SB 1052, as introduced, Torres. California Health Benefit Exchange: annual report.
Existing law establishes the California Health Benefit Exchange within 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 requires the board to undertake activities necessary to market and publicize the availability of health care coverage and federal subsidies through the Exchange and to undertake outreach and enrollment activities that seek to assist with enrolling in the Exchange in the least burdensome manner. Existing law also requires the board of the Exchange to annually prepare a written report on the implementation and performance of the Exchange functions during the preceding fiscal year, as specified, and requires that this report be submitted to the Legislature and the Governor and be made available to the public on the Internet Web site of the Exchange.
This bill, in addition, would require the report to include the total number of uninsured Californians as a percentage of the state population and an independent evaluation of the marketing and outreach and enrollment activities undertaken by the Exchange.
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
5Section 1311 of the federal act, the board shall do all of the
6following:
7(a) Determine the criteria and process for eligibility, enrollment,
8and disenrollment of enrollees and potential enrollees in the
9Exchange and coordinate that process with the state and local
10government entities administering other health care coverage
11programs, including the State Department of Health Care Services,
12the Managed Risk Medical Insurance Board, and California
13counties, in order to ensure consistent eligibility and enrollment
14processes and seamless transitions between coverage.
15(b) Develop processes to coordinate with the county entities
16that administer eligibility for the Medi-Cal
program and the entity
17that determines eligibility for the Healthy Families Program,
18including, but not limited to, processes for case transfer, referral,
19and enrollment in the Exchange of individuals applying for
20assistance to those entities, if allowed or required by federal law.
21(c) Determine the minimum requirements a carrier must meet
22to be considered for participation in the Exchange, and the
23standards and criteria for selecting qualified health plans to be
24offered through the Exchange that are in the best interests of
25qualified individuals and qualified small employers. The board
26shall consistently and uniformly apply these requirements,
27standards, and criteria to all carriers. In the course of selectively
28contracting for health care coverage offered to qualified individuals
29and qualified small employers through the Exchange, the board
30shall seek to contract with carriers so as to provide health care
31coverage choices that offer the
optimal combination of choice,
32value, quality, and service.
33(d) Provide, in each region of the state, a choice of qualified
34health plans at each of the five levels of coverage contained in
35subsections (d) and (e) of Section 1302 of the federal act.
36(e) Require, as a condition of participation in the Exchange,
37carriers to fairly and affirmatively offer, market, and sell in the
38Exchange at least one product within each of the five levels of
P3 1coverage contained in subsections (d) and (e) of Section 1302 of
2the federal act. The board may require carriers to offer additional
3products within each of those five levels of coverage. This
4subdivision shall not apply to a carrier that solely offers
5supplemental coverage in the Exchange under paragraph (10) of
6subdivision (a) of Section 100504.
7(f) (1) Except as otherwise provided in this section and Section
8100504.5, require, as a condition of participation in the Exchange,
9carriers that sell any products outside the Exchange to do both of
10the following:
11(A) Fairly and affirmatively offer, market, and sell all products
12made available to individuals in the Exchange to individuals
13purchasing coverage outside the Exchange.
14(B) Fairly and affirmatively offer, market, and sell all products
15made available to small employers in the Exchange to small
16employers purchasing coverage outside the Exchange.
17(2) For purposes of this subdivision, “product” does not include
18contracts entered into pursuant to Part 6.2 (commencing with
19Section 12693) of Division 2 of the Insurance Code between the
20Managed Risk Medical Insurance Board and carriers for enrolled
21
Healthy Families beneficiaries or contracts entered into pursuant
22to Chapter 7 (commencing with Section 14000) of, or Chapter 8
23(commencing with Section 14200) of, Part 3 of Division 9 of the
24Welfare and Institutions Code between the State Department of
25Health Care Services and carriers for enrolled Medi-Cal
26beneficiaries. “Product” also does not include a bridge plan product
27offered pursuant to Section 100504.5.
28(3) Except as required by Section 1301(a)(1)(C)(ii) of the federal
29act, a carrier offering a bridge plan product in the Exchange may
30limit the products it offers in the Exchange solely to a bridge plan
31product contract.
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
P4 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.
13(m) Employ necessary staff.
14(1) The board shall hire a chief fiscal officer, a chief operations
15officer, a director for the SHOP Exchange, a director of Health
16Plan Contracting, a chief technology and information officer, a
17general counsel, and other key executive positions, as determined
18by the board, who shall be exempt from civil service.
19(2) (A) The board shall set the salaries for the exempt positions
20described in paragraph (1) and subdivision (i) of Section 100500
21in amounts that are reasonably necessary to attract and retain
22individuals of superior qualifications. The salaries shall be
23published by the board in the board’s annual budget. The board’s
24
annual budget shall be posted on the Internet Web site of the
25Exchange. To determine the compensation for these positions, the
26board shall cause to be conducted, through the use of independent
27outside advisors, salary surveys of both of the following:
28(i) Other state and federal health insurance exchanges that are
29most comparable to the Exchange.
30(ii) Other relevant labor pools.
31(B) The salaries established by the board under subparagraph
32(A) shall not exceed the highest comparable salary for a position
33of that type, as determined by the surveys conducted pursuant to
34subparagraph (A).
35(C) The Department of Human Resources shall review the
36methodology used in the surveys conducted pursuant to
37subparagraph (A).
38(3) The positions described in paragraph (1) and subdivision (i)
39of Section 100500 shall not be subject to otherwise applicable
40provisions of the Government Code or the Public Contract Code
P5 1and, for those purposes, the Exchange shall not be considered a
2state agency or public entity.
3(n) Assess a charge on the qualified health plans offered by
4carriers that is reasonable and necessary to support the
5development, operations, and prudent cash management of the
6Exchange. This charge shall not affect the requirement under
7Section 1301 of the federal act that carriers charge the same
8premium rate for each qualified health plan whether offered inside
9or outside the Exchange.
10(o) Authorize expenditures, as necessary, from the California
11Health Trust Fund to pay program expenses to administer the
12Exchange.
13(p) Keep an accurate accounting of all activities, receipts, and
14expenditures, and annually submit to the United States Secretary
15of Health and Human Services a report concerning that accounting.
16Commencing January 1, 2016, the board shall conduct an annual
17audit.
18(q) (1) begin insert(A)end insertbegin insert end insert Annually prepare a written report on the
19implementation and performance of the Exchange functions during
20the preceding fiscal year, including, at a minimum,begin delete theend deletebegin insert all of the
21following:end insert
22begin insert(i)end insertbegin insert end insertbegin insertTheend insert manner in which funds were expended and the progress
23toward, and the achievement of, the requirements of this title.begin delete The
24report shall also include dataend delete
25begin insert(ii)end insertbegin insert end insertbegin insertDataend insert provided by health care service plans and health
26insurers offering bridge plan products regarding the extent of health
27care provider and health facility overlap in their Medi-Cal networks
28as compared to the health care provider and health facility networks
29contracting with the plan or insurer in their bridge plan contracts.
30begin delete Thisend delete
31(iii) The total number of uninsured Californians as a percentage
32of the state population.
33(iv) An evaluation of the effectiveness of the activities undertaken
34pursuant to subdivision (k). This evaluation shall be conducted by
35an independent entity selected by the board.
36begin insert(B)end insertbegin insert end insertbegin insertTheend insert reportbegin insert required by this paragraphend insert shall be transmitted
37to the Legislature and the Governor and shall be made available
38to the public on the Internet Web site of the Exchange. A report
39made to the Legislature pursuant to thisbegin delete subdivisionend deletebegin insert
paragraphend insert
40 shall be submitted pursuant to Section 9795.
P6 1(2) The Exchange shall prepare, or contract for the preparation
2of, an evaluation of the bridge plan program using the first three
3years of experience with the program. The evaluation shall be
4provided to the health policy and fiscal committees of the
5Legislature in the fourth year following federal approval of the
6bridge plan option. The evaluation shall include, but not be limited
7to, all of the following:
8(A) The number of individuals eligible to participate in the
9bridge plan program each year by category of eligibility.
10(B) The number of eligible individuals who elect a bridge plan
11option each year by category of eligibility.
12(C) The average length of
time, by region and statewide, that
13individuals remain in the bridge plan option each year by category
14of eligibility.
15(D) The regions of the state with a bridge plan option, and the
16carriers in each region that offer a bridge plan, by year.
17(E) The premium difference each year, by region, between the
18bridge plan and the first and second lowest cost plan for individuals
19in the Exchange who are not eligible for the bridge plan.
20(F) The effect of the bridge plan on the premium subsidy amount
21for bridge plan eligible individuals each year by each region.
22(G) Based on a survey of individuals enrolled in the bridge plan:
23(i) Whether individuals enrolling in the bridge plan product are
24able to
keep their existing health care providers.
25(ii) Whether individuals would want to retain their bridge plan
26product, buy a different Exchange product, or decline to purchase
27health insurance if there was no bridge plan product available. The
28Exchange may include questions designed to elicit the information
29in this subparagraph as part of an existing survey of individuals
30receiving coverage in the Exchange.
31(3) In addition to the evaluation required by paragraph (2), the
32Exchange shall post the items in subparagraphs (A) to (F),
33inclusive, on its Internet Web site each year.
34(4) In addition to the report described in paragraph (1), the board
35shall be responsive to requests for additional information from the
36Legislature, including providing testimony and commenting on
37proposed state legislation or policy issues. The
Legislature finds
38and declares that activities including, but not limited to, responding
39to legislative or executive inquiries, tracking and commenting on
40legislation and regulatory activities, and preparing reports on the
P7 1implementation of this title and the performance of the Exchange,
2are necessary state requirements and are distinct from the
3promotion of legislative or regulatory modifications referred to in
4subdivision (d) of Section 100520.
5(r) Maintain enrollment and expenditures to ensure that
6expenditures do not exceed the amount of revenue in the fund, and
7if sufficient revenue is not available to pay estimated expenditures,
8institute appropriate measures to ensure fiscal solvency.
9(s) Exercise all powers reasonably necessary to carry out and
10comply with the duties, responsibilities, and requirements of this
11act and the federal act.
12(t) Consult with stakeholders relevant to carrying out the
13activities under this title, including, but not limited to, all of the
14following:
15(1) Health care consumers who are enrolled in health plans.
16(2) Individuals and entities with experience in facilitating
17enrollment in health plans.
18(3) Representatives of small businesses and self-employed
19individuals.
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
23Exchange by qualified individuals and qualified small
employers
24no later than January 1, 2014.
25(v) Report, or contract with an independent entity to report, to
26the Legislature by December 1, 2018, on whether to adopt the
27option in Section 1312(c)(3) of the federal act to merge the
28individual and small employer markets. In its report, the board
29shall provide information, based on at least two years of data from
30the Exchange, on the potential impact on rates paid by individuals
31and by small employers in a merged individual and small employer
32market, as compared to the rates paid by individuals and small
33employers if a separate individual and small employer market is
34maintained. A report made pursuant to this subdivision shall be
35submitted pursuant to Section 9795.
36(w) With respect to the SHOP Program, collect premiums and
37administer all other necessary and related tasks, including, but not
38limited to, enrollment and plan payment, in
order to make the
39offering of employee plan choice as simple as possible for qualified
40small employers.
P8 1(x) Require carriers participating in the Exchange to immediately
2notify the Exchange, under the terms and conditions established
3by the board when an individual is or will be enrolled in or
4disenrolled from any qualified health plan offered by the carrier.
5(y) Ensure that the Exchange provides oral interpretation
6services in any language for individuals seeking coverage through
7the Exchange and makes available a toll-free telephone number
8for the hearing and speech impaired. The board shall ensure that
9written information made available by the Exchange is presented
10in a plainly worded, easily understandable format and made
11available in prevalent languages.
12(z) This section shall become inoperative on the October 1 that
13is five years after the date that federal approval of the bridge
plan
14option occurs, and, as of the second January 1 thereafter, is
15repealed, unless a later enacted statute that is enacted before that
16date deletes or extends the dates on which it becomes inoperative
17and is repealed.
Section 100503 of the Government Code, as added by
19Section 5 of Chapter 5 of the 1st Extraordinary Session of the
20Statutes of 2013, is amended to read:
In addition to meeting the minimum requirements of
22Section 1311 of the federal act, the board shall do all of the
23following:
24(a) Determine the criteria and process for eligibility, enrollment,
25and disenrollment of enrollees and potential enrollees in the
26Exchange and coordinate that process with the state and local
27government entities administering other health care coverage
28programs, including the State Department of Health Care Services,
29the Managed Risk Medical Insurance Board, and California
30counties, in order to ensure consistent eligibility and enrollment
31processes and seamless transitions between coverage.
32(b) Develop processes to coordinate with the county entities
33that administer eligibility for the Medi-Cal
program and the entity
34that determines eligibility for the Healthy Families Program,
35including, but not limited to, processes for case transfer, referral,
36and enrollment in the Exchange of individuals applying for
37assistance to those entities, if allowed or required by federal law.
38(c) Determine the minimum requirements a carrier must meet
39to be considered for participation in the Exchange, and the
40standards and criteria for selecting qualified health plans to be
P9 1offered through the Exchange that are in the best interests of
2qualified individuals and qualified small employers. The board
3shall consistently and uniformly apply these requirements,
4standards, and criteria to all carriers. In the course of selectively
5contracting for health care coverage offered to qualified individuals
6and qualified small employers through the Exchange, the board
7shall seek to contract with carriers so as to provide health care
8coverage choices that offer the
optimal combination of choice,
9value, quality, and service.
10(d) Provide, in each region of the state, a choice of qualified
11health plans at each of the five levels of coverage contained in
12subsections (d) and (e) of Section 1302 of the federal act.
13(e) Require, as a condition of participation in the Exchange,
14carriers to fairly and affirmatively offer, market, and sell in the
15Exchange at least one product within each of the five levels of
16coverage contained in subsections (d) and (e) of Section 1302 of
17the federal act. The board may require carriers to offer additional
18products within each of those five levels of coverage. This
19subdivision shall not apply to a carrier that solely offers
20supplemental coverage in the Exchange under paragraph (10) of
21subdivision (a) of Section 100504.
22(f) (1) Require, as a condition of participation in the Exchange,
23carriers that sell any products outside the Exchange to do both of
24the following:
25(A) Fairly and affirmatively offer, market, and sell all products
26made available to individuals in the Exchange to individuals
27purchasing coverage outside the Exchange.
28(B) Fairly and affirmatively offer, market, and sell all products
29made available to small employers in the Exchange to small
30employers purchasing coverage outside the Exchange.
31(2) For purposes of this subdivision, “product” does not include
32contracts entered into pursuant to Part 6.2 (commencing with
33Section 12693) of Division 2 of the Insurance Code between the
34Managed Risk Medical Insurance Board and carriers for enrolled
35Healthy Families beneficiaries or contracts entered into pursuant
36to
Chapter 7 (commencing with Section 14000) of, or Chapter 8
37(commencing with Section 14200) of, Part 3 of Division 9 of the
38Welfare and Institutions Code between the State Department of
39Health Care Services and carriers for enrolled Medi-Cal
40beneficiaries.
P10 1(g) Determine when an enrollee’s coverage commences and the
2extent and scope of coverage.
3(h) Provide for the processing of applications and the enrollment
4and disenrollment of enrollees.
5(i) Determine and approve cost-sharing provisions for qualified
6health plans.
7(j) Establish uniform billing and payment policies for qualified
8health plans offered in the Exchange to ensure consistent
9enrollment and disenrollment activities for individuals enrolled in
10the Exchange.
11(k) Undertake activities necessary to market and publicize the
12availability of health care coverage and federal subsidies through
13the Exchange. The board shall also undertake outreach and
14enrollment activities that seek to assist enrollees and potential
15enrollees with enrolling and reenrolling in the Exchange in the
16least burdensome manner, including populations that may
17experience barriers to enrollment, such as the disabled and those
18with limited English language proficiency.
19(l) Select and set performance standards and compensation for
20navigators selected under subdivision (l) of Section 100502.
21(m) Employ necessary staff.
22(1) The board shall hire a chief fiscal officer, a chief operations
23officer, a director for the SHOP Exchange, a director of Health
24
Plan Contracting, a chief technology and information officer, a
25general counsel, and other key executive positions, as determined
26by the board, who shall be exempt from civil service.
27(2) (A) The board shall set the salaries for the exempt positions
28described in paragraph (1) and subdivision (i) of Section 100500
29in amounts that are reasonably necessary to attract and retain
30individuals of superior qualifications. The salaries shall be
31published by the board in the board’s annual budget. The board’s
32annual budget shall be posted on the Internet Web site of the
33Exchange. To determine the compensation for these positions, the
34board shall cause to be conducted, through the use of independent
35outside advisors, salary surveys of both of the following:
36(i) Other state and federal health insurance exchanges that are
37most comparable to the Exchange.
38(ii) Other relevant labor pools.
39(B) The salaries established by the board under subparagraph
40(A) shall not exceed the highest comparable salary for a position
P11 1of that type, as determined by the surveys conducted pursuant to
2subparagraph (A).
3(C) The Department of Human Resources shall review the
4methodology used in the surveys conducted pursuant to
5subparagraph (A).
6(3) The positions described in paragraph (1) and subdivision (i)
7of Section 100500 shall not be subject to otherwise applicable
8provisions of the Government Code or the Public Contract Code
9and, for those purposes, the Exchange shall not be considered a
10state agency or public entity.
11(n) Assess a charge on the qualified health
plans offered by
12carriers that is reasonable and necessary to support the
13development, operations, and prudent cash management of the
14Exchange. This charge shall not affect the requirement under
15Section 1301 of the federal act that carriers charge the same
16premium rate for each qualified health plan whether offered inside
17or outside the Exchange.
18(o) Authorize expenditures, as necessary, from the California
19Health Trust Fund to pay program expenses to administer the
20Exchange.
21(p) Keep an accurate accounting of all activities, receipts, and
22expenditures, and annually submit to the United States Secretary
23of Health and Human Services a report concerning that accounting.
24Commencing January 1, 2016, the board shall conduct an annual
25audit.
26(q) (1) begin insert(A)end insertbegin insert end insert Annually prepare a written report on the
27implementation and performance of the Exchange functions during
28the preceding fiscal year, including, at a minimum,begin delete theend deletebegin insert all of the
29following:end insert
30begin insert(i)end insertbegin insert end insertbegin insertTheend insert manner in which funds were expended and the progress
31toward, and the achievement of, the requirements of this title.begin delete Thisend delete
32(ii) The total number of uninsured Californians as a percentage
33of the state population.
34(iii) An evaluation of the effectiveness of the activities
35undertaken pursuant to subdivision (k). This evaluation shall be
36conducted by an independent entity selected by the board.
37begin insert(B)end insertbegin insert end insertbegin insertTheend insert reportbegin insert required by this paragraphend insert shall be transmitted
38to the Legislature and the Governor and shall be made available
39to the public on the Internet Web site of the Exchange. A report
P12 1made to the Legislature pursuant to thisbegin delete subdivisionend deletebegin insert
paragraphend insert
2
shall be submitted pursuant to Section 9795.
3(2) In addition to the report described in paragraph (1), the board
4shall be responsive to requests for additional information from the
5Legislature, including providing testimony and commenting on
6proposed state legislation or policy issues. The Legislature finds
7and declares that activities including, but not limited to, responding
8to legislative or executive inquiries, tracking and commenting on
9legislation and regulatory activities, and preparing reports on the
10implementation of this title and the performance of the Exchange,
11are necessary state requirements and are distinct from the
12promotion of legislative or regulatory modifications referred to in
13subdivision (d) of Section 100520.
14(r) Maintain enrollment and expenditures to ensure that
15expenditures do not exceed the amount of revenue in the fund, and
16if sufficient
revenue is not available to pay estimated expenditures,
17institute appropriate measures to ensure fiscal solvency.
18(s) Exercise all powers reasonably necessary to carry out and
19comply with the duties, responsibilities, and requirements of this
20act and the federal act.
21(t) Consult with stakeholders relevant to carrying out the
22activities under this title, including, but not limited to, all of the
23following:
24(1) Health care consumers who are enrolled in health plans.
25(2) Individuals and entities with experience in facilitating
26enrollment in health plans.
27(3) Representatives of small businesses and self-employed
28individuals.
29(4) The State Medi-Cal Director.
30(5) Advocates for enrolling hard-to-reach populations.
31(u) Facilitate the purchase of qualified health plans in the
32Exchange by qualified individuals and qualified small employers
33no later than January 1, 2014.
34(v) Report, or contract with an independent entity to report, to
35the Legislature by December 1, 2018, on whether to adopt the
36option in Section 1312(c)(3) of the federal act to merge the
37individual and small employer markets. In its report, the board
38shall provide information, based on at least two years of data from
39the Exchange, on the potential impact on rates paid by individuals
40and by small employers in a merged individual and small employer
P13 1market, as compared to the rates paid by individuals and small
2employers if a separate individual and small employer
market is
3maintained. A report made pursuant to this subdivision shall be
4submitted pursuant to Section 9795.
5(w) With respect to the SHOP Program, collect premiums and
6administer all other necessary and related tasks, including, but not
7limited to, enrollment and plan payment, in order to make the
8offering of employee plan choice as simple as possible for qualified
9small employers.
10(x) Require carriers participating in the Exchange to immediately
11notify the Exchange, under the terms and conditions established
12by the board when an individual is or will be enrolled in or
13disenrolled from any qualified health plan offered by the carrier.
14(y) Ensure that the Exchange provides oral interpretation
15services in any language for individuals seeking coverage through
16the Exchange and makes available a toll-free telephone
number
17for the hearing and speech impaired. The board shall ensure that
18written information made available by the Exchange is presented
19in a plainly worded, easily understandable format and made
20available in prevalent languages.
21(z) This section shall become operative only if Section 4 of the
22act that added this section becomes inoperative pursuant to
23subdivision (z) of that Section 4.
O
99