(1) Existing federal law, the Patient Protection and Affordable Care Act (PPACA) , enacts various health care market reforms. Existing state law creates the California Health Benefit Exchange (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, until January 1, 2023, requires the Exchange to administer a program of health care coverage financial assistance to help low-income and middle-income Californians. Existing law exempted the program design of financial assistance and a related regulation, standard, criterion, procedure, determination, rule, notice, guideline, or any other guidance established or issued by the Exchange or Franchise Tax Board from the Administrative Procedure Act until January 1, 2022.
This bill would indefinitely extend the above-described financial assistance program and Administrative Procedure Act exemptions.
(2) Existing law generally requires the State Department of Public Health to license, inspect, and regulate health facilities, including hospitals. Existing law requires health facilities to meet specified cost and disclosure requirements, including maintaining an understandable written policy regarding discount payments and charity. Existing law establishes the Department of Health Care Access and Information (HCAI) to oversee various aspects of the health care market, including oversight of hospital facilities and community benefit plans.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires each department to develop and adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires that health care service plans and health insurers submit rates to their regulating entity for review.
This bill would establish, within HCAI, the Office of Health Care Affordability to analyze the health care market for cost trends and drivers of spending, develop data-informed policies for lowering health care costs for consumers and purchasers, set and enforce cost targets, and create a state strategy for controlling the cost of health care and ensuring affordability for consumers and purchasers. The bill would also establish the Health Care Affordability Board , composed of 8 members, appointed as prescribed, and the Health Care Affordability Advisory Committee.
The bill would require the board to establish statewide health care cost targets for per capita total health care expenditures by the 2025 calendar year and specific targets for each health care sector it defines, including fully integrated delivery system systems, geographic regions, and individual health care entities, as appropriate. The bill, commencing in 2026, would require the office to take progressive actions against health care entities for failing to meet the cost targets, including performance improvement plans and escalating administrative penalties. The bill would establish the Health Care Affordability Fund for the purpose of receiving and, upon appropriation by the Legislature, expending revenues collected pursuant to the provisions of the bill.
The bill would require the office to set standards for various health care metrics, including health care quality and equity , alternative payment models , primary care and behavioral health investments , and health care workforce stability. The bill would require the office to gather data and present a report on baseline health care spending trends and underlying factors on or before June 1, 2025. On or before June 1, 2027, the bill would require the office to prepare and publish annual reports concerning health care spending trends and underlying factors, along with policy recommendations to control costs and the other stated metrics. The bill would require the office to present the report's findings to the board and the broader public at a public meeting of the board and would provide for public comment and feedback on the report, as specified.
The bill would require the office to monitor cost trends in the health care market and to examine health care mergers, acquisitions, corporate affiliations, or other transactions that entail material changes to ownership, operations, or governance of health care service plans, insurers, hospitals or hospital systems, physician organizations, providers, pharmacy benefit managers, and other health care entities. The bill would require the health care entities to provide the office with written notice, as specified, of agreements and transactions that would sell, transfer, lease, exchange, option, encumber, convey, or otherwise dispose of a material amount of assets, or that would transfer control, responsibility, or governance of a material amount of the assets or operations to one or more entities. The bill would require the office to conduct a cost and market impact review, as specified, if it finds that the change is likely to have a risk of a significant impact on market competition, the state's ability to meet cost targets, or costs for purchasers and consumers. The bill would prohibit an agreement or transaction for which a cost and market impact review proceeds to be implemented without a written waiver from the office or until 60 days after the office issues its final report. The bill would require the health care entity to pay specified costs associated with that review and completing the report.
The bill would require health care service plans and health insurers, in submitting rates for review, to demonstrate the impact of any changes in the rate of growth of health care costs resulting from the health care cost targets. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program.
(3) Existing law establishes 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.
The federal Medicaid program prohibits payment to a state for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law. Existing law, after the Director of the State Department of Health Care Services has communicated the determination to the Department of Finance that systems have been programmed for the implementation of these purposes, but no sooner than May 1, 2022, extends Medi-Cal eligibility for the full scope of Medi-Cal benefits to an individual who is 50 years of age or older, and who does not have satisfactory immigrant status or is unable to establish satisfactory immigration status, as specified, if they are otherwise eligible for those benefits. Existing law makes the effective date of enrollment for those individuals the same day that systems are operational to begin processing new applications pursuant to the director's determination. Existing law provides that a person enrolled in the Medi-Cal program under these provisions is not required to file a new application for the Medi-Cal program, requires the enrollment to be conducted pursuant to a prescribed eligibility and enrollment plan, and requires the department to provide monthly updates to the Legislature, as specified.
This bill would extend Medi-Cal eligibility for the full scope of Medi-Cal benefits to an individual who is 26 to 49 years of age, inclusive, and who does not have satisfactory immigrant status if they are otherwise eligible for those benefits. The bill would make the expansion after the director has determined and communicated the determination to the Department of Finance, that systems have been programmed for the implementation of these purposes, but no later than January 1, 2024. The bill would, as described above, make the effective date of enrollment the same day that systems are operational, would not require a new application, and would require the department to include these individuals in monthly updates to the Legislature. Because counties are required to make Medi-Cal eligibility determinations and this bill would expand Medi-Cal eligibility to specified individuals who are 26 to 49 years of age, inclusive, the bill would impose a state-mandated local program.
This bill would require the eligibility and enrollment plan to enable, to the maximum extent possible, as determined by the department, an individual to maintain their primary care provider or medical home. The bill would require the department to work with counties, Medi-Cal managed care health plans, health care providers, and consumer advocations, among others, to identify and maintain such linkage.
(4) Existing law, to the extent federal financial participation is available, requires the State Department of Health Care Services to exercise its option under federal law to implement a program for individuals who are 65 years of age or older or are disabled , without a share of cost, if they meet certain financial eligibility criteria, including not exceeding 138% of the federal poverty level in their countable income or as specified. Under existing law, certain medically needy persons with higher incomes qualify for Medi-Cal with a share of cost, if they meet specified criteria. Under existing law, the share of cost for those persons is generally the total after deducting an amount for maintenance from the person's monthly income. Existing law requires the department to establish income levels for maintenance at the lowest levels that reasonably permit a medically needy person to meet their basic needs for food, clothing, and shelter, and for which federal financial participation will still be provided under applicable federal law. Under existing law, for a single individual, the amount of the income level for maintenance per month is based on a calculation of 80% of the highest amount that would ordinarily be paid to a family of 2 persons, without any income or resources, under specified cash assistance provisions, multiplied by the federal financial participation rate, adjusted as specified.
This bill, to the extent that any necessary federal authorization is obtained, would increase the above-described income level for maintenance per month to be equal to the income limit for Medi-Cal without a share of cost for individuals who are 65 years of age or older or are disabled, generally totaling 138% of the federal poverty level. The bill would make these provisions operative on January 1, 2025, or the date certified by the department, whichever is later. The bill would repeal related provisions as part of conforming changes.
(5) Existing law requires the State Department of Health Care Services ,to the extent federal financial participation is available, to exercise a federal option to extend continuous eligibility to children 19 years of age and younger until the earlier of either the end of a 12-month period following the eligibility determination or the date the child exceeds 19 years of age.
Under this bill, a child under 5 years of age would be continuously eligible for Medi-Cal, including without regard to income, until the child reaches 5 years of age. The bill would prohibit the redetermination of Medi-Cal eligibility before the child reaches 5 years of age, unless the department or county possesses facts indicating that the family has requested the child's voluntary disenrollment, the child is deceased, the child is no longer a state resident, or the child's original enrollment was based on a state or county error or on fraud, abuse, or perjury, as specified. The bill would require the department to implement those provisions on January 1, 2025, or a date specified by the direction, whichever is later.
(6) Under existing law, a pregnant woman is eligible for Medi-Cal benefits if her income is less than or equal to 109% of the federal poverty level, as specified, and meets all other eligibility requirements, subject to receipt of any necessary federal approvals and the availability of federal financial participation.
This bill would instead make a pregnant individual eligible for full-scope Medi-Cal benefits if their income, effective January 1, 2022, is less than or equal to 208% of the federal poverty level before the application of the 5% income disregard, as specified. The bill would delete certain reporting provisions and would make conforming changes to related provisions. To the extent that the bill would create new duties for counties relating to Medi-Cal eligibility determinations, the bill would impose a state-mandated local program.
Existing law requires the department to seek any state plan amendments or federal waivers necessary to provide full-scope Medi-Cal benefits without a share of cost to pregnant women during their pregnancy and for 60 days thereafter if their income is over 109% of, and is up to and including 138% of, the federal poverty level, as specified.
This bill would repeal those provisions.
(7) Existing law requires that Medi-Cal benefits be provided to optional targeted low-income children based on a certain income eligibility threshold. Existing law establishes the Medi-Cal Access Program , which provides health care services to a woman who is pregnant or in her postpartum period and whose household income is between certain thresholds, and to a child under 2 years of age who is delivered by a mother enrolled in the program, as specified. Existing law requires a subscriber to provide income information at the end of 12 months of coverage under the Medi-Cal Access Program, and requires that the infant be disenrolled from the program if the annual household income exceeds 317% of the federal poverty level or if the infant is eligible for full-scope Medi-Cal with no share of cost. Existing law also establishes a program under which certain employed persons with disabilities are eligible for Medi-Cal benefits based on income and other criteria.
Existing law creates the County Health Initiative Matching Fund in the State Treasury, administered by the State Department of Health Care Services for the purpose of providing matching state funds and local funds received by the fund through intergovernmental transfers to a county agency, a local initiative, or a county organized health system in order to provide health insurance coverage to certain children and adults in low-income households who do not qualify for health care benefits through the Healthy Families Program or Medi-Cal. Existing law requires the department to exercise the option , available to the state under federal law, to impose specified monthly premiums, based on income level, for the above-described children and employed persons with disabilities. Existing law requires the department to determine schedules for subscriber contribution amounts for persons enrolled in the Medi-Cal Access Program.
This bill would authorize the department, to the extent allowable under federal law, to elect not to impose premiums on specified individuals whose family income has been determined to be above 160% and up to and including 261% of the federal poverty level for the above-described programs. The bill would require the department to specify that election or reinstatement of premiums in the published Medi-Cal Local Assistance Estimate for the impacted state fiscal year or years, subject to appropriation in the annual Budget Act.
Beginning January 1, 2025, or the date certified by the State Department of Health Care Services, as specified, this bill would remove the requirement for providing income information at the end of the 12 months of enrollment in the Medi-Cal Access Program, and would instead require that the infant remain continuously eligible for the Medi-Cal program until they are 5 years of age, as specified. The bill would also make conforming changes.
(8) Existing law requires the State Department of Health Care Services to administer the Child Health and Disability Prevention (CHDP) Program. Under the CHDP Program , certain health and disability prevention treatment services are provided to eligible children. Existing law requires the governing board of a county to establish a community CHDP program for the purpose of providing early and periodic assessments of the health status of children in the county.
Under this bill, all qualified providers enrolled in the CHDP Program as of June 30, 2024, instead, would be automatically enrolled as providers under the Children's Presumptive Eligibility Program on July 1, 2024. The bill would require the department, before July 1, 2024, to take various steps, including developing a transition plan to transition the CHDP Program, conducting a stakeholder engagement process to inform the department in the development and implementation of the transition plan, and requiring the department to seek federal approval to implement the transition plan. The bill would make the CHDP Program inoperative on July 1, 2024, or on the date that the department certifies that all the steps have been taken to implement the transition plan, whichever date is later.
(9) Existing law created the Healthy Families Program for the provision of health, vision, and dental benefits to eligible children pursuant to the federal Children's Health Insurance Program. Existing law requires the department and the former Managed Risk Medical Insurance Board to implement a program for preenrollment of children into the Medi-Cal program and the former Healthy Families Program. Existing law requires that subscribers continue to be eligible for the Healthy Families Program for a period of 12 months from the month eligibility is established. Existing law requires the State Department of Health Care Services to develop an electronic application to serve as the application into these programs and the CHDP Program, and authorizes the department to designate CHDP Program providers as qualified entities who are authorized to determine eligibility for the CHDP Program and for preenrollment into the Medi-Cal program and the former Healthy Families Program.
This bill, beginning January 1, 2025, or on a date certified by the State Department of Health Care Services, as specified, would require that a child be continuously eligible for the Healthy Families Program at up to five years of age. The bill would delete obsolete provisions relating to the former Healthy Families Program and the former Managed Risk Medical Insurance Board, and would make technical, nonsubstantive changes.
(10) 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 law conditions implementation of the redetermination provisions on the availability of federal financial participation and receipt of any necessary federal approvals. In response to a change in circumstances, if a county cannot obtain sufficient information to redetermine eligibility, existing law requires the county to send to the beneficiary a form developed by the department that is prepopulated with the information that the county has obtained and that states the inf