(1) Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), enacts various health care coverage market reforms that took effect January 1, 2014. Among other things, PPACA requires each state to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. Existing state law establishes the California Health Benefit Exchange (the Exchange) within state government, known as Covered California, specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers. Existing law prohibits a member 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 carrier or other insurer, an agent or broker, a health care provider, or a health care facility or health clinic while serving on the board or on the staff of the Exchange and from receiving compensation for service on the board, except as specified.
This bill would create an exception to that prohibition by authorizing a member of the board or of the staff of the Exchange to perform volunteer services under specified conditions, including that the member or staff does not receive compensation, as described, for rendering services and does not have an ownership interest in the entity, facility, clinic, or provider group.
(2) Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for licensure and regulation of health care service plans by the Department of
Managed Health Care and makes a willful violation of that act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law, the Information Practices Act of 1977, regulates the collection and disclosure of personal information regarding individuals by state agencies, except as specified. Under existing law, a person who willfully requests or obtains a record containing personal information from an agency under false pretenses or a person who intentionally discloses medical, psychiatric, or psychological information held by an agency is guilty of a misdemeanor.
Existing law states the intent of the Legislature to establish the Health Care Cost Transparency Database to collect information on the cost of health care, and requires the Office of Statewide Health Planning and Development to convene a review committee to advise the office on the establishment and implementation of the database. Existing law requires,
subject to appropriation, the office to establish, implement, and administer the database by July 1, 2023. Existing law requires certain health care entities, including a health care service plan, to provide specified information to the office for collection in the database.
This bill would delete those provisions relative to the Health Care Cost Transparency Database and would instead require the office to establish the Health Care Payments Data Program to implement and administer the Health Care Payments Data System, which would include health care data submitted by health care service plans, health insurers, a city or county that offers self-insured or multiemployer-insured plans, and other specified mandatory and voluntary submitters. The bill would require the Department of Managed Health Care and the Department of Insurance to take appropriate action to bring a plan or insurer into compliance if the office notifies the appropriate department of a plan or
insurer’s failure to submit required data. Because a willful violation of these provisions by a health care service plan would be a crime, and because a city or county that offers self-insured or multiemployer-insured plans would be required to submit health care data to the office, the bill would impose a state-mandated local program. The bill would exempt multiple employer welfare arrangements, as defined, that are regulated pursuant to specified provisions of the Insurance Code from these requirements. The bill would also make a health insurer that fails to comply with the data submission requirements subject to certain civil penalties, as specified.
This bill would require the office to use the above-described data to produce publicly available information, including data products, summaries, analyses, studies, and other reports, to support goals that include improving public health, reducing disparities, and reducing health care costs. The bill would also
require the office to submit a report to the Legislature, on or before March 1, 2024, that includes, among other things, claims data reported by mandatory and voluntary submitters. The bill would protect the confidentiality of personally identifiable data submitted to the system and would exempt it from disclosure, but would authorize controlled access to that nonpublic data by outside data analysts, researchers, and other qualified applicants if the data and requesters meet specified criteria. The bill would require a person accessing nonpublic data to sign a data use agreement subject to the penalties of the Information Practices Act of 1977. Because a willful violation of a data use agreement would be a crime, the bill would impose a state-mandated local program.
This bill would authorize the office to establish pricing mechanisms for data products, custom reports, and the use of nonpublic data, and would require revenues from those activities to be deposited
into the Health Care Payments Data Fund, for use by the office upon appropriation by the Legislature. The bill would require the office to establish a Health Care Payments Data Program advisory committee with specified membership to assist and advise the director of the office in formulating program policies regarding data collection, management, use, and access, and development of public information to meet the goals of the program. The bill would also require the office to establish a data release committee with specified membership to make recommendations about applications seeking either program data with direct personal identifiers or the transmission of standardized datasets, except for data requests from other state agencies.
(3) Existing law establishes the State Department of Public Health within the California Health and Human Services Agency.
Existing law authorizes the Director of Public
Health to establish and administer a program within the department’s Office of AIDS to subsidize certain costs of medications for the prevention of human immunodeficiency virus (HIV) infection and other related medical services to residents of California who are at least 18 years of age, who are HIV negative, and who meet specified other requirements. Existing law also authorizes the program to subsidize, without regard to eligibility and for the prevention of HIV infection, up to 14 days of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medications and up to 28 days of PEP medications for a victim of sexual assault.
This bill instead would authorize the program to subsidize up to 30 days of PrEP and PEP medications for the prevention of HIV infection, without regard to whether the person was a victim of sexual assault.
Existing law requires, to the extent that funds are appropriated for these purposes,
the State Public Health Officer to establish a program to provide drug treatments to persons infected with HIV. Existing law requires the department to establish uniform standards of financial eligibility for the drugs under the program. Existing law requires the department to disclose to the Franchise Tax Board identifying information regarding an applicant for, or recipient of, services under the program for the purpose of verifying the accuracy of the applicant’s or recipient’s adjusted gross income reported on the application for the program, and requires the Franchise Tax Board to inform the department of the applicant’s federal and state adjusted gross income and other specified income. Existing law also makes this information a confidential public record, as defined. Existing law makes a person who willfully, maliciously, or negligently discloses the content of a confidential public health record to a third party, except pursuant to a written authorization, or as otherwise authorized by law, that
results in economic, bodily, or psychological harm to the person whose confidential public health record was disclosed, guilty of a misdemeanor, punishable by imprisonment in a county jail for a period not to exceed one year, or a fine not to exceed $25,000, or both.
This bill would require the department to verify, and the Franchise Tax Board to report to the department, the modified adjusted gross income, rather than the adjusted gross income, of the applicant or recipient. The bill would also require the Franchise Tax Board to inform the department of income received by the taxpayer household and the family size of the taxpayer household. By expanding the scope of the information contained in a confidential public record, the bill would expand the scope of a crime, thereby imposing a state-mandated local program.
Existing law requires the department to develop and review plans and participate in a program for the
prevention and control of sexually transmitted diseases. Existing law requires the department, contingent upon appropriation in the annual Budget Act, to allocate grants to local health jurisdictions for sexually transmitted disease, HIV, and hepatitis C virus control and prevention activities. Existing law suspends those programs as of December 31, 2021, unless projected General Fund revenues exceed the projected annual General Fund expenditures in the 2021–22 and 2022–23 fiscal years by a specified amount.
This bill would repeal the contingent suspension of those programs.
(4) Existing law requires the department to implement and administer a residential lead-based paint hazard reduction program. Existing law requires specified persons engaged in lead construction work to have a certificate issued by the department. Existing law authorizes the department to establish fees for accreditation,
certification, and licensing in connection with the program for deposit in the Lead-Related Construction Fund. Moneys in the fund are available upon appropriation. Existing law requires the department to prepare a report, as specified, by February 1 of any year in which the department raises or establishes new or additional fees, including the fees described above, to make that report and the list of fees available to the Budget Committees of the Legislature, and to post the report and the list of fees on the department’s internet website. Existing law, the Administrative Procedure Act, sets forth the requirements for the adoption, publication, review, and implementation of regulations by state agencies, and for review of those regulatory actions by the Office of Administrative Law.
This bill would make those adjustments and modifications of fees and the publication of the final fee list exempt from the Administrative Procedure Act, and would instead only require
that the revised list of fees be filed with the Secretary of State and printed in the California Code of Regulations.
(5) Existing federal law, the Patient Protection and Affordable Care Act (PPACA), establishes annual limits on health care deductibles and defines bronze, silver, gold, and platinum levels of coverage for the nongrandfathered individual and small group markets. Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and the regulation of health insurers by the Department of Insurance. Existing law authorizes the actuarial value for a nongrandfathered bronze level high deductible health plan or health insurance policy to range from plus 4% to minus 2%.
This bill would instead authorize the actuarial value for a nongrandfathered bronze level health plan or health insurance policy that either covers and pays for at least
one major service, other than preventive services, before the deductible or meets the requirements to be a high deductible health plan to range from plus 5% to minus 2%.
(6) 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.
For purposes of administering the Medi-Cal program, existing law vests the Director of Health Care Services with those powers and duties necessary to conform to requirements for securing federal approval of a state plan. Existing federal law authorizes the Secretary of California Health and Human Services to waive provisions of federal Medicaid law under specified circumstances, including when the secretary finds that the waiver would be cost
effective and efficient. Existing state law requires the department to seek a variety of waivers of federal law, such as the Medi-Cal 2020 Demonstration Project, which is scheduled to expire on December 31, 2020. Pursuant to existing law, the President, under the National Emergencies Act, and the Governor, under the California Emergency Services Act, declared a national emergency and a state of emergency, respectively, in response to the novel coronavirus, known as COVID-19.
For the duration of the COVID-19 emergency period, this bill would require the department to implement any federal Medicaid program waiver or flexibility approved by the federal Centers for Medicare and Medicaid Services related to that emergency and to exercise its option under prescribed law to extend medical assistance to uninsured individuals, as specified, for the duration of that emergency period. The bill would authorize the department to extend medical assistance afforded to uninsured
individuals to include COVID-19-related treatment services that are otherwise covered for full-scope Medi-Cal beneficiaries, and, if federal financial participation is unavailable, would authorize the department to elect to implement that provision on a state-only funding basis, subject to an appropriation by the Legislature. The bill would require the department to maximize federal financial participation for Medi-Cal expenditures for the COVID-19 public health emergency, to comply with any federal requirements and conditions for receipt of that federal financial participation, and, subject to Department of Finance approval, to seek any federal approvals to implement those provisions or to maintain sufficient access to covered Medi-Cal benefits during this emergency period. Due to the impact of the COVID-19 public health emergency on the Medi-Cal program, this bill would authorize the department to seek federal approvals for temporary extensions of the Medi-Cal 2020 Demonstration Project, and would require
the department to consult with affected stakeholder entities before seeking any extension.
Existing law provides for the suspension of Medi-Cal benefits to an inmate of a public institution, and requires county welfare departments to notify the department within 10 days of receiving information that an individual who is receiving Medi-Cal is or will be an inmate of a public institution. Existing law generally requires a county to redetermine a Medi-Cal beneficiary’s eligibility to receive Medi-Cal benefits every 12 months and whenever the county receives information about changes in a beneficiary’s circumstances that may affect their eligibility for Medi-Cal benefits. Existing federal law, the SUPPORT for Patients and Communities Act, prohibits a state from terminating Medi-Cal eligibility for an eligible juvenile if they are an inmate of a public institution, authorizes the suspension of Medicaid benefits to that eligible juvenile, and requires a state to conduct a
redetermination of Medicaid eligibility or process an application for medical assistance under the Medicaid program for an eligible juvenile who is an inmate of a public institution.
This bill would conform the suspension of benefits for juveniles, as defined, under state law with those federal provisions. The bill would require the department, in consultation with stakeholders, including the County Welfare Directors Association of California, to develop and implement a redetermination of eligibility, to the extent required by federal law, for juveniles, as defined, whose eligibility is suspended. Because counties are required to make Medi-Cal eligibility determinations, and the bill would expand Medi-Cal determinations of eligibility for eligible juveniles of public institutions, the bill would impose a state-mandated local program.
Existing law requires the Director of Health Care Services to annually review the
reimbursement levels for physician and dental services under the Medi-Cal program, and to periodically revise the rates of reimbursement to physicians and dentists to ensure the reasonable access of Medi-Cal beneficiaries to physician and dental services. Existing law requires that the annual review, as it relates to rates for physician services, take into account specified factors, including physician reimbursement levels set forth by Blue Shield of California and other third-party payers, and procedures reflected by the current Relative Value Studies (RVS).
This bill would instead require the director to periodically review those reimbursement levels under the Medi-Cal fee-for-service delivery system, and to periodically revise those rates to the extent they deem necessary to comply with federal Medicaid program requirements on reasonable access to those services for Medi-Cal beneficiaries. The bill would limit the periodic review, as it relates to physician
services, to requirements specified in the department’s federally approved access monitoring plan, or any successor methodology for monitoring reasonable access to Medi-Cal services, and to take into account specified factors. The bill would delete the above-specified factors regarding Blue Shield, third-party payers, and RVS.
Existing law establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal), under which the department is authorized to enter into contracts with each county, or enter into contracts directly with certified providers, for the provision of alcohol and drug use treatment services, including substance use disorder services, narcotic treatment program services, and naltrexone services, to Medi-Cal beneficiaries. Existing federal law requires, from October 1, 2020, to September 30, 2025, inclusive, medication-assisted treatment, as defined, to be a covered health care service under a state Medicaid program.
This bill would, subject to federal approval and the availability of federal financial participation, expand narcotic treatment program services to include medication-assisted treatment under Drug Medi-Cal, and would make conforming changes. The bill would authorize the department to implement provisions on services, reimbursement, and audits related to Drug Medi-Cal by various means, including bulletins, and would require the department, by July 1, 2023, to subsequently adopt regulations.
Existing law requires the department to establish a 3-year pilot program in specified counties to provide medically tailored meals, as defined, to Medi-Cal participants with specified health conditions, such as cancer and renal disease. Existing law requires the department to evaluate, at the conclusion of the program, the impact of the pilot program on specified matters related to participants, including hospital readmission and emergency
room utilization rates, and to send, on or before January 1, 2021, or within 12 months after the end of the program, a report on the evaluation to the Legislature. Existing law makes these provisions inoperative on the earlier of January 1, 2021, or 6 months following the end of the program.
This bill would extend the duration of the pilot program to 4 years, delete the January 1, 2021, due date for the report, and make related, conforming, and technical changes. The bill would also make these provisions inoperative on the earlier of the date the department submits its report to the Legislature or 12 months after the end of the program.
Existing law, until July 1, 2021, and only to the extent that federal participation is available, requires the department to establish and administer the Medi-Cal Electronic Health Records Incentive Program to provide federal incentive payments to Medi-Cal providers for the implementation
and use of electronic health records systems.
This bill would recast that program as the Medi-Cal Promoting Interoperability Program and would extend its operation until January 1, 2024.
(7) Existing law establishes the State Department of State Hospitals within the California Health and Human Services Agency and provides the department with jurisdiction over specified facilities for the care and treatment of persons with mental health disorders. Existing law requires the Director of State Hospitals to appoint and define the duties of specified officers, including the clinical director and hospital administrator of each state hospital. Existing law requires a hospital administrator to be a college graduate, as specified. Existing law authorizes, until September 2020, the State Department of State Hospitals to house up to 1,530 patients at Patton State Hospital.
This bill would, among other things, eliminate the clinical director position and instead require the Governor, upon the recommendation of the Director of State Hospitals, to appoint one medical director for the department and one medical director for each state hospital. The bill would include any other hospital employee appointed and deemed by the Director of State Hospitals to be an officer, and would require a hospital administrator to be selected based on their overall knowledge of the hospital and the operation of its administrative, business, and life-support functions. This bill would extend the date the State Department of State Hospitals may house up to 1,530 patients at Patton State Hospital to September 2030.
(8) Existing law authorizes the Department of Health Care Services to enter into contracts with drug manufacturers, based on the manufacturer’s best price for purposes of the Medi-Cal
program, under which qualified low-income individuals receive health care services. Under existing law, “best price” is defined to mean the negotiated price, or the manufacturer’s lowest available price, to any specified entity within the United States.
This bill instead defines “best price” to mean the negotiated price for any specified entity, including entities both within and outside of the United States.
Existing law authorizes the department, among other things, to enter into contracts with certain drug manufacturers that provide for state rebates for drugs covered under the Medi-Cal program. Under existing law, the department is entitled to various drug rebates, including federal rebates in accordance with certain conditions.
This bill authorizes the department, upon approval by the Department of Finance, to seek the necessary federal approvals to establish and administer a
drug rebate program to collect rebate payments from drug manufacturers for drugs furnished to selected populations of California residents who are ineligible for full-scope Medi-Cal.
(9) Existing law limits prescribed drugs under the Medi-Cal program to not more than 6 drugs per month, unless prior authorization is obtained, and except under specified circumstances.
This bill repeals that provision.
(10) Existing law requires Medi-Cal beneficiaries to make set copayments for specified services, including a $1 copayment for a drug prescription or refill, and prohibits the department from reducing the provider reimbursement as a result of the copayment.
This bill would repeal the copayment requirement for a drug prescription or refill.
(11) Existing law governs the licensing of clinics, excluding, among others, a clinic operated by a city or county or conducted, operated, or maintained as an outpatient department of a hospital. Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing federal law requires the United States Secretary of Health and Human Services to enter into an agreement with each manufacturer of covered drugs that are not subject to a rebate under an agreement between the state Medicaid program and the manufacturer under which the amount required to be paid to the manufacturer for covered drugs purchased by a covered entity does not exceed an amount equal to the average manufacturer price for the drug under the federal Medicaid
program in the preceding calendar quarter, reduced by the rebate received pursuant to the Medicaid agreement. This program is commonly referred to as the 340B Drug Pricing program or 340B program.
This bill would require the State Department of Health Care Services, subject to an appropriation by the Legislature, to establish, implement, and maintain a supplemental payment pool for nonhospital 340B community clinics, which include licensed clinics and clinics operated by a city, county, city and county, or hospital authority, as specified. The bill would require the department, beginning January 1, 2021, to make available fee-for-service-based supplemental payments from the pool, subject to an appropriation by the Legislature. The bill would require the department, on or before July 15, 2020, to establish a stakeholder process to develop and implement the methodology for distribution of supplemental pool payments to qualifying nonhospital 340B community clinics,
which would be finalized no later than October 1, 2020. The bill would require the department to implement these provisions only to the extent that any necessary federal approvals have been obtained, and federal financial participation is available and is not otherwise jeopardized.
(12) The federal Medicaid program prohibits payment to a state for medical assistance furnished to a person who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law. Existing law extends eligibility for full-scope Medi-Cal benefits to individuals under 25 years of age who are otherwise eligible for those benefits but for their immigration status. Existing law requires the department to claim federal financial participation to the extent that the department determines it is available, and requires the department to use state funds to the extent that federal financial
participation is not available, to implement full-scope Medi-Cal for those who are otherwise eligible but for their immigration status.
This bill would provide that Medi-Cal benefits for invidivuals who are 65 years of age or older, and who do not have satisfactory immigration statuses or are unable to establish satisfactory immigration statuses, as specified, will be prioritized in the Budget Act for the upcoming fiscal year if the Department of Finance projects a positive ending balance in the Special Fund for Economic Uncertainties for the upcoming fiscal year and each of the ensuing three fiscal years that exceeds the cost of providing those individuals full scope Medi-Cal benefits.
(13) Under existing law, health care services are provided under the Medi-Cal program pursuant to a schedule of benefits, and those benefits are provided to beneficiaries through various health care
delivery systems, including fee-for-service and managed care.
Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, including contracts with Medi-Cal managed care plans. Existing law requires the department to pay capitations rates to health plans participating in the Medi-Cal managed care program using actuarial methods, and authorizes the department to establish health-plan and county-specific rates, as specified.
Pursuant to existing law, the President, under the National Emergencies Act, and the Governor, under the California Emergency Services Act, declared a national emergency and a state of emergency, respectively, in response to the novel coronavirus, known as COVID-19.
To account for the impacts of the COVID-19 public health emergency on Medi-Cal managed care capitation rates, this bill would require
the department to develop and pay capitation rates and capitation rate increments for Medi-Cal managed care plan contracts, including developing and implementing a risk corridor. The bill would require the department to reduce applicable capitation rate increments by up to 1.5% for capitation rates associated with the period of July 1, 2019, to December 31, 2020, inclusive, and to apply this reduction to rating periods starting on or after January 1, 2021, as prescribed. The bill would require the department to evaluate the impact of the COVID-19 public health emergency on capitation rates, and to make any adjustments to ensure capitation rates are actuarially appropriate.
This bill would authorize the department, in consultation with the Department of Finance, to modify the prescribed payment methodologies and related requirements or modify any application of those provisions to Medi-Cal managed care plans, certain capitation rate increments, certain Medi-Cal
managed care enrollee categories and subcategories of aid, or certain categories or subcategories of medical assistance provided under those contracts, if the department determines the modification is necessary to meet federal requirements, to obtain or maintain federal approval, or to maximize federal financial participation.
(14) Existing law, the California Healthcare, Research, and Prevention Tobacco Tax Act of 2016, or Proposition 56, which was approved by voters at the November 8, 2016, statewide general election, increases taxes imposed on distributors of cigarettes and tobacco products and allocates a specified percentage of those revenues to the department to increase funding for the Medi-Cal program, in a manner that, among other things, ensures timely access, limits specific geographic shortages of services, or ensures quality care. Existing law establishes the Healthcare Treatment Fund for this purpose.
Existing law requires the Department of Health Care Services to develop, using moneys appropriated in the Budget Act for this purpose from the Healthcare Treatment Fund, value-based payment (VBP) programs that require designated Medi-Cal managed care plans to make incentive payments to qualified network providers in behavioral health integration, prenatal and postpartum care, and chronic disease management for specified purposes and to implement the VBP programs for a period no shorter than 3 fiscal years, as specified. Existing law requires these payments to be suspended on December 31, 2021.
This bill would suspend the authority for the State Department of Health Care Services to make value-based payments pursuant on or after July 1, 2021, unless one of two specified conditions applies.
(15) This bill would reappropriate $1,430,000 to
support the Medically Tailored Meals Pilot Program, as specified.
(16) The bill would provide that its provisions are severable.
(17) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that with regard to certain mandates no reimbursement is required by this act for a specified reason.
With regard to any other mandates, this bill would provide that, if the Commission on State Mandates determines that the bill contains costs so mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.
(18) 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.
(19) This bill would declare that it is to take effect immediately as a bill providing for appropriations related to the Budget Bill.