(1) Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law requires a health care service plan to provide disclosures regarding the benefits, services, and terms of the plan contract, as specified, to provide the public, subscribers, and enrollees with a full and fair disclosure of the provisions of the plan.
This bill would require the department to develop standard templates for the disclosure form and evidence of coverage, to include, among other things, standard definitions, benefit descriptions, and any other information that the director determines, consistent with the goals of providing fair disclosures of the provisions of a health care service plan. The bill would require the department to consult with the Department of Insurance and interested stakeholders in developing the standard templates. The bill would require health care service plans, beginning January 1, 2025, to use the standard templates for any disclosure form or evidence of coverage published or distributed, except as specified. Because a willful violation of these requirements is a crime, the bill would impose a state-mandated local program.
This bill would authorize the department to develop standard templates for a schedule of benefits, an explanation of benefits, a cost-sharing summary, or any similar document. The bill would authorize the department to require health care service plans to use the standard templates, except as specified, and would authorize the director to require health care service plans to submit forms the health care service plan created based on the department's templates for the purpose of compliance review. The bill would additionally specify that the department may implement these provisions by issuing and modifying templates and all-plan letters or similar instructions, without taking regulatory action. The bill would also update cross-references in various provisions.
(2) Existing law requires a health care service plan contract or disability insurance policy to cover mental health and substance use disorder treatment, including medically necessary treatment of a mental health or substance use disorder provided by an in-network or out-of-network 988 center or mobile crisis team. Existing law prohibits a health care service plan or insurer from requiring prior authorization for medically necessary treatment of a mental health or substance use disorder provided by a 988 center or mobile crisis team.
This bill would instead specify that mental health and substance use disorder treatment includes behavioral health crisis services that are provided by a 988 center, mobile crisis team or other provider of behavioral health crisis services. The bill would prohibit a health care service plan or health insurer from requiring prior authorization for behavioral health crisis stabilization services and care, but would authorize prior authorization for medically necessary mental health or substance use disorder services following stabilization from a behavioral health crisis addressed by services provided through the 988 system.
This bill would require a health care service plan or health insurer that is contacted by a 988 center, mobile crisis team, or other provider of behavioral health crisis services to, within 30 minutes of initial contact, either authorize poststabilization care or inform the provider that it will arrange for the prompt transfer of the enrollee's care to another provider. The bill would require the plan or insurer to reimburse a provider for poststabilization care in specified circumstances, including if the plan or insurer did not respond within 30 minutes to authorize care or arrange for transfer. The bill would require a plan or insurer to prominently display on its internet website its authorization telephone number for noncontracting providers, and would require the Department of Managed Health Care to post the telephone number on its internet website. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.
(3) Existing federal law, the 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 generally requires an individual, and any dependents of the individual, to maintain minimum essential coverage. 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 imposes the Individual Shared Responsibility Penalty for the failure to maintain minimum essential coverage, and requires the moneys collected to be deposited into the General Fund.
Existing law requires the Exchange to administer a financial assistance program to help low-income and middle-income Californians access affordable health care coverage through the Exchange. Existing law creates the Health Care Affordability Reserve Fund and requires moneys in the fund to be used, upon appropriation by the Legislature, for health care affordability programs operated by the Exchange.
This bill would require moneys collected from the Individual Shared Responsibility Penalty to be deposited into the Health Care Affordability Reserve Fund beginning July 1, 2023, and on every July 1 thereafter. The bill would authorize a loan from the Health Care Affordability Reserve Fund to the General Fund upon order of the Department of Finance.
(4) 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.
Existing law requires that the Medi-Cal program covers specified health care services, including inpatient intensive rehabilitation hospital services, and requires those services consist of programs for, among other services, strengthening and training of selected muscle groups. Existing law requires those programs to provide for an initial evaluation for assessment of medical condition, functional limitations, possible need for surgery, attitude toward rehabilitation, functional goals and plans for discharge.
This bill would eliminate the requirement for the above-described initial evaluation, and would also make technical, nonsubstantive changes.
(5) This bill would, for dates of service no sooner than January 1, 2024, or on the effective date of any necessary federal approvals, whichever is later, require the reimbursement rates for primary care services, obstetric care services, doula services, and certain outpatient mental health services to be the greater of 87.5% of the lowest maximum allowance established by the federal Medicare Program for the same or similar services or the level of reimbursement, as specified. The bill would require the department to annually review and revise the reimbursement rates, and to develop and implement a methodology for establishing rates or payments for the services. The bill would require each Medi-Cal managed care plan to reimburse a network provider furnishing those services at least the amount the network provider would be paid for those services in the Medi-Cal fee-for-service delivery system, as specified. The bill would condition implementation of these provisions on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would require the department to submit to the Legislature, as part of the 2024–25 Governor's Budget, a plan for targeted increases to Medi-Cal payments or other investments, in relation to certain domains.
Under the bill, the above-described payments would be supported by the managed care organization provider tax revenue, as specified, or other state funds appropriated to the department as the state share for this purpose, including, but not limited to, funds transferred to the Medi-Cal Provider Payment Reserve Fund, as described below, and to the Healthcare Treatment Fund under the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, as specified.
The bill would create the Medi-Cal Provider Payment Reserve Fund. The bill would require the department, subject to an appropriation, to use the moneys transferred to the fund pursuant to other specified provisions for purposes of funding targeted increases to Medi-Cal payments or other investments that advance access, quality, and equity for Medi-Cal beneficiaries and promote provider participation in the Medi-Cal program. The bill would require the department to provide an annual report to all health plans accounting for the funds deposited in, and expended from, the fund.
The bill would require those expenditures to include increased costs as a result of the above-described reimbursement requirements, transfers to the Distressed Hospital Loan Program Fund, certain transfers or appropriations to the University of California to expand graduate medical education programs, as specified, and, effective no sooner than January 1, 2025, increased costs for targeted increases to Medi-Cal payments or other investments pursuant to the above-described plan.
Existing law requires that Medi-Cal provider payments and payments for specified non-Medi-Cal programs be reduced by 10% for dates of service on and after June 1, 2011, and conditions implementation of those payment reductions on receipt of any necessary federal approvals. Existing law exempts certain services, facilities, and payments from those payment reductions.
This bill would make an additional exemption, for dates of service on and after July 1, 2022, or the effective date of any necessary federal approvals, whichever is later, for Community-Based Adult Services, as specified. The bill would make additional exemptions, for dates of service on and after January 1, 2024, or the effective date of specified payments, whichever is later.
Existing law establishes the Distressed Hospital Loan Program, administered by the Department of Health Care Access and Information, in order to provide interest-free cashflow loans to not-for-profit hospitals and public hospitals in significant financial distress or to governmental entities representing a closed hospital, except as otherwise provided, to prevent the closure of, or facilitate the reopening of, those hospitals. Existing law establishes the Distressed Hospital Loan Program Fund, with moneys in the fund being continuously appropriated for the department and the California Health Facilities Financing Authority to implement the program.
This bill would authorize the Department of Finance to transfer up to $150,000,000 from the Medi-Cal Provider Payment Reserve Fund to the Distressed Hospital Loan Program Fund in state fiscal year 2023–24 to implement the program, as specified, and would make a conforming change.
(6) Existing law requires Medi-Cal benefits to be provided to individuals eligible for services pursuant to prescribed standards, including a modified adjusted gross income (MAGI) eligibility standard. Existing law prohibits the use of an asset or resources test for individuals whose financial eligibility for Medi-Cal is determined based on the application of MAGI. Existing federal law authorizes a state to establish a non-MAGI standard for determining the eligibility of specified individuals, and existing law imposes the use of a resources test for establishing Medi-Cal eligibility for prescribed populations.
Existing law prohibits the use of resources, including property or other assets, to determine Medi-Cal eligibility for applicants or beneficiaries whose eligibility is not determined using the MAGI-based financial methods, and requires the department to seek federal authority to disregard all resources as authorized by the flexibilities provided pursuant to federal law. Existing law conditions implementation of that provision on the Director of Health Care Services determining that systems have been programmed for those disregards and their communicating that determination in writing to the Department of Finance, no sooner than January 1, 2024. Existing law also conditions implementation of that provision on the department obtaining any necessary federal approvals, and to the extent federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.
This bill, subject to the above-described timeline and implementation of the prohibition on the use of resources for determining Medi-Cal eligibility, would make various conforming changes to related provisions. Because this bill would increase county duties relating to the prohibition on the use of resources for determining Medi-Cal eligibility, the bill would impose a state-mandated local program.
(7) Existing law requires Medi-Cal reimbursement rates to be set by an applicable methodology for specified dates of service operative on August 1 of a given year.
This bill would, for dates of services on or after January 1, 2024, require the department to adopt a rate year based on the calendar year for intermediate care facilities for the developmentally disabled and facilities providing continuous skilled nursing care to developmentally disabled individuals, nursing facilities, licensed intermediate care facilities, freestanding pediatric subacute care units, and skilled nursing facilities, as specified. The bill would make these provisions subject to any necessary federal approvals and to the extent federal financial participation is available and is not otherwise jeopardized.
(8) Existing law requires the State Department of Health Care Services, no later than April 1, 2022, and until December 31, 2023, to convene a workgroup to examine the implementation of the doula benefit provided under the Medi-Cal program. Existing law requires the department, no later than July 1, 2024, to publish a report relating to Medi-Cal recipients utilizing doula services, as specified. Existing law repeals those provisions on January 1, 2025.
This bill would instead require the department to convene the workgroup no later than April 1, 2023, and until June 30, 2025, and to publish the report no later than July 1, 2025. The bill would extend the repeal date of those provisions to January 1, 2026.
(9) Existing law, until July 1, 2024, requires the State Department of Health Care Services to work with stakeholders to conduct a study to identify current requirements for medical interpretation services and make recommendations on strategies that may be employed regarding the provision of medical interpretation services for Medi-Cal beneficiaries who are limited English proficient (LEP) . Existing law requires the department to establish a pilot project to evaluate certain factors, including whether disparities in care are reduced, with respect to LEP Medi-Cal beneficiaries compared with Medi-Cal beneficiaries who are proficient in English. Existing law requires the department to expend up to $5,000,000 for the pilot project pursuant to an appropriation made in the Budget Act of 2019, and makes those funds available for that purpose until June 30, 2024.
This bill would extend these provisions until July 1, 2025, and make those funds available until June 30, 2025. By extending the period of time in which previously appropriated funds are available for encumbrance, the bill would make an appropriation.
(10) Existing law establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal) under which the State Department of Health Care Services is authorized to enter into contracts with counties for various drug treatment services to Medi-Cal recipients, or is required to directly arrange for these services if a county elects not to do so. Existing law specifies the method of determining the maximum allowable reimbursement rates for Drug Medi-Cal and group outpatient drug free services, as described. Existing law requires the claims for reimbursement of Drug Medi-Cal services to be submitted within 6 months from the date of service.
This bill would instead require claims for reimbursement of Drug Medi-Cal services to be submitted within 12 months from the date of service.
(11) Under existing law, certain medically needy persons, including those in long-term care, with higher incomes qualify for Medi-Cal with a share of cost, if they meet specified criteria. Under existing law, the term "share of cost" means the amount of the costs of health care that a specified person or family must incur prior to being certified by the department.
This bill would instead apply the term "spend down of excess income" to the above-described definition for "share of cost" for medically needy persons. The bill would change references from "share of cost" to "long-term care patient liability," in the context of those entering or in long-term care and define that term as the result of the "post-eligibility treatment of income" calculation and the amount of medical expenses the person in long-term care or an institutionalized spouse must incur or expect to incur. The bill would define the term "post-eligibility treatment of income" as the determination of long-term care patient liability for each month the person is in long-term care or as an institutionalized spouse, as specified.
(12) Existing law requires the State Department of Health Care Services to prepare and submit assumptions and estimates, as prescribed, relating to the Medi-Cal program to the Department of Finance on a semiannual basis for the purpose of clearly identifying changes within the Medi-Cal program and producing reliable forecasts of Medi-Cal expenditures. Existing law requires the department to separately identify expenditures for rate increases and fiscal intermediary services, requires that certain assumptions or estimates contain a narrative description of how the forecast is prepared, and requires that estimates compare budgeted to implemented rate increases for the current year, by provider category, among other things.
This bill would, effective July 1, 2023, strike these latter requirements and require, beginning with the estimates for the 2024–25 fiscal year, that they include separately identifying expenditures for county and other local assistance administration and a narrative description of how those forecasts were prepared.
(13) Existing law establishes the Medi-Cal Access Program, which provides health care services to a person who is pregnant or in their 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 the State Department of Health Care Services to provide presumptive eligibility to qualified individuals through programs in which authorized Medi-Cal providers make presumptive eligibility determinations.
Existing law requires the department to adopt the Newborn Hospital Gateway, which is an electronic process for families to enroll a deemed eligible newborn in the Medi-Cal program from hospitals that have elected to participate in the process. Existing law authorizes the expenditure of moneys in the Gateway Fund, upon appropriation, for purposes of establishing and maintaining the gateway. Existing law conditions adoption