Amended in Senate April 28, 2015

Amended in Senate April 6, 2015

Senate Bill No. 4

Introduced by Senator Lara

(Principal coauthor: Assembly Member Bonta)

(Coauthors: Senators begin insert Hall, end insert Hancock, begin insert Hernandez, Hill, end insert Hueso, Mitchell, Monning, begin delete and Pan end delete begin insert Pan end insert begin insert , and Wolk end insert )

( begin delete Coauthor: end delete begin insert Coauthors: end insert Assembly begin delete Member Levine end delete begin insert Members Alejo, Levine, Lopez, and Thurmond end insert )

December 1, 2014

An act to add and repeal Section 100522 of, and to add and repeal Title 22.5 (commencing with Section 100530) of, the Government Code, to add and repeal Section 1366.7 of the Health and Safety Code, to add and repeal Section 10112.31 of the Insurance Code, and to add Sections 14102.1 and 14102.2 to the Welfare and Institutions Code, relating to health care coverage, and making an appropriation therefor.

LEGISLATIVE COUNSEL’S DIGEST

SB 4, as amended, Lara. Health care coverage: immigration status.

Existing law, the federal Patient Protection and Affordable Care Act (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, and meets certain other requirements. PPACA specifies that an individual who is not a citizen or national of the United States or an alien lawfully present in the United States shall not be treated as a qualified individual and may not be covered under a qualified health plan offered through an exchange. Existing law creates the California Health Benefit Exchange for the purpose of facilitating the enrollment of qualified individual and qualified small employers in qualified health plans as required under PPACA.

Existing law governs health care service plans and insurers. A willful violation of the provisions governing health care service plans is a crime.

This bill would require the Secretary of California Health and Human Services to apply to the United States Department of Health and Human Services for a waiver to allow individuals who are not eligible to obtain health coverage because of their immigration status to obtain coverage from the California Health Benefit Exchange. The bill would require the California Health Benefit Exchange to offer qualified health benefit plans, as specified, to these individuals. The bill would require that individuals eligible to purchase California qualified health plans pay the cost of coverage without federal assistance. These requirements would become operative when federal approval of the waiver is granted. If federal approval is not granted on or before January 1, 2017, the bill would create the California Health Exchange Program begin delete for all end delete begin insert For All end insert Californians within state government.

The bill would require that the California Health Exchange Program begin delete for end delete begin insert For end insert All Californians (Program) be governed by the executive board that governs the California Health Benefit Exchange. The bill would specify the duties of the board relative to the begin delete Program end delete begin insert program end insert and would require the board to, by a specified date, facilitate the enrollment into qualified health plans of individuals who are not eligible for full-scope Medi-Cal coverage and would have been eligible to purchase coverage through the Exchange but for their immigration status. begin delete The bill would require the board to provide premium subsidies and cost-sharing reductions to eligible individuals that are the same as the premium assistance and cost-sharing reductions the individuals would have received through the Exchange. end delete The bill would create the California Health Trust Fund For All Californians as a continuously appropriated fund, thereby making an appropriation, would require the board to assess a charge on qualified health plans, and would make the implementation of the begin delete Program’s end delete begin insert program’s end insert provisions contingent on a determination by the board that sufficient financial resources exist or will exist in the fund. The bill would enact other related provisions.

The bill would require health care begin delete services end delete begin insert service end insert plans and health insurers to fairly and affirmatively offer, market, and sell in the begin delete Program end delete begin insert program end insert at least one product within each of the 5 levels of coverage, as specified. Because a violation of the requirements imposed on health care service plans would be a crime, the bill would impose a state-mandated local program.

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. The federal Medicaid Program provisions prohibit 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.

This bill would extend eligibility for full-scope Medi-Cal benefits to individuals who are otherwise eligible for those benefits but for their immigration status. The bill would require these individuals to enroll into Medi-Cal managed care health plans, and to pay copayments and premium contributions, to the extent required of otherwise eligible Medi-Cal recipients who are similarly situated. The bill would require that benefits for those services be provided with state-only funds only if federal financial participation is not available. Because counties are required to make Medi-Cal eligibility determinations and this bill would expand Medi-Cal eligibility, the bill would impose a state-mandated local program.

The bill would require the State Department of Health Care Services to develop a transition plan for individuals who are enrolled in restricted-scope Medi-Cal as of a specified date, and who are otherwise eligible for full-scope Medi-Cal coverage but for their immigration status, to transition directly to full-scope Medi-Cal coverage. The bill would require the department to notify these individuals, as specified.

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.

Vote: majority. Appropriation: yes. Fiscal committee: yes. State-mandated local program: yes.

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

SECTION 1.  

(a) (1) The Legislature finds and declares that
longstanding California law provides full-scope Medi-Cal to United
States citizens, lawful permanent residents, and individuals
permanently residing in the United States under color of law,
including those granted deferred action.

(2) It is the intent of the Legislature in enacting this act to extend
full-scope Medi-Cal eligibility to California residents who are
currently ineligible for Medi-Cal due to their immigration status,
as long as they meet the other requirements of the Medi-Cal
program.

(b) It is the intent of the Legislature that all Californians,
regardless of immigration status, have access to health coverage
and care.

(c) It is the intent of the Legislature that all Californians who
are otherwise eligible for Medi-Cal, a qualified health plan offered
through the California Health begin delete Benefits end delete begin insert Benefit end insert Exchange, or
affordable employer-based health coverage, enroll in that coverage
and obtain the care that they need.

(d) It is further the intent of the Legislature to ensure that all
Californians be included in eligibility for coverage without regard
to immigration status.

SEC. 2.  

Section 100522 is added to the Government Code, to
read:

100522.  

(a) The Secretary of California Health and Human
Services shall apply to the United States Department of Health
and Human Services for a waiver authorized under Section 1332
of the federal act as defined in subdivision (e) of Section 100501
in order to allow persons otherwise not able to obtain coverage by
reason of immigration status through the Exchange to obtain
coverage from the Exchange by waiving the requirement that the
Exchange offer only qualified health plans.

(b) The Exchange shall offer qualified health benefit plans which
shall be subject to the requirements of this title, including all of
those requirements applicable to qualified health plans. In addition,
California qualified health plans shall be subject to the
requirements of Section 1366.6 of the Health and Safety Code and
Section 10112.3 of the Insurance Code in the same manner as
qualified health plans.

(c) Persons eligible to purchase California qualified health plans
shall pay the cost of coverage without federal advanced premium
tax credit, federal cost-sharing reduction, or any other federal
assistance.

(d) Subdivisions (b) and (c) of this section shall become
operative upon federal approval of the waiver pursuant to
subdivision (a). If subdivisions (b) and (c) of this section do not
become operative on or before January 1, 2017, Title 22.5
(commencing with Section 100530) shall become operative, and
as of that date, this section is repealed, unless a later enacted
statute, that is enacted before January 1, 2017, deletes or extends
that date.

begin insert

(e) For purposes of this section, a “California qualified health
plan” means a product offered to those not otherwise eligible to
purchase coverage from the Exchange by reason of immigration
and that comply with each of the requirements of state law and
the Exchange for a qualified health plan.

end insert

SEC. 3.  

Title 22.5 (commencing with Section 100530) is added
to the Government Code, to read:

 

Title 22.5.  California Health Exchange
Program for All Californians

 

100530.  

(a) There is in state government the California Health
Exchange Program For All Californians, an independent public
entity not affiliated with an agency or department.

(b) The program shall be governed by the executive board
established pursuant to Section 100500. The board shall be subject
to Section 100500.

(c) It is the intent of the Legislature in enacting the program to
provide coverage for Californians who would be eligible begin delete for
coverage and premium subsidies under end delete begin insert to enroll in end insert the California
Health Benefit Exchange established under Title 22 (commencing
with Section 100500) but for their immigration status.

(d) This title shall become operative only if federal approval of
the waiver described in subdivision (a) of Section 100522 is not
granted on or before January 1, 2017. If this title does not become
operative by January 1, 2017, as of that date, this title is repealed,
unless a later enacted statute, that is enacted before January 1,
2017, deletes or extends that date.

100531.  

For purposes of this title, the following definitions
shall apply:

(a) “Board” means the executive board described in subdivision
(b) of Section 100530.

(b) “Carrier” means either a private health insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan, as defined under
subdivision (f) of Section 1345 of the Health and Safety Code,
licensed by the Department of Managed Health Care.

(c) “Eligible individual” means an individual who would have
been eligible to purchase coverage through the Exchange but for
his or her immigration status and who is not eligible for full-scope
Medi-Cal coverage under state law.

(d) “Exchange” means the California Health Benefit Exchange
established by Section 100500.

(e) “Federal act” means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments to, or regulations or
guidance issued under, those acts.

(f) “Fund” means the California Health Trust Fund For All
Californians established by Section 100540.

(g) “Health plan” and “qualified health plan” begin delete have the same
meanings as those terms are defined in Section 1301 of the federal
act. end delete begin insert shall be identical to “health plan” and “qualified health plan”
as defined in Title 22 (commencing with Section 100500). end insert

(h) “Medi-Cal coverage” means coverage under the Medi-Cal
program pursuant to Chapter 7 (commencing with Section 14000)
of Part 3 of Division 9 of the Welfare and Institutions Code.

(i) “Product” means one of the following:

(1) A health care service plan contract subject to Article 11.8
(commencing with Section 1399.845) of Chapter 2.2 of Division
2 of the Health and Safety Code.

(2) An individual policy of health insurance as defined in Section
106 of the Insurance Code, subject to Chapter 9.9 (commencing
with Section 10965) of Part 2 of Division 2 of the Insurance Code.

(j) “Program” means the California Health Exchange Program
For All Californians.

(k) “Supplemental coverage” means coverage through a
specialized health care service plan contract, as defined in
subdivision (o) of Section 1345 of the Health and Safety Code, or
a specialized health insurance policy, as defined in Section 106 of
the Insurance Code.

100532.  

The board shall, at a minimum, do all of the following:

(a) Enroll individuals into coverage who would be eligible to
enroll in the Exchange but for immigration status.

(b) Implement procedures for the certification, recertification,
and decertification, of health plans as qualified health plans. The
board shall require health plans seeking certification as qualified
health plans to do all of the following:

(1) Submit a justification for any premium increase before
implementation of the increase consistent with Article 6.2
(commencing with Section 1385.01) of Chapter 2.2 of Division 2
of the Health and Safety Code and Article 4.5 (commencing with
Section 10181) of Chapter 1 of Part 2 of Division 2 of the Insurance
Code.

(2) (A) Make available to the public and submit to the board
accurate and timely disclosure of the following information:

(i) Claims payment policies and practices.

(ii) Periodic financial disclosures.

(iii) Data on enrollment.

(iv) Data on disenrollment.

(v) Data on the number of claims that are denied.

(vi) Data on rating practices.

(vii) Information on cost sharing and payments with respect to
any out-of-network coverage.

(viii) Information on enrollee and participant rights under state
law.

(B) The information required under subparagraph (A) shall be
provided in plain language.

(3) Permit individuals to learn, in a timely manner upon the
request of the individual, the amount of cost sharing, including,
but not limited to, deductibles, copayments, and coinsurance, under
the individual’s plan or coverage that the individual would be
responsible for paying with respect to the furnishing of a specific
item or service by a participating provider. At a minimum, this
information shall be made available to the individual through an
Internet Web site and through other means for individuals without
access to the Internet.

(c) Provide for the operation of a toll-free telephone hotline to
respond to requests for assistance.

(d) Maintain an Internet Web site through which enrollees and
prospective enrollees of qualified health plans may obtain
standardized comparative information on those plans.

(e) Assign a rating to each qualified health plan offered through
the program in accordance with the criteria developed by the board.

(f) Utilize a standardized format for presenting health benefits
plan options in the program.

(g) Inform individuals of eligibility requirements for the
Medi-Cal program, the Exchange, or any applicable state or local
public program and, if through screening of the application by the
program, the program determines that an individual is eligible for
the state or local program, enroll that individual in that program.

(h) Establish and make available by electronic means a
calculator to determine the actual cost of coverage.

(i) Establish a navigator program. Any entity chosen by the
board as a navigator under this subdivision shall do all of the
following:

(1) Conduct public education activities to raise awareness of
the availability of qualified health plans through the program.

(2) Distribute fair and impartial information concerning
enrollment in qualified health begin delete plans, and the availability of
premium subsidies and cost-sharing reductions through the program end delete
begin insert plans end insert .

(3) Facilitate enrollment in qualified health plans.

(4) Provide referrals to any applicable office of health insurance
consumer assistance or health insurance ombudsman established
under Section 2793 of the federal Public Health Service Act (42
U.S.C. Sec. 300gg-93), or any other appropriate state agency or
agencies, for any enrollee with a grievance, complaint, or question
regarding his or her health plan, coverage, or a determination under
that plan or coverage.

(5) Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population being
served by the program.

100533.  

In addition to meeting the requirements of Section
100532, the board shall do all of the following:

(a) Determine the criteria and process for eligibility, enrollment,
and disenrollment of enrollees and potential enrollees in the
program and coordinate that process with the state and local
government entities administering other health care coverage
programs, including the Exchange, the State Department of Health
Care Services, and California counties, in order to ensure consistent
eligibility and enrollment processes and seamless transitions
between coverage.

(b) Develop processes to coordinate with the county entities
that administer eligibility for the Medi-Cal program.

(c) Determine the minimum requirements a carrier must meet
to be considered for participation in the program, and the standards
and criteria for selecting qualified health plans to be offered
through the program that are in the best interests of qualified
individuals. The board shall consistently and uniformly apply these
requirements, standards, and criteria to all carriers. In the course
of selectively contracting for health care coverage offered to
qualified individuals through the program, the board shall seek to
contract with carriers so as to provide health care coverage choices
that offer the optimal combination of choice, value, quality, and
service.

(d) Provide, in each region of the state, a choice of qualified
health plans at each of the five levels of coverage contained in
Section 1302(d) and (e) of the federal act.

(e) Require, as a condition of participation in the program,
carriers to fairly and affirmatively offer, market, and sell in the
program at least one product within each of the five levels of
coverage contained in Section 1302(d) and (e) of the federal act.
The board may require carriers to offer additional products within
each of those five levels of coverage. This subdivision shall not
apply to a carrier that solely offers supplemental coverage in the
program under paragraph (10) of subdivision (a) of Section 100534.

(f) (1) Except as otherwise provided in this section, require, as
a condition of participation in the program, carriers that sell any
products outside the program to fairly and affirmatively offer,
market, and sell all products made available to individuals in the
program to individuals purchasing coverage outside the program.

(2) For purposes of this subdivision, “product” does not include
contracts entered into pursuant to Chapter 7 (commencing with
Section 14000) or Chapter 8 (commencing with Section 14200)
of Part 3 of Division 9 of the Welfare and Institutions Code
between the State Department of Health Care Services and carriers
for enrolled Medi-Cal beneficiaries. begin delete “Product” also does not
include a bridge plan product offered pursuant to Section 100504.5. end delete

(g) Determine when an enrollee’s coverage commences and the
extent and scope of coverage.

(h) Provide for the processing of applications and the enrollment
and disenrollment of enrollees.

(i) Determine and approve cost-sharing provisions for qualified
health plans.

(j) Establish uniform billing and payment policies for qualified
health plans offered in the program to ensure consistent enrollment
and disenrollment activities for individuals enrolled in the program.

(k) Undertake activities necessary to market and publicize the
availability of health care coverage begin delete and subsidies end delete through the
program. The board shall also undertake outreach and enrollment
activities that seek to assist enrollees and potential enrollees with
enrolling and reenrolling in the program in the least burdensome
manner, including populations that may experience barriers to
enrollment, such as the disabled and those with limited English
language proficiency.

(l) Select and set performance standards and compensation for
navigators selected under subdivision (j) of Section 100532.

(m) Employ necessary staff. The board shall employ staff
consistent with the applicable requirements imposed under
subdivision (m) of Section 100503.

(n) Assess a charge on the qualified health plans offered by
carriers that is reasonable and necessary to support the
development, operations, and prudent cash management of the
program.

(o) Authorize expenditures, as necessary, from the fund to pay
program expenses to administer the program.

(p) Keep an accurate accounting of all activities, receipts, and
expenditures. Commencing January 1, 2017, the board shall
conduct an annual audit.

(q) (1) Notwithstanding Section 10231.5, annually prepare a
written report on the implementation and performance of the
program functions during the preceding fiscal year, including, at
a minimum, the manner in which funds were expended and the
progress toward, and the achievement of, the requirements of this
title. begin delete The report shall also include data provided by health care
service plans and health insurers offering bridge plan products
regarding the extent of health care provider and health facility
overlap in their Medi-Cal networks as compared to the health care
provider and health facility networks contracting with the plan or
insurer in their bridge plan contracts. end delete This report shall be
transmitted to the Legislature and the Governor and shall be made
available to the public on the Internet Web site of the program. A
report made to the Legislature pursuant to this subdivision shall
be submitted pursuant to Section 9795.

(2) In addition to the report described in paragraph (1), the board
shall be responsive to requests for additional information from the
Legislature, including providing testimony and commenting on
proposed state legislation or policy issues. The Legislature finds
and declares that activities, including, but not limited to, responding
to legislative or executive inquiries, tracking and commenting on
legislation and regulatory activities, and preparing reports on the
implementation of this title and the performance of the program,
are necessary state requirements and are distinct from the
promotion of legislative or regulatory modifications referred to in
subdivision (c) of Section 100540.

(r) Maintain enrollment and expenditures to ensure that
expenditures do not exceed the amount of revenue in the fund, and
if sufficient revenue is not available to pay estimated expenditures,
institute appropriate measures to ensure fiscal solvency.

(s) Exercise all powers reasonably necessary to carry out and
comply with the duties, responsibilities, and requirements of this
title.

(t) Consult with stakeholders relevant to carrying out the
activities under this title, including, but not limited to, all of the
following:

(1) Health care consumers who are enrolled in health plans.

(2) Individuals and entities with experience in facilitating
enrollment in health plans.

(3) The executive director of the Exchange.

(4) The State Medi-Cal Director.

(5) Advocates for enrolling hard-to-reach populations.

(u) Facilitate the purchase of qualified health plans in the
program by qualified individuals no later than January 1, 2016.

(v) Require carriers participating in the program to immediately
notify the program, under the terms and conditions established by
the board when an individual is or will be enrolled in or disenrolled
from any qualified health plan offered by the carrier.

(w) Ensure that the program provides oral interpretation services
in any language for individuals seeking coverage through the
program and makes available a toll-free telephone number for the
hearing and speech impaired. The board shall ensure that written
information made available by the program is presented in a plainly
worded, easily understandable format and made available in
prevalent languages.

100534.  

(a) The board may do the following:

(1) Collect premiums.

(2) Enter into contracts.

(3) Sue and be sued.

(4) Receive and accept gifts, grants, or donations of moneys
from any agency of the United States, any agency of the state, or
any municipality, county, or other political subdivision of the state.

(5) Receive and accept gifts, grants, or donations from
individuals, associations, private foundations, or corporations, in
compliance with the conflict-of-interest provisions to be adopted
by the board at a public meeting.

(6) Adopt rules and regulations, as necessary. Until January 1,
2018, any necessary rules and regulations may be adopted as
emergency regulations in accordance with the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2). The adoption of these regulations
shall be deemed to be an emergency and necessary for the
immediate preservation of the public peace, health and safety, or
general welfare.

(7) Collaborate with the Exchange and the State Department of
Health Care Services, to the extent possible, to allow an individual
the option to remain enrolled with his or her carrier and provider
network in the event the individual experiences a loss of eligibility
for enrollment in a qualified health plan under this title and
becomes eligible for the Exchange or the Medi-Cal program, or
loses eligibility for the Medi-Cal program and becomes eligible
for a qualified health plan through the program.

(8) Share information with relevant state departments, consistent
with the applicable laws governing confidentiality, necessary for
the administration of the program.

(9) Require carriers participating in the program to make
available to the program and regularly update an electronic
directory of contracting health care providers so that individuals
seeking coverage through the program can search by health care
provider name to determine which health plans in the program
include that health care provider in their network. The board may
also require a carrier to provide regularly updated information to
the program as to whether a health care provider is accepting new
patients for a particular health plan. The program may provide an
integrated and uniform consumer directory of health care providers
indicating which carriers the providers contract with and whether
the providers are currently accepting new patients. The program
may also establish methods by which health care providers may
transmit relevant information directly to the program, rather than
through a carrier.

(10) Make available supplemental coverage for enrollees of the
program to the extent permitted by available funding. Any
supplemental coverage offered in the program shall be subject to
the charge imposed under subdivision (n) of Section 100533.

begin delete

(11) Make available premium subsidies and cost-sharing
reductions to the extent funding is available.

end delete

(b) (1) An applicant for health care coverage shall be required
to provide only the information strictly necessary to authenticate
identity, determine eligibility, and determine the amount of the
credit or reduction.

(2) Any person who receives information provided by an
applicant pursuant to paragraph (1), whether directly or by another
person at the request of the applicant, or otherwise obtains
information about the applicant through the program process shall
do both of the following:

(A) Use the information only for the purposes of, and to the
extent necessary in, ensuring the efficient operation of the program,
including verifying the eligibility of an individual to enroll through
the program.

(B) Not disclose the information to any other person except as
provided in this section.

(c) The board shall have the authority to standardize products
to be offered through the program.

100535.  

The board shall establish and use a competitive process
to select participating carriers and any other contractors under this
title. Any contract entered into pursuant to this title shall be exempt
from Chapter 1 (commencing with Section 10100) of Part 2 of
Division 2 of the Public Contract Code, and shall be exempt from
the review or approval of any division of the Department of General
Services.

100536.  

(a) The board shall establish an appeals process for
prospective and current enrollees of the program.

(b) The board shall not be required to provide an appeal if the
subject of the appeal is within the jurisdiction of the Department
of Managed Health Care pursuant to the Knox-Keene Health Care
Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) and its
implementing regulations, or within the jurisdiction of the
Department of Insurance pursuant to the Insurance Code and its
implementing regulations.

100537.  

(a) Notwithstanding any other law, the program shall
not be subject to licensure or regulation by the Department of
Insurance or the Department of Managed Health Care.

(b) Carriers that contract with the program shall have a license
or certificate of authority from, and shall be in good standing with,
their respective regulatory agencies.

100538.  

(a) Records of the program that reveal the deliberative
processes, discussions, communications, or any other portion of
the negotiations with entities contracting or seeking to contract
with the program, entities with which the program is considering
a contract, or entities with which the program is considering or
enters into any other arrangement under which the program
provides, receives, or arranges services or reimbursement shall be
exempt from disclosure under the California Public Records Act
(Chapter 3.5 (commencing with Section 6250) of Division 7 of
Title 1).

(b) The following records of the program shall be exempt from
disclosure under the California Public Records Act (Chapter 3.5
(commencing with Section 6250) of Division 7 of Title 1) as
follows:

(1) (A) Except for the portion of a contract that contains the
rates of payments, contracts with participating carriers entered into
pursuant to this title on or after the date the act that added this
subparagraph becomes effective, shall be open to inspection one
year after the effective dates of the contracts.

(B) If contracts with participating carriers entered into pursuant
to this title are amended, the amendments shall be open to
inspection one year after the effective date of the amendments.

(c) Three years after a contract or amendment is open to
inspection pursuant to subdivision (b), the portion of the contract
or amendment containing the rates of payment shall be open to
inspection.

(d) Notwithstanding any other law, entire contracts with
participating carriers or amendments to contracts with participating
carriers shall be open to inspection by the Joint Legislative Audit
Committee. The committee shall maintain the confidentiality of
the contracts and amendments until the contracts or amendments
to a contract are open to inspection pursuant to subdivisions (b)
and (c).

100539.  

(a) No individual or entity shall hold himself, herself,
or itself out as representing, constituting, or otherwise providing
services on behalf of the program unless that individual or entity
has a valid agreement with the program to engage in those
activities.

(b) Any individual or entity who aids or abets another individual
or entity in violation of this section shall also be in violation of
this section.

100540.  

(a) The California Health Trust Fund For All
Californians is hereby created in the State Treasury for the purpose
of this title. Notwithstanding Section 13340, all moneys in the
fund shall be continuously appropriated without regard to fiscal
year for the purposes of this title. Any moneys in the fund that are
unexpended or unencumbered at the end of a fiscal year may be
carried forward to the next succeeding fiscal year.

(b) The board of the program shall establish and maintain a
prudent reserve in the fund.

(c) The board or staff of the program shall not utilize any funds
intended for the administrative and operational expenses of the
program for staff retreats, promotional giveaways, excessive
executive compensation, or promotion of federal or state legislative
or regulatory modifications.

(d) Notwithstanding Section 16305.7, all interest earned on the
moneys that have been deposited into the fund shall be retained
in the fund and used for purposes consistent with the fund.

(e) Effective January 1, 2018, if at the end of any fiscal year,
the fund has unencumbered funds in an amount that equals or is
more than the board approved operating budget of the program
for the next fiscal year, the board shall reduce the charges imposed
under subdivision (n) of Section 100533 during the following fiscal
year in an amount that will reduce any surplus funds of the program
to an amount that is equal to the agency’s operating budget for the
next fiscal year.

100541.  

(a) The board shall ensure that the establishment,
operation, and administrative functions of the program do not
exceed the combination of state funds, private donations, and other
non-General Fund moneys available for this purpose.

(b) The implementation of the provisions of this title, other than
this section, Section 100530, and paragraphs (4) and (5) of
subdivision (a) of Section 100534, shall be contingent on a
determination by the board that sufficient financial resources exist
or will exist in the fund. begin delete The determination shall be based on at
least the following: end delete

begin delete

(1) Financial projections identifying that sufficient resources
exist or will exist in the fund to implement the program.

(2) A comparison of the projected resources available to support
the program and the projected costs of activities required by this
title.

(3) The financial projections demonstrate the sufficiency of
resources for at least the first two years of operation under this
title.

(c) The board shall provide notice to the Joint Legislative Budget
Committee and the Director of Finance that sufficient financial
resources exist in the fund to implement this title.

(d)

end delete

begin insert (c) end insert  If the board determines that the level of resources in the fund
cannot support the actions and responsibilities described in
subdivision (a), it shall provide the Department of Finance and the
Joint Legislative Budget Committee a detailed report on the
changes to the functions, contracts, or staffing necessary to address
the fiscal deficiency along with any contingency plan should it be
impossible to operate the program without the use of General Fund
moneys.

begin delete

(e)

end delete

begin insert (d) end insert  The board shall assess the impact of the program’s operations
and policies on other publicly funded health programs administered
by the state and the impact of publicly funded health programs
administered by the state on the program’s operations and policies.
This assessment shall include, at a minimum, an analysis of
potential cost shifts or cost increases in other programs that may
be due to program policies or operations. The assessment shall be
completed on at least an annual basis and submitted to the Secretary
of California Health and Human Services and the Director of
Finance.

SEC. 4.  

Section 1366.7 is added to the Health and Safety Code,
to read:

1366.7.  

(a) For purposes of this section, the following
definitions shall apply:

(1) “Federal act” means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments to, or regulations or
guidance issued under, those acts.

(2) “Health plan” has the same meaning as that term is defined
in subdivision (g) of Section 100530 of the Government Code.

(3) “Program” means the California Health Exchange Program
For All Californians established in Title 22.5 (commencing with
Section 100530) of the Government Code.

(b) Health care service plans participating in the program shall
fairly and affirmatively offer, market, and sell in the program at
least one product within each of the five levels of coverage
contained in Section 1302(d) and (e) of the federal act. The
executive board established under Section 100530 of the
Government Code may require plans to sell additional products
within each of those levels of coverage. This subdivision shall not
apply to a plan that solely offers supplemental coverage in the
program under paragraph (10) of subdivision (a) of Section 100534
of the Government Code.

(c) (1) Health care service plans participating in the program
that sell any products outside the program shall fairly and
affirmatively offer, market, and sell all products made available
to individuals in the program to individuals purchasing coverage
outside the program.

(2) For purposes of this subdivision, “product” does not include
contracts entered into pursuant to Chapter 8 (commencing with
Section 14200) of Part 3 of Division 9 of the Welfare and
Institutions Code between the State Department of Health Care
Services and health care service plans for enrolled Medi-Cal
beneficiaries.

(d) Commencing January 1, 2015, a health care service plan
shall, with respect to plan contracts that cover hospital, medical,
or surgical benefits, only sell the five levels of coverage contained
in Section 1302(d) and (e) of the federal act, except that a health
care service plan that does not participate in the program shall,
with respect to plan contracts that cover hospital, medical, or
surgical benefits, only sell the four levels of coverage contained
in Section 1302(d) of the federal act.

(e) Commencing January 1, 2015, a health care service plan
that does not participate in the program shall, with respect to plan
contracts that cover hospital, medical, or surgical benefits, offer
at least one standardized product that has been designated by the
program in each of the four levels of coverage contained in Section
1302(d) of the federal act. This subdivision shall only apply if the
executive board of the program exercises its authority under
subdivision (c) of Section 100534 of the Government Code.
Nothing in this subdivision shall require a plan that does not
participate in the program to offer standardized products in the
small employer market if the plan only sells products in the
individual market. Nothing in this subdivision shall require a plan
that does not participate in the program to offer standardized
products in the individual market if the plan only sells products in
the small employer market. This subdivision shall not be construed
to prohibit the plan from offering other products provided that it
complies with subdivision (d).

(f) A health care service plan participating in the program shall
charge the same rate for the same product whether that product is
offered through the program or in the outside market
notwithstanding any charge imposed by the program pursuant to
subdivision (n) of Section 100533 of the Government Code.

(g) This section shall become operative only if Title 22.5
(commencing with Section 100530) of the Government Code
becomes operative on or before January 1, 2017. If this section
does not become operative by January 1, 2017, as of that date, this
section is repealed, unless a later enacted statute, that is enacted
before January 1, 2017, deletes or extends that date.

SEC. 5.  

Section 10112.31 is added to the Insurance Code, to
read:

10112.31.  

(a) For purposes of this section, the following
definitions shall apply:

(1) “Federal act” means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments to, or regulations or
guidance issued under, those acts.

(2) “Health plan” has the same meaning as that term is defined
in subdivision (g) of Section 100530 of the Government Code.

(3) “Program” means the California Health Exchange Program
For All Californians established in Title 22.5 (commencing with
Section 100530) of the Government Code.

(b) Health insurers participating in the program shall fairly and
affirmatively offer, market, and sell in the program at least one
product within each of the five levels of coverage contained in
Section 1302(d) and (e) of the federal act. The executive board
established under Section 100530 of the Government Code may
require insurers to sell additional products within each of those
levels of coverage. This subdivision shall not apply to an insurer
that solely offers supplemental coverage in the program under
paragraph (10) of subdivision (a) of Section 100534 of the
Government Code.

(c) (1) Health insurers participating in the program that sell any
products outside the program shall fairly and affirmatively offer,
market, and sell all products made available to individuals in the
program to individuals purchasing coverage outside the program.

(2) For purposes of this subdivision, “product” does not include
contracts entered into pursuant to Chapter 8 (commencing with
Section 14200) of Part 3 of Division 9 of the Welfare and
Institutions Code between the State Department of Health Care
Services and health insurers for enrolled Medi-Cal beneficiaries.

(d) Commencing January 1, 2015, an insurer shall, with respect
to policies that cover hospital, medical, or surgical benefits, only
sell the five levels of coverage contained in Section 1302(d) and
(e) of the federal act, except that an insurer that does not participate
in the program shall, with respect to policies that cover hospital,
medical, or surgical benefits, only sell the four levels of coverage
contained in Section 1302(d) of the federal act.

(e) Commencing January 1, 2015, an insurer that does not
participate in the program shall, with respect to policies that cover
hospital, medical, or surgical benefits, offer at least one
standardized product that has been designated by the program in
each of the four levels of coverage contained in Section 1302(d)
of the federal act. This subdivision shall only apply if the board
of the program exercises its authority under subdivision (c) of
Section 100534 of the Government Code. Nothing in this
subdivision shall require an insurer that does not participate in the
program to offer standardized products in the small employer
market if the insurer only sells products in the individual market.
Nothing in this subdivision shall require an insurer that does not
participate in the program to offer standardized products in the
individual market if the insurer only sells products in the small
employer market. This subdivision shall not be construed to
prohibit the insurer from offering other products provided that it
complies with subdivision (d).

(f) An insurer participating in the program shall charge the same
rate for the same product whether that product is offered through
the program or in the outside market notwithstanding any charge
imposed by the program pursuant to subdivision (n) of Section
100533 of the Government Code.

(g) This section shall become operative only if Title 22.5
(commencing with Section 100530) of the Government Code
becomes operative on or before January 1, 2017. If this section
does not become operative by January 1, 2017, as of that date, this
section is repealed, unless a later enacted statute, that is enacted
before January 1, 2017, deletes or extends that date.

SEC. 6.  

Section 14102.1 is added to the Welfare and
Institutions Code, to read:

14102.1.  

(a) Notwithstanding any other law, individuals who
meet all of the eligibility requirements for full-scope Medi-Cal
benefits under this chapter, but for their immigration status, shall
be eligible for full-scope Medi-Cal benefits.

(b) This section shall not apply to individuals eligible for
coverage pursuant to Section 14102.

(c) Individuals who are eligible under subdivision (a) shall be
required to enroll into Medi-Cal managed care health plans to the
extent required of otherwise eligible Medi-Cal recipients who are
similarly situated.

(d) Individuals who are eligible under subdivision (a) shall pay
copayments and premium contributions to the extent required of
otherwise eligible Medi-Cal recipients who are similarly situated.

(e) Benefits for services under this section shall be provided
with state-only funds only if federal financial participation is not
available for those services. The department shall maximize federal
financial participation in implementing this section to the extent
allowable.

(f) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking any further regulatory action, shall
implement, interpret, or make specific this section by means of
all-county letters, plan letters, plan or provider bulletins, or similar
instructions until the time regulations are adopted. The department
shall adopt regulations by July 1, 2018, in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code.
Commencing July 1, 2016, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance with
Section 9795 of the Government Code, until regulations have been
adopted begin insert pursuant to Section 14102.2 end insert .

SEC. 7.  

Section 14102.2 is added to the Welfare and
Institutions Code, to read:

14102.2.  

(a) (1) Except as provided in subdivision (c),
individuals who are enrolled in restricted scope Medi-Cal as of
December 31, 2015, who are eligible under Section 14102.1 shall
be transitioned directly to full-scope coverage under the Medi-Cal
program in accordance with the requirements of this section. The
department shall develop a transition plan for those currently
enrolled in restricted scope Medi-Cal.

(2) For purposes of this section, an “emergency care provider”
is defined as a hospital in the county of his or her residence where
the individual received emergency care, if any.

(b) Except as provided in subdivision (c), with respect to
managed care health plan enrollment, a restricted-scope enrollee
who applies and is determined eligible before October 1, 2015,
shall be notified by the department at least 60 days before January
1, 2016, in accordance with the department’s transition plan of all
of the following:

(1) Which Medi-Cal managed care health plan or plans contain
his or her existing emergency care provider, if the department has
this information and the emergency care provider is contracted
with a Medi-Cal managed care health plan.

(2) That the restricted scope enrollee, subject to his or her ability
to change as described in paragraph (3), will be assigned to a health
plan that includes his or her emergency care provider and enrolled
effective January 1, 2014. If the enrollee wants to keep his or her
emergency care provider, no additional action shall be required if
the emergency care provider is contracted with a Medi-Cal
managed care health plan.

(3) That the restricted scope enrollee may choose any available
Medi-Cal managed care health plan and primary care provider in
his or her county of residence before January 1, 2016, if more than
one such plan is available in the county where he or she resides,
and he or she will receive all provider and health plan information
required to be sent to new enrollees and instructions on how to
choose or change his or her health plan and primary care provider.

(4) That in counties with more than one Medi-Cal managed care
health plan, if the restricted scope enrollee does not affirmatively
choose a plan within 30 days of receipt of the notice, he or she
shall be enrolled into the Medi-Cal managed care health plan that
contains his or her emergency care provider as part of the Medi-Cal
managed care contracted network, if the department has this
information about the emergency care provider, and the emergency
care provider is contracted with a Medi-Cal managed care health
plan. If the emergency care provider is contracted with more than
one Medi-Cal managed care health plan, then the restricted scope
enrollee shall be assigned to one of the health plans containing his
or her emergency care provider in accordance with an assignment
process established to ensure the linkage.

(5) That the enrollee subject to this section shall receive all
provider and health plan information required to be sent to new
enrollees. If the restricted scope enrollee is not assigned to two
begin insert Medi-Cal managed care health plans end insert pursuant to paragraph (2),
and does not affirmatively select one of the available Medi-Cal
managed care health plans within 30 days of receipt of the notice,
he or she shall automatically be assigned a plan through the
department-prescribed auto-assignment process.

(6) That the restricted scope enrollee does not need to take any
action to be transitioned to full-scope Medi-Cal or to retain his or
her emergency care provider, if the emergency care provider is
available pursuant to paragraph (2).

(7) That the restricted scope enrollee may choose not to
transition to the full-scope Medi-Cal program, and what this choice
will mean for his or her health care coverage and access to health
care services.

(c) Individuals who qualify under subdivision (a) and who apply
and are determined eligible for restricted scope after the date
identified by the department, that is not later than October 1, 2015,
shall be considered late enrollees. Late enrollees shall be notified
in accordance with subdivision (b), except according to a different
timeframe, but will transition to full-scope Medi-Cal coverage on
January 1, 2016. Late enrollees after the date identified in this
subdivision shall be transitioned pursuant to the department’s
restricted scope transition plan process.

(d) Emergency care providers that receive reimbursement for
restricted scope coverage shall work with the department and its
designees during the 2015 and 2016 calendar years to facilitate
enrollment and data sharing for the purposes of delivering
Medi-Cal services in the 2016 calendar year.

SEC. 8.  

The Legislature finds and declares that begin delete Section 3 of
this act, which adds end delete Section 100538 begin delete to end delete begin insert of end insert the Government Code,
begin insert as added by Section 3 of this act, end insert imposes a limitation on the
public’s right of access to the meetings of public bodies or the
writings of public officials and agencies within the meaning of
Section 3 of Article I of the California Constitution. Pursuant to
that constitutional provision, the Legislature makes the following
findings to demonstrate the interest protected by this limitation
and the need for protecting that interest:

In order to ensure that the California Health Exchange Program
For All Californians is not constrained in exercising its fiduciary
powers and obligations to negotiate on behalf of the public, the
limitations on the public’s right of access imposed by Section 3
of this act are necessary.

SEC. 9.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution for certain
costs that may be incurred by a local agency or school district
because, in that regard, this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.

However, if the Commission on State Mandates determines that
this act contains other costs mandated by the state, reimbursement
to local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division
4 of Title 2 of the Government Code.