Amended in Senate September 6, 2013

Amended in Senate July 2, 2013

Amended in Assembly May 9, 2013

Amended in Assembly April 23, 2013

Amended in Assembly April 1, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 1208

Introduced by Assembly Member Pan

February 22, 2013

An act to begin delete add Chapter 3.5 (commencing with Section 24300) to Division 20 of the Health and Safety Code, relating to medical homes end delete begin insert amend Section 15926 of the Welfare and Institutions Code, relating to health care coverage end insert .

LEGISLATIVE COUNSEL’S DIGEST

AB 1208, as amended, Pan. begin delete Medical homes. end delete begin insert Insurance affordability programs: application form. end insert

begin insert

Existing law requires the California Health and Human Services Agency, in consultation with specified entities, to establish a single, standardized, accessible application form and related renewal procedures for insurance affordability programs, as defined, in accordance with specified requirements. Existing law authorizes the form to include questions that are voluntary for applicants to answer regarding demographic data categories, including race, ethnicity, primary language, disability status, and other categories recognized by the federal Secretary of Health and Human Services pursuant to federal law. Chapter 3 of the First Extraordinary Session of the Statutes of 2013, to be effective on the 91st day after adjournment of that session, amended these provisions, among others, to implement various provisions of the federal Patient Protection and Affordable Care Act (PPACA).

end insert begin insert

This bill would authorize the form to also include questions that are voluntary for applicants to answer regarding sexual orientation and gender identity or expression. The bill would, effective January 1, 2015, require the form to include questions that are voluntary for applicants to answer regarding the demographic data categories specified.

end insert begin delete

Existing law provides for the licensure and regulation of clinics and health facilities by the State Department of Public Health. Existing law also provides for the registration, certification, and licensure of various health care professionals and sets forth the scope of practice for these professionals.

end delete begin delete

This bill would establish the Patient Centered Medical Home Act of 2013 and would define a “medical home” and a “patient centered medical home” for purposes of the act to refer to a health care delivery model in which a patient establishes an ongoing relationship with a licensed health care provider, as specified. The bill would specify that it does not change the scope of practice of health care providers.

end delete

Vote: majority. Appropriation: no. Fiscal committee:  begin delete no end delete begin insert yes end insert . State-mandated local program: no.

The people of the State of California do enact as follows:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Section 15926 of the end insert begin insert Welfare and Institutions
Code end insert begin insert , as amended by Section 26 of Chapter 3 of the First
Extraordinary Session of the Statutes of 2013, is amended to read: end insert

15926.  

(a) The following definitions apply for purposes of
this part:

(1) “Accessible” means in compliance with Section 11135 of
the Government Code, Section 1557 of the PPACA, and regulations
or guidance adopted pursuant to these statutes.

(2) “Limited-English-proficient” means not speaking English
as one’s primary language and having a limited ability to read,
speak, write, or understand English.

(3) “Insurance affordability program” means a program that is
one of the following:

(A) The Medi-Cal program under Title XIX of the federal Social
Security Act (42 U.S.C. Sec. 1396 et seq.).

(B) The state’s children’s health insurance program (CHIP)
under Title XXI of the federal Social Security Act (42 U.S.C. Sec.
1397aa et seq.).

(C) A program that makes available to qualified individuals
coverage in a qualified health plan through the California Health
Benefit Exchange established pursuant to Title 22 (commencing
with Section 100500) of the Government Code with advance
payment of the premium tax credit established under Section 36B
of the Internal Revenue Code.

(4) A program that makes available coverage in a qualified
health plan through the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500)
of the Government Code with cost-sharing reductions established
under Section 1402 of PPACA and any subsequent amendments
to that act.

(b) An individual shall have the option to apply for insurance
affordability programs in person, by mail, online, by telephone,
or by other commonly available electronic means.

(c) (1) A single, accessible, standardized paper, electronic, and
telephone application for insurance affordability programs shall
be developed by the department in consultation with MRMIB and
the board governing the Exchange as part of the stakeholder process
described in subdivision (b) of Section 15925. The application
shall be used by all entities authorized to make an eligibility
determination for any of the insurance affordability programs and
by their agents.

(2) The department may develop and require the use of
supplemental forms to collect additional information needed to
determine eligibility on a basis other than the financial
methodologies described in Section 1396a(e)(14) of Title 42 of
the United States Code, as added by the federal Patient Protection
and Affordable Care Act (Public Law 111-148), and as amended
by the federal Health Care and Education Reconciliation Act of
2010 (Public Law 111-152) and any subsequent amendments, as
provided under Section 435.907(c) of Title 42 of the Code of
Federal Regulations.

(3) The application shall be tested and operational by the date
as required by the federal Secretary of Health and Human Services.

(4) The application form shall, to the extent not inconsistent
with federal statutes, regulations, and guidance, satisfy all of the
following criteria:

(A) The form shall include simple, user-friendly language and
instructions.

(B) The form may not ask for information related to a
nonapplicant that is not necessary to determine eligibility in the
applicant’s particular circumstances.

(C) The form may require only information necessary to support
the eligibility and enrollment processes for insurance affordability
programs.

(D) The form may be used for, but shall not be limited to,
screening.

(E) The form may ask, or be used otherwise to identify, if the
mother of an infant applicant under one year of age had coverage
through an insurance affordability program for the infant’s birth,
for the purpose of automatically enrolling the infant into the
applicable program without the family having to complete the
application process for the infant.

(F)  begin delete The end delete begin insert (i) end insert begin insert   end insert begin insert Except as specified in clause (ii), the end insert form may
include questions that are voluntary for applicants to answer
regarding demographic data categories, including race, ethnicity,
primary language, disability status, begin insert sexual orientation, gender
identity or expression, end insert and other categories recognized by the
federal Secretary of Health and Human Services under Section
4302 of the PPACA.

begin insert

(ii) Effective January 1, 2015, the form shall include questions
that are voluntary for applicants to answer regarding demographic
data categories, including race, ethnicity, primary language,
disability status, sexual orientation, gender identity or expression,
and other categories recognized by the federal Secretary of Health
and Human Services under Section 4302 of the PPACA.

end insert

(G) Until January 1, 2016, the department shall instruct counties
to not reject an application that was in existence prior to January
1, 2014, but to accept the application and request any additional
information needed from the applicant in order to complete the
eligibility determination process. The department shall work with
counties and consumer advocates to develop the supplemental
questions.

(d) Nothing in this section shall preclude the use of a
provider-based application form or enrollment procedures for
insurance affordability programs or other health programs that
differs from the application form described in subdivision (c), and
related enrollment procedures. Nothing in this section shall
preclude the use of a joint application, developed by the department
and the State Department of Social Services, that allows for an
application to be made for multiple programs, including, but not
limited to, CalWORKs, CalFresh, and insurance affordability
programs.

(e) The entity making the eligibility determination shall grant
eligibility immediately whenever possible and with the consent of
the applicant in accordance with the state and federal rules
governing insurance affordability programs.

(f) (1) If the eligibility, enrollment, and retention system has
the ability to prepopulate an application form for insurance
affordability programs with personal information from available
electronic databases, an applicant shall be given the option, with
his or her informed consent, to have the application form
prepopulated. Before a prepopulated application is submitted to
the entity authorized to make eligibility determinations, the
individual shall be given the opportunity to provide additional
eligibility information and to correct any information retrieved
from a database.

(2) All insurance affordability programs may accept
self-attestation, instead of requiring an individual to produce a
document, for age, date of birth, family size, household income,
state residence, pregnancy, and any other applicable criteria needed
to determine the eligibility of an applicant or recipient, to the extent
permitted by state and federal law.

(3) An applicant or recipient shall have his or her information
electronically verified in the manner required by the PPACA and
implementing federal regulations and guidance and state law.

(4) Before an eligibility determination is made, the individual
shall be given the opportunity to provide additional eligibility
information and to correct information.

(5) The eligibility of an applicant shall not be delayed beyond
the timeliness standards as provided in Section 435.912 of Title
42 of the Code of Federal Regulations or denied for any insurance
affordability program unless the applicant is given a reasonable
opportunity, of at least the kind provided for under the Medi-Cal
program pursuant to Section 14007.5 and paragraph (7) of
subdivision (e) of Section 14011.2, to resolve discrepancies
concerning any information provided by a verifying entity.

(6) To the extent federal financial participation is available, an
applicant shall be provided benefits in accordance with the rules
of the insurance affordability program, as implemented in federal
regulations and guidance, for which he or she otherwise qualifies
until a determination is made that he or she is not eligible and all
applicable notices have been provided. Nothing in this section
shall be interpreted to grant presumptive eligibility if it is not
otherwise required by state law, and, if so required, then only to
the extent permitted by federal law.

(g) The eligibility, enrollment, and retention system shall offer
an applicant and recipient assistance with his or her application or
renewal for an insurance affordability program in person, over the
telephone, by mail, online, or through other commonly available
electronic means and in a manner that is accessible to individuals
with disabilities and those who are limited-English proficient.

(h) (1) During the processing of an application, renewal, or a
transition due to a change in circumstances, an entity making
eligibility determinations for an insurance affordability program
shall ensure that an eligible applicant and recipient of insurance
affordability programs that meets all program eligibility
requirements and complies with all necessary requests for
information moves between programs without any breaks in
coverage and without being required to provide any forms,
documents, or other information or undergo verification that is
duplicative or otherwise unnecessary. The individual shall be
informed about how to obtain information about the status of his
or her application, renewal, or transfer to another program at any
time, and the information shall be promptly provided when
requested.

(2) The application or case of an individual screened as not
eligible for Medi-Cal on the basis of Modified Adjusted Gross
Income (MAGI) household income but who may be eligible on
the basis of being 65 years of age or older, or on the basis of
blindness or disability, shall be forwarded to the Medi-Cal program
for an eligibility determination. During the period this application
or case is processed for a non-MAGI Medi-Cal eligibility
determination, if the applicant or recipient is otherwise eligible
for an insurance affordability program, he or she shall be
determined eligible for that program.

(3) Renewal procedures shall include all available methods for
reporting renewal information, including, but not limited to,
face-to-face, telephone, mail, and online renewal or renewal
through other commonly available electronic means.

(4) An applicant who is not eligible for an insurance affordability
program for a reason other than income eligibility, or for any reason
in the case of applicants and recipients residing in a county that
offers a health coverage program for individuals with income above
the maximum allowed for the Exchange premium tax credits, shall
be referred to the county health coverage program in his or her
county of residence.

(i) Notwithstanding subdivisions (e), (f), and (j), before an online
applicant who appears to be eligible for the Exchange with a
premium tax credit or reduction in cost sharing, or both, may be
enrolled in the Exchange, both of the following shall occur:

(1) The applicant shall be informed of the overpayment penalties
under the federal Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011
(Public Law 112-9), if the individual’s annual family income
increases by a specified amount or more, calculated on the basis
of the individual’s current family size and current income, and that
penalties are avoided by prompt reporting of income increases
throughout the year.

(2) The applicant shall be informed of the penalty for failure to
have minimum essential health coverage.

(j) The department shall, in coordination with MRMIB and the
Exchange board, streamline and coordinate all eligibility rules and
requirements among insurance affordability programs using the
least restrictive rules and requirements permitted by federal and
state law. This process shall include the consideration of
methodologies for determining income levels, assets, rules for
household size, citizenship and immigration status, and
self-attestation and verification requirements.

(k) (1) Forms and notices developed pursuant to this section
shall be accessible and standardized, as appropriate, and shall
comply with federal and state laws, regulations, and guidance
prohibiting discrimination.

(2) Forms and notices developed pursuant to this section shall
be developed using plain language and shall be provided in a
manner that affords meaningful access to limited-English-proficient
individuals, in accordance with applicable state and federal law,
and at a minimum, provided in the same threshold languages as
required for Medi-Cal managed care plans.

(l) The department, the California Health and Human Services
Agency, MRMIB, and the Exchange board shall establish a process
for receiving and acting on stakeholder suggestions regarding the
functionality of the eligibility systems supporting the Exchange,
including the activities of all entities providing eligibility screening
to ensure the correct eligibility rules and requirements are being
used. This process shall include consumers and their advocates,
be conducted no less than quarterly, and include the recording,
review, and analysis of potential defects or enhancements of the
eligibility systems. The process shall also include regular updates
on the work to analyze, prioritize, and implement corrections to
confirmed defects and proposed enhancements, and to monitor
screening.

(m) In designing and implementing the eligibility, enrollment,
and retention system, the department, MRMIB, and the Exchange
board shall ensure that all privacy and confidentiality rights under
the PPACA and other federal and state laws are incorporated and
followed, including responses to security breaches.

(n) Except as otherwise specified, this section shall be operative
on January 1, 2014.

begin delete

SECTION 1.  

Chapter 3.5 (commencing with Section 24300)
is added to Division 20 of the Health and Safety Code, to read:

 

Chapter  3.5. Patient Centered Medical Home Act of
2013

 

24300.  

This chapter shall be known, and may be cited, as the
Patient Centered Medical Home Act of 2013.

24301.  

(a) “Medical home” and “patient centered medical
home” mean a health care delivery model in which a patient
establishes an ongoing relationship with a personal primary care
physician or other licensed health care provider acting within the
scope of his or her practice. The personal provider works in a
physician-led practice team to provide comprehensive, accessible,
and continuous evidence-based primary and preventative care, and
to coordinate the patient’s health care needs across the health care
system in order to improve quality and health outcomes in a
cost-effective manner.

(b) A medical home shall stress a team approach to providing
comprehensive health care that fosters a partnership among the
patient, the licensed health care provider acting within his or her
scope of practice, other health care professionals, and, if
appropriate, the patient’s family or the patient’s representative,
upon the consent of the patient.

24302.  

Unless otherwise provided by statute, a medical home
shall include all of the following characteristics:

(a) Individual patients shall have an ongoing relationship with
a physician and surgeon or other licensed health care provider
acting within his or her scope of practice, who is trained to provide
first contact and continuous and comprehensive care, or, if
appropriate, provide referrals to health care professionals that
provide continuous and comprehensive care.

(b) A provider, working in concert with a multidisciplinary team
of individuals at the practice level, shall take responsibility for the
ongoing health care of patients, including appropriately arranging
health care by other qualified health care professionals and making
appropriate referrals.

(c) Care shall be coordinated and integrated across all elements
of the complex health care system, including mental health and
substance use disorder care, and the patient’s community. Care
shall be facilitated by health information technology, such as
electronic medical records, electronic patient portals, health
information exchanges, and other means to ensure that patients
receive the indicated care when and where they need and want this
care in a culturally and linguistically appropriate manner.

(d) The medical home payment structure shall be designed to
reward the provision of the right care in the right setting, and shall
discourage the delivery of too much or too little care. The payment
structure shall encourage appropriate management of complex
medical cases, increased access to care, the measurement of patient
outcomes, continuous improvement of care quality, and
comprehensive integration and coordination across all stages and
settings of a patient’s care.

(e) All of the following quality and safety components shall be
incorporated into the medical home:

(1) Advocacy for patients to support the attainment of optimal,
patient-centered outcomes that are defined by a care planning
process driven by a compassionate, robust partnership between
providers, the patient, and the patient’s family or representative.

(2) Evidence-based medicine and clinical decision support tools
guide decisionmaking.

(3) The licensed health care providers in the practice accept
accountability for continuous quality improvement through
voluntary engagement in performance measurement and
improvement.

(4) Active patient participation in decisionmaking. Feedback is
sought to ensure that the patient’s expectations are being met.

(5) Information technology is utilized appropriately to support
optimal patient care, performance measurement, patient education,
and enhanced communication.

(6) Patients and families or representatives participate in quality
improvement activities at the practice level.

(7) Patients are provided with enhanced access to health care.

24303.  

Nothing in this chapter shall be construed to do any of
the following:

(a) Permit a medical home to engage in or otherwise aid and
abet in the unlicensed practice of medicine, either directly or
indirectly.

(b) Change the scope of practice of physicians and surgeons,
nurse practitioners, or other health care providers.

(c) Affect the ability of a nurse to operate under standardized
procedures pursuant to Section 2725 of the Business and
Professions Code.

(d) Apply to the Low Income Health Program developed
pursuant to Part 3.6 (commencing with Section 15909) of Division
9 of the Welfare and Institutions Code, including the program’s
provider network and service delivery system, or to activities
conducted as part of a demonstration project developed pursuant
to Section 14180 of the Welfare and Institutions Code.

(e) Prevent or limit participation in activities authorized by
Sections 2703, 3024, and 3502 of 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), if the participation is consistent with state
law pertaining to scope of practice.

end delete