BILL NUMBER: SB 1063 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Cox
FEBRUARY 16, 2010
An act to amend Sections 12693.21 and 12693.615 of the Insurance
Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1063, as introduced, Cox. Healthy Families Program.
Existing law creates the Healthy Families Program, administered by
the Managed Risk Medical Insurance Board, to arrange for the
provision of health care services to children less than 19 years of
age who meet certain criteria, including having a limited gross
household income. Existing law requires the board to establish the
required copayment levels for specific benefits, as specified, and
prohibits the total annual copayments charged to subscribers from
exceeding $250 per family. Existing law also prohibits copayments
from exceeding the copayment level established for state employees
through the Public Employees' Retirement System.
This bill would prohibit the total annual copayments from
exceeding $350 per family and would delete the provision prohibiting
copayments from exceeding the copayment level established for state
employees through the Public Employees' Retirement System. The bill
would also require the board to structure copayments for prescription
drugs and emergency health care services in a specified manner.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 12693.21 of the Insurance Code is amended to
read:
12693.21. (a) The board may do all of the
following consistent with the standards in this part:
(a)
(1) Determine eligibility criteria for the program.
(b)
(2) Determine the participation requirements of
applicants, subscribers, purchasing credit members, and participating
health, dental, and vision plans.
(c)
(3) Determine when subscribers' coverage begins and the
extent and scope of coverage.
(d)
(4) Determine family contribution amount schedules and
collect the contributions.
(e)
(5) Determine who may be a family contribution sponsor
and provide a mechanism for sponsorship.
(f)
(6) Provide or make available subsidized coverage
through participating health, dental, and vision plans, in a
purchasing pool, which may include the use of a purchasing credit
mechanism, through supplemental coverage, or through coordination
with other state programs.
(g)
(7) Provide for the processing of applications, the
enrollment of subscribers, and the distribution of purchasing
credits.
(h)
(8) Determine and approve the benefit designs and
copayments required by health, dental, or vision plans participating
in the purchasing pool component program.
(i)
(9) Approve those health plans eligible to receive
purchasing credits.
(j)
(10) Enter into contracts.
(k)
(11) Sue and be sued.
(i)
(12) Employ necessary staff.
(m)
(13) Authorize expenditures from the fund to pay
program expenses that exceed subscriber contributions, and to
administer the program as necessary.
(n)
(14) Maintain enrollment and expenditures to ensure
that expenditures do not exceed amounts available in the Healthy
Families Fund and if sufficient funds are not available to cover the
estimated cost of program expenditures, the board shall institute
appropriate measures to limit enrollment.
(o)
(15) Issue rules and regulations, as necessary. Until
January 1, 2000, any rules and regulations issued pursuant to this
subdivision 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 of the Government
Code). The adoption of these regulations shall be deemed an emergency
and necessary for the immediate preservation of the public peace,
health, and safety or general welfare. The regulations shall become
effective immediately upon filing with the Secretary of State.
(p)
(16) Exercise all powers reasonably necessary to carry
out the powers and responsibilities expressly granted or imposed by
this part.
(b) The board shall do both of the following to the extent
consistent with the limitations of Section 2103 of Title XXI of the
federal Social Security Act (42 U.S.C. Sec. 1397cc):
(1) Structure copayments for prescription drugs so that the
copayment for a brand name drug is at least 150 percent of the
copayment for the equivalent generic drug, except where no generic
equivalent is available or where the use of the brand name drug is
medically necessary.
(2) Structure copayments for emergency health care services so
that the copayment charged for those services is at least 150 percent
of the highest copayment charged for nonpreventive health care
services. The emergency health care services copayment shall be
waived if the subscriber is hospitalized.
SEC. 2. Section 12693.615 of the Insurance Code is amended to
read:
12693.615. (a) The board shall establish the required subscriber
copayment levels for specific benefits consistent with the
limitations of Section 2103 of Title XXI of the federal
Social Security Act (42 U.S.C. Sec. 1397cc) . The
copayment levels established by the board shall, to the extent
possible, reflect the copayment levels established for state
employees, effective January 1, 1998, through the Public Employees'
Retirement System. Under no circumstances shall copayments
exceed the copayment level established for state employees,
effective, January 1, 1998, through the Public Employees' Retirement
System. Total annual copayments charged to subscribers
shall not exceed two hundred fifty dollars ($250)
three hundred fifty dollars ($350) per family. The board
shall instruct participating health plans to work with their provider
networks to provide for extended payment plans for subscribers
utilizing a significant number of health services for which
copayments are charged. The board shall track the number of
subscribers who meet the copayment maximum in each year and make
adjustments in the amount if a significant number of subscribers
reach the copayment maximum.
(b) No deductibles shall be charged to subscribers for health
benefits.
(c) Coverage provided to subscribers shall not contain any
preexisting condition exclusion requirements.
(d) No participating health, dental, or vision plan shall exclude
any subscriber on the basis of any actual or expected health
condition or claims experience of that subscriber or a member of that
subscriber's family.
(e) There shall be no variations in rates charged to subscribers
, including premiums and copayments, on the basis of any
actual or expected health condition or claims experience of any
subscriber or subscriber's family member. The only variation in rates
charged to subscribers, including copayments and premiums, that
shall be permitted is that which is expressly authorized by Section
12693.43 and subdivision (b) of Section 12693.21 .
(f) There shall be no copayments for preventive services as
defined in Section 1367.35 of the Health and Safety Code.
(g) There shall be no annual or lifetime benefit maximums in any
of the coverage provided under the program.
(h) Plans that receive purchasing credits pursuant to Section
12693.39 shall comply with subdivisions (b), (c), (d), (e), (f), and
(g).