AB 2375, as introduced, Dababneh. California Health Benefit Exchange: navigators.
Existing law establishes the California Health Benefit Exchange within the state government, specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of qualified health plans through the Exchange by qualified individuals and small employers. Existing law also requires the board to establish the navigator program, and to select and set performance standards and compensation for navigators.
This bill would require the board to ensure that the performance standards selected for navigators are not so burdensome as to prevent a qualified entity from applying.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 100503 of the Government Code, as
2amended by Section 4 of Chapter 5 of the 1st Extraordinary Session
3of the Statutes of 2013, is amended to read:
In addition to meeting the minimum requirements of
2Section 1311 of the federal act, the board shall do all of the
3following:
4(a) Determine the criteria and process for eligibility, enrollment,
5and disenrollment of enrollees and potential enrollees in the
6Exchange and coordinate that process with the state and local
7government entities administering other health care coverage
8programs, including the State Department of Health Care Services,
9the Managed Risk Medical Insurance Board, and California
10counties, in order to ensure consistent eligibility and enrollment
11processes and seamless transitions between coverage.
12(b) Develop processes to coordinate with the county entities
13that administer eligibility for the Medi-Cal
program and the entity
14that determines eligibility for the Healthy Families Program,
15including, but not limited to, processes for case transfer, referral,
16and enrollment in the Exchange of individuals applying for
17assistance to those entities, if allowed or required by federal law.
18(c) Determine the minimum requirements a carrier must meet
19to be considered for participation in the Exchange, and the
20standards and criteria for selecting qualified health plans to be
21offered through the Exchange that are in the best interests of
22qualified individuals and qualified small employers. The board
23shall consistently and uniformly apply these requirements,
24standards, and criteria to all carriers. In the course of selectively
25contracting for health care coverage offered to qualified individuals
26and qualified small employers through the Exchange, the board
27shall seek to contract with carriers so as to provide health care
28coverage choices that offer the
optimal combination of choice,
29value, quality, and service.
30(d) Provide, in each region of the state, a choice of qualified
31health plans at each of the five levels of coverage contained in
32subsections (d) and (e) of Section 1302 of the federal act.
33(e) Require, as a condition of participation in the Exchange,
34carriers to fairly and affirmatively offer, market, and sell in the
35Exchange at least one product within each of the five levels of
36coverage contained in subsections (d) and (e) of Section 1302 of
37the federal act. The board may require carriers to offer additional
38products within each of those five levels of coverage. This
39subdivision shall not apply to a carrier that solely offers
P3 1supplemental coverage in the Exchange under paragraph (10) of
2subdivision (a) of Section 100504.
3(f) (1) Except as otherwise provided in this section and Section
4100504.5, require, as a condition of participation in the Exchange,
5carriers that sell any products outside the Exchange to do both of
6the following:
7(A) Fairly and affirmatively offer, market, and sell all products
8made available to individuals in the Exchange to individuals
9purchasing coverage outside the Exchange.
10(B) Fairly and affirmatively offer, market, and sell all products
11made available to small employers in the Exchange to small
12employers purchasing coverage outside the Exchange.
13(2) For purposes of this subdivision, “product” does not include
14contracts entered into pursuant to Part 6.2 (commencing with
15Section 12693) of Division 2 of the Insurance Code between the
16Managed Risk Medical Insurance Board and carriers for enrolled
17
Healthy Families beneficiaries or contracts entered into pursuant
18to Chapter 7 (commencing with Section 14000) of, or Chapter 8
19(commencing with Section 14200) of, Part 3 of Division 9 of the
20Welfare and Institutions Code between the State Department of
21Health Care Services and carriers for enrolled Medi-Cal
22beneficiaries. “Product” also does not include a bridge plan product
23offered pursuant to Section 100504.5.
24(3) Except as required by Section 1301(a)(1)(C)(ii) of the federal
25act, a carrier offering a bridge plan product in the Exchange may
26limit the products it offers in the Exchange solely to a bridge plan
27product contract.
28(g) Determine when an enrollee’s coverage commences and the
29extent and scope of coverage.
30(h) Provide for the processing of applications and the enrollment
31and disenrollment of enrollees.
32(i) Determine and approve cost-sharing provisions for qualified
33health plans.
34(j) Establish uniform billing and payment policies for qualified
35health plans offered in the Exchange to ensure consistent
36enrollment and disenrollment activities for individuals enrolled in
37the Exchange.
38(k) Undertake activities necessary to market and publicize the
39availability of health care coverage and federal subsidies through
40the Exchange. The board shall also undertake outreach and
P4 1enrollment activities that seek to assist enrollees and potential
2enrollees with enrolling and reenrolling in the Exchange in the
3least burdensome manner, including populations that may
4experience barriers to enrollment, such as the disabled and those
5with limited English language proficiency.
6(l) Select and set performance standards and compensation for
7navigators selected under subdivision (l) of Section 100502.begin insert When
8selecting and setting performance standards, the board shall ensure
9the standards are not so burdensome as to prevent a qualified
10entity from applying to be a navigator.end insert
11(m) Employ necessary staff.
12(1) The board shall hire a chief fiscal officer, a chief operations
13officer, a director for the SHOP Exchange, a director of Health
14Plan Contracting, a chief technology and information officer, a
15general counsel, and other key executive positions, as determined
16by the board, who shall be exempt from civil service.
17(2) (A) The board shall set the salaries
for the exempt positions
18described in paragraph (1) and subdivision (i) of Section 100500
19in amounts that are reasonably necessary to attract and retain
20individuals of superior qualifications. The salaries shall be
21published by the board in the board’s annual budget. The board’s
22annual budget shall be posted on the Internet Web site of the
23Exchange. To determine the compensation for these positions, the
24board shall cause to be conducted, through the use of independent
25outside advisors, salary surveys of both of the following:
26(i) Other state and federal health insurance exchanges that are
27most comparable to the Exchange.
28(ii) Other relevant labor pools.
29(B) The salaries established by the board under subparagraph
30(A) shall not exceed the highest comparable salary for a position
31of that type, as determined by the
surveys conducted pursuant to
32subparagraph (A).
33(C) The Department of Human Resources shall review the
34methodology used in the surveys conducted pursuant to
35subparagraph (A).
36(3) The positions described in paragraph (1) and subdivision (i)
37of Section 100500 shall not be subject to otherwise applicable
38provisions of the Government Code or the Public Contract Code
39and, for those purposes, the Exchange shall not be considered a
40state agency or public entity.
P5 1(n) Assess a charge on the qualified health plans offered by
2carriers that is reasonable and necessary to support the
3development, operations, and prudent cash management of the
4Exchange. This charge shall not affect the requirement under
5Section 1301 of the federal act that carriers charge the same
6premium rate for each qualified health plan whether offered inside
7
or outside the Exchange.
8(o) Authorize expenditures, as necessary, from the California
9Health Trust Fund to pay program expenses to administer the
10Exchange.
11(p) Keep an accurate accounting of all activities, receipts, and
12expenditures, and annually submit to the United States Secretary
13of Health and Human Services a report concerning that accounting.
14Commencing January 1, 2016, the board shall conduct an annual
15audit.
16(q) (1) Annually prepare a written report on the implementation
17and performance of the Exchange functions during the preceding
18fiscal year, including, at a minimum, the manner in which funds
19were expended and the progress toward, and the achievement of,
20the requirements of this title. The report shall also include data
21provided by health care service plans and health insurers
offering
22bridge plan products regarding the extent of health care provider
23and health facility overlap in their Medi-Cal networks as compared
24to the health care provider and health facility networks contracting
25with the plan or insurer in their bridge plan contracts. This report
26shall be transmitted to the Legislature and the Governor and shall
27be made available to the public on the Internet Web site of the
28Exchange. A report made to the Legislature pursuant to this
29subdivision shall be submitted pursuant to Section 9795.
30(2) The Exchange shall prepare, or contract for the preparation
31of, an evaluation of the bridge plan program using the first three
32years of experience with the program. The evaluation shall be
33provided to the health policy and fiscal committees of the
34Legislature in the fourth year following federal approval of the
35bridge plan option. The evaluation shall include, but not be limited
36to, all of the following:
37(A) The number of individuals eligible to participate in the
38bridge plan program each year by category of eligibility.
39(B) The number of eligible individuals who elect a bridge plan
40option each year by category of eligibility.
P6 1(C) The average length of time, by region and statewide, that
2individuals remain in the bridge plan option each year by category
3of eligibility.
4(D) The regions of the state with a bridge plan option, and the
5carriers in each region that offer a bridge plan, by year.
6(E) The premium difference each year, by region, between the
7bridge plan and the first and second lowest cost plan for individuals
8in the Exchange who are not eligible for the bridge plan.
9(F) The effect of the bridge plan on the premium subsidy amount
10for bridge plan eligible individuals each year by each region.
11(G) Based on a survey of individuals enrolled in the bridge plan:
12(i) Whether individuals enrolling in the bridge plan product are
13able to keep their existing health care providers.
14(ii) Whether individuals would want to retain their bridge plan
15product, buy a different Exchange product, or decline to purchase
16health insurance if there was no bridge plan product available. The
17Exchange may include questions designed to elicit the information
18in this subparagraph as part of an existing survey of individuals
19receiving coverage in the Exchange.
20(3) In addition to the
evaluation required by paragraph (2), the
21Exchange shall post the items in subparagraphs (A) to (F),
22inclusive, on its Internet Web site each year.
23(4) In addition to the report described in paragraph (1), the board
24shall be responsive to requests for additional information from the
25Legislature, including providing testimony and commenting on
26proposed state legislation or policy issues. The Legislature finds
27and declares that activities including, but not limited to, responding
28to legislative or executive inquiries, tracking and commenting on
29legislation and regulatory activities, and preparing reports on the
30implementation of this title and the performance of the Exchange,
31are necessary state requirements and are distinct from the
32promotion of legislative or regulatory modifications referred to in
33subdivision (d) of Section 100520.
34(r) Maintain enrollment and expenditures to
ensure that
35expenditures do not exceed the amount of revenue in the fund, and
36if sufficient revenue is not available to pay estimated expenditures,
37institute appropriate measures to ensure fiscal solvency.
38(s) Exercise all powers reasonably necessary to carry out and
39comply with the duties, responsibilities, and requirements of this
40act and the federal act.
P7 1(t) Consult with stakeholders relevant to carrying out the
2activities under this title, including, but not limited to, all of the
3following:
4(1) Health care consumers who are enrolled in health plans.
5(2) Individuals and entities with experience in facilitating
6enrollment in health plans.
7(3) Representatives of small businesses and
self-employed
8individuals.
9(4) The State Medi-Cal Director.
10(5) Advocates for enrolling hard-to-reach populations.
11(u) Facilitate the purchase of qualified health plans in the
12Exchange by qualified individuals and qualified small employers
13no later than January 1, 2014.
14(v) Report, or contract with an independent entity to report, to
15the Legislature by December 1, 2018, on whether to adopt the
16option in Section 1312(c)(3) of the federal act to merge the
17individual and small employer markets. In its report, the board
18shall provide information, based on at least two years of data from
19the Exchange, on the potential impact on rates paid by individuals
20and by small employers in a merged individual and small employer
21market, as compared to the rates paid by
individuals and small
22employers if a separate individual and small employer market is
23maintained. A report made pursuant to this subdivision shall be
24submitted pursuant to Section 9795.
25(w) With respect to the SHOP Program, collect premiums and
26administer all other necessary and related tasks, including, but not
27limited to, enrollment and plan payment, in order to make the
28offering of employee plan choice as simple as possible for qualified
29small employers.
30(x) Require carriers participating in the Exchange to immediately
31notify the Exchange, under the terms and conditions established
32by the board when an individual is or will be enrolled in or
33disenrolled from any qualified health plan offered by the carrier.
34(y) Ensure that the Exchange provides oral interpretation
35services in any language for individuals seeking
coverage through
36the Exchange and makes available a toll-free telephone number
37for the hearing and speech impaired. The board shall ensure that
38written information made available by the Exchange is presented
39in a plainly worded, easily understandable format and made
40available in prevalent languages.
P8 1(z) This section shall become inoperative on the October 1 that
2is five years after the date that federal approval of the bridge plan
3option occurs, and, as of the second January 1 thereafter, is
4repealed, unless a later enacted statute that is enacted before that
5date deletes or extends the dates on which it becomes inoperative
6and is repealed.
Section 100503 of the Government Code, as added by
8Section 5 of Chapter 5 of the 1st Extraordinary Session of the
9Statutes of 2013, is amended to read:
In addition to meeting the minimum requirements of
11Section 1311 of the federal act, the board shall do all of the
12following:
13(a) Determine the criteria and process for eligibility, enrollment,
14and disenrollment of enrollees and potential enrollees in the
15Exchange and coordinate that process with the state and local
16government entities administering other health care coverage
17programs, including the State Department of Health Care Services,
18the Managed Risk Medical Insurance Board, and California
19counties, in order to ensure consistent eligibility and enrollment
20processes and seamless transitions between coverage.
21(b) Develop processes to coordinate with the county entities
22that administer eligibility for the Medi-Cal
program and the entity
23that determines eligibility for the Healthy Families Program,
24including, but not limited to, processes for case transfer, referral,
25and enrollment in the Exchange of individuals applying for
26assistance to those entities, if allowed or required by federal law.
27(c) Determine the minimum requirements a carrier must meet
28to be considered for participation in the Exchange, and the
29standards and criteria for selecting qualified health plans to be
30offered through the Exchange that are in the best interests of
31qualified individuals and qualified small employers. The board
32shall consistently and uniformly apply these requirements,
33standards, and criteria to all carriers. In the course of selectively
34contracting for health care coverage offered to qualified individuals
35and qualified small employers through the Exchange, the board
36shall seek to contract with carriers so as to provide health care
37coverage choices that offer the
optimal combination of choice,
38value, quality, and service.
P9 1(d) Provide, in each region of the state, a choice of qualified
2health plans at each of the five levels of coverage contained in
3subsections (d) and (e) of Section 1302 of the federal act.
4(e) Require, as a condition of participation in the Exchange,
5carriers to fairly and affirmatively offer, market, and sell in the
6Exchange at least one product within each of the five levels of
7coverage contained in subsections (d) and (e) of Section 1302 of
8the federal act. The board may require carriers to offer additional
9products within each of those five levels of coverage. This
10subdivision shall not apply to a carrier that solely offers
11supplemental coverage in the Exchange under paragraph (10) of
12subdivision (a) of Section 100504.
13(f) (1) Require, as a condition of participation in the Exchange,
14carriers that sell any products outside the Exchange to do both of
15the following:
16(A) Fairly and affirmatively offer, market, and sell all products
17made available to individuals in the Exchange to individuals
18purchasing coverage outside the Exchange.
19(B) Fairly and affirmatively offer, market, and sell all products
20made available to small employers in the Exchange to small
21employers purchasing coverage outside the Exchange.
22(2) For purposes of this subdivision, “product” does not include
23contracts entered into pursuant to Part 6.2 (commencing with
24Section 12693) of Division 2 of the Insurance Code between the
25Managed Risk Medical Insurance Board and carriers for enrolled
26Healthy Families beneficiaries or contracts entered into pursuant
27to
Chapter 7 (commencing with Section 14000) of, or Chapter 8
28(commencing with Section 14200) of, Part 3 of Division 9 of the
29Welfare and Institutions Code between the State Department of
30Health Care Services and carriers for enrolled Medi-Cal
31beneficiaries.
32(g) Determine when an enrollee’s coverage commences and the
33extent and scope of coverage.
34(h) Provide for the processing of applications and the enrollment
35and disenrollment of enrollees.
36(i) Determine and approve cost-sharing provisions for qualified
37health plans.
38(j) Establish uniform billing and payment policies for qualified
39health plans offered in the Exchange to ensure consistent
P10 1enrollment and disenrollment activities for individuals enrolled in
2the Exchange.
3(k) Undertake activities necessary to market and publicize the
4availability of health care coverage and federal subsidies through
5the Exchange. The board shall also undertake outreach and
6enrollment activities that seek to assist enrollees and potential
7enrollees with enrolling and reenrolling in the Exchange in the
8least burdensome manner, including populations that may
9experience barriers to enrollment, such as the disabled and those
10with limited English language proficiency.
11(l) Select and set performance standards and compensation for
12navigators selected under subdivision (l) of Section 100502.begin insert When
13selecting and setting performance standards, the board shall ensure
14the standards are not so burdensome as to prevent a qualified
15entity from applying to be a navigator.end insert
16(m) Employ necessary staff.
17(1) The board shall hire a chief fiscal officer, a chief operations
18officer, a director for the SHOP Exchange, a director of Health
19Plan Contracting, a chief technology and information officer, a
20general counsel, and other key executive positions, as determined
21by the board, who shall be exempt from civil service.
22(2) (A) The board shall set the salaries for the exempt positions
23described in paragraph (1) and subdivision (i) of Section 100500
24in amounts that are reasonably necessary to attract and retain
25individuals of superior qualifications. The salaries shall be
26published by the board in the board’s annual budget. The board’s
27annual budget shall be posted on the Internet Web site of the
28Exchange. To determine the compensation for these positions, the
29board shall cause
to be conducted, through the use of independent
30outside advisors, salary surveys of both of the following:
31(i) Other state and federal health insurance exchanges that are
32most comparable to the Exchange.
33(ii) Other relevant labor pools.
34(B) The salaries established by the board under subparagraph
35(A) shall not exceed the highest comparable salary for a position
36of that type, as determined by the surveys conducted pursuant to
37subparagraph (A).
38(C) The Department of Human Resources shall review the
39methodology used in the surveys conducted pursuant to
40subparagraph (A).
P11 1(3) The positions described in paragraph (1) and subdivision (i)
2of Section 100500 shall not be subject to otherwise
applicable
3provisions of the Government Code or the Public Contract Code
4and, for those purposes, the Exchange shall not be considered a
5state agency or public entity.
6(n) Assess a charge on the qualified health plans offered by
7carriers that is reasonable and necessary to support the
8development, operations, and prudent cash management of the
9Exchange. This charge shall not affect the requirement under
10Section 1301 of the federal act that carriers charge the same
11premium rate for each qualified health plan whether offered inside
12or outside the Exchange.
13(o) Authorize expenditures, as necessary, from the California
14Health Trust Fund to pay program expenses to administer the
15Exchange.
16(p) Keep an accurate accounting of all activities, receipts, and
17expenditures, and annually submit to the United States Secretary
18of
Health and Human Services a report concerning that accounting.
19Commencing January 1, 2016, the board shall conduct an annual
20audit.
21(q) (1) Annually prepare a written report on the implementation
22and performance of the Exchange functions during the preceding
23fiscal year, including, at a minimum, the manner in which funds
24were expended and the progress toward, and the achievement of,
25the requirements of this title. This report shall be transmitted to
26the Legislature and the Governor and shall be made available to
27the public on the Internet Web site of the Exchange. A report made
28to the Legislature pursuant to this subdivision shall be submitted
29pursuant to Section 9795.
30(2) In addition to the report described in paragraph (1), the board
31shall be responsive to requests for additional information from the
32Legislature, including providing testimony and commenting
on
33proposed state legislation or policy issues. The Legislature finds
34and declares that activities including, but not limited to, responding
35to legislative or executive inquiries, tracking and commenting on
36legislation and regulatory activities, and preparing reports on the
37implementation of this title and the performance of the Exchange,
38are necessary state requirements and are distinct from the
39promotion of legislative or regulatory modifications referred to in
40subdivision (d) of Section 100520.
P12 1(r) Maintain enrollment and expenditures to ensure that
2expenditures do not exceed the amount of revenue in the fund, and
3if sufficient revenue is not available to pay estimated expenditures,
4institute appropriate measures to ensure fiscal solvency.
5(s) Exercise all powers reasonably necessary to carry out and
6comply with the duties, responsibilities, and requirements of this
7act and the
federal act.
8(t) Consult with stakeholders relevant to carrying out the
9activities under this title, including, but not limited to, all of the
10following:
11(1) Health care consumers who are enrolled in health plans.
12(2) Individuals and entities with experience in facilitating
13enrollment in health plans.
14(3) Representatives of small businesses and self-employed
15individuals.
16(4) The State Medi-Cal Director.
17(5) Advocates for enrolling hard-to-reach populations.
18(u) Facilitate the purchase of qualified health plans in the
19Exchange by qualified individuals and
qualified small employers
20no later than January 1, 2014.
21(v) Report, or contract with an independent entity to report, to
22the Legislature by December 1, 2018, on whether to adopt the
23option in Section 1312(c)(3) of the federal act to merge the
24individual and small employer markets. In its report, the board
25shall provide information, based on at least two years of data from
26the Exchange, on the potential impact on rates paid by individuals
27and by small employers in a merged individual and small employer
28market, as compared to the rates paid by individuals and small
29employers if a separate individual and small employer market is
30maintained. A report made pursuant to this subdivision shall be
31submitted pursuant to Section 9795.
32(w) With respect to the SHOP Program, collect premiums and
33administer all other necessary and related tasks, including, but not
34limited to, enrollment and
plan payment, in order to make the
35offering of employee plan choice as simple as possible for qualified
36small employers.
37(x) Require carriers participating in the Exchange to immediately
38notify the Exchange, under the terms and conditions established
39by the board when an individual is or will be enrolled in or
40disenrolled from any qualified health plan offered by the carrier.
P13 1(y) Ensure that the Exchange provides oral interpretation
2services in any language for individuals seeking coverage through
3the Exchange and makes available a toll-free telephone number
4for the hearing and speech impaired. The board shall ensure that
5written information made available by the Exchange is presented
6in a plainly worded, easily understandable format and made
7available in prevalent languages.
8(z) This section shall become operative
only if Section 4 of the
9act that added this section becomes inoperative pursuant to
10subdivision (z) of that Section 4.
O
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