, an analysis of California’s existing health care delivery system and options to transition to a UF system, including a single-payer financing system.
In April 2022, the HCFA issued its final report and endorsed a UF system. The report pointed to the variety of methods that other countries use to achieve UF, some, such as Canada and the United Kingdom, which land squarely within the definition of single payer, while others, such as Germany or the Netherlands, which rely on health insurance that is highly regulated. The financial analysis done in connection with the report found that without a shift to UF, health care spending in California is estimated to increase by $158 billion over nine years, which is a 30% increase over base line spending. The total cost of a UF system would depend on a number of key design decisions including eligibility and enrollment, covered benefits and services, patient cost-sharing, provider payment, purchasing arrangements and role for intermediaries, care coordination, and cost containment measures. In some areas, such as the decision to use risk-based capitation (e.g. managed care plan) versus a direct payment model, no consensus was reached by the HCFA. A number of scenarios using both a direct payment to providers model and a health plan model, and using different options that included (or not) an expansion of long-term services and supports and included (or not) income-related cost-sharing were discussed. Almost every option resulted in considerable savings compared to the baseline health expenditure of $517 billion per year with the exception of scenarios that both expanded long-term services and supports and contained zero cost-sharing for consumers.
This bill includes some of the following: i) requires the board to engage in good faith negotiations with health care providers to determine rates of FFS payments; ii) requires the board to pay to each institutional provider (hospital, skilled nursing facility, and chronic dialysis clinic) a lump sum to cover all operating expenses under global budget; iii) includes long-term services and supports; and, iv) prohibits a CalCare member from paying a premium, copayment, coinsurance, deductible, or any other form of cost sharing.
- Background on the Creation of the HCFA. On August 23, 2017, Speaker Rendon created the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage (Select Committee) to hold hearings to develop plans for achieving universal health care in California, in part as a response to SB 562 (Lara) of 2017. SB 562 would have created a universal health care system in California. The Select Committee held six days of hearings on various topics including cost containment efforts, achieving better access and greater value in California’s health care system, implementation considerations and options for universal coverage. The Select Committee also published a report and included recommendations for achieving universal coverage in California.
- Federal Waivers. This bill states intent language with respect to a revenue plan. The HCFA report found that UF cannot be accomplished in California without federal support. Commissioners disagreed about whether federal participation could be accomplished through existing Medicare, Medicaid, and ACA waiver authority, or whether changes in federal law would be required. Waiver authority allows a state to ignore certain federal program rules for experimental or demonstration projects which are generally required to cost no more than what the federal government would have spent on the program without the waiver. SB 770 (Wiener), Chapter 412, Statutes of 2023, directs the CHHSA Secretary to research, develop, and pursue discussions of a federal waiver framework in consultation with the federal government with the objective of a health care system that incorporates specified features and objectives, including, among others, a comprehensive package of medical, behavioral health, pharmaceutical, dental, and vision benefits, and the absence of cost sharing for essential services and treatments. The LA Times writes that this bill could help California obtain a waiver that could allocate federal Medicaid and Medicare funds to be used for what could eventually become a single-payer system that would cover every California resident and be financed entirely by state and federal funds.
- Other States. In 2011, under Governor Shumlin, Vermont enacted Green Mountain Care, the first state level single-payer health care system in the country. On December 17, 2014, Vermont abandoned Green Mountain Care, citing the measure’s cost. At that time, according to the governor’s financial models, financing the system would have required an 11.5% payroll tax on all businesses in Vermont and a sliding-scale, income-based premium assessment of up to 9.5%. Then Governor Shumlin indicated: “These are simply not tax rates that I can responsibly support or urge the Legislature to pass. In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”
- SUPPORT. The California Nurses Association (CNA), sponsor of this bill, writes this bill establishes a system that provides a single standard of high-quality care for every California resident regardless of ability to pay or medical condition, without being tied to a job or immigration status, and regardless of whether an insurance company deems them to be profitable. Every single day, CNA members, as nurses, witness too many patients forgo needed medications, procedures, or care because they cannot afford the costs. Nurses watch as insurance corporations refuse to cover care that is required for the health and well-being of their patients, overriding the professional judgment of health care workers who can do little to intervene when our patients do not get the care that they need. As a result, nurses see patients come to the emergency room with advanced stages of illness or disease that could have been prevented if they had access to treatment earlier. High costs and poor health outcomes persist because access to an insurance plan is not the same as guaranteed health care for all. CNA states that California must do better. The system now is beholden to the corporate interests that determine who gets treatment and what treatment they get. It is deeply inefficient and unsustainable because it prioritizes short-term financial returns rather than long-term investments in our health. The current system is unaffordable for California and for patients. CNA writes that the only way to solve the health care crisis and to heal California’s health care system is to pass this bill and enact the single-payer health care system of CalCare now. The HCFA estimated that it costs California hospitals, doctors, and other providers about $85 billion each year in insurance related administrative costs, not including the costs for patients and employers to navigate the complex web of private insurers and public program. CNA writes that even with the planned expansion of Medi-Cal, an estimated 2.6 million Californians will remain uninsured. Millions more with insurance coverage are unable to afford care due to increasing copays, deductibles, and out-of-pocket costs. This bill would improve and expand upon Medicare and Medi-Cal by consolidating existing health care programs into a single, streamlined health system to cover everyone living in California and providing comprehensive benefits to all. The HCFA found that under a single-payer model, with no cost sharing for patients and long-term care for all, California would save between $32 billion to $213 billion over ten years compared to our current system. By moving to the single-payer system of CalCare, we would transform the profit-driven health insurance system into a health care system that prioritizes patient care. CalCare would create the necessary infrastructure to target and begin to dismantle the health inequities that our current unjust system is built upon. CNA concludes the only way we can guarantee that every person living in California receives the health care they need with a single standard of excellent care is by adopting a single-payer, CalCare system for all.
- SUPPORT IN CONCEPT. Health Access California (HAC) writes that a progressively financed system, where what we pay for health care is based on what we can afford, not on how sick we are or what job we happen to have, and where the tax structure is also progressive, capturing unearned income and wealth while not relying on regressive payroll taxes to finance it. Health care is expensive, and employer health benefits are notably regressive in terms of income. The regressivity is especially stark in high deductible plans where the sick by definition pay more than the healthy. In addition, the cost of a health plan is thousands of dollars, which can be a third or a half of a low-income worker’s annual income. The ACA made strides in addressing the regressivity of health benefits by providing Medi-Cal to all legal residents below or around the poverty level, and significant but still insufficient income-based affordability assistance to those under 400% of the FPL. Additional federal and state subsidies have taken some additional steps to the single-payer goal of a government guarantee that nobody has to spend more than a percentage of their income on health care. Depending on how the taxes to finance the single payer system are structured, a single payer system could finally assure that those who can afford the most are paying the most toward the cost of financing the health system and that individuals pay based on a sliding scale based on income, both earned and unearned, or extraordinary wealth. The ACA and existing California law now puts a minimum standard on benefits and a maximum ceiling on cost-sharing, but more work is needed to assure people can get care when they need it and that they can afford that care. A well-managed single-payer system has tools for managing costs and streamlining operations and administration far greater than any individual insurer or provider. HAC appreciates the work of the author in looking at how other countries negotiate or set rates, with his previous bill AB 3087 (Kalra) of 2018 and this current proposal. Our current fragmented system creates confusion, and while the ACA filled in many gaps, there is more to do. Having a “single payer” would avoid the continuing complications with regard to the churn between coverage types, as people shift from one employer to another job, between Medi-Cal income levels and those of Covered California, and age from their parents’ coverage or into Medicare. HAC concludes that the administrative costs of so many payers include not just the overhead of the insurance industry, but the imposed burden on providers of navigating the many billing systems of multiple insurers and payers.
- OPPOSITION. The California Association of Health Plans and the Association of California Life and Health Insurance Companies (collectively “insurers”) writes that this bill ignores and destroys progress, and instead creates a massive new government- run program with no ability for consumers to opt-out or choose their own coverage. Single payer faces huge procedural hurdles in the form of receiving federal waivers, passing massive tax increases and garnering support for a constitutional amendment; all of which will have a significant impact on the state budget. According to the insurers, this proposal would include eliminating or weakening voter-approved constitutional protections for school funding and public safety, threatening funding for public schools and community colleges, hiking the state’s voter-approved constitutional spending limit by hundreds of billions of dollars a year – putting at risk California’s financial health. With single payer, supply in health care provision often fails to meet demand leading to long wait times, cost increases and provider shortages – as seen in single payer systems abroad. In the U.K.'s single payer system, 120,000 patients died in 2022 while on wait lists for care. In Canada, the median wait time between a referral from a general practitioner to a specialist procedure is 27.7 weeks. In contrast, the average wait time to see a specialist under our current system in the U.S. is 26 days.
The California Hospital Association (CHA) writes that this bill would face fiscal pressures to keep costs low while overpromising benefits. As a result, appointment wait times would increase, necessary treatments rationed, and patient choice stifled. California’s hospitals recognize that shortcomings in access and affordability remain as part of the health care system. While this bill does not reflect the right approach, CHA looks forward to collaborating with the Legislature and governor to develop solutions that constructively and meaningfully enhance health care access and outcomes for all Californians.
The California Medical Association (CMA) contends that this bill contemplates consolidating Medi-Cal, Medicare, private insurance and the Covered California exchange into a single health insurance product (CalCare) provided by the state — without the constitutional protections that are essential to ensuring that an adequate, guaranteed supply of resources will be allocated to ensure its viability. Unlike the federal government which may carry debt and finance a program of this magnitude with some uncertainties, California must pass a balanced budget and could create a situation where CalCare could face uncertain financing in tough deficit years (like this one). Without these needed protections and given the volatility of California’s tax revenue from year to year, a single-payer program could default to a system that it is unable to provide timely access to quality care for the beneficiaries it would cover. CMA agrees that a system should cover the vast amount of benefits, with limited co-pays, quick patient appointments and at a fraction of the cost of the current system. However, those decisions cannot be made in a vacuum and are not without fiscal consequences or tradeoffs. CMA concludes until we know how much money can be generated and contributed to this program, we cannot begin to discuss the specifics.
The America’s Physician Groups (APG) write that this bill expressly prohibits the use of information technology and clinical practice guidelines, in favor of individual licensees’ professional judgement. APG have been uniquely responsible for the care of millions of patients across the country under an accountable model for the past several decades and they have pioneered the use of best clinical practices guidelines to standardize care approaches, focus on evidence-based medicine, improve patient outcomes and decrease variation in medical practice. Clinical variation involves the overuse, underuse, different use and waste of healthcare practices and services with varying outcomes. It has been associated with poorer health outcomes, increased costs, disparities in care and increased burden on the public health system. This bill further defines “medically necessary and appropriate” based on the subjective determination of each licensed provider rendering services. Building accountable systems of patient care that decrease variation in medical practice involves peer-supported oversight, use of clinical practice guidelines and intensive use of information technology. It is also highly dependent upon provider payment mechanisms other than pure FFS. According to APG, this bill restricts payment of physician practices to two models, either FFS or salaried. Independent physicians may only be paid on a FFS basis. In combination, these factors dismantle the best elements of the California healthcare delivery system and replace it with outdated, obsolete 1950’s style, cottage-industry healthcare delivery.
- PREVIOUS LEGISLATION.
- SB 770 (Wiener), Chapter 412, Statutes of 2023, requires the CHHSA Secretary to research, develop and pursue discussions of a waiver framework in consultation with the federal government with the objective of creating a health care system that incorporates specified features and objectives. Requires the CHHSA Secretary, in developing the waiver framework, to engage stakeholders to provide input on topics related to discussions with the federal government and key system design issues identified by the HCFA for further analysis. Requires the CHHSA Secretary, no later than January 1, 2025, to provide an interim report to the chairs of the Assembly and Senate Budget and Health Committees that details the agency's policy priorities and preliminary analysis of issues related to the federal discussions, as well as a summary of the input received date through the stakeholder engagement process. Requires the CHHSA Secretary, no later than January 1, 2025, to propose statutory language to the chairs of these committees authorizing the development and submission of application to the federal government for waivers necessary to implement the UF.
- AB 1690 (Kalra) of 2023 stated the intent of the Legislature to guarantee accessible, affordable, equitable, and high-quality health care for all Californians through a comprehensive universal single-payer health care program that benefits every resident of the state. AB 1690 was held in the Assembly Rules Committee.
- SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2202, establishes OHCA within HCAI. Identifies OHCAs three primary responsibilities: managing spending targets, monitoring system performance, and assessing market consolidation. Requires OHCA to collect, analyze, and publicly report data on total health care expenditures, and enforce spending targets set by a Health Care Affordability Board.
- AB 1400 (Kalra) of 2021 would have established the California Guaranteed Health Care for All or CalCare as California’s single-payer health care coverage program. AB 1400 died on the Assembly Floor.
- ACA 11 (Kalra) of 2021 would have imposed an annual tax of 2.3% on businesses that have at least $2 million in annual revenue; a 1.25% tax on payroll for companies with at least 50 employees; a one percent tax for those employers who pay employees at least $49,900. ACA 11 would also have included a series of tax hikes on wealthier people, starting with a 0.5% levy on the income of people who make at least $149,509 per year and ending at a 2.5% income tax for people who make more than $2.48 million per year. ACA 11 would have permitted the Legislature to pass a statute that increases any or all of the tax rates by a majority vote; and would have authorized the Legislature, upon an economic analysis determining insufficient amounts to fund these purposes, to increase any or all of these tax rates, as specified. ACA 11 was never referred to a committee and died at the Assembly Desk.
- SB 562 (Lara and Atkins) of 2017 would have enacted the Healthy California program, which would have required the provision of comprehensive universal single-payer health care coverage system for all California residents. SB 562 died in Assembly Rules Committee. Speaker Rendon at that time called SB 562 “woefully incomplete” and instead created the Select Committee (described above).
- SB 810 (Leno) of 2011 and SB 810 (Leno) of 2009 would have established the California Healthcare System and failed passage on the Senate Floor in 2012. SB 810 (Leno) of 2009 was not taken up on the Assembly Floor.
- SB 840 (Kuehl) of 2007 was similar to SB 2009 and was vetoed by Governor Schwarzenegger. In his veto message, the Governor cited a Legislative Analyst’s Office analysis that estimated the bill to cost $210 billion in its first full year of implementation and cause annual shortfalls of $42 billion, and he could not support a bill that placed an annual shortfall of over $40 billion on California’s economy.
- SB 1014 (Kuehl) of 2007 would have imposed a payroll tax to fund the single payer system. SB 1014 was heard in the Senate Revenue and Taxation Committee but no vote was taken.
- SB 921 (Kuehl) of 2003 would have established the California Health Care System to be administered by the newly created California Health Care Agency under the control of an elected Health Care Commissioner. Would have made all California residents eligible for specified health care benefits under the California Health Care System, which would, on a single-payer basis, negotiate for or set fees for health care services provided through the system and pay claims for those services was never heard in the Assembly Appropriations Committee. SB 921 was held in the Assembly.
- AUTHOR’S AMENDMENTS. The author is proposing to amend this bill as follows:
- Revise the Governor’s board appointments to four;
- Revise the board to two patient advocacy seats and merge the public health and mental health seat;
- Revise conflict of interest provisions for the board;
- Address generic drug as a substitute;
- Include a reference to the OHCA spending target;
- Add language about prevention-oriented care to the Office of Health Equity responsibilities;
- Add intent language to existing patient rights and protections and reference to the IMR process;
- Add a provision allowing individual providers to petition for interim review of payments;
- Add a provision allowing workers and their representatives to petition for review of a global budget payment; and,
- Delete county-organized health plans and local initiatives.
- COMMENTS.
- Federal issues. HCFA noted that many factors affect California’s ability to take independent action to reorganize health care finance and delivery including: i) California would need to grapple with federal law and regulation related to Medicare and Medicaid; ii) address limitations under the Employee Retirement Income Security Act of 1974 (ERISA) on the state’s ability to impose requirements on employer benefit program (self-funded employers not subject to state law); and, iii) navigate existing constrains on how California raises and spends revenue. This bill provides that every resident of this state is eligible and entitled to enroll in CalCare. California law with respect to insurance regulation is pre-empted under ERISA from regulating employer sponsored benefits. Additionally, this bill requires the board to establish requirements and standards by regulation, to the extent authorized by federal law, to replace and merge with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the ACA, and federally matched public health programs. As noted above by CHCF, in 2022, there were 5.8 million people were enrolled through administrative services only arrangements for self-insured employers. As this bill moves forward, the author should consider any unintended consequence to employer sponsored coverage and whether or not CalCare may cause a shift to ERISA plans, diluting the intent of CalCare to provide coverage to all residents of California.
- Consumer Protections in Existing law. To address concerns raised that other similar single payer systems have long wait times as raised by the insurers above, the author may wish to consider the following consumer-oriented requirements:
- Network adequacy. According to CHCF, network adequacy standards are commonly used as a regulatory tool to ensure that health plans contain a network of health care providers adequate for enrollees to access medically necessary services in a timely manner. California law sets forth various network adequacy requirements on health plans and insurers. For example, health plans are subject to the following:
- Timely Access. Timely Access Laws and Regulations require that health plans meet a set of standards which include specific time frames under which enrollees must be able to access care. These requirements generally include the following standards for appointment availability:
- Urgent care without prior authorization: within 48 hours;
- Urgent care with prior authorization: within 96 hours;
- Non-urgent primary care appointments: within 10 business days;
- Non-urgent specialist appointments: within 15 business days;
- Non-Urgent mental health appointments: within 15 business days for psychiatrist, within 10 business days for non-physician MH provider; and,
- Non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness or other health condition: within 15 business days.
- Geographic Access. Health plans are also generally required to ensure geographic access such that there are a sufficient number of providers located within a reasonable distance from where each enrollee lives or works. For example, primary care physicians (PCPs) and hospitals should be located within 15 miles or 30 minutes from work or home. Health plans must also ensure provider capacity such that health plan networks have enough of each of the right types of providers to deliver the volume of services needed. For example, plan networks should include one PCP for every 2,000 beneficiaries.
- Timely Access. Timely Access Laws and Regulations require that health plans meet a set of standards which include specific time frames under which enrollees must be able to access care. These requirements generally include the following standards for appointment availability:
- Appeals. Another consumer right is the right to know why a health plan denies a service or treatment, and the right to file a grievance if the consumer disagrees. Health plans are required to have grievance and appeals systems to assist consumers in resolving these issues. A robust grievance program also allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement. The author should consider a similar framework that allows CalCare members to complain about the quality of care or lack of timely or geographic access to CalCare providers.
- Other consumer protections. In addition to other consumer protections under the KKA, there are other consumer protections under Medicare, Medicaid, or the Lanterman-Petris-Short (LPS) Act. As such, the author should consider adding additional intent language as follows:
- Network adequacy. According to CHCF, network adequacy standards are commonly used as a regulatory tool to ensure that health plans contain a network of health care providers adequate for enrollees to access medically necessary services in a timely manner. California law sets forth various network adequacy requirements on health plans and insurers. For example, health plans are subject to the following:
This title does not diminish or eliminate any of the rights and protections afforded Californians by the Medicare and Medicaid program under state and federal law or the LPS Act in state law.
- Health Information Exchange. The CHHSA Data Sharing Agreement (DSA) is California’s first-ever statewide data sharing agreement that governs the safe exchange of health and social services information by defining a common set of terms, conditions, and obligations—promoting whole person care and ensuring that the medical care, behavioral health and social services systems in California are able to work together and securely share information pertinent to a patient’s health and wellbeing. Most health care providers were required to sign the DSA by January 31, 2023, however, it should be noted that full compliance has not been reached. This bill should mandate all CalCare health care providers to participate in the DSA to ensure the goals of the DSA are achieved.
- Fiscal Solvency. This bill authorizes the board to do many things under this bill, including the ability to add benefits; to establish requirements and standards for CalCare and health care providers when establishing a single standard of safe, therapeutic and effective care for all state residents; and, to increase an individual’s eligibility for any federal financial support related to Medicare or the ACA. While this bill requires the CalCare Executive Director to annually submit a report to the Legislature on the implementation and performance of CalCare functions, should this board consider the value of existing state resources from any of the departments under the CHHSA, for example, a review of the fiscal solvency of CalCare? As this bill moves forward, the author should consider whether or not this bill has the appropriate oversight by the Legislature or other state agencies to ensure successful implementation.
- Role of current regulatory authorities and agencies. The fate of existing regulators and independent agencies are unclear under this bill. The author may wish to address the value of these state agencies and the role each plays to ensure relevant oversight and enforce consumer protections in the provision of health care coverage. As this bill moves forward, the author should consider adding specific enforcement language, including providing the board the authority to develop a framework for investigating potential violations of this bill.
- State Constitutional Issues. There are two state constitutional issues that must be addressed if California is to implement a single-payer program. Proposition 4 of 1979 established a constitutional state spending limit that is known as the “Gann Limit.” The original Gann Limit was later modified by two ballot measures: Proposition 98 of 1988 and Proposition 111 of 1990. Proposition 98 of 1988, as modified by Proposition 111 of 1990, constitutionally guarantees a minimum level of funding for K-12 schools and community colleges. Thus, any taxes/revenues raised to support this bill would be subject to the requirements of the Gann limit and Proposition 98 and may require a voter initiative.
- Cost Containment. This bill contains certain cost containment provisions, including establishing a global budget for institutional providers, and giving the board the authority to negotiate prices for prescription drugs, medical supplies and other health care items. However, this bill also relies on a FFS payment mechanism and although it uses 100% of Medicare FFS as the reasonable basis for payment, under a FFS payment, providers would each be paid separately for each test, procedure or treatment. This bill further defines “medically necessary and appropriate” based on the treating physician. A 2016 CHCF blog writes that in California, most physician organizations contracting with HMOs also generally receive per-member, per-month payments, or capitation, so they are accountable and generally rewarded for the health of a defined patient population. This organizational model is consistent with the overall goal of CMS and other purchasers to drive more care and payments through so-called alternative payment models that aim to deliver high-quality, affordable, patient-centered care. These are the essential characteristics of high-value care. Even using the Medicare payment rate system, the cost of health care will continue to rise. It is important for the Committee to evaluate whether this bill includes sufficient cost containment mechanisms to identify and address cost drivers in the system, ensure it eliminates waste and fraud, and evaluate the price of health care while improving quality and care. As this bill moves forward, the author should consider whether periodic review of the program’s reimbursement structures for fiscal and other impacts can be addressed.
REGISTERED SUPPORT / OPPOSITION:
Support
California Nurses Association
ACLU California Action
AIDS Healthcare Foundation
Alameda County Homeless Action Center
Alex Rechsteiner Painting
Alliance for Boys and Men of Color
Asian/Pacific Islanders for Calcare
Black Lives Matter - Los Angeles
Butte County Health Care Coalition
Cal Red Berets
California Alliance for Retired Americans
California Conference of Machinists
California Faculty Association
California Federation of Interpreters
California Federation of Teachers AFL-CIO
California Immigrant Policy Center
California Labor Federation, AFL-CIO
California OneCare
California Pan - Ethnic Health Network
California School Employees Association
California State Northridge Young Democratic Socialists of America
California Teachers Association
Cleanearth4kids.org
Coalition to Abolish Slavery and Trafficking (CAST)
Community Health Councils
Conference of California Bar Associations
Council Member Mateo Bedolla, City of Tracy
County of Santa Clara
Culver City Democratic Club
Democratic Socialists of America - San Luis Obispo
DSA-Santa Barbara
East Valley Indivisibles
Educators for Single-payer
Federation of Retired Union Members
Feel the Bern Democratic Club, Los Angeles
Feel the Bern San Fernando Valley Democratic Club
Focus Strategies
Gray Panthers of San Francisco
Green Party of California
Green Party of Santa Clara County CA
Health Access California
Health Care 4 US (HC4US)
Health Care for All - California
Healthy California Now
Hire Survivors Hollywood
Hollywood4CalCare
Holy Faith Episcopal Church
Human Agenda
Humboldt Progressive Democrats
Indivisible Ca: Statestrong
Indivisible Sacramento
Indivisible Westside Los Angeles
Initiate Justice Action
Inland Equity Partnership
International Association of Machinists & Aerospace Workers Local Lodge 1484
Iranian American Democrats of California
Katharine Gale Consulting
Labor Today International, INC.
Long Beach Gray Panthers
Midnight Books
NorCal Resist
Parivar Bay Area
Peace and Freedom Party of California
Peninsula DSA
Physicians for A National Health Program -- Bay Area Chapter
Pride At Work South Bay Chapter
Sacramento Democratic Socialists of America
Sacramento; City of
San Diego Snahp Chapter
San Gabriel Valley Neighbors for Peace and Justice
San Gabriel Valley Progressives
Santa Clara County Single Payer Health Care Coalition
Santa Cruz for Bernie
Santa Monica Democratic Club
Socialists for CalCare
South Bay Community Land Trust
South Bay Indigenous Solidarity
South Bay Progressive Alliance
Southern Alameda County Progressive Democrats
Stanislaus County Democratic Central Committee
Techequity Collaborative
Thai Community Development Center
The National Tai Chi Chuan Association
Therapists for Single Payer
Trade Show Temps
Unite Here Local 11
Unite-Here, AFL-CIO
United Democrats of Southern Solano County
Western Center on Law & Poverty, INC.
White People 4 Black Lives
Opposition
Acclamation Insurance Management Services
African American Farmers of California
Agricultural Council of California
Alameda Chamber of Commerce
Allied Managed Care
America's Physician Groups
American Composites Manufacturers Association
American Petroleum and Convenience Store Association
American Pistachio Growers
American Property Casualty Insurance Association
Antelope Valley Chambers of Commerce
Associated General Contractors
Associated General Contractors San Diego
Association of California Life & Health Insurance Companies
Bay Area Council
Blue Shield of California
Brea Chamber of Commerce
Building Owners and Managers Association of California
Business Council San Joaquin County
California Agents & Health Insurance Professionals (CAHIP)
California Agricultural Aircraft Association
California Apple Commission
California Asian Pacific Chamber of Commerce (CAPCC)
California Association of Health Plans
California Association of Highway Patrolmen
California Association of Winegrape Growers
California Attractions and Parks Association
California Beer and Beverage Distributors
California Blueberry Association
California Blueberry Commission
California Builders Alliance
California Building Industry Association
California Business Properties Association
California Business Roundtable
California Cable and Telecommunications Association
California Cattlemen's Association
California Chamber of Commerce
California Children's Hospital Association
California Correctional Peace Officers Association Benefit Trust
California Cotton Ginners and Growers Association
California Dental Association
California Financial Services Association
California Fresh Fruit Association
California Fuels and Convenience Alliance
California Hispanic Chamber of Commerce
California Hospital Association
California Independent Petroleum Association (CIPA)
California Land Title Association
California Landscape Contractor's Association
California Landscape Contractors Association
California League of Food Producers
California Lodging Industry Association
California Manufacturers & Technology Association
California Medical Association
California New Car Dealers Association
California Pool & Spa Association
California Retailers Association
California Rice Commission
California Strawberry Commission
California Taxpayers Association
California Walnut Commission
California Women for Agriculture
Can Manufacturers Institute
Carlsbad Chamber of Commerce
Cemetery and Mortuary Association of California
Chino Valley Chamber of Commerce
Cigna
Coalition of Small and Disabled Veteran Businesses
Construction Employers' Association
Corona Chamber of Commerce
Dairy Institute of California
Danville Area Chamber of Commerce
Department of California Marine Corps League
El Dorado County Chamber of Commerce
El Dorado Hills Chamber of Commerce
Elevance Health
Elk Grove Chamber of Commerce
Family Business Association of California
Flasher Barricade Association
Folsom Chamber of Commerce
Fontana Chamber of Commerce
Fountain Valley Chamber of Commerce
Fresno Chamber of Commerce
Garden Grove Chamber of Commerce
Gateway Chambers Alliance
Gilroy Chamber of Commerce
Greater Coachella Valley Chamber of Commerce
Greater Conejo Valley Chamber of Commerce
Greater Grass Valley Chamber of Commerce
Greater High Desert Chamber of Commerce
Greater Riverside Chambers of Commerce
Greater San Fernando Valley Chamber of Commerce
Greater Stockton Chamber of Commerce
Health Net
Hollywood Chamber of Commerce
Housing Contractors of California
Imperial Valley Regional Chamber of Commerce
Independent Lodging Industry Association.
Innovating Commerce Serving Communities
Kaiser Permanente
LA Cañada Flintridge Chamber of Commerce and Community Association
Laguna Niguel Chamber of Commerce
Lincoln Area Chamber of Commerce
Long Beach Area Chamber of Commerce
Los Angeles Area Chamber of Commerce
Mammoth Lakes Chamber of Commerce
Manhattan Beach Chamber of Commerce
Manteca Chamber of Commerce
Metal Finishing Association of Northern California
Metal Finishing Association of Southern California
Mission Viejo Chamber of Commerce
Murrieta Wildomar Chamber of Commerce
NAIOP California
National Electrical Contractors Association (NECA)
National Federation of Independent Business
Newport Beach Chamber of Commerce
Nisei Farmers League
North San Diego Business Chamber
Norwalk Chamber of Commerce
Oceanside Chamber of Commerce
Olive Growers Council of California
Orange County Business Council
Palos Verdes Peninsula Chamber of Commerce
Paso Robles Templeton Chamber of Commerce
Peace Officers Research Association of California (PORAC)
Pleasanton Chamber of Commerce
Rancho Cordova Area Chamber of Commerce
Redondo Beach Chamber of Commerce
Rocklin Area Chamber of Commerce
Roseville Area Chamber of Commerce
Sacramento Black Chamber of Commerce
Sacramento Regional Builders Exchange (SRBX)
San Diego Regional Chamber of Commerce
San Juan Capistrano Chamber of Commerce
San Mateo Area Chamber of Commerce
San Pedro Chamber of Commerce
San Ramon Chamber of Commerce
Santa Ana Chamber of Commerce
Santa Maria Valley Chamber of Commerce
Shasta; County of
Shingle Springs/Cameron Park Chamber of Commerce
Silicon Valley Leadership Group
Simi Valley Chamber of Commerce
South Bay Association of Chambers of Commerce
Southwest California Legislative Council
Torrance Area Chamber of Commerce
Tulare Chamber of Commerce
United Chamber Advocacy Network
United Contractors
Vacaville Chamber of Commerce
Valley Industry and Commerce Association (VICA)
Ventura Chamber of Commerce
Walnut Creek Chamber of Commerce & Visitors Bureau
Waste Management
West Coast Lumber & Building Material Association
West Hollywood Chamber of Commerce
West Ventura County Business Alliance
Western Agricultural Processors Association
Western Growers Association
Western Manufactured Housing Communities Association
Western Plant Health Association
Whittier Area Chamber of Commerce
Word & Brown
Yuba Sutter Chamber of Commerce
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097
Discussed in Hearing
1H
Assembly Standing Committee on Health
1MIN
Assembly Standing Committee on Health
24SEC
Assembly Standing Committee on Health
Bill Author
