Amended in Senate June 1, 2015

Amended in Senate April 28, 2015

Amended in Senate April 6, 2015

Senate BillNo. 4


Introduced by Senator Lara

(Principal coauthor: Assembly Member Bonta)

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

(Coauthors: Assembly Members Alejo, Levine, Lopez, and Thurmond)

December 1, 2014


An act to addbegin delete and repealend delete Section 100522begin delete of, and to add and repeal Title 22.5 (commencing with Section 100530) of,end deletebegin insert toend insert the Government Code,begin delete to add and repeal Section 1366.7 of the Health and Safety Code, to add and repeal Section 10112.31 of the Insurance Code,end delete and to add Sections 14102.1 and 14102.2 to the Welfare and Institutions Code, relating to health carebegin delete coverage, and making an appropriation therefor.end deletebegin insert coverage.end insert

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 qualifiedbegin delete individualend deletebegin insert individualsend insert 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.begin delete If federal approval is not granted on or before January 1, 2017, the bill would create the California Health Exchange Program For All Californians within state government.end delete

begin delete

The bill would require that the California Health Exchange Program For 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 program 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. 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 program’s 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.

end delete
begin delete

The bill would require health care service plans and health insurers to fairly and affirmatively offer, market, and sell in the program 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.

end delete

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 individualsbegin insert under 19 years of ageend insert who are otherwise eligible for those benefits but for their immigration status.begin insert The bill would also extend eligibility for either limited scope Medi-Cal benefits or full-scope Medi-Cal benefits to individuals 19 years of age and older who are otherwise eligible for those benefits but for their immigration status if the department determines that sufficient funding is available.end insert 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.

begin delete

The

end delete

begin insertThisend insert bill would require the State Department of Health Care Services to develop a transition plan for individualsbegin insert under 19 years of ageend insert who are enrolled in restricted-scope Medi-Cal as ofbegin delete a specified date,end deletebegin insert the effective date of the bill,end insert 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: begin deleteyes end deletebegin insertnoend insert. Fiscal committee: yes. State-mandated local program: yes.

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

begin delete
P4    1

SECTION 1.  

(a) (1) The Legislature finds and declares that
2longstanding California law provides full-scope Medi-Cal to United
3States citizens, lawful permanent residents, and individuals
4permanently residing in the United States under color of law,
5including those granted deferred action.

6(2) It is the intent of the Legislature in enacting this act to extend
7full-scope Medi-Cal eligibility to California residents who are
8currently ineligible for Medi-Cal due to their immigration status,
9as long as they meet the other requirements of the Medi-Cal
10program.

11(b) It is the intent of the Legislature that all Californians,
12regardless of immigration status, have access to health coverage
13and care.

14(c) It is the intent of the Legislature that all Californians who
15are otherwise eligible for Medi-Cal, a qualified health plan offered
16through the California Health Benefit Exchange, or affordable
17employer-based health coverage, enroll in that coverage and obtain
18the care that they need.

19(d) It is further the intent of the Legislature to ensure that all
20Californians be included in eligibility for coverage without regard
21to immigration status.

end delete
22begin insert

begin insertSECTION 1.end insert  

end insert

begin insert(a)end insertbegin insertend insertbegin insertThe Legislature finds and declares all of the
23following:end insert

begin insert

24(1) No child in California should endure suffering and pain due
25to a lack of access to health care services.

end insert
begin insert

26(2) No individual in California should be excluded from
27obtaining coverage through the California Health Benefit
28Exchange by reason of immigration status.

end insert
begin insert

29(3) Expanding access and increasing enrollment in
30comprehensive health care coverage benefits the health and welfare
31of all Californians.

end insert
begin insert

32(4) Longstanding California law provides full-scope Medi-Cal
33to United States citizens, lawful permanent residents, and
34individuals permanently residing in the United States under color
35of law, including those granted deferred action.

end insert
begin insert

P5    1(b) It is the intent of the Legislature in enacting this act to extend
2full-scope Medi-Cal eligibility to every child in California who is
3currently ineligible for Medi-Cal due to his or her immigration
4status, as long as he or she meets the other requirements of the
5Medi-Cal program.

end insert
begin insert

6(c) It is further the intent of the Legislature to ensure that all
7Californians are eligible to obtain health care coverage through
8the exchange.

end insert
begin insert

9(d) It is further the intent of the Legislature to increase
10opportunities for enrollment in comprehensive coverage for adults,
11regardless of immigration status, through the enactment of this
12bill.

end insert
begin insert

13(e) It is further the intent of the Legislature that all Californians
14who are otherwise eligible for Medi-Cal, a qualified health plan
15offered through the California Health Benefit Exchange, or
16affordable employer-based health coverage, enroll in that
17coverage, and obtain the care that they need.

end insert
18

SEC. 2.  

Section 100522 is added to the Government Code, to
19read:

20

100522.  

(a) The Secretary of California Health and Human
21Services shall apply to the United States Department of Health
22and Human Services for a waiver authorized under Section 1332
23of the federal act as defined in subdivision (e) of Section 100501
24in order to allow persons otherwise not able to obtain coverage by
25reason of immigration status through the Exchange to obtain
26coverage from the Exchange by waiving the requirement that the
27Exchange offer only qualified health plans.

28(b) The Exchange shall offer qualified health benefit plansbegin delete whichend delete
29begin insert thatend insert shall be subject to the requirements of this title, including all
30of those requirements applicable to qualified health plans. In
31addition, California qualified health plans shall be subject to the
32requirements of Section 1366.6 of the Health and Safety Code and
33Section 10112.3 of the Insurance Code in the same manner as
34qualified health plans.

35(c) Persons eligible to purchase California qualified health plans
36shall pay the cost of coverage without federal advanced premium
37tax credit, federal cost-sharing reduction, or any other federal
38assistance.

39(d) Subdivisions (b) and (c) of this section shall become
40operative upon federal approval of the waiver pursuant to
P6    1subdivision (a). begin delete If subdivisions (b) and (c) of this section do not
2become operative on or before January 1, 2017, Title 22.5
3(commencing with Section 100530) shall become operative, and
4as of that date, this section is repealed, unless a later enacted
5statute, that is enacted before January 1, 2017, deletes or extends
6that date.end delete

7(e) For purposes of this section, a “California qualified health
8plan” means a product offered to those not otherwise eligible to
9purchase coverage from the Exchange by reason of immigration
10begin insert statusend insert and that comply with each of the requirements of state law
11and the Exchange for a qualified health plan.

begin delete
12

SEC. 3.  

Title 22.5 (commencing with Section 100530) is added
13to the Government Code, to read:

14 

15Title 22.5.  California Health Exchange
16Program for All Californians

17

 

18

100530.  

(a) There is in state government the California Health
19Exchange Program For All Californians, an independent public
20entity not affiliated with an agency or department.

21(b) The program shall be governed by the executive board
22established pursuant to Section 100500. The board shall be subject
23to Section 100500.

24(c) It is the intent of the Legislature in enacting the program to
25provide coverage for Californians who would be eligible to enroll
26in the California Health Benefit Exchange established under Title
2722 (commencing with Section 100500) but for their immigration
28status.

29(d) This title shall become operative only if federal approval of
30the waiver described in subdivision (a) of Section 100522 is not
31granted on or before January 1, 2017. If this title does not become
32operative by January 1, 2017, as of that date, this title is repealed,
33unless a later enacted statute, that is enacted before January 1,
342017, deletes or extends that date.

35

100531.  

For purposes of this title, the following definitions
36shall apply:

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

39(b) “Carrier” means either a private health insurer holding a
40valid outstanding certificate of authority from the Insurance
P7    1Commissioner or a health care service plan, as defined under
2subdivision (f) of Section 1345 of the Health and Safety Code,
3licensed by the Department of Managed Health Care.

4(c) “Eligible individual” means an individual who would have
5been eligible to purchase coverage through the Exchange but for
6 his or her immigration status and who is not eligible for full-scope
7 Medi-Cal coverage under state law.

8(d) “Exchange” means the California Health Benefit Exchange
9established by Section 100500.

10(e) “Federal act” means the federal Patient Protection and
11Affordable Care Act (Public Law 111-148), as amended by the
12federal Health Care and Education Reconciliation Act of 2010
13(Public Law 111-152), and any amendments to, or regulations or
14guidance issued under, those acts.

15(f) “Fund” means the California Health Trust Fund For All
16Californians established by Section 100540.

17(g) “Health plan” and “qualified health plan” shall be identical
18to “health plan” and “qualified health plan” as defined in Title 22
19(commencing with Section 100500).

20(h) “Medi-Cal coverage” means coverage under the Medi-Cal
21 program pursuant to Chapter 7 (commencing with Section 14000)
22of Part 3 of Division 9 of the Welfare and Institutions Code.

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

24(1) A health care service plan contract subject to Article 11.8
25(commencing with Section 1399.845) of Chapter 2.2 of Division
262 of the Health and Safety Code.

27(2) An individual policy of health insurance as defined in Section
28106 of the Insurance Code, subject to Chapter 9.9 (commencing
29with Section 10965) of Part 2 of Division 2 of the Insurance Code.

30(j) “Program” means the California Health Exchange Program
31For All Californians.

32(k) “Supplemental coverage” means coverage through a
33specialized health care service plan contract, as defined in
34subdivision (o) of Section 1345 of the Health and Safety Code, or
35a specialized health insurance policy, as defined in Section 106 of
36the Insurance Code.

37

100532.  

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

38(a) Enroll individuals into coverage who would be eligible to
39enroll in the Exchange but for immigration status.

P8    1(b) Implement procedures for the certification, recertification,
2and decertification, of health plans as qualified health plans. The
3board shall require health plans seeking certification as qualified
4health plans to do all of the following:

5(1) Submit a justification for any premium increase before
6implementation of the increase consistent with Article 6.2
7(commencing with Section 1385.01) of Chapter 2.2 of Division 2
8of the Health and Safety Code and Article 4.5 (commencing with
9Section 10181) of Chapter 1 of Part 2 of Division 2 of the Insurance
10Code.

11(2) (A) Make available to the public and submit to the board
12accurate and timely disclosure of the following information:

13(i) Claims payment policies and practices.

14(ii) Periodic financial disclosures.

15(iii) Data on enrollment.

16(iv) Data on disenrollment.

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

18(vi) Data on rating practices.

19(vii) Information on cost sharing and payments with respect to
20any out-of-network coverage.

21(viii) Information on enrollee and participant rights under state
22law.

23(B) The information required under subparagraph (A) shall be
24provided in plain language.

25(3) Permit individuals to learn, in a timely manner upon the
26request of the individual, the amount of cost sharing, including,
27but not limited to, deductibles, copayments, and coinsurance, under
28the individual’s plan or coverage that the individual would be
29responsible for paying with respect to the furnishing of a specific
30item or service by a participating provider. At a minimum, this
31information shall be made available to the individual through an
32Internet Web site and through other means for individuals without
33access to the Internet.

34(c) Provide for the operation of a toll-free telephone hotline to
35respond to requests for assistance.

36(d) Maintain an Internet Web site through which enrollees and
37prospective enrollees of qualified health plans may obtain
38standardized comparative information on those plans.

39(e) Assign a rating to each qualified health plan offered through
40the program in accordance with the criteria developed by the board.

P9    1(f) Utilize a standardized format for presenting health benefits
2plan options in the program.

3(g) Inform individuals of eligibility requirements for the
4Medi-Cal program, the Exchange, or any applicable state or local
5public program and, if through screening of the application by the
6program, the program determines that an individual is eligible for
7the state or local program, enroll that individual in that program.

8(h) Establish and make available by electronic means a
9calculator to determine the actual cost of coverage.

10(i) Establish a navigator program. Any entity chosen by the
11board as a navigator under this subdivision shall do all of the
12following:

13(1) Conduct public education activities to raise awareness of
14the availability of qualified health plans through the program.

15(2) Distribute fair and impartial information concerning
16enrollment in qualified health plans.

17(3) Facilitate enrollment in qualified health plans.

18(4) Provide referrals to any applicable office of health insurance
19consumer assistance or health insurance ombudsman established
20under Section 2793 of the federal Public Health Service Act (42
21U.S.C. Sec. 300gg-93), or any other appropriate state agency or
22agencies, for any enrollee with a grievance, complaint, or question
23regarding his or her health plan, coverage, or a determination under
24that plan or coverage.

25(5) Provide information in a manner that is culturally and
26linguistically appropriate to the needs of the population being
27served by the program.

28

100533.  

In addition to meeting the requirements of Section
29100532, the board shall do all of the following:

30(a) Determine the criteria and process for eligibility, enrollment,
31and disenrollment of enrollees and potential enrollees in the
32program and coordinate that process with the state and local
33government entities administering other health care coverage
34programs, including the Exchange, the State Department of Health
35Care Services, and California counties, in order to ensure consistent
36eligibility and enrollment processes and seamless transitions
37between coverage.

38(b) Develop processes to coordinate with the county entities
39that administer eligibility for the Medi-Cal program.

P10   1(c) Determine the minimum requirements a carrier must meet
2to be considered for participation in the program, and the standards
3and criteria for selecting qualified health plans to be offered
4through the program that are in the best interests of qualified
5individuals. The board shall consistently and uniformly apply these
6requirements, standards, and criteria to all carriers. In the course
7of selectively contracting for health care coverage offered to
8qualified individuals through the program, the board shall seek to
9contract with carriers so as to provide health care coverage choices
10that offer the optimal combination of choice, value, quality, and
11service.

12(d) Provide, in each region of the state, a choice of qualified
13health plans at each of the five levels of coverage contained in
14Section 1302(d) and (e) of the federal act.

15(e) Require, as a condition of participation in the program,
16carriers to fairly and affirmatively offer, market, and sell in the
17program at least one product within each of the five levels of
18coverage contained in Section 1302(d) and (e) of the federal act.
19The board may require carriers to offer additional products within
20each of those five levels of coverage. This subdivision shall not
21apply to a carrier that solely offers supplemental coverage in the
22program under paragraph (10) of subdivision (a) of Section 100534.

23(f) (1) Except as otherwise provided in this section, require, as
24a condition of participation in the program, carriers that sell any
25products outside the program to fairly and affirmatively offer,
26market, and sell all products made available to individuals in the
27program to individuals purchasing coverage outside the program.

28(2) For purposes of this subdivision, “product” does not include
29contracts entered into pursuant to Chapter 7 (commencing with
30Section 14000) or Chapter 8 (commencing with Section 14200)
31of Part 3 of Division 9 of the Welfare and Institutions Code
32between the State Department of Health Care Services and carriers
33for enrolled Medi-Cal beneficiaries.

34(g) Determine when an enrollee’s coverage commences and the
35extent and scope of coverage.

36(h) Provide for the processing of applications and the enrollment
37and disenrollment of enrollees.

38(i) Determine and approve cost-sharing provisions for qualified
39health plans.

P11   1(j) Establish uniform billing and payment policies for qualified
2health plans offered in the program to ensure consistent enrollment
3and disenrollment activities for individuals enrolled in the program.

4(k) Undertake activities necessary to market and publicize the
5availability of health care coverage through the program. The board
6shall also undertake outreach and enrollment activities that seek
7to assist enrollees and potential enrollees with enrolling and
8reenrolling in the program in the least burdensome manner,
9including populations that may experience barriers to enrollment,
10such as the disabled and those with limited English language
11proficiency.

12(l) Select and set performance standards and compensation for
13navigators selected under subdivision (j) of Section 100532.

14(m) Employ necessary staff. The board shall employ staff
15consistent with the applicable requirements imposed under
16subdivision (m) of Section 100503.

17(n) Assess a charge on the qualified health plans offered by
18carriers that is reasonable and necessary to support the
19development, operations, and prudent cash management of the
20program.

21(o) Authorize expenditures, as necessary, from the fund to pay
22program expenses to administer the program.

23(p) Keep an accurate accounting of all activities, receipts, and
24expenditures. Commencing January 1, 2017, the board shall
25conduct an annual audit.

26(q) (1) Notwithstanding Section 10231.5, annually prepare a
27written report on the implementation and performance of the
28program functions during the preceding fiscal year, including, at
29a minimum, the manner in which funds were expended and the
30progress toward, and the achievement of, the requirements of this
31title. This report shall be transmitted to the Legislature and the
32Governor and shall be made available to the public on the Internet
33Web site of the program. A report made to the Legislature pursuant
34to this subdivision shall be submitted pursuant to Section 9795.

35(2) In addition to the report described in paragraph (1), the board
36shall be responsive to requests for additional information from the
37Legislature, including providing testimony and commenting on
38proposed state legislation or policy issues. The Legislature finds
39and declares that activities, including, but not limited to, responding
40to legislative or executive inquiries, tracking and commenting on
P12   1legislation and regulatory activities, and preparing reports on the
2implementation of this title and the performance of the program,
3are necessary state requirements and are distinct from the
4promotion of legislative or regulatory modifications referred to in
5subdivision (c) of Section 100540.

6(r) Maintain enrollment and expenditures to ensure that
7expenditures do not exceed the amount of revenue in the fund, and
8if sufficient revenue is not available to pay estimated expenditures,
9institute appropriate measures to ensure fiscal solvency.

10(s) Exercise all powers reasonably necessary to carry out and
11comply with the duties, responsibilities, and requirements of this
12title.

13(t) Consult with stakeholders relevant to carrying out the
14activities under this title, including, but not limited to, all of the
15following:

16(1) Health care consumers who are enrolled in health plans.

17(2) Individuals and entities with experience in facilitating
18enrollment in health plans.

19(3) The executive director of the Exchange.

20(4) The State Medi-Cal Director.

21(5) Advocates for enrolling hard-to-reach populations.

22(u) Facilitate the purchase of qualified health plans in the
23program by qualified individuals no later than January 1, 2016.

24(v) Require carriers participating in the program to immediately
25notify the program, under the terms and conditions established by
26the board when an individual is or will be enrolled in or disenrolled
27from any qualified health plan offered by the carrier.

28(w) Ensure that the program provides oral interpretation services
29in any language for individuals seeking coverage through the
30program and makes available a toll-free telephone number for the
31hearing and speech impaired. The board shall ensure that written
32information made available by the program is presented in a plainly
33worded, easily understandable format and made available in
34prevalent languages.

35

100534.  

(a) The board may do the following:

36(1) Collect premiums.

37(2) Enter into contracts.

38(3) Sue and be sued.

P13   1(4) Receive and accept gifts, grants, or donations of moneys
2from any agency of the United States, any agency of the state, or
3any municipality, county, or other political subdivision of the state.

4(5) Receive and accept gifts, grants, or donations from
5individuals, associations, private foundations, or corporations, in
6compliance with the conflict-of-interest provisions to be adopted
7 by the board at a public meeting.

8(6) Adopt rules and regulations, as necessary. Until January 1,
92018, any necessary rules and regulations may be adopted as
10emergency regulations in accordance with the Administrative
11Procedure Act (Chapter 3.5 (commencing with Section 11340) of
12Part 1 of Division 3 of Title 2). The adoption of these regulations
13shall be deemed to be an emergency and necessary for the
14immediate preservation of the public peace, health and safety, or
15general welfare.

16(7) Collaborate with the Exchange and the State Department of
17Health Care Services, to the extent possible, to allow an individual
18the option to remain enrolled with his or her carrier and provider
19network in the event the individual experiences a loss of eligibility
20for enrollment in a qualified health plan under this title and
21becomes eligible for the Exchange or the Medi-Cal program, or
22loses eligibility for the Medi-Cal program and becomes eligible
23for a qualified health plan through the program.

24(8) Share information with relevant state departments, consistent
25with the applicable laws governing confidentiality, necessary for
26the administration of the program.

27(9) Require carriers participating in the program to make
28available to the program and regularly update an electronic
29directory of contracting health care providers so that individuals
30seeking coverage through the program can search by health care
31provider name to determine which health plans in the program
32include that health care provider in their network. The board may
33also require a carrier to provide regularly updated information to
34the program as to whether a health care provider is accepting new
35patients for a particular health plan. The program may provide an
36integrated and uniform consumer directory of health care providers
37indicating which carriers the providers contract with and whether
38the providers are currently accepting new patients. The program
39may also establish methods by which health care providers may
P14   1transmit relevant information directly to the program, rather than
2through a carrier.

3(10) Make available supplemental coverage for enrollees of the
4program to the extent permitted by available funding. Any
5supplemental coverage offered in the program shall be subject to
6the charge imposed under subdivision (n) of Section 100533.

7(b) (1) An applicant for health care coverage shall be required
8to provide only the information strictly necessary to authenticate
9identity, determine eligibility, and determine the amount of the
10credit or reduction.

11(2) Any person who receives information provided by an
12applicant pursuant to paragraph (1), whether directly or by another
13person at the request of the applicant, or otherwise obtains
14information about the applicant through the program process shall
15do both of the following:

16(A) Use the information only for the purposes of, and to the
17extent necessary in, ensuring the efficient operation of the program,
18including verifying the eligibility of an individual to enroll through
19the program.

20(B) Not disclose the information to any other person except as
21provided in this section.

22(c) The board shall have the authority to standardize products
23to be offered through the program.

24

100535.  

The board shall establish and use a competitive process
25to select participating carriers and any other contractors under this
26title. Any contract entered into pursuant to this title shall be exempt
27from Chapter 1 (commencing with Section 10100) of Part 2 of
28Division 2 of the Public Contract Code, and shall be exempt from
29the review or approval of any division of the Department of General
30Services.

31

100536.  

(a) The board shall establish an appeals process for
32prospective and current enrollees of the program.

33(b) The board shall not be required to provide an appeal if the
34subject of the appeal is within the jurisdiction of the Department
35of Managed Health Care pursuant to the Knox-Keene Health Care
36Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
371340) of Division 2 of the Health and Safety Code) and its
38implementing regulations, or within the jurisdiction of the
39Department of Insurance pursuant to the Insurance Code and its
40implementing regulations.

P15   1

100537.  

(a) Notwithstanding any other law, the program shall
2not be subject to licensure or regulation by the Department of
3Insurance or the Department of Managed Health Care.

4(b) Carriers that contract with the program shall have a license
5or certificate of authority from, and shall be in good standing with,
6their respective regulatory agencies.

7

100538.  

(a) Records of the program that reveal the deliberative
8processes, discussions, communications, or any other portion of
9the negotiations with entities contracting or seeking to contract
10with the program, entities with which the program is considering
11a contract, or entities with which the program is considering or
12enters into any other arrangement under which the program
13provides, receives, or arranges services or reimbursement shall be
14exempt from disclosure under the California Public Records Act
15(Chapter 3.5 (commencing with Section 6250) of Division 7 of
16Title 1).

17(b) The following records of the program shall be exempt from
18disclosure under the California Public Records Act (Chapter 3.5
19(commencing with Section 6250) of Division 7 of Title 1) as
20follows:

21(1) (A) Except for the portion of a contract that contains the
22rates of payments, contracts with participating carriers entered into
23pursuant to this title on or after the date the act that added this
24subparagraph becomes effective, shall be open to inspection one
25year after the effective dates of the contracts.

26(B) If contracts with participating carriers entered into pursuant
27to this title are amended, the amendments shall be open to
28inspection one year after the effective date of the amendments.

29(c) Three years after a contract or amendment is open to
30inspection pursuant to subdivision (b), the portion of the contract
31or amendment containing the rates of payment shall be open to
32inspection.

33(d) Notwithstanding any other law, entire contracts with
34participating carriers or amendments to contracts with participating
35carriers shall be open to inspection by the Joint Legislative Audit
36Committee. The committee shall maintain the confidentiality of
37the contracts and amendments until the contracts or amendments
38to a contract are open to inspection pursuant to subdivisions (b)
39and (c).

P16   1

100539.  

(a) No individual or entity shall hold himself, herself,
2or itself out as representing, constituting, or otherwise providing
3services on behalf of the program unless that individual or entity
4has a valid agreement with the program to engage in those
5activities.

6(b) Any individual or entity who aids or abets another individual
7or entity in violation of this section shall also be in violation of
8this section.

9

100540.  

(a) The California Health Trust Fund For All
10Californians is hereby created in the State Treasury for the purpose
11of this title. Notwithstanding Section 13340, all moneys in the
12fund shall be continuously appropriated without regard to fiscal
13year for the purposes of this title. Any moneys in the fund that are
14unexpended or unencumbered at the end of a fiscal year may be
15carried forward to the next succeeding fiscal year.

16(b) The board of the program shall establish and maintain a
17prudent reserve in the fund.

18(c) The board or staff of the program shall not utilize any funds
19intended for the administrative and operational expenses of the
20program for staff retreats, promotional giveaways, excessive
21executive compensation, or promotion of federal or state legislative
22or regulatory modifications.

23(d) Notwithstanding Section 16305.7, all interest earned on the
24moneys that have been deposited into the fund shall be retained
25in the fund and used for purposes consistent with the fund.

26(e) Effective January 1, 2018, if at the end of any fiscal year,
27the fund has unencumbered funds in an amount that equals or is
28more than the board approved operating budget of the program
29for the next fiscal year, the board shall reduce the charges imposed
30under subdivision (n) of Section 100533 during the following fiscal
31year in an amount that will reduce any surplus funds of the program
32to an amount that is equal to the agency’s operating budget for the
33next fiscal year.

34

100541.  

(a) The board shall ensure that the establishment,
35operation, and administrative functions of the program do not
36exceed the combination of state funds, private donations, and other
37non-General Fund moneys available for this purpose.

38(b) The implementation of the provisions of this title, other than
39this section, Section 100530, and paragraphs (4) and (5) of
40subdivision (a) of Section 100534, shall be contingent on a
P17   1determination by the board that sufficient financial resources exist
2or will exist in the fund.

3(c) If the board determines that the level of resources in the fund
4cannot support the actions and responsibilities described in
5subdivision (a), it shall provide the Department of Finance and the
6Joint Legislative Budget Committee a detailed report on the
7changes to the functions, contracts, or staffing necessary to address
8the fiscal deficiency along with any contingency plan should it be
9impossible to operate the program without the use of General Fund
10moneys.

11(d) The board shall assess the impact of the program’s operations
12and policies on other publicly funded health programs administered
13by the state and the impact of publicly funded health programs
14administered by the state on the program’s operations and policies.
15This assessment shall include, at a minimum, an analysis of
16potential cost shifts or cost increases in other programs that may
17be due to program policies or operations. The assessment shall be
18completed on at least an annual basis and submitted to the Secretary
19of California Health and Human Services and the Director of
20Finance.

21

SEC. 4.  

Section 1366.7 is added to the Health and Safety Code,
22to read:

23

1366.7.  

(a) For purposes of this section, the following
24definitions shall apply:

25(1) “Federal act” means the federal Patient Protection and
26Affordable Care Act (Public Law 111-148), as amended by the
27federal Health Care and Education Reconciliation Act of 2010
28(Public Law 111-152), and any amendments to, or regulations or
29guidance issued under, those acts.

30(2) “Health plan” has the same meaning as that term is defined
31in subdivision (g) of Section 100530 of the Government Code.

32(3) “Program” means the California Health Exchange Program
33For All Californians established in Title 22.5 (commencing with
34Section 100530) of the Government Code.

35(b) Health care service plans participating in the program shall
36fairly and affirmatively offer, market, and sell in the program at
37least one product within each of the five levels of coverage
38contained in Section 1302(d) and (e) of the federal act. The
39executive board established under Section 100530 of the
40Government Code may require plans to sell additional products
P18   1within each of those levels of coverage. This subdivision shall not
2apply to a plan that solely offers supplemental coverage in the
3program under paragraph (10) of subdivision (a) of Section 100534
4of the Government Code.

5(c) (1) Health care service plans participating in the program
6that sell any products outside the program shall fairly and
7affirmatively offer, market, and sell all products made available
8to individuals in the program to individuals purchasing coverage
9 outside the program.

10(2) For purposes of this subdivision, “product” does not include
11contracts entered into pursuant to Chapter 8 (commencing with
12Section 14200) of Part 3 of Division 9 of the Welfare and
13Institutions Code between the State Department of Health Care
14Services and health care service plans for enrolled Medi-Cal
15beneficiaries.

16(d) Commencing January 1, 2015, a health care service plan
17shall, with respect to plan contracts that cover hospital, medical,
18or surgical benefits, only sell the five levels of coverage contained
19in Section 1302(d) and (e) of the federal act, except that a health
20care service plan that does not participate in the program shall,
21with respect to plan contracts that cover hospital, medical, or
22surgical benefits, only sell the four levels of coverage contained
23in Section 1302(d) of the federal act.

24(e) Commencing January 1, 2015, a health care service plan
25that does not participate in the program shall, with respect to plan
26contracts that cover hospital, medical, or surgical benefits, offer
27at least one standardized product that has been designated by the
28program in each of the four levels of coverage contained in Section
291302(d) of the federal act. This subdivision shall only apply if the
30executive board of the program exercises its authority under
31subdivision (c) of Section 100534 of the Government Code.
32Nothing in this subdivision shall require a plan that does not
33participate in the program to offer standardized products in the
34small employer market if the plan only sells products in the
35individual market. Nothing in this subdivision shall require a plan
36that does not participate in the program to offer standardized
37products in the individual market if the plan only sells products in
38the small employer market. This subdivision shall not be construed
39to prohibit the plan from offering other products provided that it
40complies with subdivision (d).

P19   1(f) A health care service plan participating in the program shall
2charge the same rate for the same product whether that product is
3offered through the program or in the outside market
4notwithstanding any charge imposed by the program pursuant to
5subdivision (n) of Section 100533 of the Government Code.

6(g) This section shall become operative only if Title 22.5
7(commencing with Section 100530) of the Government Code
8becomes operative on or before January 1, 2017. If this section
9does not become operative by January 1, 2017, as of that date, this
10section is repealed, unless a later enacted statute, that is enacted
11before January 1, 2017, deletes or extends that date.

12

SEC. 5.  

Section 10112.31 is added to the Insurance Code, to
13read:

14

10112.31.  

(a) For purposes of this section, the following
15definitions shall apply:

16(1) “Federal act” means the federal Patient Protection and
17Affordable Care Act (Public Law 111-148), as amended by the
18federal Health Care and Education Reconciliation Act of 2010
19(Public Law 111-152), and any amendments to, or regulations or
20guidance issued under, those acts.

21(2) “Health plan” has the same meaning as that term is defined
22in subdivision (g) of Section 100530 of the Government Code.

23(3) “Program” means the California Health Exchange Program
24For All Californians established in Title 22.5 (commencing with
25Section 100530) of the Government Code.

26(b) Health insurers participating in the program shall fairly and
27affirmatively offer, market, and sell in the program at least one
28product within each of the five levels of coverage contained in
29Section 1302(d) and (e) of the federal act. The executive board
30established under Section 100530 of the Government Code may
31require insurers to sell additional products within each of those
32levels of coverage. This subdivision shall not apply to an insurer
33that solely offers supplemental coverage in the program under
34paragraph (10) of subdivision (a) of Section 100534 of the
35Government Code.

36(c) (1) Health insurers participating in the program that sell any
37products outside the program shall fairly and affirmatively offer,
38market, and sell all products made available to individuals in the
39program to individuals purchasing coverage outside the program.

P20   1(2) For purposes of this subdivision, “product” does not include
2contracts entered into pursuant to Chapter 8 (commencing with
3Section 14200) of Part 3 of Division 9 of the Welfare and
4Institutions Code between the State Department of Health Care
5Services and health insurers for enrolled Medi-Cal beneficiaries.

6(d) Commencing January 1, 2015, an insurer shall, with respect
7to policies that cover hospital, medical, or surgical benefits, only
8sell the five levels of coverage contained in Section 1302(d) and
9(e) of the federal act, except that an insurer that does not participate
10in the program shall, with respect to policies that cover hospital,
11medical, or surgical benefits, only sell the four levels of coverage
12contained in Section 1302(d) of the federal act.

13(e) Commencing January 1, 2015, an insurer that does not
14participate in the program shall, with respect to policies that cover
15hospital, medical, or surgical benefits, offer at least one
16standardized product that has been designated by the program in
17each of the four levels of coverage contained in Section 1302(d)
18of the federal act. This subdivision shall only apply if the board
19of the program exercises its authority under subdivision (c) of
20Section 100534 of the Government Code. Nothing in this
21subdivision shall require an insurer that does not participate in the
22program to offer standardized products in the small employer
23market if the insurer only sells products in the individual market.
24Nothing in this subdivision shall require an insurer that does not
25participate in the program to offer standardized products in the
26individual market if the insurer only sells products in the small
27employer market. This subdivision shall not be construed to
28prohibit the insurer from offering other products provided that it
29complies with subdivision (d).

30(f) An insurer participating in the program shall charge the same
31rate for the same product whether that product is offered through
32the program or in the outside market notwithstanding any charge
33imposed by the program pursuant to subdivision (n) of Section
34100533 of the Government Code.

35(g) This section shall become operative only if Title 22.5
36(commencing with Section 100530) of the Government Code
37becomes operative on or before January 1, 2017. If this section
38does not become operative by January 1, 2017, as of that date, this
39section is repealed, unless a later enacted statute, that is enacted
40before January 1, 2017, deletes or extends that date.

end delete
P21   1

begin deleteSEC. 6.end delete
2begin insertSEC. 3.end insert  

Section 14102.1 is added to the Welfare and Institutions
3Code
, to read:

begin delete
4

14102.1.  

(a) Notwithstanding any other law, individuals who
5meet all of the eligibility requirements for full-scope Medi-Cal
6benefits under this chapter, but for their immigration status, shall
7be eligible for full-scope Medi-Cal benefits.

end delete
8begin insert

begin insert14102.1.end insert  

end insert
begin insert

(a) (1) Notwithstanding any other law, an individual
9under 19 years of age who meets all of the eligibility requirements
10for full-scope Medi-Cal benefits under this chapter, but for his or
11her immigration status, shall be eligible for full-scope Medi-Cal
12benefits.

end insert
begin insert

13(2) Notwithstanding any other law, an individual 19 years of
14age or older who meets all of the eligibility requirements for
15full-scope Medi-Cal benefits under this chapter, but for his or her
16immigration status, may be enrolled for full-scope Medi-Cal
17benefits, pursuant to paragraph (3).

end insert
begin insert

18(3) When a county completes the Medi-Cal eligibility
19determination process for an individual 19 years of age or older
20who meets all of the eligibility requirements for full-scope
21Medi-Cal benefits under this chapter, but for his or her
22immigration status, the county shall transmit this information to
23the department to determine if sufficient funding is available for
24this individual to receive full-scope Medi-Cal benefits. If sufficient
25funding is available, the individual shall be eligible for full-scope
26benefits. If sufficient funding is not available, the individual shall
27be eligible for limited scope Medi-Cal benefits.

end insert

28(b) This section shall not apply to individuals eligible for
29coverage pursuant to Section 14102.

30(c) Individuals who are eligible under subdivision (a) shall be
31required to enroll into Medi-Cal managed care health plans to the
32extent required of otherwise eligible Medi-Cal recipients who are
33similarly situated.

34(d) Individuals who are eligible under subdivision (a) shall pay
35copayments and premium contributions to the extent required of
36otherwise eligible Medi-Cal recipients who are similarly situated.

37(e) Benefits for services under this section shall be provided
38with state-only funds only if federal financial participation is not
39available for those services. The department shall maximize federal
P22   1financial participation in implementing this section to the extent
2allowable.

begin insert

3(f) Eligibility for full-scope benefits for an individual 19 years
4of age or older pursuant to subdivision (a) shall not be an
5entitlement. The department shall have the authority to determine
6eligibility, determine the number of individuals who may be
7enrolled, establish limits on the number enrolled, and establish
8processes for waiting lists needed to maintain program
9expenditures within available funds.

end insert
begin delete

10(f)

end delete

11begin insert(g)end insert Notwithstanding Chapter 3.5 (commencing with Section
1211340) of Part 1 of Division 3 of Title 2 of the Government Code,
13the department, without taking any further regulatory action, shall
14implement, interpret, or make specific this section by means of
15all-county letters, plan letters, plan or provider bulletins, or similar
16instructions until the time regulations are adopted. The department
17shall adopt regulations by July 1, 2018, in accordance with the
18requirements of Chapter 3.5 (commencing with Section 11340) of
19Part 1 of Division 3 of Title 2 of the Government Code.
20Commencing July 1, 2016, and notwithstanding Section 10231.5
21of the Government Code, the department shall provide a status
22report to the Legislature on a semiannual basis, in compliance with
23Section 9795 of the Government Code, until regulations have been
24adopted pursuant to Section 14102.2.

25

begin deleteSEC. 7.end delete
26begin insertSEC. 4.end insert  

Section 14102.2 is added to the Welfare and Institutions
27Code
, to read:

28

14102.2.  

(a) (1) Except as provided in subdivision (c),
29individualsbegin insert under 19 years of ageend insert who are enrolled in restricted
30scope Medi-Cal as of December 31, 2015,begin insert andend insert who are eligible
31under Sectionbegin delete 14102.1end deletebegin insert 14102.1,end insert shall be transitioned directly to
32full-scope coverage under the Medi-Cal program in accordance
33with the requirements of this section. The department shall develop
34a transition plan for thosebegin delete currently enrolledend deletebegin insert individuals under 19
35years of age who are enrolledend insert
in restricted scopebegin delete Medi-Cal.end delete
36begin insert Medi-Cal as of the effective date of the act adding this section.end insert

37(2) For purposes of this section, an “emergency care provider”
38is defined as a hospital in the county ofbegin delete his or herend deletebegin insert the individual’send insert
39 residence wherebegin delete the individualend deletebegin insert he or sheend insert received emergency care,
40if any.

P23   1(b) Except as provided in subdivision (c), with respect to
2managed care health plan enrollment, a restricted-scope enrollee
3whobegin insert is under 19 years of age and whoend insert applies and is determined
4eligible before October 1, 2015, shall be notified by the department
5at least 60 days before January 1, 2016, in accordance with the
6department’s transition plan of all of the following:

7(1) Which Medi-Cal managed care health plan or plans contain
8his or her existing emergency care provider, if the department has
9this information and the emergency care provider is contracted
10with a Medi-Cal managed care health plan.

11(2) That the restricted scope enrolleebegin insert who is under 19 years of
12ageend insert
, subject to his or her ability to change as described in paragraph
13(3), will be assigned to a health plan that includes his or her
14emergency care provider and enrolled effective January 1, 2014.
15If the enrolleebegin insert who is under 19 years of ageend insert wants to keep his or
16her emergency care provider, no additional action shall be required
17if the emergency care provider is contracted with a Medi-Cal
18managed care health plan.

19(3) That the restricted scope enrolleebegin insert who is under 19 years of
20ageend insert
may choose any available Medi-Cal managed care health plan
21and primary care provider in his or her county of residence before
22January 1, 2016, if more than one such plan is available in the
23county where he or she resides, and he or she will receive all
24provider and health plan information required to be sent to new
25enrollees and instructions on how to choose or change his or her
26health plan and primary care provider.

27(4) That in counties with more than one Medi-Cal managed care
28health plan, if the restricted scope enrolleebegin insert who is under 19 years
29of ageend insert
does not affirmatively choose a plan within 30 days of
30receipt of the notice, he or she shall be enrolled into the Medi-Cal
31managed care health plan that contains his or her emergency care
32provider as part of the Medi-Cal managed care contracted network,
33if the department has this information about the emergency care
34provider, and the emergency care provider is contracted with a
35Medi-Cal managed care health plan. If the emergency care provider
36is contracted with more than one Medi-Cal managed care health
37plan, then the restricted scope enrolleebegin insert who is under 19 years of
38ageend insert
shall be assigned to one of the health plans containing his or
39her emergency care provider in accordance with an assignment
40process established to ensure the linkage.

P24   1(5) That the enrolleebegin delete subject to this sectionend deletebegin insert who is under 19
2years of ageend insert
shall receive all provider and health plan information
3required to be sent to new enrollees. If the restricted scope enrollee
4begin insert who is under 19 years of ageend insert is not assigned to two Medi-Cal
5managed care health plans pursuant to paragraph (2), and does not
6affirmatively select one of the available Medi-Cal managed care
7health plans within 30 days of receipt of the notice, he or she shall
8automatically be assigned a plan through the department-prescribed
9auto-assignment process.

10(6) That the restricted scope enrolleebegin insert who is under 19 years of
11ageend insert
does not need to take any action to be transitioned to full-scope
12Medi-Cal or to retain his or her emergency care provider, if the
13emergency care provider is available pursuant to paragraph (2).

14(7) That the restricted scope enrolleebegin insert who is under 19 years of
15ageend insert
may choose not to transition to the full-scope Medi-Cal
16program, and what this choice will mean for his or her health care
17coverage and access to health care services.

18(c) Individuals whobegin insert are under 19 years of age, whoend insert qualify
19underbegin delete subdivision (a)end deletebegin insert subdivision (a),end insert and who apply and are
20determined eligible for restricted scope after the date identified by
21the department,begin delete thatend deletebegin insert whichend insert is not later than October 1, 2015, shall
22be considered late enrollees. Late enrollees shall be notified in
23accordance with subdivision (b), except according to a different
24timeframe, but will transition to full-scope Medi-Cal coverage on
25January 1, 2016. Late enrollees after the date identified in this
26subdivision shall be transitioned pursuant to the department’s
27restricted scope transition plan process.

28(d) Emergency care providers that receive reimbursement for
29restricted scope coverage shall work with the department and its
30designees during the 2015 and 2016 calendar years to facilitate
31enrollment and data sharing for the purposes of delivering
32Medi-Cal services in the 2016 calendar year.

begin delete
33

SEC. 8.  

The Legislature finds and declares that Section 100538
34of the Government Code, as added by Section 3 of this act, imposes
35a limitation on the public’s right of access to the meetings of public
36bodies or the writings of public officials and agencies within the
37meaning of Section 3 of Article I of the California Constitution.
38Pursuant to that constitutional provision, the Legislature makes
39the following findings to demonstrate the interest protected by this
40limitation and the need for protecting that interest:

P25   1In order to ensure that the California Health Exchange Program
2For All Californians is not constrained in exercising its fiduciary
3powers and obligations to negotiate on behalf of the public, the
4limitations on the public’s right of access imposed by Section 3
5of this act are necessary.

end delete
6

begin deleteSEC. 9.end delete
7begin insertSEC. 5.end insert  

No reimbursement is required by this act pursuant to
8Section 6 of Article XIII B of the California Constitution for certain
9costs that may be incurred by a local agency or school district
10because, in that regard, this act creates a new crime or infraction,
11eliminates a crime or infraction, or changes the penalty for a crime
12or infraction, within the meaning of Section 17556 of the
13Government Code, or changes the definition of a crime within the
14meaning of Section 6 of Article XIII B of the California
15Constitution.

16However, if the Commission on State Mandates determines that
17this act contains other costs mandated by the state, reimbursement
18to local agencies and school districts for those costs shall be made
19pursuant to Part 7 (commencing with Section 17500) of Division
204 of Title 2 of the Government Code.



O

    96