Bill Text: CA AB164 | 2025-2026 | Regular Session | Amended
Bill Title: Health.
Sponsorship: Committee Bill
Status: (Engrossed) 2026-08-06 - Ordered to inactive file at the request of Senator Laird. [AB164 Detail]
Download: California-2025-AB164-Amended.html
|
Amended
IN
Senate
June 26, 2026 |
CALIFORNIA LEGISLATURE—
2025–2026 REGULAR SESSION
Assembly Bill
No. 164
| Introduced by |
January 08, 2025 |
LEGISLATIVE COUNSEL'S DIGEST
AB 164, as amended, Committee on Budget.
Budget Act of 2025. Health.
(1) Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is in part governed by, and funded pursuant to, federal Medicaid program provisions.
Existing federal law, H.R. 1 (Public Law 119-21), enacted in 2025, sets forth various Medicaid eligibility changes for implementation at different stages of a certain timeline, including changes applied to beneficiaries between 19 and 64 years of age, inclusive, with income up to 138% of the federal poverty level, commonly known as Medicaid expansion adults.
Federal H.R. 1 generally requires a
Medicaid expansion adult to undergo an eligibility redetermination once every 6 months, instead of an annual redetermination. The federal law generally requires a Medicaid expansion adult to demonstrate community engagement through any of certain methods for the corresponding month, including a minimum of 80 hours of work or community service or a minimum of half-time enrollment in an educational program. The federal law reduces the period of retroactive coverage prior to the date of Medicaid application from 3 months to one month for Medicaid expansion adults and to 2 months for other Medicaid beneficiaries. The federal law requires the state to provide for a process to regularly obtain beneficiary address information from reliable data sources, and to utilize a system to prevent an individual from being simultaneously enrolled under Medicaid state plans or waivers of multiple states.
This bill would make various changes to related state provisions, or would add
new provisions, conforming them to the above-described changes under federal H.R. 1. The bill would require a county to accept specified methods of signatures for renewal forms.
Federal H.R. 1 restricts the scope of certain categories of immigrants who qualify for Medicaid eligibility.
This bill would make conforming changes to related state provisions. The bill would also modify provisions regarding individuals with certain immigration statuses, so that they would be eligible for the full scope of Medi-Cal state-funded benefits, subject to certain service limitations.
Existing law requires an individual without satisfactory immigration status, as specified, who is eligible for full-scope Medi-Cal to enroll in a Medi-Cal managed care plan.
This bill would instead specify that an individual without satisfactory immigration status who is
eligible for the Medi-Cal program is eligible for services in the Medi-Cal fee-for-service delivery system. The bill would make conforming changes to related provisions.
Existing law requires the department to develop an application for insurance affordability programs, including Medi-Cal, for use by all entities authorized to make an eligibility determination for those programs. Existing law authorizes the department to develop and require use of supplemental forms to collect additional information needed to determine eligibility.
This bill would make various changes to those provisions, relating to user testing, accuracy, readability, and the work or community engagement requirements under federal H.R. 1.
The bill would require the department to undertake efforts to conduct outreach regarding the changes made under federal H.R. 1, and to establish a data dashboard. Under the
bill, beneficiary outreach and education would be coordinated across public social services programs to help minimize barriers to administrative disenrollments. The bill would incorporate federal H.R. 1 requirements into county outreach efforts, as specified.
By creating new duties for counties regarding Medi-Cal eligibility determinations, procedures, and outreach, the bill would impose a state-mandated local program.
(2) Existing law, beginning no sooner than July 1, 2027, requires certain individuals who do not have satisfactory immigration status to pay a monthly premium of $30 as a condition of eligibility for the full scope of Medi-Cal benefits, subject to certain exceptions.
This bill would require, no sooner than May 14, 2027, the Governor’s 2027–28 May Revision to include the level of the monthly premiums, to be set at no less than $30 and no greater
than $50 per beneficiary.
Under existing law, no sooner than July 1, 2026, the above-described individuals who are 19 years of age or older are not eligible for dental services under the Medi-Cal program, except as specified.
This bill would delay the ineligibility for dental services to a period no sooner than July 1, 2027.
(3) Under existing law, to the extent that federal financial participation is available, federally qualified health center (FQHC) services and rural health clinic (RHC) services are covered Medi-Cal benefits. Under existing law, FQHC and RHC services are reimbursed on a per-visit basis, as defined. Under existing law, commencing on July 1, 2026, that reimbursement is conditioned on the services being eligible for federal financial participation.
This bill would instead apply that condition
commencing on July 1, 2027.
(4) Existing law, the California Advancing and Innovating Medi-Cal (CalAIM) Act, subject to receipt of any necessary federal approvals, establishes the CalAIM initiative in order to, among other things, improve quality outcomes, reduce health disparities, and transition and transform the Medi-Cal program to a more consistent and seamless system by reducing complexity and increasing flexibility. Under existing law, the CalAIM initiative ends on December 31, 2026.
Existing law appropriates to the department certain amounts of federal financial participation that the department is authorized to claim for expenditures associated with the designated state health programs identified in the CalAIM Terms and Conditions. Existing law appropriates to the Health Care Deposit Fund, a continuously appropriated fund, an amount of General Fund moneys equal to the federal financial
participation for use by the department for CalAIM implementation purposes. Existing law also continuously appropriates moneys from the Medi-Cal County Behavioral Health Fund to the department for purposes of implementing certain behavioral health provisions within CalAIM.
This bill, subject to receipt of any necessary federal approvals, would extend the CalAIM initiative to December 31, 2031, thereby making an appropriation.
The bill would require the department to seek federal approval for implementation of Employment Supports and BridgeCare, the latter of which is to provide home- and community-based services and caregiver supports to individuals enrolled in the federal Medicare Program who meet the near dual eligibility criteria, as specified.
Existing law requires an individual county, or counties acting jointly, to provide and administer covered behavioral health Medi-Cal
benefits under a single Medi-Cal behavioral health delivery system contract, in accordance with the CalAIM Terms and Conditions.
This bill would require the county or counties, if participating in the Drug Medi-Cal organized delivery system, to deliver the behavioral health benefits through a single Prepaid Inpatient Health Plan.
(5) Existing law sets forth various requirements and procedures for the enrollment of providers in the Medi-Cal program.
This bill, for the period beginning on July 1, 2026, and ending on June 30, 2027, would prohibit the granting of provisional or preferred provisional enrollment status in the Medi-Cal program to an applicant or provider as a result of the department’s failure to act within any of specified timeframes. Under those circumstances, the bill would require that the application remain pending unless
and until the department issues a written determination consistent with all applicable state and federal Medicaid screening requirements.
(6) Existing law prohibits the use of an assets or resources test for individuals whose income eligibility for Medi-Cal is determined based on the application of a modified adjusted gross income (MAGI). Existing federal law authorizes a state to establish a non-MAGI standard for determining the eligibility of certain populations.
Existing law, subject to receipt of any necessary federal approvals, implements a disregard of $130,000 in nonexempt property for a case with one member and $65,000 for each additional household member, up to a maximum of 10 members, as specified.
This bill, beginning July 1, 2027, would instead implement a resource limit of $21,000 in nonexempt property for a household with one member, $31,000 for
a household with 2 members, and $1,550 for each additional household member, up to a maximum of 10 members, as specified. The bill would make conforming changes to related provisions.
By creating new duties for counties relating to the consideration of resources for determining Medi-Cal eligibility, the bill would impose a state-mandated local program.
(7) Existing law requires a Medi-Cal managed care plan to comply with a minimum 85% medical loss ratio consistent with certain federal regulations. Under existing law, after the department returns the requisite federal share amounts associated with any remittance funds collected in any applicable fiscal year to the federal Centers for Medicare and Medicaid Services, the remaining amounts remitted by a Medi-Cal managed care plan under these provisions are transferred to the Medi-Cal Loan Repayment Program Special Fund for purposes of
the Medi-Cal Physicians and Dentists Loan Repayment Program.
This bill instead would deposit the remaining amounts remitted by a Medi-Cal managed care plan into the General Fund. The bill would remove an inoperative provision.
(8) Existing law requires the department to establish and maintain a plan, known as the County Administrative Cost Control Plan, whereby costs for county administration of the determination of eligibility for Medi-Cal benefits are effectively controlled within the amounts annually appropriated for that administration. Existing law makes legislative findings that, in order for counties to do the work that is expected of them, it is necessary that they receive adequate funding, including adjustments for reasonable annual cost-of-doing-business increases. Existing law expresses the intent of the Legislature to not appropriate funds for
cost-of-doing-business adjustments for the 2024–25 to 2027–28, inclusive, fiscal years, among certain other previous fiscal years.
This bill would remove the 2026–27 and 2027–28 fiscal years from the above-described statement of intent regarding the lack of appropriation of funds for the cost-of-doing-business adjustments.
(9) Existing law provides for the licensure and regulation of health facilities, including general acute care hospitals and skilled nursing facilities, by the State Department of Public Health. A violation of these provisions is generally a crime.
Existing law sets forth various provisions relating to distinct parts of acute care hospitals, including those operating skilled nursing facilities. Existing regulations define “distinct part” as an identifiable unit accommodating beds, including, but not limited to, contiguous
rooms, a wing, floor, or building that is approved by the department for a specific purpose.
This bill would require a general acute care hospital seeking to provide skilled nursing services in a distinct part, as defined, to submit an application and documentation to the department. If the distinct part meets certain criteria, the bill would authorize the department to approve a hospital’s application for a distinct part on a case-by-case basis. The bill would require a skilled nursing distinct part to meet specified conditions, including, among others, being wholly owned by the hospital and being subject to the bylaws and operating decisions of the hospital’s governing body.
The bill would require a general acute care hospital seeking to add a composite distinct part to its license to submit a proposal to the department, as specified. Under the bill, “composite distinct part” would be defined as a distinct part consisting
of 2 or more noncontiguous components that are not located within the same campus. If the department determines that the composite distinct part may improve access to care and address a specific unmet need in the geographical area served by the hospital, the bill would authorize the hospital to submit an application for approval of a composite distinct part.
The bill would require a freestanding component of a composite distinct part to independently meet all of the licensing requirements applicable to a freestanding skilled nursing facility, including staffing requirements and ratios. The bill would prohibit a hospital from using composite distinct parts to segregate residents by payment source or on a basis other than care needs.
The bill would limit the hospital to a maximum of only one licensed skilled nursing distinct part, which may be a composite distinct part, with the hospital and the distinct part or composite
distinct part having only one license number. The bill would set forth related identification duties for the department.
Existing law requires the department, upon approval, to issue a separate license for the provision of basic services relating to skilled nursing or intermediate care, whenever these basic services are to be provided by an acute care hospital in a separate freestanding facility, whether or not contiguous to the hospital. Existing law sets forth various exemptions to this requirement, including for beds licensed to an acute care hospital and located within the physical structure in which acute care is provided.
This bill would exempt, from the above-described requirement, licensed skilled nursing beds in a distinct part located on a general acute care hospital’s campus, as specified. Under the bill, a composite distinct part would be exempt only if the hospital’s license has a distinct part on its campus
approved for skilled nursing.
By creating new requirements for general acute care hospitals, distinct parts, and composite distinct parts, the violation of which would be a crime, the bill would impose a state-mandated local program.
(10) Existing law requires the State Department of Public Health to develop and maintain a statewide comprehensive community-based perinatal services program, as specified, to deliver services in medically underserved areas or areas with demonstrated need.
Existing law requires the department, by July 1, 2026, to establish a 10-year pilot project within up to 5 critical access hospitals to allow participating hospitals, on an application basis, to establish standby perinatal services, as defined. Existing law requires, if qualified, the first 2 hospitals selected to be nonprofit and
located in the Counties of Humboldt and Plumas.
This bill would require, if qualified, a nonprofit hospital located in the County of Lake to be one of the first 3 hospitals selected. The bill would make various changes to certain criteria, with regard to staff responsibilities and procedures, for a hospital requesting approval to establish a standby perinatal service. Because a violation of these provisions would be a crime, the bill would impose a state-mandated local program.
The bill would make legislative findings and declarations as to the necessity of a special statute for the County of Lake.
(11) Existing law provides for the licensure and regulation of home health agencies by the State Department of Public Health. Existing law generally makes a violation of those provisions a
misdemeanor. Existing law prescribes various requirements for the application for a home health agency license, including a provisional license for an applicant that has not been previously licensed.
This bill, except as provided, would require a home health agency to have an administrator, administrator designee, director of patient care services, and director of patient care services designee, and to submit to the department specified information for each individual on an initial application. The bill would require existing agencies to provide this information no later than March 31, 2027. The bill would require the department to verify specified details of home health agency management personnel. The bill, except as provided, would require an applicant for licensure of a home health agency or a branch office to demonstrate an unmet need for home health services in the agency’s geographic service area. The bill would specify additional grounds by which the
department is authorized to deny an application for, or suspend or revoke, a license. Because a violation of these provisions would be a crime, the bill would impose a state-mandated local program.
The bill would prohibit the transfer of a license that is issued pursuant to these provisions. The bill would prohibit the department from approving a change of ownership of a licensed home health agency within 5 years of the date a license was initially issued to the licensee. The bill would authorize the department to make an exception for extenuating circumstances, as specified.
The bill, for a specified period of time, would prohibit the department from issuing a new license to operate a home health agency or add a branch office to an existing license. The bill would authorize the department to grant an exception upon a written finding that an applicant for a new license or with a pending application has demonstrated an unmet
need for home health services in the area where the applicant proposes to operate.
The bill would require the department to update existing home health agency regulations as necessary and adopt regulations that, among other things, clarify the maximum time and distance that home health agency staff may travel to reach patients, as specified.
(12) Existing law requires the State Department of Health Care Services to license and regulate alcohol or other drug programs that provide recovery, treatment, or detoxification services or medications for addiction treatment. Under existing law, a licensee is required to provide at least one specified nonmedical service. Existing law requires the department to adopt American Society of Addiction Medicine (ASAM) treatment criteria, or an equivalent evidence-based standard, as the minimum standard of care for licensed
facilities, and required the department to adopt regulations to implement the ASAM Criteria by January 1, 2023. The ASAM Criteria, 4th Edition, changes the levels of care for substance use treatment and integrates withdrawal management services, formerly referred to as detoxification services, into other care levels.
This bill would recast detoxification as withdrawal management and would make conforming changes. The bill would require a licensee to provide recovery and treatment services or recovery, treatment, and withdrawal management services. The bill would require a license to provide detoxification-only services to expire on July 1, 2027. The bill would prohibit a licensee from providing detoxification-only services on and after that date and would prohibit the department from issuing or extending a license for detoxification-only services on or after that date. The bill would require the department to promulgate regulations to implement the ASAM Criteria by
January 1, 2030, and in the interim would authorize the department to implement the ASAM Criteria through all-county letters, plan letters, information notices, or similar instructions. On and after July 1, 2027, the bill would require a licensee that provides withdrawal management services to provide those services as required in guidance issued by the department.
(13) Existing law imposes certain fair pricing requirements on hospitals, including, among other things, requiring that hospitals provide patients with a written notice containing information about the availability of the hospital’s discount payment and charity care policies and restricting the sale of patient debts. Existing law requires the Director of the Department of Health Care Access and Information to impose administrative penalties for each violation against a hospital that fails to comply with these provisions, except as
specified.
This bill would establish the Hospital Fair Pricing Penalties Fund and would require any moneys collected from the above-described administrative penalties to be deposited into the fund. The bill would, upon appropriation, authorize the department to use moneys from the fund to carry out the above-described fair-pricing provisions.
(14) Existing law requires the Center for Data Insights and Innovation to compile an annual quality of care report card and produce an annual report regarding health care consumer or patient assistance help centers. Existing law establishes the Health Plan Improvement Trust Fund and requires moneys in the fund to be used for these purposes, upon appropriation by the Legislature. Existing law sets forth the shares of funding from the Managed Care Fund and Insurance Fund to be deposited into the Health Plan Improvement Trust
Fund. Existing law makes personal information obtained or maintained by the center confidential and exempt from other disclosure requirements.
This bill would repeal and recast the above-described provisions to be administered by the Department of Health Care Access and Information beginning July 1, 2026. The bill would also make conforming changes.
Existing law requires the Department of Health Care Access and Information to establish and implement the California Health and Human Services Data Exchange Framework, which is required to include a single data sharing agreement and common set of policies and procedures that will leverage and advance national standards for information exchange and data content, and that will govern and require the exchange of health information among health care entities and governmental agencies in the state. Existing law generally requires specified entities to execute the data sharing
agreement on or before January 31, 2023, and to exchange health information or provide access to health information pursuant to the framework by July 1, 2026.
This bill would delay required compliance with the above-described provisions until July 1, 2027, for specified community clinics, intermittent clinics, and rural health clinics.
(15) Existing law establishes the California Reproductive Health Equity Program within the Department of Health Care Access and Information to ensure abortion and contraception services are affordable for and accessible to all patients and to provide financial support for safety net providers of these services. Existing law authorizes a Medi-Cal enrolled provider to apply to the department for a grant, and a continuation award after the initial grant, to provide abortion and contraception services if specified criteria are met. Existing law
establishes the California Reproductive Health Equity Fund, a continuously appropriated fund, to provide this grant funding. Existing law establishes the Abortion Access Fund, a continuously appropriated fund in the State Treasury, to provide funding for abortion services.
This bill would rename the program as the California Reproductive and TGI Health Equity Program, would expand the program’s purposes to ensure affordability and access to gender-affirming care, and would make conforming changes. The bill would require the department to develop an application form and begin accepting grant applications on or before January 1, 2027. The bill would authorize the department to use the money in the Abortion Access Fund to provide grant funding to safety net providers for abortion services through the program and would expand the purposes of the California Reproductive Health Equity Fund to include grant funding for gender-affirming care services, thus making an
appropriation. The bill would make contracts, grants, and related program information confidential and exempt from disclosure to the public.
(16) Existing law, the Medical Practice Act, provides for the licensure and regulation of physicians and surgeons by the Medical Board of California and requires the board to adopt and administer standards for the continuing education of those licensees. Existing law requires the board, in determining its continuing education requirements, to consider including a course in menopausal mental or physical health. Existing law, the Osteopathic Act, provides for the licensure and regulation of osteopathic physicians and surgeons by the Osteopathic Medical Board of California and requires the board to adopt and administer standards for the continuing education of those licensees.
Under this bill, beginning July 1, 2027, a qualifying physician and surgeon or osteopathic
physician and surgeon who completes continuing medical education courses in perimenopause, menopause, and postmenopausal care would receive 2 hours of credit for each hour completed of that coursework, as specified. The bill would make changes to related provisions regarding course hours for nurse practitioners and physician assistants.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and generally makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance.
This bill would require a health care service plan contract or health insurance policy, as specified, to include coverage for certain treatments for menopausal symptoms, as medically necessary. The bill would require these contracts and policies to include a
program that meets specified criteria to ensure the individuals have access to current menopause information and covered items and services.
The bill would require a plan or insurer to base a medical necessity determination or utilization review criteria for the treatment of symptoms resulting from menopause on current generally accepted standards of menopause care. Beginning January 1, 2027, the bill would require a plan or insurer conducting utilization review for the treatment of symptoms resulting from menopause to apply certain criteria and guidelines, as specified.
Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.
Existing law sets forth a schedule of benefits under the Medi-Cal program.
This bill would cover certain treatments for
menopausal symptoms under the Medi-Cal program, subject to medical necessity and to the extent that federal financial participation is available. The bill would require the department to establish and maintain a policy to reimburse providers for provision of services related to menopause care.
(17) Existing law establishes the Breast Cancer Fund, which consists of 2 accounts, the Breast Cancer Research Account and the Breast Cancer Control Account. Under existing law, revenues from a specified cigarette tax are deposited into the fund and divided between the 2 accounts, to be allocated upon appropriation by the Legislature. Existing law requires 10% of moneys in the Breast Cancer Research Account to be allocated to the Cancer Surveillance Section, as specified.
This bill would correct an erroneous reference within the above provisions.
(18) Existing law creates the California Health Benefit Exchange, also known as Covered California, to facilitate the enrollment of qualified individuals and qualified small employers in qualified health plans as required under the Patient Protection and Affordable Care Act (PPACA). Existing law establishes the Health Care Affordability Reserve Fund to be used, upon appropriation, for health care affordability programs operated by the Exchange, among other things.
Existing law requires the Exchange, upon appropriation, to provide payments equaling the cost of providing coverage of abortion services for which federal funding is prohibited to individuals enrolled in a qualified health plan through the Exchange in the individual market. Existing law prohibits the payments from being less than $1 per enrollee per month.
This bill would require that the Health Care
Affordability Reserve Fund be utilized, upon appropriation, for the above-described payments.
(19) Existing law, the Mental Health Services Act (MHSA), an initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general election, creates the Mental Health Service Fund, a continuously appropriated fund, for the purpose of funding a system of county mental health plans for the provision of mental health services. Existing law authorizes the Legislature to clarify procedures and terms of the MHSA by majority vote.
Existing law, the Behavioral Health Services Act (BHSA), a legislative act amending the MHSA that was approved by the voters as Proposition 1 at the March 5, 2024, statewide primary election, recast the MHSA by, among other things, renaming the Mental Health Service Fund as the Behavioral Health Service Fund, expanding the MHSA to include treatment of
substance use disorders, changing the county planning process, and expanding services for which counties and the state can use funds. Existing law requires a county to calculate a maximum amount it establishes as the funding level for its prudent reserve for its Local Behavioral Health Services Fund, not to exceed 20% of the average of the total funds distributed to the county, as specified, and requires a county with a population of less than 200,000 to calculate a maximum amount it establishes as the prudent reserve for its Local Behavioral Health Services Fund, not to exceed 25% of the average of the total funds distributed to the county, as specified.
This bill would, commencing with the 2029–30 fiscal year and every 3 fiscal years thereafter, require a county to calculate the maximum funding level of its prudent reserve, as specified, and include a plan for the expenditure of funds exceeding the maximum amount funding level in the county’s integrated plan.
Existing law requires the Controller, on or before the 15th day of each month, to distribute to each Local Behavioral Health Service Fund established by counties all unexpended and unreserved funds on deposit as of the last day of the prior month in the Behavioral Health Services Fund for the provision of behavioral health programs and other related activities pursuant to a methodology provided by the State Department of Health Care Services.
This bill, commencing July 1, 2028, would require the department to establish a methodology for determining annual minimum expenditure levels for funds distributed to counties, as described above. The bill would, beginning in the 2028–29 fiscal year, set the minimum expenditure level at the average annual amount of distributed funds for a county in the preceding 3 years. The bill would require a county, commencing with the 2029–30 fiscal year and each fiscal year thereafter, to spend an
amount of distributed funds that is equal to or greater than the minimum expenditure level for that fiscal year, as specified. The bill would authorize a county to spend funds from its prudent reserve only during a fiscal year for which the department publishes a revised minimum expenditure level, during any fiscal year in which the amount of distributed funds is less than the minimum expenditure level calculated for that fiscal year, or during a fiscal year in which the county determines that there has been a change in local behavioral health needs or circumstances.
Existing law requires each county to prepare and submit an integrated plan and annual updates to the Behavioral Health Services Oversight and Accountability Commission and the department. Existing law requires the integrated plan and annual update to include a budget that includes the county planned expenditures and reserves for the county distributions from the Behavioral Health Service Fund and any
other funds allocated to the county to provide specified services and programs. Existing law requires all expenditures for county behavioral health programs to be consistent with a currently approved county integrated plan, annual update, or intermittent update. If a county fails to submit certain data and information or fails to allocate funding as specified, existing law authorizes the department to impose a corrective action plan, monetary sanctions, or temporarily withhold payments to the county. Existing law requires these monetary sanctions to be deposited in the Behavioral Health Services Act Accountability Fund, a continuously appropriated fund, to be allocated and distributed to the county that paid the monetary sanction upon the department’s determination that the county has come into compliance.
If a county fails to comply with the minimum expenditure requirements described above, this bill would authorize the department to impose a corrective action
plan, monetary sanctions, or temporarily withhold payments to the county. Because the monetary sanctions would be a new source of moneys for the Behavioral Health Services Act Accountability Fund, a continuously appropriated fund, this bill would make an appropriation.
By creating additional duties for counties, the bill would impose a state-mandated local program.
(20) Existing law requires the State Department of State Hospitals to designate a community program director who is responsible for administering community treatment programs for certain committed persons. Existing law establishes the Forensic Conditional Release Program to provide outpatient and community-based treatment to committed persons. Existing law requires the department, until June 30, 2026, to establish a statewide panel of independent evaluators to identify and evaluate state hospital patients who are appropriate for
participation in the program.
This bill would rename the independent evaluation panel as the independent placement panel. The bill would make certain changes to the designation process for case reviews and placement recommendations. The bill would extend these provisions indefinitely.
Existing law prohibits outpatient status for a person who is charged with and found incompetent on a charge of, convicted of, or found not guilty by reason of insanity of, certain crimes until the person has actually been confined in a state hospital or other treatment facility for at least 180 days. Existing law permits outpatient status, without a person first being confined in a state hospital or other treatment facility, in the case of other crimes. Existing law requires the court to consider certain criteria before placing those persons on outpatient status.
This bill would modify some of those
factors that the court would be required to consider. The bill would also make changes to related provisions regarding procedures for the independent placement panel or designee to submit certain recommendations and for the court to give notice of hearing dates to specified entities.
(21) Existing law authorizes the State Public Health Officer, to the extent allowable under federal law, and upon the availability of funds, to expend moneys from the continuously appropriated AIDS Drug Assistance Program (ADAP) Rebate Fund for a program to cover the costs of prescribed ADAP formulary medications for the prevention of HIV infection and other specified costs.
This bill would additionally allow moneys from the ADAP Rebate Fund to be used to cover costs related to state and local public health department disease intervention and investigation
activities and services for specified communicable diseases, to the extent that funds are available for these purposes. The bill would also allow moneys from the fund to be used to cover costs related to housing support and other programs or initiatives relating to HIV treatment or overdose prevention and harm reduction.
The bill would, to the extent deemed an allowable use of the fund, authorize the State Department of Public Health to spend up to $134,840,000 in fiscal year 2026–27, $134,490,000 in fiscal year 2027–28, $126,590,000 in fiscal year 2028–29, and $130,090,000 in fiscal year 2029–30, from the fund to implement specified programs. The bill would authorize the department to spend up to $50,000,000 for related purposes, as specified.
By adding to the purposes of the ADAP Rebate Fund, the bill would make an appropriation.
(22) 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.
(23) Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the
limitation and the need for protecting that interest.
This bill would make legislative findings to that effect.
(24) This bill would declare that it is to take effect immediately as a bill providing for appropriations related to the Budget Bill.
This bill would express the intent of the Legislature to enact statutory changes relating to the Budget Act of 2025.
Digest Key
Vote: MAJORITY Appropriation:Bill Text
The people of the State of California do enact as follows:
SECTION 1.
Section 2190.4 is added to the Business and Professions Code, to read:2190.4.
(a) Beginning July 1, 2027, a qualifying physician and surgeon who completes continuing medical education courses in perimenopause, menopause, and postmenopausal care shall receive two hours of credit for each hour completed of that coursework, for a total earned credit that does not exceed eight course hours, toward the requirement set forth in Section 1336 of Title 16 of the California Code of Regulations.(b) For purposes of this section, “qualifying physician and surgeon” means a holder of a physician’s and surgeon’s certificate from the board who is certified by a member board of the American Board of Medical Specialties in internal medicine, family medicine, obstetrics and gynecology, neurology, neurological surgery, or psychiatry and
whose patient population includes adult women under 65 years of age.
SEC. 2.
Section 2191 of the Business and Professions Code is amended to read:2191.
(a) In determining its continuing education requirements, the board shall consider including a course in human sexuality, defined as the study of a human being as a sexual being and how they function with respect thereto, and nutrition to be taken by those licensees whose practices may require knowledge in those areas.(b) The board shall consider including a course in child abuse detection and treatment to be taken by those licensees whose practices are of a nature that there is a likelihood of contact with abused or neglected children.
(c) The board shall consider including a course in acupuncture to be taken by those licensees whose practices may require knowledge in the area of acupuncture and
whose education has not included instruction in acupuncture.
(d) The board shall encourage every physician and surgeon to take nutrition as part of their continuing education, particularly a physician and surgeon involved in primary care.
(e) The board shall consider including a course in elder abuse detection and treatment to be taken by those licensees whose practices are of a nature that there is a likelihood of contact with abused or neglected persons 65 years of age and older.
(f) In determining its continuing education requirements, the board shall consider including a course in the early detection and treatment of substance abusing pregnant women to be taken by those licensees whose practices are of a nature that there is a likelihood of contact with these women.
(g) In determining its continuing education requirements, the board shall consider including a course in the special care needs of drug-addicted infants to be taken by those licensees whose practices are of a nature that there is a likelihood of contact with these infants.
(h) In determining its continuing education requirements, the board shall consider including a course providing training and guidelines on how to routinely screen for signs exhibited by abused women, particularly for physicians and surgeons in emergency, surgical, primary care, pediatric, prenatal, and mental health settings. In the event the board establishes a requirement for continuing education coursework in spousal or partner abuse detection or treatment, that requirement shall be met by each licensee within no more than four years from the date the requirement is imposed.
(i) In determining its continuing education requirements, the board shall consider including a course in the special care needs of individuals and their families facing end-of-life issues, including, but not limited to, all of the following:
(1) Pain and symptom management.
(2) The psychosocial dynamics of death.
(3) Dying and bereavement.
(4) Hospice care.
(j) In determining its continuing education requirements, the board shall give its highest priority to considering a course on pain management and the risks of addiction associated with the use of Schedule II drugs.
(k) In determining its continuing education requirements, the board shall consider including a course in geriatric care for emergency room physicians and surgeons.
(l)In determining its continuing education requirements, the board shall consider including a course in menopausal mental or physical health.
SEC. 3.
Section 2454.7 is added to the Business and Professions Code, to read:2454.7.
(a) Beginning July 1, 2027, a qualifying osteopathic physician and surgeon who completes continuing medical education courses in perimenopause, menopause, and postmenopausal care shall receive two hours of credit for each hour completed of that coursework, for a total earned credit that does not exceed eight course hours, toward the requirement set forth in Section 1635 of Title 16 of the California Code of Regulations.(b) For purposes of this section, “qualifying osteopathic physician and surgeon” means a holder of a physician’s and surgeon’s certificate who is certified by a member board of the American Board of Medical Specialties or the American Osteopathic Association in internal medicine, family medicine, obstetrics and gynecology,
neurology, neurological surgery, or psychiatry and whose patient population is composed of adult women under 65 years of age.
SEC. 4.
Section 2811.5 of the Business and Professions Code is amended to read:2811.5.
(a) Each person renewing their license under Section 2811 shall submit proof satisfactory to the board that, during the preceding two-year period, they have been informed of the developments in the registered nurse field or in any special area of practice engaged in by the licensee, occurring since the last renewal thereof, either by pursuing a course or courses of continuing education in the registered nurse field or relevant to the practice of the licensee, and approved by the board, or by other means deemed equivalent by the board.(b) Notwithstanding Section 10231.5 of the Government Code, the board, in compliance with Section 9795 of the Government Code, shall do the following:
(1) By January
1, 2019, deliver a report to the appropriate legislative policy committees detailing a comprehensive plan for approving and disapproving continuing education opportunities.
(2) By January 1, 2020, report to the appropriate legislative committees on its progress implementing this plan.
(c) For purposes of this section, the board shall, by regulation, establish standards for continuing education. The standards shall be established in a manner to ensure that a variety of alternative forms of continuing education are available to licensees, including, but not limited to, online, academic studies, in-service education, institutes, seminars, lectures, conferences, workshops, extension studies, and home study programs. The standards shall take cognizance of specialized areas of practice, and content shall be relevant to the practice of nursing and shall be related to the scientific
knowledge or technical skills required for the practice of nursing or be related to direct or indirect patient or client care. The continuing education standards established by the board shall not exceed 30 hours of direct participation in a course or courses approved by the board, or its equivalent in the units of measure adopted by the board.
(d) The board shall audit continuing education providers at least once every five years to ensure adherence to regulatory requirements, and shall withhold or rescind approval from any provider that is in violation of the regulatory requirements.
(e) The board shall encourage continuing education in spousal or partner abuse detection and treatment. In the event the board establishes a requirement for continuing education coursework in spousal or partner abuse detection or treatment, that requirement shall be met by each licensee within no
more than four years from the date the requirement is imposed.
(f) In establishing standards for continuing education, the board shall consider including a course in the special care needs of individuals and their families, including, but not limited to, all of the following:
(1) Pain and symptom management, including palliative care.
(2) The psychosocial dynamics of death.
(3) Dying and bereavement.
(4) Hospice care.
(g) (1) In establishing standards for continuing education, the board shall consider including a course in menopausal mental or physical health.
(2) In establishing standards for continuing education, the board shall consider including a course in maternal mental health.
(h) This section shall not apply to licensees during the first two years immediately following their initial licensure in California or any other governmental jurisdiction, except that, beginning January 1, 2023, those licensees shall complete one hour of direct participation in an implicit bias course offered by a continuing education provider approved by the board that meets all the same requirements outlined in paragraph (1) of subdivision (f) of Section 2786, including, but not limited to, the identification of the licensees’ previous or current unconscious biases and misinformation and corrective measures to decrease implicit bias at the interpersonal and institutional levels, including ongoing policies and practices for that purpose.
(i) The board may, in accordance with the intent of this section, make exceptions from continuing education requirements for licensees residing in another state or country, or for reasons of health, military service, or other good cause.
(j) For the purpose of fulfilling the requirements of subdivision (a), a the following apply:
(1) A nurse practitioner who provides primary care to a patient population of which over 25 percent are 65 years of age or
older shall certify that they have completed at least 20 percent of all existing mandatory continuing education hours in a course in the field of gerontology, the special care needs of patients with dementia, or the care of older patients at the time of renewal.
(2) Beginning July 1, 2027, a nurse practitioner who provides care to a patient population composed of adult women under 65 years of age who completes one or more continuing education courses in perimenopause, menopause, or postmenopausal care shall receive two hours for each hour of a completed course, not to exceed six hours, if the following are met:
(A) The course or course provider is accredited by one of the following:
(i) American Nurses Credentialing Center.
(ii) American Association of Nurse Practitioners.
(iii) Accreditation Council for Continuing Medical Education.
(iv) Joint Accreditation for Interprofessional Continuing Education.
(v) The successor organization to an organization specified under this subparagraph.
(B) If the course covers multiple topics, the additional hours are only granted for the hours specified by the course provider as covering perimenopause, menopause, or postmenopausal care.
SEC. 5.
Section 3524.65 is added to the Business and Professions Code, immediately following Section 3524.6, to read:3524.65.
Notwithstanding subdivision (e) of Section 3524.5, beginning July 1, 2027, a physician assistant who provides care to a patient population composed of adult women under 65 years of age who completes one or more continuing education courses in perimenopause, menopause, or postmenopausal care shall receive two hours towards the requirement in Section 3524.5 for each hour of a completed course, not to exceed eight hours.SEC. 6.
Section 100520.5 of the Government Code is amended to read:100520.5.
(a) The Health Care Affordability Reserve Fund is hereby created in the State Treasury.(b) Notwithstanding any other law, the Controller may use the funds in the Health Care Affordability Reserve Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381.
(c) Upon the enactment of the Budget Act of 2021, and upon order of the Director of Finance, the Controller shall transfer three hundred thirty-three million four hundred thirty-nine thousand dollars ($333,439,000) from the General Fund to the Health Care Affordability Reserve Fund.
(d) Upon appropriation by the Legislature, the Health Care Affordability
Reserve Fund shall be utilized, in addition to any other appropriations made by the Legislature for the same purpose, for the purpose of health care affordability programs, and benefit programs pursuant to Section 100503.6, and payments authorized pursuant to Section 100503.5, operated by the California Health Benefit Exchange.
(e) (1) The California Health Benefit Exchange shall, in consultation with stakeholders and the Legislature, develop options for providing cost sharing reduction subsidies to reduce cost sharing for low- and middle-income Californians. On or before January 1, 2022, the Exchange shall report those developed options to the Legislature, Governor, and the Healthy California for All Commission, established pursuant
to Section 1001 of the Health and Safety Code, for consideration in the 2022–23 budget process.
(2) In developing the options, the Exchange shall do all of the following:
(A) Include options for all Covered California enrollees with income up to 400 percent of the federal poverty level to reduce cost sharing, including copays, deductibles, coinsurance, and maximum out-of-pocket costs.
(B) Include options to provide zero deductibles for all Covered California enrollees with income under 400 percent of the federal poverty level and upgrading those with income between 200 percent and 400 percent, inclusive, of the federal poverty level to gold-tier cost sharing.
(C) Address any operational issues that might impede implementation of enhanced cost-sharing
reductions for the 2023 calendar year.
(D) Maximize federal funding and address interactions with federal law regarding federal cost-sharing reduction subsidies.
(3) The Exchange shall make the report publicly available on its internet website.
(4) The Exchange shall submit the report in compliance with Section 9795 of the Government Code.
(f) Upon order of the Department of Finance, a loan of six hundred million dollars ($600,000,000) is authorized from the Health Care Affordability Reserve Fund to the General Fund in the 2023–24 fiscal year. The loan shall be repaid in annual installments of two hundred million dollars ($200,000,000) over the 2026–27, 2027–28, and 2028–29 fiscal years.
SEC. 7.
Section 1253.4 is added to the Health and Safety Code, to read:1253.4.
(a) (1) A general acute care hospital, as defined in subdivision (a) of Section 1250, seeking to provide skilled nursing services in a distinct part shall submit an application and documentation to the State Department of Public Health. If the distinct part meets the requirements and criteria specified in this section, the department may approve a hospital’s application for a distinct part on a case-by-case basis consistent with Section 1254.(2) “Distinct part” means an identifiable unit accommodating beds and related facilities, including, but not limited to, contiguous rooms, a wing, a floor, or a building. A skilled nursing distinct part may comprise one or more buildings or designated parts of buildings. The term
“distinct part” includes a “composite distinct part” that is not on the hospital’s campus and that meets the definition, requirements, and other criteria specified in this section.
(A) “Composite distinct part” means a distinct part consisting of two or more noncontiguous components that are not located within the same campus.
(B) “Campus” means the physical area immediately adjacent to the hospital’s main buildings or to other areas and structures that are not strictly contiguous to the main buildings.
(C) If the requirements for a “distinct part” and a “composite distinct part” conflict, then the more specific and strict standards shall apply.
(b) A skilled nursing distinct part shall meet and be subject to state licensing statutes and regulations
applicable to skilled nursing facilities, unless there is a specific exception or exemption applicable to a distinct part.
(c) (1) A skilled nursing distinct part shall meet all of the following conditions:
(A) Be under the same ownership, control, and governance as the general acute care hospital of which it is a distinct part.
(B) Be wholly owned by the general acute care hospital of which it is a distinct part.
(C) Be subject to the bylaws and operating decisions of the hospital’s governing body.
(2) The general acute care hospital shall have final responsibility for the skilled nursing distinct part’s administrative decisions and personnel policies and
procedures.
(d) A general acute care hospital seeking to add a composite distinct part to its license shall submit a proposal to the department demonstrating that a composite distinct part would improve access to care and serve a specific unmet need in the geographical area served by the hospital. If the department determines that the composite distinct part may improve access to care and address a specific unmet need in the geographical area served by the hospital, the general acute care hospital may submit an application with documentation for approval of a composite distinct part.
(e) In deciding whether to approve a general acute care hospital’s application for a composite distinct part, the department may consider the following additional criteria:
(1) Whether the facility is in a rural or underserved area.
(2) The compliance history of the general acute care hospital, the existing distinct part, and the entities and individuals involved with the ownership, administration, operation, and governance of the facilities.
(3) The plan of operation and plan for sharing services with the general acute care hospital and other components of the composite distinct part.
(4) Ability to demonstrate and maintain compliance with the requirements of this section and the licensing statutes and regulations applicable to skilled nursing facilities.
(5) Whether the general acute care hospital and the components of the composite distinct part are so organizationally or geographically separate that it is not feasible to operate and provide safe, quality, and adequate care as a
single licensed entity.
(6) Any additional criteria that the department deems relevant or necessary to protect resident safety or ensure quality of care.
(f) Each composite distinct part component that is not located on the general acute care hospital’s campus shall have a dedicated nursing home administrator.
(g) The skilled nursing distinct part shall be integrated with the general acute care hospital of which it is a distinct part. The skilled nursing distinct part shall function as an integral and subordinate part of the hospital of which it is a distinct part, which includes, but is not limited to, common resource usage of buildings, equipment, personnel, and services.
(h) A general acute care hospital shall have a maximum of only one licensed
skilled nursing distinct part, which may be a composite distinct part.
(1) A general acute care hospital with a distinct part or composite distinct part shall have only one license number.
(2) The department shall identify on the general acute care hospital’s license each distinct part, including the number of beds, location, and address of each distinct part and components of a composite distinct part.
(i) Each freestanding component of a composite distinct part shall independently meet all of the licensing requirements applicable to a freestanding skilled nursing facility, including staffing requirements and ratios. Staffing exceptions for distinct parts, including, but not limited to, the distinct part exception in Section 1276.65, shall not apply to a freestanding component of a composite distinct part.
(j) The general acute care hospital shall not use composite distinct parts to segregate residents by payment source or on a basis other than care needs.
(k) Existing distinct parts shall meet the requirements of this section before they are approved as a composite distinct part. In deciding whether to approve a consolidation, change of ownership, or other similar restructuring, the department shall consider whether the composite distinct part meets the requirements and satisfies the criteria described in this section.
(l) Notwithstanding any other law, the department may, without taking any regulatory actions pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of an All Facilities Letter (AFL) or
similar instruction.
SEC. 8.
Section 1254 of the Health and Safety Code is amended to read:1254.
(a) Except as provided in subdivisions (e) and (f), the state department shall inspect and license health facilities. The state department shall license health facilities to provide their respective basic services specified in Section 1250. Except as provided in Section 1253, the state department shall inspect and approve a general acute care hospital to provide special services as specified in Section 1255. The state department shall develop and adopt regulations to implement the provisions contained in this section.(b) Upon approval, the state department shall issue a separate license for the provision of the basic services enumerated in subdivision (c) or (d) of Section 1250 whenever these basic services are to be provided by an acute care hospital, as
defined in subdivision (a), (b), or (f) of that section, where the services enumerated in subdivision (c) or (d) of Section 1250 are to be provided in any separate freestanding facility, whether or not the location of the separate freestanding facility is contiguous to the acute care hospital. The same requirement shall apply to any new freestanding facility constructed for the purpose of providing basic services, as defined in subdivision (c) or (d) of Section 1250, by any acute care hospital on or after January 1, 1984.
(c) (1) Those beds licensed to an acute care hospital which, prior to January 1, 1984, were separate freestanding beds and were not part of the physical structure licensed to provide acute care, and which beds were licensed to provide those services enumerated in subdivision (c) or (d) of Section 1250, are exempt from the requirements of subdivision (b).
(2) (A) All beds licensed to an acute care hospital and located within the physical structure in which acute care is provided are exempt from the requirements of subdivision (b) irrespective of the date of original licensure of the beds, or the licensed category of the beds.
(B) Licensed skilled nursing beds in a distinct part located on a general acute care hospital’s campus are exempt from subdivision (b). If a general acute care hospital has a distinct part approved for skilled nursing beds on its campus, the state department may approve additional licensed skilled nursing beds in a composite distinct part that meets the applicable definition, requirements, and criteria set forth in Section 1253.4. A composite distinct
part is exempt from subdivision (b) only if the general acute care hospital’s license has a distinct part on its campus approved for skilled nursing.
(3) All beds licensed to an acute care hospital owned and operated by the State of California or any other public agency are exempt from the requirements of subdivision (b).
(4) All beds licensed to an acute care hospital in a rural area as defined by Chapter 1010, of the Statutes of 1982, are exempt from the requirements of subdivision (b), except where there is a freestanding skilled nursing facility or intermediate care facility which
that has experienced an occupancy rate of 95 percent or less during the past 12 months within a 25-mile radius or which that may be reached within 30 minutes using a motor vehicle.
(5) All beds licensed to an acute care hospital which that meet the criteria for designation within peer group six or eight, as defined in the report entitled Hospital Peer Grouping for Efficiency Comparison, dated December 20, 1982, and published by the California Health Facilities Commission, and all beds in hospitals which
that have fewer than 76 licensed acute care beds and which that are located in a census designation place of 15,000 or less population, are exempt from the requirements of subdivision (b), except where there is a freestanding skilled nursing facility or intermediate care facility which that has experienced an occupancy rate of 95 percent or less during the past 12 months within a 25-mile radius or which that
may be reached within 30 minutes using a motor vehicle.
(6) All beds licensed to an acute care hospital which that has had a certificate of need approved by a health systems agency on or before July 1, 1983, are exempt from the requirements of subdivision (b).
(7) All beds licensed to an acute care hospital are exempt from the requirements of subdivision (b), if reimbursement from the Medi-Cal program for beds licensed for the provision of services enumerated in subdivision (c) or (d) of Section 1250 and not otherwise exempt does not exceed the reimbursement which
that would be received if the beds were in a separately licensed facility.
(d) Except as provided in Section 1253, the state department shall inspect and approve a general acute care hospital to provide special services as specified in Section 1255. The state department shall develop and adopt regulations to implement subdivisions (a) to (d), inclusive, of this section.
(e) The State Department of Health Care Services shall inspect and license psychiatric health facilities. The State Department of Health Care Services shall license psychiatric health facilities to provide their basic services specified in Section 1250.2. The State Department of Health Care Services shall develop, adopt, or amend regulations to implement this subdivision.
(f) The State Department of Health
Care Services shall inspect and license psychiatric residential treatment facilities as defined in Section 1250.10.
SEC. 9.
Section 1256.05 of the Health and Safety Code is amended to read:1256.05.
(a) For purposes of this section and Section 1256.06, the following definitions apply:(1) “Critical access hospital” means a hospital designated by the State Department of Public Health as a critical access hospital, and certified as such by the Secretary of the United States Department of Health and Human Services under the federal Medicare Rural Hospital Flexibility Program.
(2) “Department” means the State Department of Public Health, unless otherwise specified.
(3) “Standardized order sets” means predefined groups of orders that support clinical decisions, including, but not limited to, appropriate treatments, medications, and
dosages, for specific conditions or procedures and that are developed using relevant evidence-based guidelines.
(4) “Standby perinatal services” means the provision of obstetric and neonatal medical care to patients who are transferred from an alternative birth center, or who present to the hospital’s emergency department with an urgent or emergent obstetric issue, in a specifically designated area of the hospital that is equipped and maintained at all times to receive patients and capable of providing physician, midwifery, and nursing services within a reasonable time not to exceed 30 minutes.
(b) The department shall do all of the following:
(1) By July 1, 2026, establish a 10-year pilot project within up to five critical access hospitals to allow participating hospitals to establish standby perinatal services. If
qualified, the first two three hospitals selected shall be nonprofit and located in the County of Humboldt and the County of Counties of Humboldt, Lake, and Plumas. Up to three two additional critical access hospitals may be selected at any time if the application includes a signed agreement from the exclusive employee representatives of the workforce that the proposed pilot project site would not adversely impact the workforce or includes an
attestation that there is no existing exclusive employee representative.
(2) Within a reasonable time, determine whether hospitals requesting to participate meet applicable statutory requirements, including, but not limited to, maintaining all of the following:
(A) Ability to meet the standards of the standby perinatal service, as described in Section 1256.06.
(B) Provide surgery Surgery and anesthesia as basic services of the hospital.
(C) Maintain capability Capability
for obtaining or performing timely blood gas, pH, and microbiologic analyses.
(D) Provide ability Ability to maintain premixed infusions.
(E) Maintain a A basic emergency medical service, comprehensive emergency medical service, or standby emergency medical service licensed as a supplemental service.
(F) (i) Have a A
designated room or rooms for the standby perinatal service space. A hospital may designate an existing room or rooms with a licensed general acute care bed as the standby perinatal service space. If a hospital designates an existing room or rooms for the standby perinatal service space, the hospital may continue to provide general acute care services in that room or rooms when the room or rooms are not in use by the standby perinatal services only if all remaining general acute care beds are occupied or a plan for management of perinatal patients using alternate space is approved by the department.
(ii) The operating room may serve as the delivery room in hospitals having a licensed bed capacity of 25 or less, but the operating room shall not serve as the sole standby perinatal service space.
(G)
(3) In consultation with stakeholders, establish any additional requirements that the department deems necessary to protect patient safety or to ensure quality of care under the pilot project.
(3)
(4) (A) Develop a template to collect and evaluate data on safety, outcomes, utilization, and populations served under the pilot project using stratified demographic data, to the extent statistically reliable data are available and comply with medical privacy laws and practices. The department
may, in consultation with relevant stakeholders, establish additional requirements for participating hospitals to collect and report any additional data under the pilot project that the department deems necessary.
(B) Compile the data collected pursuant to subparagraph (A), prepare and submit an evaluation to the Legislature, and make the evaluation publicly available. The department shall submit the evaluation to the Legislature on or before two years after the completion of the pilot project. Data-collection requests shall be provided in a timely manner to enable the pilot hospital to collect and report the data before the deadline. The evaluation to be submitted to the Legislature pursuant to this subparagraph shall be submitted in compliance with Section 9795 of the Government Code.
(4)
(5) Consult with relevant state departments and stakeholders on the matter of meeting
implementation of the requirements of this subdivision. Stakeholders shall include The department shall invite representatives of hospitals, consumers, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Nurse-Midwives, health plans, labor, and other health care professionals who provide pediatric and pregnancy-related services, including, but not limited to, registered nurses, certified nurse-midwives, and licensed midwives.
(c) A hospital seeking to participate in the pilot project shall submit an application to the department.
(d) An
approved standby perinatal service shall be subject to all relevant licensing enforcement provisions as established under this chapter and Chapter 1 (commencing with Section 70001) of Division 5 of Title 22 of the California Code of Regulations.
(e) If, at any time, a hospital with a standby perinatal service fails to meet the requirements set forth in this section or Section 1256.06, or fails to ensure patient health and safety, as determined by the department, the department may suspend or revoke its approval of the hospital’s participation in the pilot project.
(f)(1)Notwithstanding any other law or regulation, a hospital participating in the pilot project may, in consultation with the medical and any other relevant staff, request program flexibility for the statutory requirements of this section or Section 1256.06, in order to meet the particular capacities and needs of the hospital and community.
(2)If the department approves the request described in paragraph (1), the department’s approval shall provide for the terms and conditions under which the program flexibility is granted.
(3)To request program flexibility for the statutory requirements of this section or Section 1256.06, the hospital shall follow existing procedures established by the department for program flexibility requests pursuant to subdivision (b) of Section 1276.
(g)
(f) Notwithstanding any other law, the department may, without taking any regulatory actions pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section and Section 1256.06 by means of an All Facilities Letter (AFL) or similar instruction.
SEC. 10.
Section 1256.06 of the Health and Safety Code is amended to read:1256.06.
A hospital requesting approval to establish a standby perinatal service pursuant to Section 1256.05 shall implement and maintain all of the following requirements:(a) (1) Comply with the most recent standards and recommendations for Level I (Basic Care) of the Levels of Maternal Care and Level 1 (Well Newborn Nursery) of the Neonatal Levels of Care, within the Guidelines for Perinatal Care developed by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.
(2) Have the capacity for operative delivery, including caesarean section, and neonatal resuscitation and stabilization at all times.
(3) Have the ability, equipment, and supplies necessary to provide care for mothers and infants needing emergency or immediate life support measures to sustain life up to 12 hours or to prevent major disability, including, but not limited to, all of the following services:
(A) Administration of intravenous or intramuscular antibiotics.
(B) Administration of intravenous or intramuscular uterotonic drugs, including oxytocin.
(C) Administration of intravenous or intramuscular anticonvulsants.
(D) Administration of antihypertensives.
(E) Manual removal of the placenta.
(F) Removal of retained products of
conception.
(G) Basic neonatal resuscitation.
(H) Surgery, including caesarean sections.
(I) Blood transfusions.
(J) Additional services specified by the department, in consultation with relevant stakeholders.
(4) Have capabilities for risk identification and determination of conditions necessitating consultation, referral, and transfer.
(5) Have capabilities, including necessary equipment, for stabilization and the ability to facilitate transfer or transport to a higher level of care at all times.
(6) (A) Have the equipment and supplies
specified in Section 70551 of Title 22 of the California Code of Regulations, or its successor.
(B) In addition to the items required under subparagraph (A), have all of the following equipment and supplies:
(i) A fetal heart rate monitor that includes both the ability to monitor multiple gestation pregnancies using internal monitors, including fetal scalp electrodes and intrauterine pressure catheters, and maternal pulse integrated to ensure monitoring of fetal pulse and not maternal pulse.
(ii) Provision for oxygen and suction for the mother and infant, including, but not limited to, specialized supplies needed for neonatal resuscitation and breathing support.
(iii) A ventilatory assistance bag and infant masks of assorted sizes for infants of
different gestational ages.
(iv) A postpartum hemorrhage kit, including a uterine tamponade device.
(v) Neonatal resuscitation supplies, including supplies for umbilical access for medications.
(vi) Maternal steroid medications available for initial administration in the case of preterm labor while awaiting transport.
(vii) A refrigerated medication storage unit in the standby perinatal service for uterotonic medications requiring refrigerated storage to be immediately accessible in emergencies.
(viii) A suction device appropriate for neonatal resuscitation.
(b) (1) In consultation with the medical
staff, define Define the responsibilities of the medical staff and administration associated with the standby perinatal services. Defined responsibilities shall be consistent with the medical staff bylaws and policies established in consultation with the medical staff.
(2) (A) Ensure that a provider that provides services pursuant to this section in the hospital of services subject to this section meets all applicable requirements set forth in both of the following:
(i) The medical staff bylaws.
(ii) Rules, regulations, and policies of that facility.
(B) Nothing in this section shall be construed to require changes to the medical staff bylaws or policies regarding credentialing or privileges.
(c) (1) Ensure that a physician who is certified, or eligible for certification, by the American Board of Obstetrics and Gynecology, the American Board of Pediatrics, or the American Board of Family Medicine, and who is a member of the medical staff of the facility, has overall responsibility of for the standby perinatal
services.
(2) The physician described in paragraph (1) shall be responsible for ensuring that contracts and agreements are in place as applicable and
for the development of of, and the hospital shall be responsible for the implementation of, policies and procedures for all of the following:
(A) Developing policies Policies and procedures specified in paragraphs (1) through (28) to (28), inclusive, of subdivision (b) of Section 70547 of Title 22 of the California Code of Regulations that align with the
standards specified in paragraph (1) of subdivision (a).
(B) Admission policies for infants transferred from an alternative birth center.
(C) Consultations, including, but not limited to, real-time telemedicine services, between the standby perinatal service and health care personnel from an intensive care newborn nursery and from a perinatal service, qualified and available at all times to provide maternal fetal medicine consultation.
(D) Formal arrangements for consultation or transfer of an infant to an intensive newborn nursery and a mother to a hospital with the necessary services for medical problems
needs beyond the capability of the standby perinatal services.
(E) Current state newborn screening requirements.
(F) Standby perinatal service activation protocols.
(G) Condition-specific management protocols outlining best practices.
(H) Emergency codes.
(I)Monitoring and checkoff to ensure that equipment stays in the standby perinatal service and does not outdate.
(J)
(I) Documentation standards for antepartum, intrapartum, postpartum, and newborn care.
(K)
(J) Surgery and anesthesia services readily available at all times.
(L)
(K) Arrangements for incidents of more than one patient requiring the use of the designated standby perinatal service space.
(M)
(L) Care management for mothers, fetuses, and neonates in alignment with the standards specified in this section.
(N)
(M) Development by an appropriate committee of the medical staff of standardized
obstetric and newborn nursing procedures and standardized order sets for pregnant patients presenting to the emergency department and for the standby perinatal service, and for neonates. Standardized order sets shall be annually reviewed and updated
The committee shall annually review the standardized order sets and update them as necessary.
(O)
(N) Convening of an appropriate obstetric and neonatal or pediatric committee that, at a minimum annually, evaluates the services provided and makes appropriate recommendations to the executive committee of the medical staff and administration.
(d) In consultation with the physician described in subdivision (c) and with other appropriate health care professionals, do all of the following:
(1) Implement and
maintain contracts, and transfer agreements as applicable, and develop and implement policies and procedures for any maternal or neonatal care outside the scope of the standby perinatal service, including, but not limited to, all of the following services:
(A) Transfer of mothers and neonates to appropriate higher levels of care, including a reliable, accurate, and comprehensive communication system between hospitals initiating and hospitals receiving a patient transfer from a standby perinatal service, hospital personnel, and transport teams.
(B) A blood bank, if the facility might need additional blood.
(C) Ambulance transport and rescue services.
(2) Develop a system for ensuring coverage to provide care for both the mother and the neonate, on call
24 hours a day for the standby perinatal service, including, but not limited to, both of the following:
(A) Physician and nursing staff coverage onsite within 30 minutes.
(B) A roster of physicians and certified nurse-midwives who have an agreement or contract with the hospital, and their immediate contact information, who are available to provide emergency perinatal services.
(3) Have a registered nurse immediately available within the hospital to provide nursing care, including emergency maternal fetal triage and infant resuscitation.
(4) Develop a roster of specialty physicians who have an agreement or contract with the hospital, and their immediate contact information, who are available for consultation at all times.
(5) Conduct monitoring and checkoff to ensure that equipment stays in the standby perinatal service and does not outdate. outdate, including a process for the medical staff to report equipment and supplies that are out of date or that were not replaced prior to expiration.
(6) Ensure continuing education for the medical staff.
(7) Establish, and document compliance with, continuing education and training program requirements for nursing staff in perinatal nursing and infection control, including, but not limited to, all of the following:
(A) Biennial, week-long
rotations at a Level II, III, or IV maternal or neonatal care facility.
(B) Participation in simulation-based training to reinforce response to obstetric emergencies.
(C) All other continuing education and training programs that are necessary to ensure the safe provision of care for both mothers and neonates in the standby perinatal service.
(8) (A) Annually verify and document all nursing competencies, including, but not limited to, maternal care, fetal and newborn care, postdelivery care, and emergency condition competencies.
(B) Maintain evidence of continuing education and training programs for the nursing staff in perinatal nursing and infection control, including all of the following:
(i) Documented current registered nurse license.
(ii) Current Basic Life Support (BLS) certification.
(iii) Current Advanced Cardiovascular Life Support (ACLS) certification.
(iv) Electronic fetal monitoring certification.
(v) S.T.A.B.L.E. neonatal education program certification.
(vi) Neonatal resuscitation program certification.
(e) Require a physician, certified-nurse midwife, certified
nurse-midwife, or registered nurse to attend to patients, within the scope of their licensure, under the effect of anesthesia or regional anesthesia, when in active labor, during delivery, or in the immediate postpartum period.
(f) Initiate and sustain an education program and develop
a quality improvement program that are specific to the standby perinatal services to maximize patient safety, in collaboration with facility partners that provide higher levels of care.
(g) Comply with the existing licensed nurse-to-patient ratios for a combined labor/delivery/postpartum area of perinatal services. This subdivision does not alter or amend the effect of any regulation adopted pursuant to Section 1276.4.
(h) Report the data required by Section 1256.05 quarterly and in the manner and method required by the department.
(i) Maintain compliance with federal Medicare obstetrical services conditions of participation, if applicable.
(j) (1) Notwithstanding any other law or regulation, a hospital participating in the pilot project may, in consultation with the medical staff and any relevant personnel, request program flexibility for the statutory requirements of this section, in order to meet the particular capacities and needs of the hospital and community.
(2) If the department approves the request described in paragraph (1), the department’s approval shall provide for the terms and conditions under which the program flexibility is granted.
(3) To request program flexibility for the statutory requirements of this section, the hospital shall follow existing procedures established by the department for program flexibility requests pursuant to subdivision (b) of Section 1276.
SEC. 11.
Section 1367.03 of the Health and Safety Code is amended to read:1367.03.
(a) A health care service plan that provides or arranges for the provision of hospital or physician services, including a specialized mental health plan that provides physician or hospital services, or that provides mental health services pursuant to a contract with a full service plan, shall comply with the following timely access requirements:(1) A health care service plan shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. A plan shall establish and maintain networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness
standard. A health care service plan that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.
(2) A health care service plan shall ensure that all plan and provider processes necessary to obtain covered health care services, including, but not limited to, prior authorization processes, are completed in a manner that assures the provision of covered health care services to an enrollee in a timely manner appropriate for the enrollee’s condition and in compliance with this section.
(3) If it is necessary for a provider or an enrollee to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs, and ensures continuity of care consistent with good professional practice, and consistent with this
section and the regulations adopted thereunder.
(4) Interpreter services required by Section 1367.04 of this code and Section 1300.67.04 of Title 28 of the California Code of Regulations shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. This subdivision does not modify the requirements established in Section 1300.67.04 of Title 28 of the California Code of Regulations, or approved by the department pursuant to Section 1300.67.04 of Title 28 of the California Code of Regulations for a plan’s language assistance program.
(5) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), a health care service plan shall ensure that its network has adequate capacity
and availability of licensed health care providers to offer enrollees appointments that meet the following timeframes:
(A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subparagraph (H).
(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subparagraph (H).
(C) Nonurgent appointments for primary care: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(D) Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and
(I).
(E) Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(F) Commencing July 1, 2022, nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subparagraph (H). This subparagraph does not limit coverage for nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.
(G) Nonurgent appointments for ancillary services for the diagnosis or treatment of injury,
illness, or other health condition: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(H) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.
(I) Preventive care services, as defined in subdivision (e), and periodic followup care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder conditions, and
laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
(J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subparagraph (A), (B), or (D), unless the requirements in subparagraph (H) or (I) are met, and shall be subject to the other provisions of this section.
(K) A plan may demonstrate compliance with the primary care time-elapsed standards established by this subdivision through implementation of standards, processes, and systems providing advanced access to primary care appointments, as defined in subdivision (e).
(6) In
addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), each dental plan, and each full service plan offering coverage for dental services, shall ensure that dental networks have adequate capacity and availability of licensed health care providers to offer enrollees appointments for covered dental services in accordance with the following requirements:
(A) Urgent appointments within the dental plan network shall be offered within 72 hours of the time of request for appointment, if consistent with the enrollee’s individual needs and as required by professionally recognized standards of dental practice.
(B) Nonurgent appointments shall be offered within 36 business days of the request for appointment, except as provided in subparagraph (C).
(C) Preventive dental care
appointments shall be offered within 40 business days of the request for appointment.
(7) A plan shall ensure it has sufficient numbers of network providers to maintain compliance with the standards established by this section.
(A) This section does not modify the requirements regarding provider-to-enrollee ratio or geographic accessibility established by Section 1300.51, 1300.67.2, or 1300.67.2.1 of Title 28 of the California Code of Regulations.
(B) A plan operating in a network service area that has a shortage of one or more types of providers shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by referring an enrollee to, or, in the case of a preferred provider network, by assisting an enrollee to locate available and accessible
network providers in neighboring network service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee’s health needs.
(C) A plan shall arrange for the provision of covered services from providers outside the plan’s network if unavailable within the network if medically necessary for the enrollee’s condition. A plan shall ensure that enrollee costs for medically necessary referrals to nonnetwork providers shall not exceed applicable in-network copayments, coinsurance, and deductibles. This requirement does not prohibit a plan or its delegated provider group from accommodating an enrollee’s preference to wait for a later appointment from a specific network provider. If medically necessary treatment of a mental health or substance use disorder is not available in network within the geographic and timely access standards set by law or regulation, a health care service plan
shall arrange coverage outside the plan’s network in accordance with subdivision (d) of Section 1374.72.
(8) A plan shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone, as defined in subdivision (e).
(A) A plan shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee’s condition, and that the triage or screening waiting time does not exceed 30 minutes.
(B) A plan may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: plan-operated telephone triage or screening services, telephone medical advice services pursuant to Section 1348.8, the plan’s primary care and mental health care or substance use disorder network, or
another method that provides triage or screening services consistent with this section.
(i) A plan that arranges for the provision of telephone triage or screening services through network primary care, mental health care, and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening enrollee telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine, an answering service, or office staff, that shall inform the caller of both of the following:
(I) Regarding the length of wait for a return call from the provider.
(II) How the caller may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or if
needed, deliver urgent or emergency care.
(ii) A plan that arranges for the provision of triage or screening services through network primary care, mental health care, and substance use disorder providers who are unable to meet the time-elapsed standards established in subparagraph (A) shall also provide or arrange for the provision of plan-contracted or operated triage or screening services, which shall, at a minimum, be made available to enrollees affected by that portion of the plan’s network.
(iii) An unlicensed staff person handling enrollee calls may ask questions on behalf of a licensed staff person to help ascertain the condition of an insured so that the enrollee may be referred to licensed staff. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions in an attempt to assess, evaluate, advise, or make a decision
regarding the condition of an enrollee or determine when an enrollee needs to be seen by a licensed medical professional.
(9) Dental, vision, chiropractic, and acupuncture plans shall ensure that network providers employ an answering service or a telephone answering machine during nonbusiness hours, which provide instructions regarding how an enrollee may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or if needed, deliver urgent or emergency care.
(10) A plan shall ensure that, during normal business hours, the waiting time for an enrollee to speak by telephone with a plan customer service representative knowledgeable and competent regarding the enrollee’s questions and concerns shall not exceed 10 minutes.
(b) With regard to subdivision (a), dental, vision, chiropractic, and acupuncture plans shall comply with paragraphs (1), (3), (4), (7), (9), and (10).
(c) The obligation of a plan to comply with this section shall not be waived if the plan delegates to its provider groups or other contracting entities any services or activities that the plan is required to perform. A plan’s implementation of this section shall be consistent with the Health Care Providers’ Bill of Rights, and a material change in the obligations of a plan’s network providers shall be considered a material change to the provider contract, within the meaning of subdivision (b) and paragraph (2) of subdivision (h) of Section 1375.7.
(d) A health care service plan shall incorporate the standards set forth in subdivision (a) into the health plan’s quality assurance systems and the processes set forth in
Sections 1367 and 1370 of this code and Title 28 of the California Code of Regulations, including Sections 1300.67.2, 1300.67.2.2, 1300.68, and 1300.70. A plan shall not prevent, discourage, or discipline a network provider or employee for informing an enrollee or subscriber about the timely access standards.
(e) For purposes of this section:
(1) “Advanced access” means the provision, by a network provider, or by the provider group to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or the next business day.
(2) “Appointment waiting time” means the time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its network providers.
(3) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or another health condition and, in the case of a full service plan includes all of the basic health care services required by Sections 1345, 1367.002, 1367.3, and 1367.35 of this code and subdivision (f) of Section 1300.67 of Title 28 of the California Code of Regulations.
(4) “Provider group” has the meaning set forth in subdivision (g) of Section
1373.65.
(5) “Triage” or “screening” means the assessment of an enrollee’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care for the purpose of determining the urgency of the enrollee’s need for care.
(6) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care.
(7) “Urgent care” means health care for a condition that requires prompt attention, consistent with paragraph (2) of subdivision (h) of Section 1367.01.
(f) (1) Contracts between health care service plans and health care providers shall ensure compliance with the standards developed under this chapter. These contracts shall require reporting by health care providers to health care service plans and by health care service plans to the department to ensure compliance with the standards.
(2) Health care service plans shall report annually to the department on compliance with the standards in a manner specified by the department. The reported information shall allow consumers to compare the performance of plans and their network providers in complying with the standards, as well as changes in the compliance of plans with these standards.
(3) The department shall develop standardized methodologies for reporting that shall be used by health care service
plans to demonstrate compliance with this section and any regulations adopted pursuant to it, including demonstration of the average waiting time for each class of appointment regulated under this section, except the department may develop methodologies to demonstrate compliance with, and the average appointment wait time for, each class of appointments regulated under paragraph (6) of subdivision (a). The methodologies shall be sufficient to determine compliance with the standards developed under this section for different networks of providers if a health care service plan uses a different network for Medi-Cal managed care products than for other products or if a health care service plan uses a different network for individual market products than for small group market products. The development and adoption of these methodologies shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December
31, 2025. The department shall consult with stakeholders in developing standardized methodologies under this paragraph.
(4) Notwithstanding paragraph (3), the department may take compliance or disciplinary action, including assessment of administrative penalties, on the basis of noncompliance with any of the provisions of this section, including, but not limited to, timeframes for appointments and followup appointments.
(5) The department may review and adopt standards, in addition to those specified in this article, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. In so doing, the department shall consider the nature of physician practices, including individual and group practices, as well as the nature of the plan network. The department shall also consider various
circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. If the department finds that health care service plans and health care providers have difficulty meeting these standards, the department may make recommendations to the Assembly Committee on Health and the Senate Committee on Health pursuant to subdivision (i). The development and adoption of standards under this paragraph shall not be subject to the Administrative Procedure Act until December 31, 2028. The department shall consult with stakeholders in developing the standards and methodologies described in this section.
(g) (1) The director may investigate and, by order, take enforcement action against plans, including, but not limited to, assessing administrative penalties subject to appropriate notice of, and the opportunity for, a hearing in accordance with Section 1397, regarding
noncompliance with the requirements of this section. The director shall consider, as an aggravating factor when assessing administrative penalties, if harm to an enrollee, including financial or health impacts to an enrollee or substantial harm as defined in Section 3428 of the Civil Code, has occurred as a result of plan noncompliance. The director has the discretion to determine what harm constitutes harm to an enrollee. The plan may provide to the director, and the director may consider, information regarding the plan’s overall compliance with the requirements of this section. When taking enforcement action against a plan, the director may consider patterns of noncompliance. The administrative penalties shall not be deemed an exclusive remedy available to the director. These penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45. The director shall periodically evaluate grievances to determine if any audit,
investigative, or enforcement actions should be undertaken by the department.
(2) The director may, after appropriate notice and opportunity for hearing in accordance with Section 1397, by order, assess administrative penalties if the director determines that a health care service plan has knowingly committed, or has performed with a frequency that indicates a general business practice, either of the following:
(A) Repeated failure to act promptly and reasonably to assure timely access to care consistent with this chapter.
(B) Repeated failure to act promptly and reasonably to require network providers to assure timely access that the plan is required to perform under this chapter and that have been delegated by the plan to the network provider when the obligation of the plan to the enrollee or subscriber is
reasonably clear.
(C) The administrative penalties available to the director pursuant to this section are not exclusive, and may be sought and employed in any combination with civil, criminal, and other administrative remedies deemed warranted by the director to enforce this chapter.
(3) The administrative penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45.
(h) The department shall work with the patient advocate Department of Health Care Access and Information to assure that the quality of care report card incorporates information
provided pursuant to subdivision (f) regarding the degree to which health care service plans and health care providers comply with the requirements for timely access to care.
(i) The department shall annually review information regarding compliance with the standards developed under this section and shall make recommendations for changes that further protect enrollees. Commencing no later than December 1, 2015, and annually thereafter, the department shall post its final findings from the review on its internet website.
(j) The department shall post on its internet website any waivers or alternative standards that the department approves under this section on or after January 1, 2015.
(k) This section applies to a licensed health care service plan that provides services to Medi-Cal beneficiaries. Except for
appointment wait time standards set forth in paragraph (5) of subdivision (a) of this section and in Section 1300.67.2.2 of Title 28 of the California Code of Regulations, this section does not alter the requirements or standards of the State Department of Health Care Services specified in Section 14197 of the Welfare and Institutions Code.
(l) This section does not prevent the department from developing additional standards to improve timely access to care and network adequacy.
SEC. 12.
Section 1367.04 of the Health and Safety Code is amended to read:1367.04.
(a) Not later than January 1, 2006, the department shall develop and adopt regulations establishing standards and requirements to provide health care service plan enrollees with appropriate access to language assistance in obtaining health care services.(b) In developing the regulations, the department shall require every health care service plan and specialized health care service plan to assess the linguistic needs of the enrollee population, excluding Medi-Cal enrollees, and to provide for translation and interpretation for medical services, as indicated. A health care service plan that participates in the Healthy Families Program may assess the Healthy Families Program enrollee population separately from the remainder of its enrollee population for
purposes of subparagraph (A) of paragraph (1). A health care service plan that chooses to separate its Healthy Families Program enrollment from the remainder of its enrollee population shall treat the Healthy Families Program population separately for purposes of determining whether subparagraph (A) of paragraph (1) is applicable, and shall also treat the Healthy Families Program population separately for purposes of applying the percentage and numerical thresholds in subparagraph (A) of paragraph (1). The regulations shall include the following:
(1) Requirements for the translation of vital documents that include the following:
(A) A requirement that all vital documents, as defined pursuant to subparagraph (B), be translated into an indicated language, as follows:
(i) A health care service plan with an enrollment of
1,000,000 or more shall translate vital documents into the top two languages other than English as determined by the needs assessment as required by this subdivision and any additional languages when 0.75 percent or 15,000 of the enrollee population, whichever number is less, excluding Medi-Cal enrollment and treating Healthy Families Program enrollment separately indicates in the needs assessment as required by this subdivision a preference for written materials in that language.
(ii) A health care service plan with an enrollment of 300,000 or more but less than 1,000,000 shall translate vital documents into the top one language other than English as determined by the needs assessment as required by this subdivision and any additional languages when 1 percent or 6,000 of the enrollee population, whichever number is less, excluding Medi-Cal enrollment and treating Healthy Families Program enrollment separately indicates in the needs assessment
as required by this subdivision a preference for written materials in that language.
(iii) A health care service plan with an enrollment of less than 300,000 shall translate vital documents into a language other than English when 3,000 or more or 5 percent of the enrollee population, whichever number is less, excluding Medi-Cal enrollment and treating Healthy Families Program enrollment separately indicates in the needs assessment as required by this subdivision a preference for written materials in that language.
(B) Specification of vital documents produced by the plan that are required to be translated. The specification of vital documents shall not exceed that of the United States Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Policy Guidance (65 Federal Register 52762 (August 30, 2000)), but shall include all of the following:
(i) Applications.
(ii) Consent forms.
(iii) Letters containing important information regarding eligibility and participation criteria.
(iv) Notices pertaining to the denial, reduction, modification, or termination of services and benefits, and the right to file a grievance or appeal.
(v) Notices advising limited-English-proficient persons of the availability of free language assistance and other outreach materials that are provided to enrollees.
(vi) Translated documents shall not include a health care service plan’s explanation of benefits or similar claim processing information that is sent to enrollees, unless the document
requires a response by the enrollee.
(C) (i) For those documents described in subparagraph (B) that are not standardized but contain enrollee specific information, health care service plans shall not be required to translate the documents into the threshold languages identified by the needs assessment as required by this subdivision, but rather shall include with the documents a written notice of the availability of interpretation services in the threshold languages identified by the needs assessment as required by this subdivision. A health care service plan subject to the requirements in Section 1367.042 shall also include with the documents a written notice of the availability of interpretation services in the top 15 languages spoken by limited-English-proficient (LEP) individuals in California as determined by the State Department of Health Care Services.
(ii) Upon request, the enrollee shall receive a written translation of the documents described in clause (i). The health care service plan shall have up to, but not to exceed, 21 days to comply with the enrollee’s request for a written translation. If an enrollee requests a translated document, all timeframes and deadline requirements related to the document that apply to the health care service plan and enrollees under the provisions of this chapter and under any regulations adopted pursuant to this chapter shall begin to run upon the health care service plan’s issuance of the translated document.
(iii) For grievances that require expedited plan review and response in accordance with subdivision (b) of Section 1368.01, the health care service plan may satisfy this requirement by providing notice of the availability and access to oral interpretation services.
(D) A
requirement that health care service plans advise limited-English-proficient enrollees of the availability of interpreter services.
(2) Standards to ensure the quality and accuracy of the written translations and that a translated document meets the same standards required for the English language version of the document. The English language documents shall determine the rights and obligations of the parties, and the translated documents shall be admissible in evidence only if there is a dispute regarding a substantial difference in the material terms and conditions of the English language document and the translated document.
(3) Requirements for surveying the language preferences and needs assessments of health care service plan enrollees within one year of the effective date of the regulations that permit health care service plans to utilize various survey methods, including,
but not limited to, the use of existing enrollment and renewal processes, subscriber newsletters, or other mailings. Health care service plans shall update the needs assessment, demographic profile, and language translation requirements every three years.
(4) Requirements for individual enrollee access to interpretation services that include the following:
(A) A requirement that an interpreter meets, at a minimum, all of the following qualifications:
(i) Demonstrated proficiency in both English and the target language.
(ii) Knowledge in both English and the target language of health care terminology and concepts relevant to health care delivery systems.
(iii) Adheres to generally accepted
interpreter ethics principles, including client confidentiality.
(B) A requirement that the enrollee with limited English proficiency shall not be required to provide their own interpreter or rely on a staff member who does not meet the qualifications described in subparagraph (A) to communicate directly with the limited-English-proficient enrollee.
(C) A requirement that the enrollee with limited English proficiency shall not be required to rely on an adult or minor child accompanying the enrollee to interpret or facilitate communication except under either of the following circumstances:
(i) In an emergency, as described in Section 1317.1, if a qualified interpreter is not immediately available for the enrollee with limited English proficiency.
(ii) If the individual with limited English proficiency specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide that assistance, and reliance on that accompanying adult for that assistance is appropriate under the circumstances.
(5) Standards to ensure the quality and timeliness of oral interpretation services provided by health care service plans.
(c) In developing the regulations, standards, and requirements, the department shall consider the following:
(1) Publications and standards issued by federal agencies, such as the Culturally and Linguistically Appropriate Services (CLAS) in Health Care issued by the United States Department of Health and Human Services Office of Minority Health in December 2000, and the United States
Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Policy Guidance (65 Federal Register 52762 (August 30, 2000)).
(2) Other cultural and linguistic requirements under state programs, such as Medi-Cal Managed Care Policy Letters, cultural and linguistic requirements imposed by the State Department of Health Care Services on health care service plans that contract to provide Medi-Cal managed care services, and cultural and linguistic requirements imposed by the Managed Risk Medical Insurance Board on health care service plans that contract to provide services in the Healthy Families Program.
(3) Standards adopted by other states pertaining to language assistance requirements for health care service plans.
(4) Standards established by California or nationally recognized accrediting, certifying,
or licensing organizations and medical and health care interpreter professional associations regarding interpretation services.
(5) Publications, guidelines, reports, and recommendations issued by state agencies or advisory committees, such as the report card to the public on the comparative performance of plans and reports on cultural and linguistic services issued by the Center for Data Insights and Innovation and
the report to the Legislature from the Task Force on Culturally and Linguistically Competent Physicians and Dentists established by former Section 852 of the Business and Professions Code.
(6) Examples of best practices relating to language assistance services by health care providers and health care service plans, including existing practices.
(7) Information gathered from complaints to the HMO Helpline and consumer assistance centers regarding language assistance services.
(8) The cost of compliance and the availability of translation and interpretation services and professionals.
(9) Flexibility to accommodate variations in plan networks and method of service delivery. The department shall allow for health care service plan
flexibility in determining compliance with the standards for oral and written interpretation services.
(d) The department shall work to ensure that the biennial reports required by this section, and the data collected for those reports, are consistent with reports required by government-sponsored programs and do not require duplicative or conflicting data collection or reporting.
(e) The department shall seek public input from a wide range of interested parties through advisory bodies established by the director.
(f) A contract between a health care service plan and a health care provider shall require compliance with the standards developed under this section. In furtherance of this section, the contract shall require providers to cooperate with the plan by providing any information necessary to assess
compliance.
(g) The department shall report biennially to the Legislature and advisory bodies established by the director regarding plan compliance with the standards, including results of compliance audits made in conjunction with other audits and reviews. The reported information shall also be included in the publication required under subparagraph (B) of paragraph (1) of subdivision (b) of Section 136000. The department shall also utilize the reported information to make recommendations for changes that further enhance standards pursuant to this section. The department may also delay or otherwise phase-in implementation of standards and requirements in recognition of costs and availability of translation and interpretation services and professionals.
(h) (1) Except for contracts with the State Department of Health Care Services Medi-Cal program, the
standards developed under this section shall be considered the minimum required for compliance.
(2) The regulations shall provide that a health plan is in compliance if the plan is required to meet the same or similar standards by the Medi-Cal program, either by contract or state law, if the standards provide as much access to cultural and linguistic services as the standards established by this section for an equal or higher number of enrollees and therefore meet or exceed the standards of the regulations established pursuant to this section, and the department determines that the health care service plan is in compliance with the standards required by the Medi-Cal program. To meet this requirement, the department shall not be required to perform individual audits. The department shall, to the extent feasible, rely on audits, reports, or other oversight and enforcement methods used by the State Department of Health Care Services.
(3) The determination pursuant to paragraph (2) shall only apply to the enrollees covered by the Medi-Cal program standards. A health care service plan subject to paragraph (2) shall comply with the standards established by this section with regard to enrollees not covered by the Medi-Cal program.
(i) This section does not prohibit a government purchaser from including in their contracts additional translation or interpretation requirements, to meet linguistic or cultural needs, beyond those set forth pursuant to this section.
SEC. 13.
Section 1367.252 is added to the Health and Safety Code, to read:1367.252.
(a) A health care service plan contract that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date of this section shall include coverage for United States Food and Drug Administration-approved treatments used to treat menopausal symptoms, as medically necessary, including, but not limited to, all of the following:(1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss.
(2) Low-dose antidepressants.
(3) Anticonvulsants.
(4) Medications to prevent or treat osteoporosis.
(5) Nonhormonal medications for vasomotor-related symptoms.
(b) A health care service plan contract that is issued, amended, or renewed on or after January 1, 2027, shall include a program to ensure enrollees have access to current menopause information and covered items and services.
(c) For the program to satisfy subdivision (b), the plan shall do all of the following:
(1) Provide, no later than July 1, 2027, and biannually thereafter, all contracted providers
delivering primary care with information about current clinical care recommendations for menopause care, including hormone therapy, from the Menopause Society or other nationally recognized professional association. The plan shall encourage providers delivering primary care to review the information.
(2) Establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall identify the Current Procedural Terminology (CPT) codes for services commonly used to evaluate, diagnose, and treat symptoms resulting from menopause.
(3) Establish and maintain a policy to provide enrollees who may experience menopause and who are 40 years of age and older with an annual menopause assessment during primary care and obstetrician-gynecologist appointments.
Enrollees may opt out of receiving the assessments. The policy shall include a copy of the assessment tool and information on how it was developed or chosen.
(4) Provide enrollees who may experience menopause and who are age 40 years of age and older with a notice that includes a definition of menopause and that lists the covered items and services used to evaluate and treat symptoms resulting from menopause. The first notice shall be sent within 60 days of the enrollee’s 40th birthday and shall be sent biannually thereafter. Enrollees may opt out of receiving the notices. The notice shall include a description of at least all of the following types of federal Food and Drug Administration-approved items and services:
(A) Hormone therapy in the full range of formulations and methods of administration.
(B) Low-dose
antidepressants.
(C) Anticonvulsants.
(D) Medications to prevent or treat osteoporosis.
(E) Nonhormonal medications for vasomotor-related symptoms.
(5) Establish and maintain a policy to contract with providers delivering primary care, including advanced practice providers such as licensed nurse practitioners and certified nurse-midwives, who hold a certification or credential in menopause care from a nationally recognized organization, such as the Menopause Society or other similar organization. The policy shall state what steps the plan will take to incentivize providers to receive and maintain the certification or credential.
(d) The plan shall file with the director within six months
of the operative date of this statute the policies and notices specified in subdivision (c). The plan shall also disclose the policies to network providers, provider groups, and delegated entities that may be impacted by the policies and notices and shall attest to that disclosure to the director.
(e) Coverage for the treatment options pursuant to this section shall be provided without discrimination on the basis of gender expression or identity.
(f) This section does not apply to a Medi-Cal managed care plan contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. This section also does not apply to a Medicare supplement health care service plan contract. This section only applies to a specialized health care service
plan to the extent it provides coverage for the treatment of symptoms resulting from menopause.
(g) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause.
SEC. 14.
Section 1367.253 is added to the Health and Safety Code, to read:1367.253.
(a) A health care service plan shall base a medical necessity determination or the utilization review criteria that the plan, and an entity acting on the plan’s behalf, applies to determine the medical necessity of health care services and benefits for the treatment of symptoms resulting from menopause on current generally accepted standards of menopause care.(b) Beginning January 1, 2027, when conducting utilization review of all covered health care services and benefits for the treatment of symptoms resulting from menopause, a health care service plan shall apply criteria and guidelines developed by the Menopause Society or another nationally recognized professional association, as specified by the department.
(c) In conducting utilization review involving patient care decisions that are within the scope of the sources specified in subdivision (b), a health care service plan shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in those sources. This subdivision does not prohibit a plan from applying utilization review criteria to health care services and benefits for menopause care that meet either of the following criteria:
(1) Are outside the scope of the criteria and guidelines set forth in the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).
(2) Relate to advancements in technology or types of care that are not covered in the most recent versions of the
sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).
(d) If a health care service plan purchases or licenses utilization review criteria pursuant to paragraph (1) or (2) of subdivision (c), the plan shall verify and document before use that the criteria were developed in accordance with subdivision (a).
(e) A health care service plan shall not adopt, impose, or enforce terms in its contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with this section.
(f) For purposes of this section, the following definitions apply:
(1) “Generally accepted standards of menopause care” means standards of care and clinical practice that are generally
recognized by health care providers practicing in relevant clinical specialties, including gynecology, endocrinology, and family practice. Valid, evidence-based sources establishing generally accepted standards of menopause care include peer reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit health care provider professional associations, specialty societies, and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.
(2) “Menopause” includes perimenopause, menopause, and postmenopause.
(3) “Utilization review” means either of the following:
(A) Prospectively, retrospectively, or concurrently reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests
by health care providers, enrollees, or their authorized representatives for coverage of health care services prior to, retrospectively, or concurrent with the provision of health care services to enrollees.
(B) Evaluating the medical necessity, appropriateness, or efficacy of health care services, benefits, or procedures, under any circumstances, to determine if a health care service or benefit subject to a medical necessity coverage requirement in a health care service plan contract is covered as medically necessary for an enrollee.
(4) “Utilization review criteria” means criteria, standards, protocols, or guidelines used by a health care service plan to conduct utilization review.
(g) (1) This section applies to all health care services and benefits for the treatment of symptoms resulting
from menopause covered by a health care service plan contract, including prescription drugs.
(2) This section applies to a health care service plan that conducts utilization review and an entity or contracting provider that performs utilization review or utilization management functions on a plan’s behalf.
(3) This section does not apply to a Medi-Cal managed care plan contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. This section also does not apply to a Medicare supplement health care service plan contract. This section only applies to a specialized health care service plan to the extent it provides coverage for the treatment of symptoms resulting from menopause.
(h) The director may assess administrative penalties for violations of this section as provided for in Section 1368.04, in addition to any other remedies permitted by law.
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and Section 1367.252 by means of all-plan letters or similar instructions, without taking regulatory action, until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Insurance and interested stakeholders in developing guidance.
SEC. 15.
Section 1367.626 of the Health and Safety Code is amended to read:1367.626.
(a) (1) On or before January 1, 2025, a health care service plan shall develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas. This may be achieved by integrating the program into existing maternal mental health programs, including those encouraging the coverage of doula care, or by expanding existing doula programs.(2) (A) A Medi-Cal managed care plan shall be considered compliant with the requirements of this section by providing coverage of doula services so long as doula services are a Medi-Cal covered benefit.
(B) For the purpose of this
section, “Medi-Cal managed care plan” has the same meaning as provided in subdivision (j) of Section 14184.101 of the Welfare and Institutions Code.
(b) The department, in consultation with the Department of Insurance, shall collect data and submit a report describing the doula coverage and programs established pursuant to subdivision (a) to the Legislature by January 1, 2027. The report may do both of the following:
(1) Include the department’s Healthcare Effectiveness Data and Information Set (HEDIS) measures or the Center for Data Insights and Innovation’s quality of care report card. measures.
(2) Assess quality of care,
increased access, ongoing barriers to access, and more.
SEC. 16.
Section 1728.1 of the Health and Safety Code is amended to read:1728.1.
(a) To qualify for a home health agency license, the following requirements shall be met:(1) Every applicant shall satisfy the following conditions:
(A) Be of good moral character. If the applicant is a firm, association, organization, partnership, business trust, corporation, or company, all principal managing members thereof, and the person in charge of the agency for which application for license is made, shall satisfy this requirement. If the applicant is a political subdivision of the state or other governmental agency, the person in charge of the agency for which application for license is made, shall satisfy this requirement.
(B) Possess and demonstrate the ability to comply with this chapter and the rules and regulations adopted under this chapter by the state
department.
(C) File their application pursuant to and in full compliance with this chapter.
(2) (A) The following persons shall submit to the State Department of Public Health an application and shall submit electronic fingerprint images to the Department of Justice for the furnishing of the person’s criminal record to the state department, State Department of Public Health, at the person’s expense as provided in subdivision (b), for the purpose of a criminal record review:
(i) The owner or owners of a private agency if the owners are individuals.
(ii) If the owner of a private agency is a corporation, partnership, or association, any person having a 10
5 percent or greater interest in that corporation, partnership, or association.
(iii) The administrator of a home health agency.
(B) When the conditions set forth in paragraph (3) of subdivision (a) of Section 1265.5, subparagraph (A) of paragraph (1) of subdivision (a) of Section 1338.5, and paragraph (1) of subdivision (a) of Section 1736.6 are met, the licensing and certification program shall issue an All Facilities Letter (AFL) informing facility licensees. After the AFL is issued, facilities must not allow newly hired administrators, program directors, and fiscal officers to have direct contact with clients or residents of the facility prior to completion of the criminal record clearance. A criminal record clearance shall be complete when the department has obtained the person’s criminal offender record information search response
from the Department of Justice and has determined that the person is not disqualified from engaging in the activity for which clearance is required.
(3) The information required pursuant to this section shall be provided to the Licensing and Certification Program upon initial application for licensure. Unless otherwise specified, any change in the information that requires the licensee to submit a report of change or written notification to the Licensing and Certification Program shall be provided within 10 business days of the change along with any applicable fee according to subdivision (b) of Section 1266.
(b) The persons specified in paragraph (2) of subdivision (a) shall be responsible for any costs associated with transmitting the electronic fingerprint images. The fee to cover the processing costs of the Department of Justice, not including the costs associated with
capturing or transmitting the fingerprint images and related information, shall not exceed thirty-two dollars ($32) per submission.
(c) If the criminal record review conducted pursuant to paragraph (2) of subdivision (a) discloses a conviction for a felony or any crime that evidences an unfitness to provide home health services, the application for a license shall be denied or the person shall be prohibited from providing service in the home health agency applying for a license. This subdivision shall not apply to deny a license or prohibit the provision of service if the person presents evidence satisfactory to the state
department that the person has been rehabilitated and presently is of such good character as to justify the issuance of the license or the provision of service in the home health agency.
(d) An applicant and any other person specified in this section, as part of the background clearance process, shall provide information as to whether or not the person has any prior criminal convictions, has had any arrests within the past 12-month period, or has any active arrests, and shall certify that, to the best of their knowledge, the information provided is true. This requirement is not intended to duplicate existing requirements for individuals who are required to submit fingerprint images as part of a criminal background clearance process. Every applicant shall provide information on any prior administrative action taken against them by any federal, state, or local government agency and shall certify that, to the best of their
knowledge, the information provided is true. An applicant or other person required to provide information pursuant to this section that knowingly or willfully makes false statements, representations, or omissions may be subject to administrative action, including, but not limited to, denial of their application or exemption or revocation of any exemption previously granted.
(e) (1) A home health agency shall have an administrator, administrator designee, director of patient care services, and director of patient care services designee, and shall submit to the department all of the following information for each individual on an initial application:
(A) An HS 215A form or
its successor form.
(B) A résumé.
(C) A list of all licensed facilities and home health agencies in which the individual is currently serving as an administrator, administrator designee, director of patient care services, or director of patient care services designee.
(2) A home health agency shall notify the department of any change in the administrator, administrator designee, director of patient care services, or director of patient care services designee by submitting the information described in paragraph (1) within 10 business days of the change.
(3) All home health agencies shall report to the department the name of the agency’s administrator, administrator designee, director of patient care services, and director of patient care services
designee by submitting the information required in paragraph (1). Existing agencies shall provide this information no later than March 31, 2027.
(4) This subdivision does not apply to a branch office of a parent home health agency.
(f) (1) The department shall verify the status of professional licensure for home health agency management personnel.
(2) The department may also verify either or both of the following:
(A) Association of home health agency management personnel listed on the licensing application with the home health agency.
(B) Work history of home health agency management personnel.
(3) For
purposes of this subdivision, verification may include contacting the home health agency personnel or previous employers by telephone.
(g) (1) Except as provided in paragraph (2), an applicant for licensure of a home health agency or a branch office shall demonstrate an unmet need for home health services in the home health agency’s geographic service area.
(2) An applicant for a home health agency change of ownership does not need to comply with paragraph (1) for the previously approved service area if the license has been continuously held by the previous licensee for five years and one of the following conditions is met:
(A) The home health agency has previously qualified for licensure after demonstrating and providing evidence of unmet need of home health services in the home health agency’s
geographic service area.
(B) The home health agency can demonstrate it is meeting a need for home health services in the geographic service area.
(3) If the home health agency’s approved geographic service area will change upon the change in ownership, the new applicant for licensure shall demonstrate an unmet need for home health services for any new service area.
(4) The department may consider and request additional supporting evidence to determine whether there is an unmet need in the home health agency’s geographic service area.
SEC. 17.
Section 1728.3 of the Health and Safety Code is amended to read:1728.3.
(1) The home health agency demonstrates an unmet need for home health services in the home health agency’s geographic service area. The department may consider and request additional supporting evidence to determine whether there is an unmet need in the home health
agency’s geographic service area.
(a)
(2) The agency and the applicant for licensure substantially meet the standards specified by this chapter and regulations adopted pursuant to this chapter.
(b)
(3) No violation of this chapter or regulations adopted under this chapter exists in the agency which jeopardizes the health or safety of patients.
(c)
(4) The applicant has adopted a plan for correction of any existing violations which is satisfactory to the state department.
A
(b) A
provisional license issued under this section shall expire not later than six months after the date of issuance, or at an earlier time as determined by the state department at the time of issuance, and may shall not be renewed.
The
(c) The department shall not apply less stringent criteria when granting a
provisional license pursuant to this section than it applies when granting a permanent license.
SEC. 18.
Section 1728.7 of the Health and Safety Code is amended to read:1728.7.
(a) Notwithstanding any other provision of this chapter, the department shall issue a license to a home health agency that applies to the department for a home health agency license and meets all of the following requirements:(1) Is accredited as a home health agency by an entity approved by the federal Centers for Medicare and Medicaid Services as a national accreditation organization, and the national accreditation organization forwards to the department copies of all initial and subsequent survey and other accreditation reports or findings.
(2) Files an application with fees pursuant to this chapter.
(3) Demonstrates an unmet need for home health services in the home health agency’s geographic service area. The department may consider and request additional supporting evidence to determine whether there is an unmet need in the home health agency’s geographic service area.
(3)
(4) Meets any other additional licensure requirements of, or regulations adopted pursuant to, this chapter that the department identifies, after consulting with the national accreditation organizations, as more stringent than the accreditation requirements of the national accreditation organizations.
(b) The department may conduct a survey of an accredited home health agency to ensure the accreditation requirements are met. These surveys shall be conducted using a selective sample basis.
(c) The department may conduct a survey of an accredited
home health agency to investigate complaints against an accredited home health agency for substantial noncompliance, as determined by the department, with these accreditation standards.
(d) Notwithstanding subdivisions (a), (b), and (c), the department shall retain its full range of authority over accredited home health agencies to ensure the licensure and accreditation requirements are met. This authority shall include the entire scope of enforcement sanctions and options available for unaccredited home health agencies.
SEC. 19.
Section 1728.75 is added to the Health and Safety Code, to read:1728.75.
(a) A license issued by the department pursuant to this chapter shall not be transferable.(b) The department shall not approve a change of ownership of a licensed home health agency within five years of the date a license was initially issued to the licensee. Only the person, political subdivision of the state, or other governmental agency issued a license for the purposes of operating a home health agency may use that license during that initial five-year period.
(c) Notwithstanding subdivision (b), the department may make an exception for extenuating circumstances and approve a change of ownership within the initial five-year period if the home health agency demonstrates
and provides evidence to the department of either of the following:
(1) The need to ensure continuity of care for existing patients of the home health agency.
(2) The home health agency is suffering financial hardship and if it were to close, there would be an unmet need for home health services in the home health agency’s geographic service area.
SEC. 20.
Section 1728.9 is added to the Health and Safety Code, to read:1728.9.
Notwithstanding any other law and except as provided in Section 1728.95, beginning on the effective date of the act that added this section and until no later than 90 days following the effective date of the revised regulations adopted pursuant to Section 1734, the department shall not issue a new license to operate a home health agency or add a branch office to an existing license pursuant to this chapter.SEC. 21.
Section 1728.95 is added to the Health and Safety Code, to read:1728.95.
(a) The department may grant an exception to the moratorium imposed by Section 1728.9 upon making a written finding that an applicant for a new license to operate a home health agency or add a branch office to an existing license, or with a license application pending on the effective date of the act that added this section, has demonstrated an unmet need for home health services in the area where the applicant proposes to operate based on the concentration of all existing home health services in that area.(b) The department shall only issue a new license during the moratorium pursuant to an exception allowed under this section in accordance with this chapter.
SEC. 22.
Section 1734 of the Health and Safety Code is amended to read:1734.
(a) The(b) The state department shall adopt rules and regulations regarding the purchase, storage, furnishing, and transportation of legend devices for a patient of a home health agency. As used in this subdivision, “legend devices” means any device that bears the label “Caution: federal law restricts this device to sale by or on the order of a ____” or words of similar meaning.
(c) The department shall update existing home health agency regulations as necessary and adopt regulations that include, but are not limited to, all of the following:
(1) Clarify the maximum time and distance that home health agency staff may travel to reach patients, taking into consideration typical traffic conditions and whether the home health agency is serving patients in rural or urban areas.
(2) Establish a limit for the number of home health agencies that home health agency management personnel can be involved with concurrently.
(3) Establish specific requirements for home health agency office space.
SEC. 23.
Section 1735 of the Health and Safety Code is amended to read:1735.
The(a) Violation by the licensee of any of the provisions of this chapter or of any other law of this state or of the rules and regulations promulgated under this chapter.
(b) Aiding, abetting or permitting the commission of any illegal act.
(c) Misrepresentation of a material fact in the application for a license.
(d) Prior termination from the federal Medicare Program or the Medi-Cal program due to noncompliance, or licensure suspension or revocation, of a home health agency owned, operated, or managed by the applicant or licensee.
(e) Demonstration of a pattern and practice of violations of state or federal standards during the last three years of a home health agency owned, operated, or managed by the applicant or licensee.
(f) The applicant or licensee is on the List of Excluded Individuals/Entities of the United States Department of Health and Human Services Office of Inspector General.
(g) Failure by home health agency management personnel to cooperate with the department for the purposes of conducting an inspection or complaint investigation.
(h) Failure by a home health agency to report a change in owner, home health agency management personnel, service area, or location.
SEC. 24.
Section 11832.2 of the Health and Safety Code is amended to read:11832.2.
(a) As used in this chapter, “alcohol or other drug program” or “program” means a business entity with a physical location in the State of California that provides one or more of the following services to clients:(1) Treatment services.
(2) Recovery services.
(3) Detoxification Withdrawal management services.
(4) Medications for addiction treatment.
(b) An individual health care practitioner duly licensed and regulated under Division 2 (commencing with Section 500) of the Business and Professions Code, acting within the scope of their license or certificate is not a program as described in subdivision (a).
SEC. 25.
Section 11832.18 of the Health and Safety Code is amended to read:11832.18.
(a) If a program is alleged to be in violation of Section 11832.7, the department shall conduct a site visit to investigate the allegation. If the department finds evidence that the program is providing treatment, recovery,(1) The date by which the program shall cease providing services.
(2) Notice that the department may assess against the program a civil penalty of two thousand dollars ($2,000) per day for every day the program continues to provide services beyond the date specified in the notice.
(3) Notice that the case may be referred for civil proceedings if the program continues to provide services beyond the date specified in the notice.
(4) Inform the program of the certification requirements of this chapter.
(b) A person or entity found to be in violation of Section 11832.7 shall be prohibited from applying for initial certification for a period of five years from the date of the notice specified in subdivision (a).
(c) The department may levy a civil penalty for a
violation of Section 11832.7 in an amount not to exceed two thousand dollars ($2,000) per day for every day the program continues to provide services beyond the date specified in a notice pursuant to subdivision (a).
SEC. 26.
Section 11834.015 of the Health and Safety Code is amended to read:11834.015.
(a) The department shall adopt the American Society of Addiction Medicine treatment criteria, or an equivalent evidence-based standard, as the minimum standard of care for licensed facilities and shall require a licensee to maintain those standards with respect to the level of care to be provided by the licensee.(b)The department may implement, interpret, or make specific this section by means of plan or provider bulletins or similar instructions until regulations are adopted. The
department shall adopt regulations by January 1, 2023.
(b) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, and make specific this section by means of all-county letters, plan letters, information notices, or similar instructions, until regulations are promulgated or amended in accordance with paragraph (2).
(2) The department shall promulgate or amend regulations, as necessary, to implement, interpret, and make specific this section in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, by January 1, 2030.
SEC. 27.
Section 11834.02 of the Health and Safety Code is amended to read:11834.02.
(a) As used in this chapter, “alcohol or other drug recovery or treatment facility” or “facility” means a premises, place, or building that provides residential nonmedical services to adults who are recovering from problems related to alcohol, drug, or alcohol and drug misuse or addiction, and who need alcohol, drug, or alcohol and drug recovery treatment or(b) As used in this chapter, “adults” may include, but is not limited to, all of the following:
(1) Mothers over 18 years of age and their children.
(2) Emancipated minors, which may include, but is not limited to, mothers under 18 years of age and their children.
(c) As used in this chapter, “emancipated minors” means persons under 18 years of age who have acquired emancipation status pursuant to Section 7002 of the Family Code.
(d) Notwithstanding subdivision (a), an alcohol or other drug recovery or treatment facility may serve adolescents upon the issuance of a waiver granted by the department pursuant to regulations adopted under subdivision (c) of Section 11834.50.
SEC. 28.
Section 11834.026 of the Health and Safety Code is amended to read:11834.026.
(a) As used in this section, “incidental medical services” means services that are in compliance with the community standard of practice and are not required to be performed in a licensed clinic or licensed health facility, as defined by Section 1200 or 1250, respectively, to address medical issues associated with either(1) Obtaining
medical histories.
(2) Monitoring health status to determine whether the health status warrants transfer of the patient in order to receive urgent or emergent care.
(3) Testing associated with detoxification from alcohol or other drugs. withdrawal management services.
(4) Providing alcohol or other drug recovery or treatment recovery, treatment, or withdrawal management services.
(5) Overseeing patient self-administered medications.
(6) Treating substance use disorders, including detoxification.
withdrawal management services.
(b) Incidental medical services do not include the provision of general primary medical care.
(c) Notwithstanding any other law, a licensed alcohol or other drug recovery or treatment facility may permit incidental medical services to be provided to a resident at the facility premises by, or under the supervision of, one or more physicians and surgeons licensed by the Medical Board of California or the Osteopathic Medical Board who are knowledgeable about addiction medicine, or one or more other health care practitioners acting within the scope of practice of their license and under the direction of a physician and surgeon, and who are also knowledgeable about addiction medicine, if all of the following conditions are met:
(1) The facility, in
the judgment of the department, has the ability to comply with the requirements of this chapter and all other applicable laws and regulations to meet the needs of a resident receiving incidental medical services pursuant to this chapter. The department shall specify in regulations the minimum requirements that a facility shall meet in order to be approved to permit the provision of incidental medical services on its premises. The license of a facility approved to permit the provision of incidental medical services shall reflect that those services are permitted at the facility premises.
(2) The physician and surgeon and any other health care practitioner has signed an acknowledgment on a form provided by the department that they have been advised of and understand the statutory and regulatory limitations on the services that may legally be provided at a licensed alcohol or other drug recovery or treatment facility and the statutory and
regulatory requirements and limitations for the physician and surgeon or other health care practitioner and for the facility, related to providing incidental medical services. The licensee shall maintain a copy of the signed form at the facility for a physician and surgeon or other health care practitioner providing incidental medical services at the facility premises.
(3) A physician and surgeon or other health care practitioner shall assess a resident, prior to that resident receiving incidental medical services, to determine whether it is medically appropriate for that resident to receive these services at the premises of the licensed facility. A copy of the form provided by the department shall be signed by the physician and surgeon and maintained in the resident’s file at the facility.
(4) The resident has signed an admission agreement.
(A) The admission agreement, at a minimum, shall describe the incidental medical services that the facility may permit to be provided and shall state that the permitted incidental medical services will be provided by, or under the supervision of, a physician and surgeon.
(B) The department shall not require an admission agreement to require a person to have been abstinent, to not be intoxicated, or to otherwise not be under the influence in order to be admitted into care, be considered for treatment, or continue treatment.
(C) The department shall specify in regulations, at a minimum, the content and manner of providing the admission agreement, and any other information that the department deems appropriate. The facility shall maintain a copy of the signed admission agreement in the resident’s file.
(5) Once incidental medical services are initiated for a resident, the physician and surgeon and facility shall monitor the resident to ensure that the resident remains appropriate to receive those services. If the physician and surgeon determines that a change in the resident’s medical condition requires other medical services or that a higher level of care is required, the facility shall immediately arrange for the other medical services or higher level of care, as appropriate.
(6) The facility maintains in its files a copy of the relevant professional license or other written evidence of licensure to practice medicine or perform medical services in the state for the physician and surgeon and any other health care practitioner providing incidental medical services at the facility.
(d) The department is not required to
evaluate or have any responsibility or liability with respect to evaluating the incidental medical services provided by a physician and surgeon or other health care practitioner at a licensed facility. This section does not limit the department’s ability to report suspected misconduct by a physician and surgeon or other health care practitioner to the appropriate licensing entity or to law enforcement.
(e) A facility licensed and approved by the department to allow provision of incidental medical services shall not by offering approved incidental medical services be deemed a clinic or health facility within the meaning of Section 1200 or 1250, respectively.
(f) Other than incidental medical services permitted to be provided or any urgent or emergent care required in the case of a life-threatening emergency, including the administration of naloxone hydrochloride, or any other
opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid overdose, this section does not authorize the provision at the premises of the facility of any medical or health care services or any other services that require a higher level of care than the care that may be provided within a licensed alcohol or other drug recovery or treatment facility.
(g) This section does not require a residential treatment facility licensed by the department to provide incidental medical services or any services not otherwise permitted by law.
(h) (1) On or before July 1, 2024, the department shall adopt regulations to implement this section 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).
(2) Notwithstanding the rulemaking provisions of the Administrative Procedure Act, the department may, if it deems appropriate, implement, interpret, or make specific this section by means of provider bulletins, written guidelines, or similar instructions from the department until regulations are adopted.
SEC. 29.
Section 11834.26 of the Health and Safety Code is amended to read:11834.26.
(a) The licensee shall provide(1) Recovery and treatment services.
(2)Treatment services.
(3)Detoxification services.
(2) Recovery, treatment, and withdrawal management services.
(b) (1) A licensee with an existing license to provide detoxification-only services may provide those services before July 1, 2027.
(2) A license to provide detoxification-only services shall expire on July 1, 2027.
(3) The department shall not issue a new license to provide detoxification-only services, and shall not extend an existing license to provide detoxification-only services on or after July 1, 2027.
(b)
(c) The department shall adopt regulations requiring records and procedures that are appropriate for each of the services specified in subdivision (a). The records and procedures may include all of the following:
(1) Admission criteria.
(2) Intake process.
(3) Assessments.
(4) Recovery, treatment, or detoxification withdrawal management planning.
(5) Referral.
(6) Documentation of provision of recovery, treatment, or detoxification
withdrawal management services.
(7) Discharge and continuing care planning.
(8) Indicators of recovery, treatment, or detoxification
withdrawal management outcomes.
(c)
(d) A licensee shall not deny admission to any individual based solely on either of the following:
(1) The individual having a valid prescription from a licensed health care professional for a medication approved by the federal Food and Drug Administration for the purpose of narcotic replacement treatment or medication-assisted treatment of substance use disorders.
(2) The individual having consumed, used, or otherwise been under the influence of alcohol or other drugs,
as these circumstances represent symptoms of the condition of substance use disorders.
(d)
(e) A licensee shall develop a plan to address when a resident relapses, including when a resident is on the licensed premises after using alcohol or other drugs.
(1) The plan shall include details of how the treatment stay and treatment plan of the resident will be adjusted to address the relapse episode and how the resident will be treated and supervised while under the influence of alcohol or other drugs, as well as discharge and continuing care planning, including when a licensee determines that a resident requires
services beyond the scope of the licensee.
(2) This subdivision does not require a licensee to discharge a resident, as relapse, lapses, and momentary reengagement with alcohol or other drugs are symptoms of the condition of substance use disorders.
(3) In developing a plan pursuant to this subdivision, the licensee shall prioritize the individual maintaining some level of connection to treatment and shall consider options to avoid complete disconnection of the resident from treatment.
(e)
(f) (1) The department shall have
the authority to implement subdivisions (d) and (f)
this section by bulletin or all-county or all-provider letter, after stakeholder input, until regulations are promulgated. The department shall promulgate regulations to implement subdivisions (d) and (f) no later than July 1, 2027.
this section no later than January 1, 2030.
(2) On and after July 1, 2027, a licensee that provides withdrawal management services shall provide those services as required in guidance issued by the department.
(f)
(g) (1) A licensee shall, at all times, maintain at least two unexpired doses of naloxone hydrochloride, or any other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid
overdose, on the premises and shall, at all times, have at least one staff member on the premises who knows the specific location of the naloxone hydrochloride, or other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid overdose, and who has been trained on the administration of naloxone hydrochloride, or the other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid overdose, in accordance with the training requirements set forth by the department. Proof of completion of training on the administration of naloxone hydrochloride, or other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid overdose, shall be documented in the staff member’s individual personnel file.
(2) A trained staff member shall not be liable for damages in a civil action or subject to criminal
prosecution for the administration, in good faith, of naloxone hydrochloride, or any other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an opioid overdose, to a person appearing to experience an overdose. This paragraph shall not apply in a case where the person who renders emergency care treatment by the use of naloxone hydrochloride, or any other opioid antagonist that is approved by the United States Food and Drug Administration for treatment of an overdose, acts with gross negligence or engages in willful and wanton misconduct.
(g)
(h) In the development of regulations implementing this section, the written record
requirements shall be modified or adapted for social model programs.
SEC. 30.
Section 11834.29 of the Health and Safety Code is repealed.Any licensee that provides recovery, treatment, or detoxification services, that is not in compliance with the requirements of this article, shall have one year from the effective date of the regulations adopted by the department pursuant to this article and pursuant to Article 5 (commencing with Section 11834.50) to comply. In the event that the licensee fails to comply, the department shall take action against the licensee pursuant to Article 4 (commencing with Section 11834.36).
SEC. 31.
Section 11834.30 of the Health and Safety Code is amended to read:11834.30.
A person, firm, partnership, association, corporation, or local governmental entity shall not operate, establish, manage, conduct, or maintain an alcohol or other drug recovery or treatment facility to provideSEC. 32.
Section 11834.31 of the Health and Safety Code is amended to read:11834.31.
If a facility is alleged to be in violation of Section 11834.30, the department shall conduct a site visit to investigate the allegation. If the department’s employee or agent finds evidence that the facility is providing(a) Submit the findings of the investigation to the department.
(b) Upon departmental authorization,
issue a written notice to the facility stating that the facility is operating in violation of Section 11834.30. The notice shall include all of the following:
(1) The date by which the facility shall cease providing services.
(2) Notice that the department will assess against the facility a civil penalty of two thousand dollars ($2,000) per day for every day the facility continues to provide services beyond the date specified in the notice.
(3) Notice that the case will be referred for civil proceedings pursuant to Section 11834.32 in the event the facility continues to provide services beyond the date specified in the notice.
(c) Inform the facility of the licensing requirements of this chapter.
(d) A person or entity found to be in violation of Section 11834.30 shall be prohibited from applying for initial licensure for a period of five years from the date of the notice specified in subdivision (b).
SEC. 33.
Section 11834.40 of the Health and Safety Code is amended to read:11834.40.
A license shall terminate by operation of law, prior to its expiration date, when any of the following conditions occur:(a) The licensee sells or otherwise transfers the facility or the property of the facility as identified on the license, unless the transfer of ownership applies to the transfer of stock when the facility is owned by and licensed as a corporation, and when the transfer of stock does not constitute a majority change in ownership.
(b) The licensee surrenders the license to the department.
(c) The licensee moves the facility identified on the license from one location to another. The department shall develop regulations to provide for an
expedited application and licensing process for a newly located facility.
(d) The licensee is a sole proprietor and the licensee dies.
(e) The licensee actually or constructively abandons the licensed facility. Constructive abandonment includes insolvency, eviction, or seizure of assets or equipment resulting in the failure to provide recovery, treatment, or detoxification withdrawal management services to residents.
SEC. 34.
Section 11834.50 of the Health and Safety Code is amended to read:11834.50.
The department shall adopt regulations to implement this chapter in accordance with the purposes required by Section 11835. These regulations shall be adopted only after consultation with appropriate groups affected by the proposed regulations. The regulations shall include, but not be limited to, all of the following:(a) Provision for a formal appeal process for the denial, suspension, or revocation of a license.
(b) Establishment of requirements for compliance, procedures for issuance of deficiency notices, and civil penalties for noncompliance.
(c) Provision for the issuance of a waiver for an alcohol or other drug recovery or treatment facility to
serve not more than three adolescents, or 10 percent of the total licensed capacity, whichever is less, 14 years of age and older, when a need exists and services specific to adolescents are otherwise unavailable. The regulations shall specify the procedures and criteria for granting the waiver. The procedures shall include, but not be limited to, criminal record reviews and fingerprinting.
(d) Establishment of the elements and minimum requirements for recovery, treatment, and detoxification withdrawal management services.
(e) Provision for an expedited process for reviewing an application for licensure when a license is terminated pursuant to subdivision (c) of Section
11834.40.
SEC. 35.
Section 11839.2 of the Health and Safety Code is amended to read:11839.2.
The following medications are authorized for use in narcotic replacement therapy and medication-assisted treatment by licensed narcotic treatment programs:(a) Methadone.
(b) Buprenorphine products or combination of products approved by the federal Food and Drug Administration for maintenance or detoxification treatment of opioid dependence.
(c) Any other medication approved by the federal Food and Drug Administration for the purpose of narcotic replacement
treatment or medication-assisted treatment of substance use disorders.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of plan or provider bulletins, or similar instructions. The department shall adopt regulations by no later than January 1, 2021.
SEC. 36.
Section 11839.3 of the Health and Safety Code is amended to read:11839.3.
(a) In addition to the duties authorized by other statutes, the department shall perform all of the following:(1) License the establishment of narcotic treatment programs in this state to use narcotic replacement therapy in the treatment of addicted persons whose addiction was acquired or supported by the use of a narcotic drug or drugs, not in compliance with a physician and surgeon’s legal prescription, except that the Research Advisory Panel shall have authority to approve methadone research programs. The department shall establish and enforce the criteria for the eligibility of patients to be included in the programs, program operation guidelines, such as dosage levels, recordkeeping and reporting, urinalysis requirements, take-home doses of controlled
substances authorized for use pursuant to Section 11839.2, security against redistribution of the narcotic replacement drugs, and any other regulations that are necessary to protect the safety and well-being of the patient, the local community, and the public, and to carry out this chapter. A program may admit a patient to narcotic maintenance or narcotic detoxification treatment maintenance treatment or withdrawal management at the discretion of the medical director. The program shall assign a unique identifier to, and maintain an individual record for, each patient of the program. The arrest and conviction records and the records of pending charges against a person seeking admission to a narcotic treatment program shall be furnished to narcotic treatment program directors upon written request of the narcotic treatment
program director provided the request is accompanied by a signed release from the person whose records are being requested.
(2) Inspect narcotic treatment programs in this state and ensure that programs are operating in accordance with the law and regulations. The department shall have sole responsibility for compliance inspections of all programs in each county. Annual compliance inspections shall consist of an evaluation by onsite review of the operations and records of licensed narcotic treatment programs’ compliance with applicable state and federal laws and regulations and the evaluation of input from local law enforcement and local governments, regarding concerns about the narcotic treatment program. At the conclusion of each inspection visit, the department shall conduct an exit conference to explain the cited deficiencies to the program staff and to provide recommendations to ensure compliance with applicable laws and regulations. The
department shall provide an inspection report to the licensee within 30 days of the completed onsite review describing the program deficiencies. A corrective action plan shall be required from the program within 30 days of receipt of the inspection report. All corrective actions contained in the plan shall be implemented within 30 days of receipt of approval by the department of the corrective action plan submitted by the narcotic treatment program. For programs found not to be in compliance, a subsequent inspection of the program shall be conducted within 30 days after the receipt of the corrective action plan in order to ensure that corrective action has been implemented satisfactorily. Subsequent inspections of the program shall be conducted to determine and ensure that the corrective action has been implemented satisfactorily. For purposes of this requirement, “compliance” shall mean to have not committed any of the grounds for suspension or revocation of a license provided for under subdivision (a) of
Section 11839.9 or paragraph (2) of subdivision (b) of Section 11839.9. Inspection of narcotic treatment programs shall be based on objective criteria including, but not limited to, an evaluation of the programs’ adherence to all applicable laws and regulations and input from local law enforcement and local governments. Nothing in this section shall preclude counties from monitoring their contract providers for compliance with contract requirements.
(3) Charge and collect licensure fees. In calculating the licensure fees, the department shall include staff salaries and benefits, related travel costs, and state operational and administrative costs. Fees shall be used to offset licensure and inspection costs, not to exceed actual costs.
(4) Study and evaluate, on an ongoing basis, narcotic treatment programs including, but not limited to, the adherence of the programs, to all
applicable laws and regulations and the impact of the programs on the communities in which they are located.
(5) Provide advice, consultation, and technical assistance to narcotic treatment programs to ensure that the programs comply with all applicable laws and regulations and to minimize any negative impact that the programs may have on the communities in which they are located.
(6) In its discretion, to approve local agencies or bodies to assist it in carrying out this chapter provided that the department may not delegate responsibility for inspection or any other licensure activity without prior and specific statutory approval. However, the department shall evaluate recommendations made by county alcohol and drug program administrators regarding licensing activity in their respective counties.
(7) The director
may grant exceptions to the regulations adopted under this chapter if the director determines that this action would improve treatment services or achieve greater protection to the health and safety of patients, the local community, or the general public. An exception shall not be granted if it is contrary to, or less stringent than, the federal laws and regulations that govern narcotic treatment programs.
(b) It is the intent of the Legislature in enacting this section, in order to protect the general public and local communities, that take-home doses of narcotic replacement therapy medications authorized for use pursuant to Section 11839.2 shall only be provided when the patient is clearly adhering to the requirements of the program, or if the program is closed on Sundays or holidays and providing a take-home dose is not contrary to federal laws and regulations governing narcotic treatment programs. The department shall define “satisfactory
adherence” and shall ensure that patients not satisfactorily adhering to their programs shall not be provided take-home doses. A narcotic treatment program medical director shall determine whether or not to dilute take-home doses.
(c) There is established in the State Treasury the Narcotic Treatment Program Licensing Trust Fund. All licensure fees collected from the providers of narcotic treatment services shall be deposited in this fund. Except as otherwise provided in this section, if funds remain in this fund after appropriation by the Legislature and allocation for the costs associated with narcotic treatment licensure actions and inspection of narcotic treatment programs, a percentage of the excess funds shall be annually rebated to the licensees based on the percentage their licensing fee is of the total amount of fees collected by the department. A reserve equal to 10 percent of the total licensure fees collected during the preceding
fiscal year may be held in each trust account to reimburse the department if the actual cost for the licensure and inspection exceed fees collected during a fiscal year.
(d) Notwithstanding any provision of this code or regulations to the contrary, the department shall have sole responsibility and authority for determining if a state narcotic treatment program license shall be granted and for administratively establishing the maximum treatment capacity of a license. However, the department shall not increase the capacity of a program unless it determines that the licensee is operating in full compliance with applicable laws and regulations.
SEC. 37.
Section 11839.6.1 of the Health and Safety Code is amended to read:11839.6.1.
(a) No sooner than July 1, 2022, the department shall establish a program for the operation and regulation of mobile narcotic treatment programs. A mobile narcotic treatment program established pursuant to this section shall do all of the following:(1) Operate under the license of a primary narcotic treatment program with which it is affiliated and associated.
(2) Provide opioid addiction treatment in a motor vehicle.
(3) Comply with any applicable federal requirements.
(4) Receive approval from the department prior to operating a mobile narcotic treatment
program.
(b) The department shall do all of the following:
(1) Establish the requirements for approval of a mobile narcotic treatment program.
(2) Oversee and enforce the requirements developed pursuant to this section.
(c) (1) The primary narcotic treatment program shall be subject to action under Section 11839.9 for any violation by its mobile narcotic treatment program of any requirements imposed under this section or any regulations promulgated under this article.
(2) The department may terminate the operation of a mobile narcotic treatment program for failing to comply with this section.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section through the use of all-county letters, provider bulletins, or similar instructions, without taking any further regulatory action.
(e) The following definitions apply for purposes of this section:
(1) “Mobile narcotic treatment program” means a narcotic treatment program operating from a motor vehicle that serves as a mobile component and is operating under a primary narcotic treatment program, and engages in treatment of opioid addiction, including maintenance or detoxification treatment, treatment or withdrawal
management,
at a location or locations remote from the primary narcotic treatment program, but within California.
(2) “Motor vehicle” means a vehicle propelled under its own motive power and lawfully used on public streets, roads, or highways with more than three wheels in contact with the ground. This term does not include a trailer.
SEC. 38.
Section 11839.16 of the Health and Safety Code is amended to read:11839.16.
(a) (1) The director shall, in addition to any other remedy, issue an order that prohibits a narcotic treatment program from admitting new patients or from providing patients with take-home dosages of a narcotic drug if the director determines, pursuant to the compliance inspection procedures set out in paragraph (2) of subdivision (a) of Section 11839.3, that a program has done any of the following:(A) Failed to provide adequate security measures over its narcotic drug supply as agreed in the program’s approved protocol.
(B) Failed to maintain a narcotic drug reconciliation system that accounts for all incoming and outgoing narcotic drugs.
(C) Diverted narcotic drugs.
(D) Repeatedly violated one or more departmental or federal regulations governing narcotic treatment programs, which violations may subject, or may have subjected, a patient to a health or life-endangering situation.
(E) Repeatedly violated one or more departmental or federal regulations governing the provisions of take-home medication.
(F) Operated above combined licensed capacity for maintenance and detoxification withdrawal management programs at a single location.
(2) (A) The order becomes effective when the department serves the program with a copy of the order. The order shall state the deficiencies forming the basis for the order and shall state the corrective action required for the department to vacate the order. The order, as it pertains to subparagraph (F) only, shall automatically be vacated when the department receives the program’s written notification that licensed capacity has been achieved. If the order is issued pursuant to subparagraph (A), (B), (C), (D), or (E), the department shall vacate the order when the program submits a corrective action plan that reasonably addresses the deficiency or substantially conforms to the required action set out in the order.
(B) The department shall notify the program that the corrective action plan is accepted or rejected within 10 working days after receipt of the plan. If the department rejects the corrective action
plan, it shall detail its reason in writing. The department order is vacated when the department either accepts a corrective action plan and ensures substantial conformity with the required action set out in the order or fails to reject a plan within 10 working days after receipt of the plan.
(3) In addition to any other remedies, a failure of the program to comply with the order of the department under this subdivision shall give rise to a civil penalty of five hundred dollars ($500) a day for each day that the order is violated.
(4) All civil penalties collected by the department under paragraph (3) shall be deposited in the Narcotic Treatment Program Licensing Trust Fund, and shall be used to offset the department’s costs associated with collecting the civil penalties, or associated with any civil, administrative, or criminal action against the program when appropriated for
this purpose.
(b) (1) The director may, in addition to any other remedy, issue an order temporarily suspending a narcotic treatment program license prior to any administrative hearing for the reasons stated in subparagraphs (A) to (E), inclusive, of paragraph (1) of subdivision (a) when the department determines pursuant to the compliance inspection procedures set out in paragraph (2) of subdivision (a) of Section 11839.3, that the action is necessary to protect patients of the program from any substantial threat to their health or safety, or to protect the health or safety of the local community or the people of the State of California. Prior to issuing the order, the director shall ensure continuity of patient care by the program’s guarantor or through the transfer of patients to other licensed programs. The director may issue any needed license or amend any other license in his or her
the director’s effort to assure that patient care is not impacted adversely by the suspension order.
(2) The director shall notify the licensee of the temporary suspension and the effective date thereof and at the same time shall serve the licensee with an accusation. Upon receipt of a notice of defense to the accusation by the licensee, the director shall, within 15 days, set the matter for hearing, and the hearing shall be held as soon as possible, but not later than 20 days, exclusive of weekends, after receipt of the notice. The temporary suspension shall remain in effect until the hearing is completed and the director has made a final determination on the merits. However, the temporary suspension shall be deemed vacated if the director fails to make a final determination on the merits within 20 days after the original hearing has been completed. Failure to cease operating after the department
issues an order temporarily suspending the license shall constitute an additional ground for license revocation and shall constitute a violation of Section 11839.8. The department shall suspend the program’s license if the hearing outcome is adverse to the license. The department shall notify the program of the license suspension within five days of the director’s final decision.
(c) A program may, at any time after it is served with an order, petition the superior court to review the department’s issuance of an order or rejection of a corrective action plan.
SEC. 39.
Section 120956 of the Health and Safety Code is amended to read:120956.
(a) The AIDS Drug Assistance Program Rebate Fund is hereby created as a special fund in the State Treasury.(b) All rebates collected from drug manufacturers on drugs purchased through the AIDS Drugs Assistance Program (ADAP) implemented pursuant to this chapter and, notwithstanding Section 16305.7 of the Government Code, interest earned on these moneys shall be deposited in the fund exclusively to cover costs related to the purchase of drugs and services provided through ADAP and the HIV prevention programs as described in Sections 120972, 120972.1, and 120972.2 and services related to HIV prevention and care and treatment for individuals living with HIV provided through the programs funded by the Two-Spirit, Transgender, Gender Nonconforming, and Intersex (2TGI) Wellness and Equity Fund as described in Section 150900.
any of the following:
(1) The purchase of drugs and services provided through ADAP and the HIV prevention programs as described in this chapter and in Sections 120972, 120972.1, and 120972.2.
(2) Services related to HIV prevention and care and treatment for individuals living with HIV provided through the programs funded by the Two-Spirit, Transgender, Gender Nonconforming, and Intersex (2TGI) Wellness and Equity Fund as described in Section 150900, to the extent that funds are available for these purposes.
(3) State and local public health department disease intervention and investigation activities and services, as determined by the State Department of Public Health, to the extent that funds
are available for these purposes, for any of the following purposes:
(A) HIV.
(B) Sexually transmitted infections.
(C) Hepatitis C.
(D) Mpox.
(E) Other communicable diseases transmitted via sexual or intimate physical contact.
(4) To the extent that funding is available, housing support for individuals living with HIV who are eligible for the Housing Opportunities for Persons with AIDS program based on income but are otherwise ineligible for the program, and are current residents of California.
(5) To the extent that funding is available, services authorized under Part A or B of the Ryan White HIV/AIDS Program.
(6) California Overdose Prevention and Harm Reduction Initiative services and activities, to the extent that funds are available for these purposes.
(c) Notwithstanding Section 13340 of the Government Code, moneys in the fund are continuously appropriated without regard to fiscal year to State Department of Public Health and available for expenditure for those purposes specified under this section.
(d) The department may, in
consultation with the Department of Finance, use an alternative local fiscal agent, if necessary, to implement this section.
SEC. 40.
Section 127437 is added to the Health and Safety Code, to read:127437.
The Hospital Fair Pricing Penalties Fund is created in the State Treasury. Any moneys collected from administrative penalties pursuant to this article shall be deposited into the fund. Upon appropriation by the Legislature, the department may use moneys from the fund to carry out this article.SEC. 41.
Section 127630 of the Health and Safety Code is amended to read:127630.
For purposes of this chapter:(a) “Abortion” has the same meaning as defined in Section 123464.
(b) “Contraception” means the services and contraceptive methods described in paragraph (1) of subdivision (b) of Section 1367.25.
(c) “Department” means the Department of Health Care Access and Information.
(d) “Fund” means the California Reproductive Health Equity Fund established pursuant to Section 127631.
(e) “Gender-affirming health care” and
“gender-affirming mental health care” have the same meanings as defined in Section 16010.2 of the Welfare and Institutions Code.
(e)
(f) “Program” means the California Reproductive and TGI Health Equity Program established pursuant to Section 127632.
(f)
(g) “Religious employer” has the same meaning as described in Section 1367.25.
SEC. 42.
Section 127631 of the Health and Safety Code is amended to read:127631.
(a) The California Reproductive Health Equity Fund is hereby established.(b) The primary purpose of the fund is to provide grant funding to safety net providers of abortion and contraception abortion, contraception, or gender-affirming care services through the California Reproductive and TGI Health Equity Program and to otherwise ensure affordability of and access to abortion and contraception
abortion, contraception, or gender-affirming care to anyone who seeks care in California, regardless of their ability to pay for care. The department shall distribute moneys in the fund to further its primary purpose.
(c) The fund shall also be used to pay for the cost of administering the program and for any other purpose authorized by this chapter. The level of expenditure by the department for the administrative support of the program created pursuant to this chapter shall be subject to review and approval annually through the annual budget process.
(d) The department may receive private donations to be deposited into the fund.
(e) The money in the fund is
continuously appropriated to the department for the purposes of this chapter. The department shall manage this fund prudently in accordance with the law.
SEC. 43.
Section 127631.1 is added to the Health and Safety Code, to read:127631.1.
In addition to the California Reproductive Health Equity Fund established in this chapter, the department may also use the money in the Abortion Access Fund established in Section 127641 to provide grant funding for abortion services to safety net providers of abortion services through the California Reproductive and TGI Health Equity Program.SEC. 44.
Section 127632 of the Health and Safety Code is amended to read:127632.
(a) The California Reproductive and TGI Health Equity Program is hereby established within the department.(b) The purpose of the program is to ensure abortion and contraception abortion, contraception, and gender-affirming care are affordable for and accessible to all patients, regardless of their ability to pay, and to provide financial support for safety net providers of these services to offset the costs of providing uncompensated care to patients with low
incomes who would otherwise lack access to care.
(c) The department may carry out the program described in this chapter through grants and contracts, including exclusive or nonexclusive contracts, or amending existing contracts, on a bid or negotiated basis. Contracts and grants entered into or amended pursuant to this chapter shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual.
(d) Contracts, grants, and related information created pursuant to this chapter shall not be made public and are exempt from disclosure under the California Public Records Act (Division 10 (commencing
with Section 7920.000) of Title 1 of the Government Code).
(e) In administering this chapter, the department shall be exempt from the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
SEC. 45.
Section 127633 of the Health and Safety Code is amended to read:127633.
(a) A Medi-Cal enrolled provider, as determined by the State Department of Health Care Services, may apply for a grant, and a continuation award after the initial grant, under this chapter if they agree to provide either, both abortion and contraception(1) The abortion and contraception
abortion, contraception, or gender-affirming care services provided are within the provider’s scope of practice and licensure.
(2) The provider agrees to be identified, in a manner determined by the department, as a participating provider in the program. An institutional provider shall not be required to identify any individual who is an abortion or gender-affirming care provider as a condition of a grant awarded pursuant to this chapter.
(3) To the extent services provided are covered pursuant to Section 14132 of the Welfare and Institutions Code, the services shall be provided at no cost or a reduced cost to an individual with a household income at or below 400 percent of the federal poverty level who meets both of the following
criteria:
(A) Is uninsured or has health care coverage that does not include both abortion and contraception.
contraception or does not include coverage for gender-affirming care.
(B) Is not otherwise eligible to receive both abortion and contraception care at no cost through the Medi-Cal and Family PACT programs. programs or receive gender-affirming care at no cost through the Medi-Cal program.
(b) For purposes of this chapter, an individual’s self-declaration of income and source of health care coverage made to the provider at the time of service shall be all that is required to determine whether the individual may be able to access no-cost or
reduced-cost services pursuant to this chapter.
(c) This chapter does not require a provider to accept additional patients if, in the reasonable professional judgment of the provider, accepting additional patients would endanger access to, or continuity of, care for existing patients.
(d) The department shall work with the State Department of Health Care Services to notify Medi-Cal enrolled providers of the availability of funding under this chapter, including any pertinent deadlines and other requirements.
SEC. 46.
Section 127634 of the Health and Safety Code is amended to read:127634.
(a) An application for a grant under this chapter shall be made on a form to be developed by the department.(b) An application shall include both of the following:
(1) A justification of the amount of grant funds requested, including both of the following:
(A) The cost of uncompensated abortion and contraceptive abortion, contraception, and gender-affirming care services the applicant provided to patients with household incomes at or below 400
percent of the federal poverty level in the previous 12 months.
(B) The anticipated cost of uncompensated abortion and contraception
abortion, contraception, and gender-affirming care services to be provided to patients with household incomes at or below 400 percent of the federal poverty level in the upcoming 12 months.
(2) Other pertinent information that the department requires.
(c) The department shall develop an application form and shall begin accepting applications for grants pursuant to this chapter on or before January 1, 2023. 2027.
(d) For purposes of subdivision (b), the cost of uncompensated abortion and contraception
abortion, contraception, and gender-affirming care services shall:
(1) Be calculated based on the amount the provider would expect to receive for providing these services to a patient enrolled in the Medi-Cal program.
(2) Include those services provided through prescription, including laboratory and pharmaceutical, as well as services that are the result of complications related to services provided pursuant to this chapter, to the extent they would be covered pursuant to Section 14132 of the Welfare and Institutions Code.
(e) For purposes of this section, the department shall not require the submission of personal information about individuals receiving uncompensated abortion and contraception
abortion, contraception, and gender-affirming care services as part of an application. Information required by the department shall only include information in summary, statistical, or other forms that do not identify particular individuals.
(f)An application for a grant under this chapter shall be
(f) Contracts, grants, and related information created pursuant to this chapter shall not be made public and are exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section
7920.000) of Title 1 of the Government Code).
SEC. 47.
Section 127635 of the Health and Safety Code is amended to read:127635.
(a) Within the limits of funds available, the department may award grants that, in the department’s judgment, best promote the purposes described in Section 127632, taking into account all of the following:(1) The extent to which abortion and contraception abortion, contraception, and gender-affirming care services are needed locally.
(2) The ability of the applicant to advance health equity.
(3) The relative need of the applicant.
(b) The department shall determine the amount of an award on the basis of the amount of funds requested.
(c) Unless otherwise specified by the department, an initial grant shall be for a 12-month period.
(d) Determination regarding a grant award shall be made within 60 days of receipt of a completed application.
SEC. 48.
Section 127638 of the Health and Safety Code is amended to read:127638.
In implementing the program, the department shall consult with interested parties, including the State Department of Health Care Services, the Department of Managed Health Care, the Department of Insurance, abortion and contraception providers, gender-affirming care providers, consumer advocates, and other stakeholders it deems appropriate.SEC. 49.
Chapter 11 (commencing with Section 127770) is added to Part 2 of Division 107 of the Health and Safety Code, to read:CHAPTER 11. Health Care Data
127770.
For purposes of this chapter:(a) “Department” means the Department of Health Care Access and Information.
(b) “State entities” means all state departments, agencies, boards, commissions, programs, and other organizational units of the executive branch of state government.
127770.5.
It is the intent of the Legislature that the department collect data and publish reports on quality of care and patient experience.127771.
(a) (1) Beginning July 1, 2026, the department shall compile annual publications, to be made publicly available on the department’s internet website, including a quality of care report card that reflects health care service plans, health insurers, preferred provider organizations, and medical groups.(2) The Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, the Exchange, the State Department of Social Services, and any other state health coverage program or state entity shall provide to the department data concerning the quality of care report card in the time, manner, and format requested by the department. The department may also request data related to the
cost of care, quality of care, patient experience, socioeconomic status impact on health, access to care, and access to social services programs. The data described in this section may be linked with other department data and used for other department data reports, to the extent allowed by state and federal law.
(3) The department may request data from, and contract with, academic or nonprofit organizations related to quality of health care and patient experience to develop the quality of care report card.
(b) The department shall produce a biennial report in even-numbered calendar years, to be made publicly available on the department’s internet website, of health care consumer or patient assistance help centers, call centers, ombudsperson, or other assistance centers operated by the Department of Managed Health Care, the State Department of Health Care Services, the Department
of Insurance, and the Exchange that includes, at a minimum, all of the following:
(1) The types and volume of inquiries received.
(2) The call center’s role with regard to each type of call, question, complaint, or grievance.
(3) The call center’s protocol for responding to requests for assistance from health care consumers, including any performance standards.
(4) The protocol for referring or transferring calls outside the jurisdiction of the call center.
(5) The call center’s methodology of tracking calls, complaints, grievances, or inquiries.
(c) (1) In odd-numbered calendar years, the department
shall produce an analysis of the data collected on problems and complaints by, and questions from, consumers about health care coverage for the purpose of providing public information about problems faced and information needed by consumers in obtaining coverage and care. The data collected shall include demographic data, insurer or plan data, appeals, source of coverage, regulator, type of problem or issue, and resolution of complaints, including timeliness of resolution, to the extent that data is readily available. The analysis shall be made public on the department’s internet website. In analyzing the data collected, the department may also identify examples of best practices when responding to consumer inquiries. The analysis may also include identification of practices that could be revised to improve responses to inquiries.
(2) The Department of Managed Health Care, the State Department of Health Care Services, the Department of
Insurance, the Exchange, and any other state public health coverage programs shall provide to the department data concerning consumer complaints and issues to meet the reporting requirements in this section in the time, data elements, manner, and format requested by the department.
(3) For the purpose of publicly reporting information as required in paragraph (1) and this paragraph about the challenges in obtaining care and coverage, the department shall analyze data on consumer complaints, appeals, and grievances resolved by the agencies listed in subdivision (b), including demographic data, source of coverage, insurer or plan, resolution of complaints, and other information intended to improve health care and coverage for consumers, to the extent that data is readily available.
(4) The data described in this section may be linked with other department data and used for other
department data reports, to the extent allowed by state and federal law.
(d) The department may implement, interpret, or make specific this section by means of a departmental letter or other similar instruction, as necessary, notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(e) For purposes of this section:
(1) “Data” means information that is not individually identifiable health information, as defined in Section 160.103 of Title 45 of the Code of Federal Regulations.
(2) “Exchange” means the California Health Benefit Exchange, established pursuant to Title 22 (commencing with Section 100500) of the Government Code.
(3) “Health care” includes services provided by any health care coverage program.
(4) “Health care service plan” has the same meaning as that set forth in subdivision (f) of Section 1345. “Health care service plan” includes specialized health care service plans, including behavioral health plans.
(5) “Health coverage program” includes the Medi-Cal program, tax subsidies and premium credits under the Exchange, and county health care programs.
(6) “Health insurer” means an insurer that offers health insurance, as defined in Section 106 of the Insurance Code.
127772.
(a) The Legislature finds and declares that the department performs public health activities described in Section 164.512(b) of Title 45 of the Code of Federal Regulations when carrying out activities pursuant to this chapter. Personal information collected in accordance with this chapter is necessary to carry out projects with public health purposes.(b) All personal information obtained or maintained by the department shall be confidential and shall be subject to the following requirements:
(1) Only deidentified and aggregated information shall be included in a publicly available analysis, data product, or research.
(2) All policies and procedures developed in implementing this chapter shall provide that the privacy, security, and confidentiality of consumers’ personal information is protected, as required by the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code), and consistent with state and federal health privacy laws, including the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code). Data shall not be disclosed until the department has developed a policy regarding the release of data.
(c) Unless otherwise specified in this chapter, personal information collected by the department from other state entities shall be exempt from the disclosure requirements of the California Public Records Act
(Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), and shall not be made available except pursuant to this chapter.
(d) Any information collected or obtained pursuant to this chapter shall not be used for determinations regarding individual patient care or treatment and shall not be used for any individual eligibility or coverage decisions or similar purposes.
127773.
(a) This section governs the use of the Health Plan Improvement Trust Fund, previously renamed in former Section 130208.(b) The moneys in the Health Plan Improvement Trust Fund shall, upon appropriation by the Legislature, be made available for the purposes in Sections 127771 and 127772 and Chapter 8.5 (commencing with Section 127671).
(c) Notwithstanding Section 16305.7 of the Government Code, all interest earned on moneys that have been deposited in the Health Plan Improvement Trust Fund shall be retained in the fund and used for purposes consistent with Sections 127771 and 127772 and Chapter 8.5 (commencing with Section 127671).
127774.
(a) Moneys transferred from the Managed Care Fund and the Insurance Fund for use by the department for purposes described in Section 127773 shall be deposited into the Health Plan Improvement Trust Fund.(b) The share of funding to be provided from the Managed Care Fund shall be based on the number of covered lives in the state that are covered under plans regulated by the Department of Managed Health Care, including covered lives under Medi-Cal managed care, as determined by the Department of Managed Health Care, in proportion to the total number of all covered lives in the state.
(c) The share of funding to be provided from the Insurance Fund shall be based on the number of
covered lives in the state that are covered under health insurance policies and benefit plans regulated by the Department of Insurance, including covered lives under Medicare supplement plans, as determined by the Department of Insurance, in proportion to the total number of all covered lives in the state.
SEC. 50.
Section 130201 of the Health and Safety Code is amended to read:130201.
The Legislature finds and declares all of the following:(a) The California Health and Human Services Agency manages great amounts of valuable data on all aspects of life for Californians, including, but not limited to, health care delivery, business, social services, child welfare, and public health.
(b) California has long recognized that securing individual privacy rights and confidentiality of personal health and medical records is of paramount importance to establishing public confidence in the provision of state services, and that ensuring transparent accountability, governance, and oversight are critical components to maintaining the public’s trust.
(c) Data is a fundamental asset that can be more fully utilized without compromising patient privacy and data security. Improving and streamlining collection practices, interoperability of data and technology, data infrastructure, data security, and data sharing is critical to the improvement of the lives of Californians and will foster person-centered and not program-centered decisionmaking.
(d) When data practices safeguard individual privacy, interpreting and using data improves public programs and policies and enriches the lives of people in many ways, including, but not limited to, all of the following:
(1) Analytics increase efficiency and help target resources to vulnerable and underserved populations.
(2) Data analytics allow for optimal use of existing resources and information assets to drive
operational decisions and avoid changes that may result in adverse impacts or negative outcomes for vulnerable and underserved populations.
(3) Health and social services outcomes are improved through use of analytics to identify underserved populations, detect gaps in services, and improve and facilitate access to programs and services.
(4) Demographic and services information can be assessed to identify and address disparities, including racial, ethnic, gender, and geographic disparities, in health and socioeconomic status to advance equity and improve person-centered outcomes.
(e) Information sharing among state departments for integrated health and social services has been hindered by a lack of standardized interpretation and application of health privacy laws throughout the state. State departments often do not
share information for integrated health and social services, even when sharing is appropriate, lawful, and permissible to all identifiable individuals. In order to provide efficient and effective health and social services, information should be securely exchanged among state departments in a manner that prioritizes individual privacy and autonomy over access to personal data.
(f) Unmitigated sharing and centralization of personal data relating to individuals presents unique risks to privacy, as that data can be used in concert to produce profiles revealing intimate details of individuals’ personal lives. Any policy related to data sharing, especially among governmental entities, must, therefore, be responsive to potential risks to personal privacy and include safeguards against invasive or excessive sharing of personal information.
(g) Data sharing has the potential to positively
affect health and social services outcomes by linking vulnerable populations to services for which they are eligible.
(h) It is the intent of the Legislature to establish the Center for Data Insights and Innovation to do all of the following:
(1) Establish health information sharing guidance that balances the need for patient privacy with the benefits of data sharing to support and encourage integrated care and services to assist California health and social services organizations.
(2) Increase privacy protections by ensuring only required health data is transmitted for purposes and uses consistent with state and federal law.
(3) Administer the State Committee for the Protection of Human Subjects.
(4)Collect data and publish reports on quality of care and patient experience.
(5)
(4) Administer the California Health and Human Services Agency Open Data Portal.
(6)
(5) Develop and administer the California Health and Human Services Agency Research Data Hub and other future data initiatives.
(7)
(6) Improve and strengthen the security of data processes within the departments of the California Health and Human Services Agency.
(8)
(7) Identify and guide tangible and program-specific efforts, from the California Health and Human Services Agency leadership perspective, toward enhanced person-centered services that bridge and connect access to all health and social services programs for which an individual may be eligible.
SEC. 51.
Section 130204 of the Health and Safety Code is repealed.(a)(1)The center shall compile annual publications, to be made publicly available on the center’s internet website, including, but not limited to, a quality of care report card that reflects health care service plans, preferred provider organizations, and medical groups.
(2)The Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, the Exchange, the State Department of Social Services, the Office of Statewide Health Planning and Development, and any other public health coverage program or state entity shall provide to the center data concerning the quality of care report card in the time, manner, and format requested by the center. The center may also request data related to the cost of care, quality of care, patient experience, socioeconomic status impact on health, access to care, and access to social services programs.
(3)The center may request data from and contract with academic or nonprofit organizations related to quality of health care and patient experience to develop the quality of care report card.
(b)The center shall produce an annual report to be made publicly available on the center’s internet website by December 31, 2022, and annually thereafter, of health care consumer or patient assistance help centers, call centers, ombudsperson, or other assistance centers operated by the Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, and the Exchange, that includes, at a minimum, all of the following:
(1)The types of calls received and the number of calls.
(2)The call center’s role with regard to each type of call, question, complaint, or grievance.
(3)The call center’s protocol for responding to requests for assistance from health care consumers, including any performance standards.
(4)The protocol for referring or transferring calls outside the jurisdiction of the call center.
(5)The call center’s methodology of tracking calls, complaints, grievances, or inquiries.
(c)(1)The center may collect and analyze data on problems and complaints by, and questions from, consumers about health care coverage for the purpose of providing public information about problems faced and information needed by consumers in obtaining coverage and care. The data collected shall include demographic data, insurer or plan data, appeals, source of coverage, regulator, type of problem or issue or comparable types of problems or issues, and resolution of complaints, including timeliness of resolution. Notwithstanding Section 10231.5 of the Government Code, the center shall submit a report by December 31, 2022, and annually thereafter to the Legislature. The report shall be submitted in compliance with Section 9795 of the Government Code. The format may be modified annually as needed based
upon comments from the Legislature and stakeholders.
(2)The Department of Managed Health Care, the State Department of Health Care Services, the Department of Insurance, the Exchange, and any other public health coverage programs shall provide to the center data concerning call centers to meet the reporting requirements in this section in the time, data elements, manner, and format requested by the center.
(3)For the purpose of publicly reporting information as required in paragraph (1) and this paragraph about the problems faced by consumers in obtaining care and coverage, the center shall analyze data on consumer complaints, appeals, and grievances resolved by the agencies listed in subdivision (b), including demographic data, source of coverage, insurer or plan, resolution of complaints, and other information intended to improve health care and coverage for consumers.
(d)To the extent that funds are appropriated in the annual Budget Act for this purpose, the center shall do all of the following to assist state entities that provide public health coverage programs or oversight of health insurance or health care service plans:
(1)After evaluation of data from the Department of Insurance and the Department of Managed Health Care, coordinate with public health coverage programs and state oversight departments of public and commercial health coverage programs to provide assistance related to addressing the quality of care and patient experience of public and commercial health coverage programs that have been determined to be deficient in the annual quality of care report card.
(2)Create and provide tools and education to consumers of health insurance and public health coverage programs to better enable them to access and utilize the quality of care report card and the health care services to which they are eligible.
(3)Develop tools and education related to improvement of consumer access to care, quality of care, and addressing the disparities in quality of care related to socioeconomic status.
(4)Develop and implement consumer surveys of the patient experience, quality of care, and any other topic consistent with this section.
(5)Develop standards for departments within the California Health and Human Services Agency related to public reports published by the departments to ensure consumer readability and understanding across programs.
(e)If the departmental letters or other similar instruction are only issued to other state entities, the center may implement, interpret, or make specific this section by means of a departmental letter or other similar instruction, as necessary, notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(f)For purposes of this section, the following definitions apply:
(1)“Data” means information that is not individually identifiable health information, as defined in Section 160.103 of Title 45 of the Code of Federal Regulations.
(2)“Exchange” means the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code.
(3)“Health care” includes services provided by any health care coverage program.
(4)“Health care service plan” has the same meaning as that set forth in subdivision (f) of Section 1345. Health care service plan includes “specialized health care service plans,” including behavioral health plans.
(5)“Health coverage program” includes the Medi-Cal program, tax subsidies and premium credits under the Exchange, the Basic Health Program, if enacted, and county health care programs.
(6)“Health insurance” has the same meaning as set forth in Section 106 of the Insurance Code.
SEC. 52.
Section 130206 of the Health and Safety Code is repealed.(a)The Legislature finds and declares that the center performs public health activities described in Section 164.512(b) of Title 45 of the Code of Federal Regulations when carrying out activities pursuant to this division. Personal information collected in accordance with this division is necessary to carry out projects with public health purposes.
(b)All personal information obtained or maintained by the center shall be confidential and shall be subject to the following requirements:
(1)Only deidentified and aggregated information shall be included in a publicly available analysis, data product, or research.
(2)All policies and procedures developed in implementing this division shall ensure that the privacy, security, and confidentiality of consumers’ personal information is protected, as required by the Information Practices Act of 1977, and consistent with state and federal health privacy laws, including the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code), and data shall not be disclosed until the center has developed a policy regarding the release of data.
(c)Unless otherwise specified in this division, personal information collected by the center from other states entities shall be exempt from the disclosure
requirements of the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), and shall not be made available except pursuant to this division.
(d)Any information collected or obtained shall not be used for determinations regarding individual patient care or treatment and shall not be used for any individual eligibility or coverage decisions or similar purposes.
SEC. 53.
Section 130208 of the Health and Safety Code is repealed.(a)The Office of Patient Advocate Trust Fund shall be renamed to the Health Plan Improvement Trust Fund.
(b)The moneys in the Health Plan Improvement Trust Fund shall, upon appropriation by the Legislature, be made available for the purposes in Section 130204.
(c)All moneys in the Health Plan Improvement Trust Fund created pursuant to former Section 130208, as added by Section 11 of Chapter 696 of the Statutes of 2021, shall be transferred to the renamed Health Plan Improvement Trust Fund, identified as Fund 3209 in the Department of Finance’s Uniform Codes Manual.
(d)Notwithstanding Section 16305.7 of the
Government Code, all interest earned on moneys that have been deposited in the Health Plan Improvement Trust Fund shall be retained in the fund and used for purposes consistent with Section 130204.
SEC. 54.
Section 130209 of the Health and Safety Code is repealed.(a)Moneys transferred from the Managed Care Fund and the Insurance Fund for use by the center shall be deposited into the Health Plan Improvement Trust Fund.
(b)The share of funding from the Managed Care Fund shall be based on the number of covered lives in the state that are covered under plans regulated by the Department of Managed Health Care, including covered lives under Medi-Cal managed care, as determined by the Department of Managed Health Care, in proportion to the total number of all covered lives in the state.
(c)The share of funding to be provided from the Insurance Fund shall be based on the number of covered lives in the state that are covered under health
insurance policies and benefit plans regulated by the Department of Insurance, including covered lives under Medicare supplement plans, as determined by the Department of Insurance, in proportion to the total number of all covered lives in the state.
SEC. 55.
Section 130290 of the Health and Safety Code is amended to read:130290.
(a) On or before July 1, 2022, and subject to an appropriation in the annual Budget Act, the California Health and Human Services Agency, along with its departments and offices and in consultation with stakeholders and local partners, shall establish the California Health and Human Services Data Exchange Framework that shall include a single data sharing agreement and common set of policies and procedures that will leverage and advance national standards for information exchange and data content, and that will govern and require the exchange of health information among health care entities and government agencies in California. On or before January 1, 2026, the Department of Health Care Access and Information shall take over the establishment, implementation, and all of the functions related to the California Health and Human Services Data Exchange Framework, including the data sharing agreement and policies and procedures, from the California Health and Human Services Agency.(1) The California Health and Human Services Data Exchange Framework is not intended to be an information technology system or single repository of data, rather it is technology agnostic and is a collection of organizations that are required to share health information using a common set of policies and procedures in order to improve the health outcomes of the individuals they serve.
(2) The California Health and Human Services Data Exchange Framework will be designed to enable and require real-time access to, or exchange of, health information among participants through any health information exchange network, health information organization, or technology that adheres to specified standards and policies.
(3) The California Health and Human Services Data Exchange Framework shall align with state and federal data requirements, including the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code), Sections 827, 10850, and 14100.2 of the Welfare and Institutions Code, and other applicable state and federal privacy laws related to the sharing of data among and between providers, payers, and the government, while also streamlining and reducing reporting burden.
(4) For the purposes of this section, “health information” means:
(A) For hospitals, skilled nursing facilities, clinical laboratories, and physician organizations and medical groups, all electronic health information
as defined under federal regulation in Section 171.102 of Title 45 of the Code of Federal Regulations and held by the entity. The information pursuant to this subparagraph shall be at a minimum the information included in Section 171.102 of Title 45 of the Code of Federal Regulations as of April 15, 2025. In accordance with the California Health and Human Services Data Exchange Framework data sharing agreement and policies and procedures, a signatory to the data sharing agreement is not required to share information that is not maintained by the entity.
(B) For health insurers and health care service plans, at a minimum, the data required to be shared under the federal Centers for Medicare and Medicaid Services Interoperability and Patient Access regulations for public programs as contained in United States Department of Health and Human Services final rule CMS-9115-F, 85 FR 25510 as of April 15, 2025.
(b) (1) On or before January 31, 2024, and except as provided in paragraphs (2) to (4), (5),
inclusive, the entities listed in subdivision (f) shall exchange health information or provide access to health information to and from every other entity in subdivision (f) in real time as specified by the department pursuant to the California Health and Human Services Data Exchange Framework data sharing agreement for treatment, payment, or health care operations, except that the health care organizations in subparagraph (C) of paragraph (2) of subdivision (f) and paragraph (7) of subdivision (f) shall exchange or provide access to health information by July 1, 2026.
(2) The requirement in paragraph (1) shall not apply to physician practices of fewer than 25 physicians, rehabilitation hospitals, long-term acute care hospitals, acute psychiatric hospitals, critical access hospitals, and rural general acute care hospitals with fewer than 100 acute care beds, and any nonprofit clinic with fewer than 10 health care providers
until January 31, 2026.
(3) The requirement in paragraph (1) shall not apply to facilities described in subdivision (a) of Section 1180.2 until January 31, 2029.
(4) The requirement in paragraph (1) shall not apply to the exchange of health information related to abortion, abortion-related services, gender-affirming care, immigration or citizenship status, or place of birth.
(5) The requirement in paragraph (1) shall not apply to health care organizations described in subparagraph (D) of paragraph (2) of subdivision (f) until July 1, 2027.
(c) The California Health and Human Services Agency shall convene a stakeholder advisory group no later than
September 1, 2021, to advise on the development, implementation, and administration of the California Health and Human Services Data Exchange Framework. On or before January 1, 2026, the department shall take over the responsibilities of the stakeholder advisory group.
(1) The members of the stakeholder advisory group shall be appointed by the director and shall not have a financial interest, individually or through a family member, related to issues the stakeholder advisory group will advise on. The stakeholder advisory group may consider and vote on recommendations for updates to the data sharing agreement and its policies and procedures that the department may, but is not obligated to, enact.
(2) The director shall appoint to the stakeholder advisory group representatives from health care stakeholders and experts with representation of the following groups:
(A) State departments and other state entities, including signatories of the California Data Exchange Framework data sharing agreement that shall serve as ex officio nonvoting members.
(B) Health care service plans and health insurers.
(C) Physicians, including those with small practices.
(D) Hospitals, including public, private, rural, and critical access hospitals.
(E) Clinics, long-term care facilities, behavioral health facilities, or substance use disorder facilities.
(F) Consumers.
(G) Organized labor.
(H) Privacy and security professionals.
(I) Health information technology professionals.
(J) Community health information organizations.
(K) County health, social services, and public health.
(L) Community-based organizations providing social services.
(M) Skilled nursing facilities.
(N) Physician organizations and medical groups.
(O) Management services organizations.
(3) The stakeholder advisory group shall not exceed 17 voting members
and shall maintain a balance of perspectives with not more than 50 percent of voting members who are signatories of the data sharing agreement.
(4) The director shall select a chair from amongst the members.
(5) The stakeholder advisory group shall provide information and advice to the department on health and social services information technology issues, including all of the following:
(A) Identify which data beyond health information as defined in paragraph (4) of subdivision (a), at minimum, should be shared for specified purposes between the entities outlined in this subdivision and subdivision (f).
(B) Identify gaps, and propose solutions to gaps, in the life cycle of health information, including gaps in any of the following:
(i) Health information creation, including the use of national standards in clinical documentation, health plan records, and social services data.
(ii) Translation, mapping, controlled vocabularies, coding, and data classification.
(iii) Storage, maintenance, and management of health information.
(iv) Linking, sharing, exchanging, and providing access to health information.
(C) Identify ways to incorporate data related to social determinants of health, such as housing and food insecurity, into shared health information.
(D) Identify ways to incorporate data related to underserved or underrepresented populations, including, but
not limited to, data regarding sexual orientation and gender identity, language, race, and ethnicity.
(E) Identify ways to incorporate relevant data on behavioral health, developmental disabilities, and substance use disorder conditions.
(F) Address the privacy, security, and equity risks of expanding care coordination, health information exchange, access, and telehealth in a dynamic technological, and entrepreneurial environment, where data and network security are under constant threat of attack.
(G) Develop policies and procedures consistent with national standards and federally adopted standards in the exchange of health and social services information, including matters of meaningful and informed consent, privacy, confidentiality, identity management, liability and security, and ensure that health and social
services information sharing broadly implements national frameworks and agreements.
(H) Develop definitions of complete clinical, administrative, and claims data consistent with federal policies and national standards.
(I) Identify how all payers will be required to provide enrollees with electronic access to their health information, consistent with rules applicable to federal payer programs.
(J) Assess governance structures to help guide policy decisions and general oversight.
(K) Identify federal, state, private, and philanthropic sources of funding that can support health and social services information exchange.
(6) On or before January 1, 2027, the stakeholder advisory group shall
develop recommendations in consultation with signatories, consumer advocates, and racial equity experts for statutory changes, training and technical assistance, and best practices to require the entities listed in subdivision (f) to collect individual-level demographic and health-related social needs data about Californians served.
(7) The stakeholder advisory group shall hold public meetings with stakeholders, solicit input, and set its own meeting agendas. Meetings of the stakeholder advisory group are subject to the Bagley-Keene Open Meeting Act (Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of the Government Code).
(8) The members of the stakeholder advisory group shall serve without compensation, but shall be reimbursed for any actual and necessary expenses incurred in connection with their duties as members of the group.
(d) No later than April 1, 2022, the California Health and Human Services Agency shall submit an update, including written recommendations, to the Legislature based on input from the stakeholder advisory group on the issues identified in paragraph (5) of subdivision (c).
(e) On or before January 31, 2023, the California Health and Human Services Agency shall work with the California State Association of Counties to encourage the inclusion of county health, public health, and social services, to the extent possible, as part of the California Health and Human Services Data Exchange Framework in order to assist both public and private entities to connect through uniform standards and policies. It is the intent of the Legislature that all state and local public health agencies will exchange electronic health information in real time with participating health care entities to protect and
improve the health and well-being of Californians.
(f) On or before January 31, 2023, and in alignment with existing federal standards and policies, the following health care organizations shall execute the California Health and Human Services Data Exchange Framework data sharing agreement pursuant to subdivision (a), except that the health care organizations in subparagraph (C) of paragraph (2) and paragraph (7) shall execute the data sharing agreement by July 1, 2026: 2026, and health care organizations in subparagraph (D) of paragraph (2) shall execute the data sharing agreement by July 1, 2027:
(1) General acute care hospitals, as defined by Section 1250.
(2) Physician organizations and medical groups, which include any of the following:
(A) A medical group practice, a professional medical corporation, a medical partnership, or any lawfully organized group of physicians and surgeons that provides, delivers, furnishes, or otherwise arranges for health care services.
(B) An independent practice association, to the extent that it maintains electronic health information on behalf of their participating physicians.
(C) A medical foundation exempt from licensure pursuant to subdivision (l) of Section 1206.
(D) A community clinic licensed under subdivision (a) of Section 1204, an intermittent clinic exempt from licensure under subdivision (h) of
Section 1206, or a rural health clinic, as defined in paragraph (1) of subdivision (l) of Section 1396d of Title 42 of the United States Code.
(E) A specialty clinic, as described in paragraphs (1) to (3), inclusive, of subdivision (b) of Section 1204.
(F) An ambulatory surgical center or accredited outpatient setting.
(3) Skilled nursing facilities, as defined by Section 1250, that currently maintain electronic health records.
(4) Health care service plans and disability insurers that provide hospital, medical, or surgical coverage that are regulated by the Department of Managed Health Care or the Department of Insurance. This section shall also apply to a Medi-Cal managed care plan under a comprehensive risk contract with the State Department of
Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code that is not regulated by the Department of Managed Health Care or the Department of Insurance.
(5) Clinical laboratories, as that term is used in Section 1265 of the Business and Professions Code, and that are regulated by the State Department of Public Health.
(6) Acute psychiatric hospitals, as defined by Section 1250.
(7) Emergency medical services, as defined by Section 1797.72.
(g) Commencing July 1, 2026, unless already required by an existing contract requirement, including any existing contract requirement that extends to subcontractors and delegates, compliance with
subdivision (f) shall be required as a condition of continuing, amending, or entering into a new or existing contract for the coverage of or provision of health care services with the Department of Health Care Services, the Public Employees’ Retirement System, and the California Health Benefit Exchange. This subdivision shall not be construed to prevent any future contract requirement that extends this provision to subcontractors and delegates.
(h) The department shall work with experienced nonprofit organizations and entities represented in the stakeholder advisory group in subdivision (c) to provide technical assistance to the entities outlined in subdivisions (e) and (f).
(i) On or before July 31, 2022, the California Health and Human Services Agency shall develop in consultation with the stakeholder advisory group in subdivision (c) a strategy for unique, secure digital
identities capable of supporting master person indices to be implemented by both private and public organizations in California.
(j) For purposes of implementing this section, including, but not limited to, hiring staff and consultants, facilitating and conducting meetings, conducting research and analysis, and developing the required reports, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis. Contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. A person hired or otherwise retained pursuant to this subdivision shall not be permitted to have any
financial interest in the California Health and Human Services Data Exchange Framework or shall be, or shall not be affiliated with, any health care organization required to participate in the California Health and Human Services Data Exchange Framework pursuant to subdivisions (b) and (f). The term “person,” as used in this subdivision, means any individual, partnership, joint venture, association, corporation, or any other organization or any combination thereof.
(k) (1) The department shall administer, manage, oversee, and enforce the California Health and Human Services Data Exchange Framework and its data sharing agreement, including its related policies and procedures, governance, and all other materials or initiatives related to the California Health and Human Services Data Exchange Framework. The department shall propose and publish updates to the framework and new policies and procedures of the framework that are
necessary to advance the goals of this section. There shall be at least a forty-five-calendar-day public review period to review updates to the framework and new policies and procedures. The department shall publish approved updates in a publicly accessible format 180 calendar days before the effective date of the amendment, except when a shorter time period is necessary to comply with applicable law.
(2) Commencing January 1, 2027, the department shall publish and keep current on its internet website the names of any known entities the department deems not to be in compliance with the requirement to execute the California Health and Human Services Data Exchange Framework data sharing agreement pursuant to subdivision (f). Entities may submit to the department a statement of extenuating circumstances which may impact an entity’s ability to come into compliance. The department shall publish these statements on its internet website. The
department may submit information regarding compliance with the requirement in subdivision (f) to relevant state licensing entities.
(3) Upon appropriation and after submission of the report described in paragraph (4), the department may develop enforcement actions subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(4) In collaboration with the stakeholder advisory group, the department shall develop and submit a report to the Legislature by July 1, 2027, in compliance with Section 9795 of the Government Code that includes all of the following:
(A) A list of all entities in paragraphs (1), (3), and (4) of subdivision (f) deemed to be required signatories to the California Health and Human Services Data Exchange Framework
data sharing agreement per subdivision (f).
(B) The status of each entity’s execution of the data sharing agreement.
(C) The compliance pathway or pathways utilized to meet its contractual requirements under the data sharing agreement, and, where applicable, if the signatory has a contract in place pursuant to subdivision (g).
(D) An evaluation as to the need for an independent governing board for the California Health and Human Services Data Exchange Framework.
(E) An evaluation of the need for technical assistance and other grant programs to support signatories’ legal requirements under the data sharing requirement.
(F) An evaluation of other categories of entities for participation in
the California Health and Human Services Data Exchange Framework.
(G) An evaluation of the need for a framework for enforcement and investigation and resolution of disputes between California Health and Human Services Data Exchange Framework participants regarding the data sharing agreement and its policies and procedures.
(H) An assessment of consumer experiences with health and social services information exchange.
(l) Except where otherwise indicated in this section, all actions to implement the California Health and Human Services Data Exchange Framework, including the adoption or development of any data sharing agreement, requirements, policies and procedures, guidelines, subgrantee contract provisions, or reporting requirements, shall be exempt from 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 department shall release program notices that detail the requirements of the California Health and Human Services Data Exchange Framework.
(m) For purposes of this section, both of the following definitions shall apply:
(1) “Department” means the Department of Health Care Access and Information.
(2) “Director” means the Director of the Department of Health Care Access and Information.
SEC. 56.
Section 10123.861 is added to the Insurance Code, to read:10123.861.
(a) A health insurance policy that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date of this section shall include coverage for United States Food and Drug Administration-approved treatments used to treat menopausal symptoms, as medically necessary, including, but not limited to, all of the following:(1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss.
(2) Low-dose antidepressants.
(3) Anticonvulsants.
(4) Medications to prevent or treat osteoporosis.
(5) Nonhormonal medications for vasomotor-related symptoms.
(b) A health insurance policy that is issued, amended, or renewed on or after January 1, 2027, shall include a program to ensure insured individuals have access to current menopause information and covered items and services.
(c) For the program to satisfy subdivision (b), the insurer shall do all of the following:
(1) Provide, no later than July 1, 2027, and biannually thereafter, all contracted providers
delivering primary care with information about current clinical care recommendations for menopause care, including hormone therapy, from the Menopause Society or other nationally recognized professional association. The insurer shall encourage providers delivering primary care to review the information.
(2) Establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall identify the Current Procedural Terminology (CPT) codes for services commonly used to evaluate, diagnose, and treat symptoms resulting from menopause.
(3) Establish and maintain a policy to provide insured individuals who may experience menopause and who are 40 years of age and older with an annual menopause assessment during primary care and obstetrician-gynecologist
appointments. Insured individuals may opt out of receiving the assessments. The policy shall include a copy of the assessment tool and information on how it was developed or chosen.
(4) Provide insured individuals who may experience menopause and who are 40 years of age and older with a notice that includes a definition of menopause and that lists the covered items and services used to evaluate and treat symptoms resulting from menopause. The first notice shall be sent within 60 days of the insured individual’s 40th birthday and shall be sent biannually thereafter. Insured individuals may opt out of receiving the notices. The notice shall include a description of at least all of the following types of federal Food and Drug Administration-approved items and services:
(A) Hormone therapy in the full range of formulations and methods of administration.
(B) Low-dose antidepressants.
(C) Anticonvulsants.
(D) Medications to prevent or treat osteoporosis.
(E) Nonhormonal medications for vasomotor-related symptoms.
(5) Establish and maintain a policy to contract with providers delivering primary care, including advanced practice providers such as licensed nurse practitioners and certified nurse-midwives, who hold a certification or credential in menopause care from a nationally recognized organization, such as the Menopause Society or other similar organization. The policy shall state what steps the insurer will take to incentivize providers to receive and maintain the certification or credential.
(d) The health insurer shall file with the commissioner within six months of the operative date of this statute the policies and notices specified in subdivision (c). The insurer shall also disclose the policies to network providers, provider groups, and delegated entities that may be impacted by the policies and notices and shall attest to that disclosure to the commissioner.
(e) Coverage for the treatment options pursuant to this section shall be provided without discrimination on the basis of gender expression or identity.
(f) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause.
(g) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause.
SEC. 57.
Section 10123.862 is added to the Insurance Code, to read:10123.862.
(a) A health insurer shall base a medical necessity determination or the utilization review criteria that the insurer, and an entity acting on the insurer’s behalf, applies to determine the medical necessity of health care services and benefits for the treatment of symptoms resulting from menopause on current generally accepted standards of menopause care.(b) Beginning January 1, 2027, when conducting utilization review of all covered health care services and benefits for the treatment of symptoms resulting from menopause, a health insurer shall apply criteria and guidelines developed by the Menopause Society or another nationally recognized professional association, as specified by the commissioner.
(c) In conducting utilization review involving patient care decisions that are within the scope of the sources specified in subdivision (b), a health insurer shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria and guidelines set forth in those sources. This subdivision does not prohibit an insurer from applying utilization review criteria to health care services and benefits for menopause care that meet either of the following criteria:
(1) Are outside the scope of the criteria and guidelines set forth in the sources specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).
(2) Relate to advancements in technology or types of care that are not covered in the most recent versions of the sources
specified in subdivision (b), if the utilization review criteria were developed in accordance with subdivision (a).
(d) If a health insurer purchases or licenses utilization review criteria pursuant to paragraph (1) or (2) of subdivision (c), the insurer shall verify and document before use that the criteria were developed in accordance with subdivision (a).
(e) A health insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with this section.
(f) For purposes of this section, the following definitions apply:
(1) “Generally accepted standards of menopause care” means standards of care and clinical practice that are generally recognized by health care
providers practicing in relevant clinical specialties, including gynecology, endocrinology, and family practice. Valid, evidence-based sources establishing generally accepted standards of menopause care include peer reviewed scientific studies and medical literature, clinical practice guidelines and recommendations of nonprofit health care provider professional associations, specialty societies, and federal government agencies, and drug labeling approved by the United States Food and Drug Administration.
(2) “Menopause” includes perimenopause, menopause, and postmenopause.
(3) “Utilization review” means either of the following:
(A) Prospectively, retrospectively, or concurrently reviewing and approving, modifying, delaying, or denying, based in whole or in part on medical necessity, requests by health care providers,
insured individuals, or their authorized representatives for coverage of health care services prior to, retrospectively, or concurrent with the provision of health care services to insured individuals.
(B) Evaluating the medical necessity, appropriateness, or efficacy of health care services, benefits, or procedures, under any circumstances, to determine if a health care service or benefit subject to a medical necessity coverage requirement in a health insurance policy is covered as medically necessary for an insured individual.
(4) “Utilization review criteria” means criteria, standards, protocols, or guidelines used by a health insurer to conduct utilization review.
(g) (1) This section applies to all health care services and benefits for the treatment of symptoms resulting from menopause
covered by a health insurance policy, including prescription drugs.
(2) This section applies to a health insurer that conducts utilization review and an entity or contracting provider that performs utilization review or utilization management functions on an insurer’s behalf.
(3) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause.
(h) If the commissioner determines that a health insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation.
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and Section 10123.861 through guidance or similar instructions, without taking regulatory action, until the department adopts regulations pursuant to the Administrative Procedure Act. The department shall consult with the Department of Managed Health Care and interested stakeholders in developing guidance.
SEC. 58.
Section 10133.8 of the Insurance Code is amended to read:10133.8.
(a) The commissioner shall, on or before January 1, 2006, promulgate regulations applicable to all individual and group policies of health insurance establishing standards and requirements to provide insureds with appropriate access to translated materials and language assistance in obtaining covered benefits. A health insurer that participates in the Healthy Families Program may assess the Healthy Families Program enrollee population separately from the remainder of its population for purposes of subparagraph (A) of paragraph (3) of subdivision (b). An insurer that chooses to separate its Healthy Families Program enrollment from the remainder of its population shall treat the Healthy Families Program population separately for purposes of determining whether subparagraph (A) of paragraph (3) of subdivision (b) is applicable and shall also treat the Healthy Families Program population separately for purposes of applying the percentage and numerical thresholds in subparagraph (A) of paragraph (3) of subdivision (b).(b) The regulations described in subdivision (a) shall include the following:
(1) A requirement to conduct an assessment of the needs of the insured group, pursuant to this subdivision.
(2) Requirements for surveying the language preferences and assessment of linguistic needs of insureds within one year of the effective date of the regulations that permit health insurers to utilize various survey methods, including, but not limited to, the use of existing enrollment and renewal processes, newsletters, or other mailings. Health insurers shall update the linguistic needs assessment, demographic profile, and language translation
requirements every three years. However, the regulations may provide that the surveys and assessments by insurers of supplemental insurance products may be conducted less frequently than three years if the commissioner determines that the results are unlikely to affect the translation requirements.
(3) Requirements for the translation of vital documents that include the following:
(A) A requirement that all vital documents, as defined pursuant to subparagraph (B), be translated into an indicated language, as follows:
(i) A health insurer with an insured population of 1,000,000 or more shall translate vital documents into the top two languages other than English as determined by the needs assessment pursuant to paragraph (2) and any additional languages when 0.75 percent or 15,000 of the insured population, whichever
number is less, indicates in the needs assessment pursuant to paragraph (2) a preference for written materials in that language.
(ii) A health insurer with an insured population of 300,000 or more but less than 1,000,000 shall translate vital documents into the top one language other than English as determined by the needs assessment pursuant to paragraph (2) and any additional languages when 1 percent or 6,000 of the insured population, whichever number is less, indicates in the needs assessment pursuant to paragraph (2) a preference for written materials in that language.
(iii) A health insurer with an insured population of less than 300,000 shall translate vital documents into a language other than English when 3,000 or more or 5 percent of the insured population, whichever number is less, indicates in the needs assessment pursuant to paragraph (2) a preference for written
materials in that language.
(B) Specification of vital documents produced by the insurer that are required to be translated. The specification of vital documents shall not exceed that of the United States Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Policy Guidance (65 Federal Register 52762 (August 30, 2000)), but shall include all of the following:
(i) Applications.
(ii) Consent forms.
(iii) Letters containing important information regarding eligibility or participation criteria.
(iv) Notices pertaining to the denial, reduction, modification, or termination of services and benefits, the right to file a complaint or appeal.
(v) Notices advising limited-English-proficient persons of the availability of free language assistance and other outreach materials that are provided to insureds.
(vi) Translated documents shall not include an insurer’s explanation of benefits or similar claim processing information that are sent to insureds unless the document requires a response by the insured.
(C) For those documents described in subparagraph (B) that are not standardized but contain insured specific information, health insurers shall not be required to translate the documents into the threshold languages identified by the needs assessment pursuant to paragraph (2) but rather shall include with the document a written notice of the availability of interpretation services in the threshold languages identified by the needs assessment pursuant to
paragraph (2). A health insurer subject to the requirements in Section 10133.11 shall also include with the documents a written notice of the availability of interpretation services in the top 15 languages spoken by limited-English-proficient (LEP) individuals in California as determined by the State Department of Health Care Services.
(i) Upon request, the insured shall receive a written translation of those documents. The health insurer shall have up to, but not to exceed, 21 days to comply with the insured’s request for a written translation. If an enrollee requests a translated document, all timeframes and deadlines requirements related to the documents that apply to the health insurer and insureds under the provisions of this chapter and under any regulations adopted pursuant to this chapter shall begin to run upon the health insurer’s issuance of the translated document.
(ii) For appeals that require expedited review and response in accordance with the statutes and regulations of this chapter, the health insurer may satisfy this requirement by providing notice of the availability and access to oral interpretation services.
(D) A requirement that health insurers advise limited-English-proficient insureds of the availability of interpreter services.
(4) Standards to ensure the quality and accuracy of the written translation and that a translated document meets the same standards required for the English version of the document. The English language documents shall determine the rights and obligations of the parties, and the translated documents shall be admissible in evidence only if there is a dispute regarding a substantial difference in the material terms and conditions of the English language document and the translated document.
(5) Requirements for individual access to interpretation services that include the following:
(A) A requirement that an interpreter meets, at a minimum, all of the following qualifications:
(i) Demonstrated proficiency in both English and the target language.
(ii) Knowledge in both English and the target language of health care terminology and concepts relevant to health care delivery systems.
(iii) Adheres to generally accepted interpreter ethics principles, including client confidentiality.
(B) A requirement that the insured with limited English proficiency shall not be required to provide their own interpreter or rely on a
staff member who does not meet the qualifications described in subparagraph (A) to communicate directly with the limited-English-proficient insured.
(C) A requirement that the insured with limited English proficiency shall not be required to rely on an adult or minor child accompanying the insured to interpret or facilitate communication except under either of the following circumstances:
(i) In an emergency, as described in Section 1317.1 of the Health and Safety Code, if a qualified interpreter is not immediately available for the insured with limited English proficiency.
(ii) If the individual with limited English proficiency specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide that assistance, and reliance on that accompanying adult for
that assistance is appropriate under the circumstances.
(6) Standards to ensure the quality and timeliness of oral interpretation services provided by health insurers.
(c) In developing the regulations, standards, and requirements described in this section, the commissioner shall consider the following:
(1) Publications and standards issued by federal agencies, including the Culturally and Linguistically Appropriate Services (CLAS) in Health Care issued by the United States Department of Health and Human Services Office of Minority Health in December 2000, and the United States Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Policy Guidance 65 (65 Federal Register 52762 (August 30, 2000)).
(2) Other cultural and linguistic
requirements under state programs, including the Medi-Cal Managed Care Policy Letters, cultural and linguistic requirements imposed by the State Department of Health Care Services on health care service plans that contract to provide Medi-Cal managed care services, and cultural and linguistic requirements imposed by the Managed Risk Medical Insurance Board on health insurers that contract to provide services in the Healthy Families Program.
(3) Standards adopted by other states pertaining to language assistance requirements for health insurers.
(4) Standards established by California or nationally recognized accrediting, certifying, or licensing organizations and medical and health care interpreter professional associations regarding interpretation services.
(5) Publications, guidelines, reports, and recommendations
issued by state agencies or advisory committees, such as the report card to the public on the comparative performance of plans and reports on cultural and linguistic services issued by the Center for Data Insights and Innovation and the report to the Legislature from the Task Force on Culturally and Linguistically Competent Physicians and Dentists required pursuant to former Section 852 of the Business and Professions Code.
(6) Examples of best practices relating to language assistance services by health care providers and health insurers that contract for alternative rates of payment with providers, including existing practices.
(7) Information gathered from complaints to the commissioner and consumer assistance help lines regarding language assistance services.
(8) The cost of compliance and the availability of translation and interpretation services and professionals.
(9) Flexibility to accommodate variations in networks and method of service delivery. The commissioner shall allow for health insurer flexibility in determining compliance with the standards for oral and written interpretation services.
(d) In designing the regulations, the commissioner shall consider all other relevant guidelines in an effort to accomplish maximum accessibility within a cost-efficient system of indemnification. The commissioner shall seek public input from a wide range of interested parties.
(e) Services, verbal communications, and written materials provided by or developed by the health insurers that contract for alternative
rates of payment with providers, shall comply with the standards developed under this section.
(f) Beginning on January 1, 2008, the department shall report biennially to the Legislature regarding health insurer compliance with the standards established by this section, including results of compliance audits made in conjunction with other audits and reviews. The department shall also utilize the reported information to make recommendations for changes that further enhance standards pursuant to this section. The commissioner shall work to ensure that the biennial reports required by this section, and the data collected for the reports, do not require duplicative or conflicting data collection with other reports that may be required by government-sponsored programs. The commissioner may also delay or otherwise phase in implementation of the standards and requirements in recognition of costs and availability of translation and interpretation
services and professionals.
(g) This section does not prohibit government purchasers from including in their contracts additional translation or interpretation requirements, to meet the linguistic and cultural needs, beyond those set forth pursuant to this section.
SEC. 59.
Section 1602 of the Penal Code is amended to read:1602.
(a) Before any person subject to the provisions of subdivision (b) of Section 1601 may be placed on outpatient status, the court shall consider all of the following criteria:(1) In the case of a person who is an inpatient, whether the medical director or designee of the state hospital or other treatment facility to which the person has been committed advises the court that the defendant will not
committing court, defense counsel, and the prosecutor that the defendant would no longer be a danger to the health and safety of others while on outpatient status, and will others, or to themselves, while under supervision and treatment in the community, and would benefit from such outpatient status.
(2) In all cases, whether the community program director or a designee, or pursuant to Section 4360.5 of the Welfare and Institutions Code,
the independent evaluation placement panel, advises the court that the defendant will not be a danger to the health and safety of others others, or to themselves, while on outpatient status, will benefit from such status, and identifies an appropriate program of supervision and treatment.
(b) Prior to determining whether to place the person on outpatient status, the court shall provide actual notice to the prosecutor and defense counsel, and to the victim, and shall hold a hearing at which the court may specifically order outpatient status for the
person.
(c) The community program director or a designee, or the independent evaluation placement panel, shall prepare and submit the evaluation and the treatment plan specified in paragraph (2) of subdivision (a) to the court within 15 calendar days after notification by the court to do so, except that in the case of a person who is an inpatient, the evaluation and treatment plan shall be submitted within 30 calendar days after notification by the court to do so.
(d) Any evaluations and recommendations pursuant to paragraphs (1) and (2) of subdivision (a) shall include review and consideration of complete, available information regarding the circumstances of the criminal offense and the
person’s prior criminal history.
SEC. 60.
Section 1603 of the Penal Code is amended to read:1603.
(a) Before any person subject to subdivision (a) of Section 1601 may be placed on outpatient status the court shall consider all of the following criteria:(1) Whether the medical director or designee of the state hospital or other treatment facility to which the person has been committed advises the committing court court, defense counsel, and the prosecutor
that the defendant would no longer be a danger to the health and safety of others, including themselves, while under supervision and treatment in the community, and will benefit from that status. status, and identifies an appropriate program of supervision and treatment.
(2) Whether the community program director or a designee, or pursuant to Section 4360.5 of the Welfare and Institutions Code, the independent evaluation
placement panel, advises the court that the defendant
committing court, defense counsel, and the prosecutor that the defendant would no longer be a danger to the health and safety of others, including themselves, while under supervision and treatment in the community, will benefit from that status, and identifies an appropriate program of supervision and treatment.
(b) (1) Prior to release of a person under subdivision (a), the prosecutor shall provide notice of the hearing date and pending release to the victim or next of kin of the victim of the offense for which the person was committed where a request for the notice has been filed with the court, and after a hearing in court, the court shall specifically approve the recommendation and plan for outpatient status pursuant to Section 1604. The burden shall be on the victim or next of kin to the victim to keep the court apprised of the party’s current mailing address.
(2) In any case in which the victim or next of kin to the victim has filed a request for notice with the director of the state hospital or other treatment facility, they shall be notified by the director at the inception of any program in which the committed person would be allowed any type of day release unattended by the staff of the facility.
(c) The community program director, their designee, or the independent evaluation placement panel, shall prepare and submit the evaluation and the treatment plan specified in paragraph (2) of subdivision (a) to the court within 30 calendar days after notification by the court to do so.
(d) Any evaluations and recommendations pursuant to paragraphs (1) and (2) of subdivision (a) shall include review and consideration of complete, available information regarding the circumstances of the criminal offense and the person’s prior criminal history.
SEC. 61.
Section 1604 of the Penal Code is amended to read:1604.
(a) Upon receipt by the committing court of the recommendation of the medical director or designee of the state hospital or other treatment facility to which the person has been committed that the person may be eligible for outpatient status as set forth in subdivision (a)(1) of Section 1602 or 1603, the court shall immediately forward such recommendation to the independent(b) Within 30 calendar days the community program director,
designee, or panel, independent placement panel or designee shall submit to the court and, when appropriate, and to the medical director of the state hospital or other treatment facility, a recommendation regarding the defendant’s eligibility for outpatient status, as set forth in subdivision (a)(2) of Section 1602 or 1603 and the recommended plan for outpatient supervision and treatment. The plan shall set forth specific terms and conditions to be followed during outpatient status. The court shall provide copies of this report to the prosecutor and the defense counsel.
(c) The court shall calendar the matter for hearing within 15 judicial days of the receipt of the report described in subdivision (b) and shall give notice of the hearing date to the prosecutor, defense counsel, the community program director, the independent placement panel, and, when appropriate, to the and the medical director of the state hospital or other facility. In any hearing conducted pursuant to this section, the court shall consider the circumstances and nature of the criminal offense leading to commitment and shall consider the person’s prior criminal history.
(d) The court
shall, after a hearing in court, either approve or disapprove the recommendation for outpatient status. If the approval of the court is given, the defendant shall be placed on outpatient status subject to the terms and conditions specified in the supervision and treatment plan. If the outpatient treatment occurs in a county other than the county of commitment, the court shall transmit a copy of the case record to the superior court in the county where outpatient treatment occurs, so that the record will be available if revocation proceedings are initiated pursuant to Section 1608 or 1609.
SEC. 62.
Section 30461.6 of the Revenue and Taxation Code is amended to read:30461.6.
(a) Notwithstanding Section 30461, the board shall transmit the revenue derived from the increase in the cigarette tax rate of one mill ($0.001) per cigarette imposed by Section 30101 on and after January 1, 1994, to the Treasurer to be deposited in the State Treasury to the credit of the Breast Cancer Fund, which fund is hereby created. The Breast Cancer Fund shall consist of two accounts: the Breast Cancer Research Account and the Breast Cancer Control Account. The revenues deposited in the fund shall be divided equally between the two accounts.(b) The moneys in the accounts within the Breast Cancer Fund shall, upon appropriation by the Legislature, be allocated as follows:
(1) The moneys in
the Breast Cancer Research Account shall be allocated for research with respect to the cause, cure, treatment, earlier detection, and prevention of breast cancer as follows:
(A) Ten percent to the Cancer Surveillance Section of the State Department of Health Care Services Public Health for the collection of breast cancer-related data and the conduct of breast cancer-related epidemiological research by the state cancer registry established pursuant to Section 103885 of the Health and Safety Code.
(B) Ninety percent to the Breast Cancer Research Program, that is hereby created at the University of California, for the awarding of grants and contracts to researchers for research with respect to
the cause, cure, treatment, prevention, and earlier detection of breast cancer and with respect to the cultural barriers to accessing the health care system for early detection and treatment of breast cancer.
(2) The moneys in the Breast Cancer Control Account shall be allocated to the Breast Cancer Control Program, that is hereby created for the provision of early breast cancer detection services for uninsured and underinsured women. The Breast Cancer Control Program shall be established in the State Department of Health Care Services and shall be administered in coordination with the breast and cervical cancer control program established pursuant to Public Law 101-354.
(c) The early breast cancer detection services provided by the Breast Cancer Control Program shall include all of the following:
(1) Screening,
including mammography, of women for breast cancer as an early detection health care measure.
(2) After screening, medical referral of screened women and services necessary for definitive diagnosis, including nonradiological techniques or biopsy.
(3) If a positive diagnosis is made, then assistance and advocacy shall be provided to help the person obtain necessary treatment.
(4) Outreach and health education activities to ensure that uninsured and underinsured women are aware of and appropriately utilize the services provided by the Breast Cancer Control Program.
(d) (1) Any entity funded by the Breast Cancer Control Program shall coordinate with other local providers of breast cancer screening, diagnostic, followup, education, and
advocacy services to avoid duplication of effort. Any entity funded by the program shall comply with any applicable state and federal standards regarding mammography quality assurance.
(2) To the extent required or permitted by federal law, a provider of breast cancer screening or diagnostic services may employ digital mammography technology for the purposes of mammography screening and diagnostic procedures that are conducted prior to January 1, 2014, when film, otherwise known as analog, mammography technology is unavailable. To the extent required or permitted by federal law and notwithstanding paragraph (3) of subdivision (a) of Section 14105.18 of the Welfare and Institutions Code, the payment rate for all mammography screening that is conducted prior to January 1, 2014, shall be limited to the Medi-Cal payment rate for film mammography screening.
(e) Notwithstanding Section
10231.5 of the Government Code, each year, the State Department of Health Care Services shall submit an annual report about the Breast Cancer Control Program, including information described in subdivision (f), to the fiscal and appropriate policy committees of the Legislature and to other appropriate entities. The department shall submit the report, in accordance with Section 9795 of the Government Code, no later than February 28 each fiscal year.
(f) Any entity funded by the Breast Cancer Control Program shall collect data and maintain records that are determined by the State Department of Health Care Services to be necessary to facilitate the department’s ability to monitor and evaluate the effectiveness of the program entities and the program. The costs associated with the report described in subdivision (e) shall be paid from the allocation made pursuant to paragraph (2) of subdivision (b). The report shall describe the activities and
effectiveness of the program and shall include, but not be limited to, the following types of information:
(1) The number of recipients served.
(2) The ethnic, geographic, and age breakdown.
(3) The breast and cervical cancer stages of presentation.
(4) The breast and cervical cancer diagnostic and treatment status.
(5) Program caseload.
(6) Estimated clinical claims and expenditures.
(7) Program activities and monitoring data.
(8) A breakdown of expenditures for clinical service activities,
including, but not limited to, office visits and consults, screening mammograms, diagnostic mammograms, diagnostic breast procedures, case management, and other clinical services.
(g) The Breast Cancer Control Program shall be conducted in consultation with the Breast Cancer Research Program created pursuant to subparagraph (B) of paragraph (1) of subdivision (b).
(h) In implementing the Breast Cancer Control Program, the State Department of Health Care Services may appoint and consult with an advisory panel appointed by the Director of Health Care Services and consisting of one ex officio, nonvoting member from the Breast Cancer Research Program, breast cancer researchers, and representatives from voluntary, nonprofit health organizations, health care professional organizations, breast cancer survivor groups, and breast cancer and health care-related advocacy groups. It is the
intent of the Legislature that breast cancer-related survivors and advocates and health advocates for low-income women compose at least one-third of the advisory panel. It is also the intent of the Legislature that the State Department of Health Care Services collaborate closely with the panel.
(i) It is the intent of the Legislature in enacting the Breast Cancer Control Program to decrease cancer mortality rates attributable to breast cancer among uninsured and underinsured women, with special emphasis on low-income, Native American, and minority women. It is also the intent of the Legislature that the communities served by the Breast Cancer Control Program reflect the ethnic, racial, cultural, and geographic diversity of the state and that the Breast Cancer Control Program fund entities where uninsured and underinsured women are most likely to seek their health care.
(j) The
State Department of Health Care Services or any entity funded by the Breast Cancer Control Program shall collect personal and medical information necessary to administer this program from any individual applying for services under the program. The information shall be confidential and shall not be disclosed other than for purposes directly connected with the administration of this program or except as otherwise provided by law or pursuant to prior written consent of the subject of the information.
The State Department of Health Care Services or any entity funded by the Breast Cancer Control Program may disclose the confidential information to medical personnel and fiscal intermediaries of the state to the extent necessary to administer this program, and to other state public health agencies or medical researchers when the confidential information is necessary to carry out the duties of those agencies or researchers in the investigation, control, or surveillance of
breast cancer.
(k) The State Department of Health Care Services shall adopt regulations to implement this act in accordance with the rulemaking provisions of 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 initial adoption of implementing regulations shall be deemed an emergency and shall be considered as necessary for the immediate preservation of the public peace, health and safety, or general welfare, within the meaning of Section 11346.1 of the Government Code. Emergency regulations adopted pursuant to this section shall remain in effect for no more than 180 days.
(l) It is the intent of the Legislature in enacting this section that this section supersede and be operative in place of Section 30461.6 of the Revenue and Taxation Code as added by Chapter 660 of the Statutes of 1993.
(m) To implement the Breast Cancer Control Program, the State Department of Health Care Services may contract, to the extent permitted by Section 19130 of the Government Code, with public and private entities, or utilize existing health care service provider enrollment and payment mechanisms, including the Medi-Cal program’s fiscal intermediary. However, the Medi-Cal program’s fiscal intermediary shall only be utilized if services provided under the program are specifically identified and reimbursed in a manner that does not claim federal financial reimbursement. Any contracts with, and the utilization of, the Medi-Cal program’s fiscal intermediary shall not be subject to Chapter 3 (commencing with Section 12100) of Part 2 of Division 2 of the Public Contract Code. Contracts to implement the Breast Cancer Control Program entered into by the State Department of Health Care Services with entities other than the Medi-Cal program’s fiscal intermediary
shall not be subject to Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code.
SEC. 63.
Section 4360.5 is added to the Welfare and Institutions Code, to read:4360.5.
(a) The State Department of State Hospitals shall establish a statewide panel of independent evaluators responsible for Forensic Conditional Release Program placement determinations for patients committed to the department and transitioning to community treatment settings for services pursuant to Section 4360.(b) The purpose of the statewide independent placement panel is to identify state hospital patients who are ready for discharge to the Forensic Conditional Release Program pursuant to Section 4360, to promote successful community reintegration. The panel may consist of both contracted and civil service licensed psychologists and licensed social workers designated by the department. A licensed psychologist or licensed social worker
panel member shall evaluate the state hospital patient to determine if the patient is suitable for community outpatient treatment and to determine whether an appropriate placement is available for the patient in the community-based treatment system based upon guidelines provided by the department, including the use of evidence-based risk assessment tools for all community release determinations. The panel member shall provide the court that has jurisdiction over the patient’s placement with a written placement recommendation on behalf of the statewide independent placement panel.
(c) (1) The statewide independent placement panel or designee shall be used to provide placement recommendations and conduct case reviews for patients committed to the State Department of State Hospitals on appropriateness for the Forensic Conditional Release Program.
(2) The
department may designate the community program director, in lieu of the statewide independent placement panel, to perform case reviews and placement recommendations. The department shall notify the court of the designation.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of a departmental letter or other similar instruction, as necessary.
(e) Contracts awarded pursuant to this statute are exempt from the requirements contained in the Public Contract Code and the State Administrative Manual and are not subject to approval by the Department of General Services.
SEC. 64.
Section 5892 of the Welfare and Institutions Code, as added by Section 95 of Chapter 790 of the Statutes of 2023, is amended to read:5892.
(a) To promote efficient implementation of this act, subject to subdivision (c), the county shall use funds distributed from the Behavioral Health Services Fund as follows:(1) (A) (i) Thirty percent of funds distributed to the counties pursuant to subdivision (c) of Section 5891 shall be used for housing interventions programs pursuant to Part 3.2 (commencing with Section 5830).
(ii) Of the funds distributed pursuant to clause (i), 50 percent shall be used for housing interventions for persons who are chronically homeless, with a focus on those in encampments.
(iii) Of the funds distributed
to pursuant clause (i), no more than 25 percent may be used for capital development projects pursuant to paragraph (2) of subdivision (b) of Section 5830.
(B) Commencing with the 2026–29 fiscal years’ county integrated plan, pursuant to Section 5963.02, and ongoing thereafter, for counties with a population of less than 200,000, the State Department of Health Care Services shall establish criteria and a process for approving county requests for an exemption from subparagraph (A) that considers factors including a county’s homeless population, the number of individuals receiving Medi-Cal specialty behavioral health services or substance use disorder treatment services in another county, and other factors as determined by the State Department of Health Care Services. The State Department of Health Care Services shall collaborate with the California State Association of Counties and the County Behavioral Health Directors Association of California
on reasonable criteria for those requests and a timely and efficient exemption process. Requests for approval of an exemption under this subparagraph shall be responded to, approved, or denied within 30 days of receipt by the department, or shall otherwise be deemed approved by the department.
(C) Commencing with the 2032–35 fiscal years’ county integrated plan, pursuant to Section 5963.02, and ongoing thereafter, the State Department of Health Care Services may establish criteria and a process for approving county requests for an exemption from subparagraph (A) that considers the factors set forth in subparagraph (B), regardless of the population size of the county. The State Department of Health Care Services shall collaborate with the California State Association of Counties and the County Behavioral Health Directors Association of California on reasonable criteria for those requests and a timely and efficient exemption process.
(2) (A) Thirty-five percent of the funds distributed to counties pursuant to subdivision (c) of Section 5891 shall be used for full-service partnership programs pursuant to Part 4.1 (commencing with Section 5887).
(B) Commencing with the 2032–35 fiscal years’ county integrated plan, pursuant to Section 5963.02, and ongoing thereafter, the State Department of Health Care Services may establish criteria and a process for approving requests for an exemption from subparagraph (A) that considers factors such as county population, client counts, and other factors as determined by the State Department of Health Care Services. The State Department of Health Care Services shall collaborate with the California State Association of Counties and the County Behavioral Health Directors Association of California on reasonable criteria for those requests and a timely and
efficient exemption process.
(C) Housing interventions provided to individuals enrolled in full-service partnership programs shall be funded pursuant to subparagraph (A) of paragraph (1).
(3) (A) Thirty-five percent of the funds distributed to counties pursuant to subdivision (c) of Section 5891 shall be used for the following Behavioral Health Services and Supports:
(i) Services pursuant to Part 4 (commencing with Section 5850) for the children’s system of care and Part 3 (commencing with Section 5800) for the adult and older adult system of care, excluding those services specified in paragraphs (1) and (2).
(ii) Early intervention programs in accordance with Part 3.6 (commencing with Section 5840).
(iii) Outreach and engagement.
(iv) Workforce education and training.
(v) Capital facilities and technological needs.
(vi) Innovative behavioral health pilots and projects.
(B) (i) A county shall utilize at least 51 percent of Behavioral Health Services and Supports funding for early intervention programs.
(ii) A county shall utilize at least 51 percent of the county’s funding allocated for early intervention programs to serve individuals who are 25 years of age and younger.
(iii) A county shall comply with other funding allocations specified
by the State Department of Health Care Services for the purposes listed in subparagraph (A).
(4) (A) A county may pilot and test innovative behavioral health models of care programs or innovative promising practices for the programs specified in paragraphs (1), (2), and (3).
(B) The goal of these innovative pilots and innovative promising practices is to build the evidence base for the effectiveness of new statewide strategies.
(5) The programs established pursuant to paragraphs (1), (2), (3), and (4) shall include services to address the needs of eligible children and youth, 0 to 5 years of age, inclusive, transition age youth, and foster youth.
(6) A county is only obligated to fund the programs established pursuant to paragraphs
(1) to (4), inclusive, with the funds it receives pursuant to subdivision (c) of Section 5891.
(b) (1) A county shall establish and maintain a prudent reserve to ensure county programs are able to continue to meet the needs of children and youth, adults, and older adults participating in housing intervention programs pursuant to paragraph (1) of subdivision (a), full-service partnership programs pursuant to paragraph (2) of subdivision (a), and receiving services pursuant to clauses (i), (ii), and (iii) (iii), (iv), and (vi) of paragraph (3) of subdivision (a), during years in which revenues for the Behavioral
Health Services Fund are below recent averages adjusted by changes in the state population and the California Consumer Price Index. fiscal years in which the conditions described in subdivision (c) of Section 5892.2 occur.
(2) Notwithstanding the allocation percentages specified in paragraphs (1), (2), and (3) of subdivision (a), a county may transfer funds into the prudent reserve from housing intervention programs pursuant to paragraph (1) of subdivision (a), full-service partnership programs pursuant to paragraph (2) of subdivision (a), and Behavioral Health Services and Supports pursuant to paragraph (3) of subdivision (a).
(3) A county shall calculate a maximum amount it establishes as the
funding level for its prudent reserve for its Local Behavioral Health Services Fund, not to exceed 20 percent of the average of the total funds distributed to the county pursuant to subdivision (c) of Section 5891 in the preceding five years.
(4) A county with a population of less than 200,000 shall calculate a maximum amount it establishes as the funding level for its prudent reserve for its Local Behavioral Health Services Fund, not to exceed 25 percent of the average of the total funds distributed to the county pursuant to subdivision (c) of Section 5891 in the preceding five years.
(5) (A) A county shall assess the maximum amount
funding level amount of its prudent reserve pursuant to paragraphs (3) and (4) every three years by June 30, 2026, and every three years thereafter and shall include a plan for the expenditure of funds exceeding the maximum amount
funding level amount in the county’s integrated plan required pursuant to Section 5963.02.
(B) A county shall spend funds exceeding the maximum amount
funding level for its prudent reserve on programs and services authorized in paragraphs (1), (2), and (3) of subdivision (a). (a) and shall comply with the allocation percentages specified in subdivision (a).
(C) Notwithstanding subparagraph (B), for funds exceeding the maximum funding level of a county’s prudent reserve identified pursuant to subparagraphs (A) and (B), both of the following apply:
(i) The county is not required to comply with the allocation percentages specified in clause (i) of subparagraph (A) of paragraph (1) of, subparagraph (A) of paragraph (2)
of, or subparagraph (A) of paragraph (3) of, subdivision (a).
(ii) A county shall comply with the allocation percentages specified in clauses (ii) and (iii) of subparagraph (A) of paragraph (1) of, and subparagraph (B) of paragraph (3) of, subdivision (a).
(6) (A) A county shall spend prudent reserve funds on the programs and services authorized in paragraphs (1) and (3), (2) of,
and clauses (i), (ii), and (iii) of paragraph (3) of (iii), (iv), and (vi) of paragraph (3) of, subdivision (a).
(B) A county shall not spend prudent reserve funds for the purposes specified in paragraph (2) of subdivision (b) of Section 5830.
(C) The reversion period specified in subdivision (i) begins the fiscal year a county transfers funds from the county’s local prudent reserve to one of the purposes authorized in paragraphs (1), (2), and (3) of subdivision (a).
(c) (1) A county
may transfer up to 14 percent of the total funds allocated to the county in a fiscal year between one or more of the purposes authorized in paragraphs (1), (2) and (3) of subdivision (a). A county shall not decrease the allocation for any one of the purposes authorized in paragraph (1), (2) or (3) by more than 7 percent of the total funds allocated to the county in a fiscal year. County changes to the allocation percentages specified in paragraphs (1), (2), and (3) of subdivision (a) shall be subject to the approval of the State Department of Health Care Services.
(2) A county changing its allocation percentages pursuant to this subdivision does not relieve the county from the obligation to comply with any applicable laws, including, but not limited to, clauses (ii) and (iii) of subparagraph (A) of paragraph (1), and paragraphs (3) and (5), of subdivision (a).
(3) A county shall
include proposed changes to the allocation percentages in the county integrated plan pursuant to Section 5963.02, and shall consult with local stakeholders pursuant to Section 5963.03.
(4) A county shall submit a request to shift funding allocation to the State Department of Health Care Services for approval after fulfilling the integrated planning and local stakeholder consultation requirements pursuant to Sections 5963.02 and 5963.03. The county shall submit the request for approval in a form and manner, and in accordance with timelines, prescribed by the department. Counties shall provide any other information, records, and reports that the department deems necessary for the purposes of this subdivision. The State Department of Health Care Services shall collaborate with the California State Association of Counties and the County Behavioral Health Directors Association of California on reasonable criteria for those requests and a timely and
efficient approval process. Requests for approval of a shift under this subparagraph
paragraph shall be responded to, approved, or denied within 30 days of receipt by the department, or shall otherwise be deemed approved by the department.
(A) The department shall review and approve a county’s request based on the county’s compliance with paragraphs (1) and (2) and demonstration that the requested shift is responsive to local priorities, based on, at a minimum, local data and community input in the planning process.
(B) The State Department of Health Care Services may approve a proposed shift in funding allocations for the current integrated planning period based upon data and information a county submits demonstrating the need for the adjustment.
(C) Unless an annual change is approved by the State Department of Health Care Services, approved allocation adjustments are irrevocable during the applicable three-year period and a county shall not adjust the allocation of funds in the county’s subsequent annual and intermittent updates to the county’s integrated plan. The State Department of Health Care Services shall collaborate with the California State Association of Counties and the County Behavioral Health Directors Association on reasonable criteria for such requests and a timely and efficient approval process. Requests for approval of a change under this subparagraph shall be responded to, approved, or denied within 30 days of receipt by the department, or shall otherwise be deemed approved by the department.
(d) The programs established pursuant to subdivision (a) shall prioritize
services for the following populations:
(1) Eligible adults and older adults, as defined in subdivision (k), who satisfy one of the following:
(A) Are chronically homeless or experiencing homelessness or are at risk of homelessness.
(B) Are in, or are at risk of being in, the justice system.
(C) Are reentering the community from prison or jail.
(D) Are at risk of conservatorship pursuant to Chapter 3 (commencing with Section 5350) of Part 1 of Division 5.
(E) Are at risk of institutionalization.
(2) Eligible children and youth, as defined in subdivision (k), who
satisfy one of the following:
(A) Are chronically homeless or experiencing homelessness or are at risk of homelessness.
(B) Are in, or at risk of being in, the juvenile justice system.
(C) Are reentering the community from a youth correctional facility.
(D) Are in the child welfare system pursuant to Section 300, 601, or 602.
(E) Are at risk of institutionalization.
(e) (1) (A) Notwithstanding subdivision (a) of Section 5891, the allocations pursuant to subdivision (a) shall include funding for annual planning costs pursuant to Sections 5963.02 and 5963.03.
(B) The total of these costs shall not exceed 5 percent of the total of annual revenues received for the Local Behavioral Health Services Fund.
(C) The planning costs shall include funds for county mental health and substance use disorder programs to pay for the costs of consumers, family members, and other stakeholders to participate in the planning process.
(2) (A) Notwithstanding subdivision (a) of Section 5891, the allocations pursuant to subdivision (a) may include funding to improve plan operations, quality outcomes, fiscal and programmatic data reporting pursuant to Section 5963.04, and monitoring of subcontractor compliance for all county behavioral health programs, including, but not limited to, programs administered by a Medi-Cal behavioral health delivery system, as defined in
subdivision (i) of Section 14184.101, and programs funded by the Projects for Assistance in Transition from Homelessness grant, the Community Mental Health Services Block Grant, and other Substance Abuse and Mental Health Services Administration grants.
(B) The total of the costs in subparagraph (A) shall not exceed 2 percent of the total of annual revenues received for the Local Behavioral Health Services Fund. For counties with a population of less than 200,000, the total of the costs in subparagraph (A) shall not exceed 4 percent of the total annual revenues received from the Local Behavioral Health Services Fund.
(C) A county may commence use of funding pursuant to this paragraph on July 1, 2025.
(D) Notwithstanding any other law, new costs to implement this article that exceed existing county obligations and are
in excess of the funds provided by subparagraph (B) of paragraph (2) of subdivision (e) shall be evaluated by the State Department of Health Care Services for inclusion in the Governor’s 2024–25 May Revision. The department shall consult with the California State Association of Counties and the County Behavioral Health Directors Association of California, no later than March 15, 2024, to evaluate the resources needed to implement this article.
(f) (1) Notwithstanding subdivision (a) of Section 5891, prior to making the allocations pursuant to subdivisions (a), (b), (d), and (e), funds shall be reserved for:
(A) State directed purposes consistent with the Behavioral Health Services Act, for the California Health and Human Services Agency, State Department of Health Care Services, the California Behavioral Health Planning Council, the Department of Health Care
Access and Information, the Behavioral Health Services Oversight and Accountability Commission, the State Department of Public Health, and any other state agency.
(B) The costs to assist consumers and family members so that the appropriate state and county agencies give full consideration to concerns about quality, structure of service delivery, or access to services.
(C) The costs for research and evaluation regarding the effectiveness of programs and services listed in subdivision (a) and achievement of the outcome measures and metrics pursuant to subdivision (d) of Section 5897.
(D) (i) The costs of the Department of Health Care Access and Information to implement a behavioral health workforce initiative. The cost for this initiative shall be a minimum of 3 percent of the total funds
allocated pursuant to this subdivision.
(ii) This initiative shall be developed in consultation with stakeholders, including, but not limited to, behavioral health professionals, counties, behavioral health education and training programs, and behavioral health consumer advocates. The initiative shall focus on efforts to build and support the workforce to meet the need to provide holistic and quality services and support the development and implementation of strategies for training, supporting, and retaining the county behavioral health workforce and noncounty contracted behavioral health workforce, including efforts to increase the racial, ethnic, and linguistic diversity of behavioral health providers and increase access to behavioral health providers in geographically underserved areas.
(iii) A portion of the workforce initiative may focus on providing technical assistance and
support to county contracted providers to implement and maintain workforce provisions that support the stabilization and retention of the broad behavioral health workforce.
(iv) A portion of the workforce initiative may focus on providing technical assistance and support to county and contracted providers to maximize the use of peer support specialists.
(E) The costs for the State Department of Public Health to provide population-based mental health and substance use disorder prevention programs. A minimum of 4 percent of the total funds allocated pursuant to this subdivision shall be distributed to the State Department of Public Health for this purpose. Of these funds, at least 51 percent shall be used for programs serving populations who are 25 years of age or younger. The State Department of Public Health shall consult with the State Department of Health Care Services and the
Behavioral Health Services Oversight and Accountability Commission to ensure the provision of these programs.
(i) Population-based prevention programs are activities designed to reduce the prevalence of mental health and substance use disorders and resulting conditions.
(ii) Population-based prevention programs shall incorporate evidence-based promising or community-defined evidence practices and meet one or more of the following conditions:
(I) Target the entire population of the state, county, or particular community to reduce the risk of individuals developing a mental health or substance use disorder.
(II) Target specific populations at elevated risk for a mental health, substance misuse, or substance use disorder.
(III) Reduce stigma associated with seeking help for mental health challenges and substance use disorders.
(IV) Target populations disproportionately impacted by systemic racism and discrimination.
(V) Prevent suicide, self-harm, or overdose.
(iii) Population-based prevention programs may be implemented statewide or in community settings.
(iv) Population-based prevention programs shall not include the provision of early intervention, diagnostic, and treatment for individuals.
(v) Population-based prevention programs shall be provided on a schoolwide or classroom basis and may be provided by a community-based organization off
campus or on school grounds.
(vi) School-based prevention supports and programs shall be provided at a school site or arranged for by a school on a schoolwide or classroom basis and shall not provide services and supports for individuals. These supports and programs may include, but are not limited to:
(I) School-based health centers, student wellness centers, or student wellbeing centers.
(II) Activities, including, but not limited to, group coaching and consultation, designed to prevent substance misuse, increase mindfulness, self-regulation, development of protective factors, calming strategies, and communication skills.
(III) Integrated or embedded school-based programs designed to reduce stigma associated with seeking help for mental health
challenges and substance use disorders.
(IV) Student mental health first aid programs designed to identify and prevent suicide or overdose.
(V) Integrated training and systems of support for teachers and school administrators designed to mitigate suspension and expulsion practices and assist with classroom management.
(vii) Early childhood population-based prevention programs for children 0 to 5 years of age, inclusive, shall be provided in a range of settings.
(viii) Funding under this provision shall comply with Section 5891 and shall be used to strengthen population-based strategies and not supplant funding for services and supports for which ongoing funding is available through Children and Youth Behavioral Health Initiative or other sources.
(F) The Behavioral Health Services Act Innovation Partnership Fund as provided for in Section 5845.1. A maximum of twenty million dollars ($20,000,000) shall be deposited into the fund annually, for fiscal years 2026–27 to 2030–31, inclusive. Thereafter funding shall be determined through the annual budget act.
(G) At its discretion, the commission may utilize funding received in support of the Mental Health Wellness Act to support this section, consistent with subparagraph (F) of paragraph (2) of subdivision (g), and subdivision (h), of Section 5848.5.
(2) The costs for the purposes specified in paragraph (1) shall not exceed 10 percent of the total of annual revenues received for the State Behavioral Health Services Fund. The amount of funds available for the purposes of this subdivision in any fiscal year is subject
to appropriation in the annual Budget Act.
(g) Each county shall place all funds received from the State Behavioral Health Services Fund in a local Behavioral Health Services Fund. The Local Behavioral Health Services Fund balance shall be invested consistent with other county funds and the interest earned on the investments shall be transferred into the fund. The earnings on investment of these funds shall be available for distribution from the fund in future fiscal years.
(h) All expenditures for county behavioral health programs shall be consistent with a currently approved county integrated plan or annual update pursuant to Section 5963.02 or an intermittent update prepared pursuant to subdivision (c) of Section 5963.03.
(i) (1) Other than funds placed in a reserve in accordance with an
approved plan, any funds allocated to a county that have not been spent for their authorized purpose within three years, and the interest accruing on those funds, shall revert to the state to be deposited into the Reversion Account, hereby established in the fund, and available for other counties in future years, provided, however, that funds, including interest accrued on those funds, for capital facilities, technological needs, or education and training may be retained for up to 10 years before reverting to the Reversion Account.
(2) (A) The Controller shall revert funds by offsetting amounts from each monthly distribution to a county’s Local Behavioral Health Service Fund pursuant to subdivision (c) of Section 5891, until the full amount of the reverted funds has been offset. The reverted funds shall be deposited into the Reversion Account for use, consistent with this section and Sections 5890, 5891 and 5891.5, as
determined by the State Department of Health Care Services.
(B) Funds that have been reverted that are owed to a county as a result of an audit adjustment, or for other reasons, shall be paid from the Reversion Account. If the balance of funds in the Reversion Account is inadequate, funds owed to a county shall be offset from the monthly distributions to other counties pursuant to subdivision (c) of Section 5891, based on a methodology provided by the State Department of Health Care Services. Owed funds shall be paid to a county in the monthly distribution pursuant to subdivision (c) of Section 5891.
(C) If the State Department of Health Care Services withholds funds from a monthly distribution to a county pursuant to subdivision (e) of Section 5963.04, funds shall be reverted first and the remaining balance shall be withheld.
(3) Notwithstanding paragraph (1), funds allocated to a county with a population of less than 200,000 that have not been spent for their authorized purpose within five years shall revert to the state as described in paragraph (1).
(j) If there are revenues available in the fund after the State Department of Health Care Services has determined there are prudent reserves and no unmet needs for any of the programs funded pursuant to this section, the department, in consultation with counties, shall develop a plan for expenditures of these revenues to further the purposes of this act and the Legislature may appropriate these funds for any purpose consistent with the department’s plan that furthers the purposes of this act.
(k) For purposes of this section, the following definitions shall apply:
(1) “Behavioral health services” means mental health services and substance use disorder treatment services, as defined in Section 5891.5.
(2) “Chronically homeless” means an individual or family that is chronically homeless, as defined in Section 11360 of Title 42 of the United States Code, or as otherwise modified or expanded by the State Department of Health Care Services.
(3) “Experiencing homelessness or are at risk of homelessness” means people who are homeless or at risk of homelessness, as defined in Section 91.5 of Title 24 of the Code of Federal Regulations, or as otherwise defined by the State Department of Health Care Services for purposes of the Medi-Cal program.
(4) “Outreach and engagement” means activities to reach, identify, and engage individuals and communities in the behavioral health
system, including peers and families, and to reduce disparities. Counties may include evidence-based practices and community-defined evidence practices in the provision of activities.
(5) “Workforce education and training” includes, but is not limited to, the following for the county workforce:
(A) Workforce recruitment, development, training, and retention.
(B) Professional licensing and/or certification testing and fees.
(C) Loan repayment.
(D) Retention incentives and stipends.
(E) Internship and apprenticeship programs.
(F) Continuing education.
(G) Efforts to increase the racial, ethnic, and geographic diversity of the behavioral health workforce.
(6) “Community-defined evidence practices” means an alternative or complement to evidence-based practices, that offer culturally anchored interventions that reflect the values, practices, histories, and lived-experiences of the communities they serve. These practices come from the community and the organizations that serve them and are found to yield positive results as determined by community consensus over time.
(7) (A) “Eligible children and youth” means persons who are 25 years of age or under, including early childhood or transition age youth who do either of the following:
(i) Meet the criteria specified in subdivision (d) of
Section 14184.402, notwithstanding age limitations.
(ii) Have a substance use disorder, as defined in subdivision (c) of Section 5891.5.
(B) Eligible children and youth are not required to be enrolled in the Medi-Cal program.
(8) (A) “Eligible adults and older adults” means persons who are 26 years of age or older who do either of the following:
(i) Meet the criteria specified in subdivision (c) of Section 14184.402.
(ii) Have a substance use disorder, as defined in subdivision (c) of Section 5891.5.
(B) Eligible adults and older adults are not required to be enrolled in the Medi-Cal program.
(l) This section shall become operative on July 1, 2026, if amendments to the Mental Health Services Act are approved by the voters at the March 5, 2024, statewide primary election.
SEC. 65.
Section 5892.2 is added to the Welfare and Institutions Code, to read:5892.2.
(a) The State Department of Health Care Services, in consultation with the County Behavioral Health Directors Association of California, shall establish a methodology for determining annual minimum expenditure levels for funds distributed pursuant to subdivision (c) of Section 5891. Beginning in the 2028–29 fiscal year, the minimum expenditure level shall be calculated using the average annual amount of distributed funds for a county in the preceding three years, without weighting or adjustment.(1) Beginning in the 2028–29 fiscal year, by November 1 of each year the State Department of Health Care Services shall calculate minimum expenditure levels for each county for the following three fiscal years.
(2) (A) Each year, the State Department of Health Care Services shall calculate a revised minimum expenditure level for the next fiscal year to be used for the annual update upon receipt of an updated Behavioral Health Services Fund local assistance revenue projection from the State Department of Finance.
(B) The State Department of Health Care Services shall publish the revised minimum expenditure level if it is lower than the minimum expenditure level by 10 percent or more.
(b) (1) Commencing with the 2029–30 fiscal year and each fiscal year thereafter, a county shall spend an amount of distributed funds that is equal to or greater than the minimum expenditure level for that fiscal year, calculated in the prior year, pursuant to paragraph (1) of subdivision (a).
(2) Notwithstanding paragraph (1), if the State Department of Health Care Services publishes a minimum expenditure level for a fiscal year pursuant to subparagraph (B) of paragraph (2) of subdivision (a) a county shall spend an amount of distributed funds that is equal to or greater than the revised minimum expenditure level.
(c) A county may only spend funds from its prudent reserve when any of the following conditions occur:
(1) During any fiscal year for which the department publishes a revised minimum expenditure level pursuant to subparagraph (B) of paragraph (2) of subdivision (a).
(2) During any fiscal year in which the amount of distributed funds is less than the minimum expenditure level calculated pursuant to paragraph (1) of subdivision (a) for
that fiscal year.
(3) During any fiscal year in which the county determines that there has been a change in local behavioral health needs or circumstances, such that transfers from the prudent reserve are necessary to maintain behavioral health services, respond to local, state, or federally declared emergency, or mitigate unanticipated fiscal constraints.
(d) (1) A county shall update the budget in the county’s integrated plan or annual update pursuant to paragraph (2) of subdivision (c) of Section 5963.02 for any fiscal year the minimum expenditure level calculated pursuant to paragraph (1) of subdivision (a) is higher or lower than the prior year’s minimum expenditure level for the same fiscal year by 10 percent or more.
(2) A county shall update the budget in the county’s integrated plan or
annual update pursuant to paragraph (2) of subdivision (c) of Section 5963.02 for any fiscal year for which the department publishes a revised minimum expenditure level pursuant to subparagraph (B) of paragraph (2) of subdivision (a).
(e) For purposes of this section “distributed funds” means funds the State Controller distributes to a county pursuant to subdivision (c) of Section 5891.
(f) Notwithstanding Chapter 3.5 (commencing Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions without taking further regulatory action. Instructions issued by the department shall be consistent with this section.
(g) This
section shall become operative July 1, 2028.
SEC. 66.
Section 5963.02 of the Welfare and Institutions Code is amended to read:5963.02.
(a) (1) Each county shall prepare and submit an integrated plan and annual updates to the Behavioral Health Services Oversight and Accountability Commission and the department.(2) All references to the three-year program and expenditure plan mean the integrated plan.
(3) Each county’s board of supervisors shall approve the integrated plan and annual updates by June 30 prior to the fiscal year or years the integrated plan or update would cover.
(4) A county shall not use the integrated plan to demonstrate compliance with federal law, state law, or requirements imposed by the department related to programs
listed in subdivision (c).
(b) (1) Each section of the integrated plan and annual update listed in subdivision (c) shall be based on available funding or obligations under Section 30025 of the Government Code and corresponding contracts for the applicable fiscal years and in accordance with established stakeholder engagement and planning requirements as required in Section 5963.03.
(2) A county shall consider relevant data sources, including local data, to guide addressing local needs, including the prevalence of mental health and substance use disorders, the unmet need for mental health and substance use disorder treatment in the county, behavioral health disparities, and the homelessness point-in-time count, in preparing each integrated plan and annual update, and should use the data to demonstrate how the plan appropriately allocates funding between mental
health and substance use disorder treatment services.
(3) A county shall consider the population needs assessment of each Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, that covers residents of the county in preparing each integrated plan and annual update.
(4) A county shall consider the community health improvement plan of the local health jurisdiction for the county in preparing each integrated plan and annual update.
(5) A county shall stratify data to identify behavioral health disparities and consider approaches to eliminate disparities, including, but not limited to, promising practices, models of care, community-defined evidence practices, workforce diversity, and cultural responsiveness in preparing each integrated plan and annual update.
(6) A county shall report and consider the achievement of defined goals and outcomes measures of the prior integrated plan and annual update, in addition to other data and information as specified by the department pursuant to Section 5963.05, in preparing each integrated plan and annual update.
(7) A county with a population greater than 200,000 shall collaborate with the five most populous cities in the county, managed care plans, and continuums of care to outline respective responsibilities and coordination of services related to housing interventions described in Section 5830.
(8) A county shall consider input and feedback into the plan provided by stakeholders, including, but not limited to, those with lived behavioral health experience, including peers and families.
(c) The integrated plan and annual updates shall include a section for each of the following:
(1) (A) Community mental health services provided pursuant to Part 2 (commencing with Section 5600).
(B) Programs and services funded from the Behavioral Health Services Fund pursuant to Section 5890, including a description of how the county meets the requirements of paragraph (7) of subdivision (b).
(C) Programs and services funded by the Projects for Assistance in Transition from Homelessness grant pursuant to Sections 290cc-21 to 290cc-35, inclusive, of Title 42 of the United States Code.
(D) Programs and services funded by the Community Mental Health Services Block Grant
pursuant to Sections 300x to 300x-9, inclusive, of Title 42 of the United States Code.
(E) Programs and services funded by the Substance Abuse Block Grant pursuant to Sections 300x-21 to 300x-35, inclusive, of Title 42 of the United States Code.
(F) Programs and services provided pursuant to Article 5 (commencing with Section 14680) of Chapter 8.8 of Part 3 of Division 9 and Chapter 8.9 (commencing with Section 14700) of Part 3 of Division 9.
(G) Programs and services provided pursuant to Article 3.2 (commencing with Section 14124.20) of Chapter 7 of Part 3 of Division 9.
(H) Programs and services provided pursuant to Section 14184.401.
(I) Programs and services funded by distributions
from the Opioid Settlements Fund established pursuant to Section 12534 of the Government Code.
(J) Services provided through other federal grants or other county mental health and substance use disorder programs.
(2) A budget that includes the county planned expenditures and reserves for the county distributions from the Behavioral Health Service Fund and any other funds allocated to the county to provide the services and programs set forth in paragraph (1). The budget shall also include proposed adjustments pursuant to the requirements set forth in paragraph (c) of Section 5892. subdivision (c) of Section 5892 and subdivision (d) of Section 5892.2.
(3) (A) A description of how the integrated plan and annual update aligns with statewide behavioral health goals and outcome measures, including goals and outcome measures to reduce identified disparities, as defined by the department in consultation with counties, stakeholders, and the Behavioral Health Services and Oversight Accountability Commission, pursuant to Section 5963.05.
(B) Outcome measures may include, but are not limited to, measures that demonstrate achievement of goals to reduce homelessness among those eligible for housing interventions pursuant to Section 5830 and measures that demonstrate reductions in the number of people who are justice-involved in the county and who are eligible adults or older adults, as defined in Section 5892, or eligible children and youth, as defined in Section 5892.
(4) A description of how the integrated plan aligns with local goals and outcome measures for behavioral health, including goals and outcome measures to reduce identified disparities.
(5) The programs and services specified in paragraph (1) shall include descriptions of efforts to reduce identified disparities in behavioral health outcomes.
(6) A description of the data sources considered to meet the requirements specified in paragraph (2) of subdivision (b).
(7) A description of how the county has considered the unique needs of LGBTQ+ youth, justice-involved youth, child welfare-involved, justice-involved adults, and older adults in the housing intervention program pursuant to Part 3.2 (commencing with Section 5830) and Full Service Partnership program pursuant to Part 4.1 (commencing with Section
5887).
(8) A description of its workforce strategy, to include actions the county will take to ensure its county and noncounty contracted behavioral health workforce is well-supported and culturally and linguistically concordant with the population to be served, and robust enough to achieve the statewide and local behavioral health goals and measures. This description shall include how the county will do all of the following:
(A) Maintain and monitor a network of appropriate, high-quality, culturally and linguistically concordant county and noncounty contracted providers, where applicable, that is sufficient to provide adequate access to services and supports for individuals with behavioral health needs.
(B) Meet federal and state standards for timely access to care and services, considering the urgency of the need
for services.
(C) Ensure the health and welfare of the individual and support community integration of the individual.
(D) Promote the delivery of services in a culturally competent manner to all individuals, including those with limited English proficiency and diverse cultural and ethnic backgrounds and disabilities, regardless of age, religion, sexual orientation, and gender identity.
(E) Ensure physical access, reasonable accommodations, and accessible equipment for individuals with physical, intellectual and developmental, and mental disabilities.
(F) Select and retain all contracted network providers, including ensuring all contracted providers meet minimum standards for license, certification, training, experience, and credentialing
requirements.
(G) Ensure that the contractor’s hiring practices meet applicable nondiscrimination standards and demonstrate best practices in promoting diversity and equity.
(H) Adequately fund contracts to ensure that noncounty contracted providers are resourced to achieve the behavioral health goals outlined in their contract for the purposes of meeting statewide metrics.
(I) Conduct oversight of compliance of all federal and state laws and regulations of all contracted network providers.
(J) Fill county vacancies and retain county employees providing direct behavioral health services, if applicable.
(9) A description of the system developed to transition a beneficiary’s care between the
beneficiary’s mental health plan and their managed care plan based upon the beneficiary’s health condition.
(10) Certification by the county behavioral health director, that ensures that the county has complied with all pertinent regulations, laws, and statutes, including stakeholder participation requirements.
(11) Certification by the county behavioral health director and by the county chief administration officer or their designee that the county has complied with fiscal accountability requirements, as directed by the department, and that all expenditures are consistent with applicable state and federal law.
(d) The county shall submit its integrated plan and annual updates to the department and the commission in a form and manner prescribed by the department.
(e) The department shall post on its internet website, in a timely manner, the integrated plan submitted by every county pursuant to this section.
(f) This section shall become operative on July 1, 2026, if amendments to the Mental Health Services Act are approved by the voters at the March 5, 2024, statewide primary election.
SEC. 67.
Section 5963.04 of the Welfare and Institutions Code is amended to read:5963.04.
(a) (1) Annually, counties and Medi-Cal behavioral health delivery systems, as defined in subdivision (i) of Section 14184.101, shall submit the County Behavioral Health Outcomes, Accountability, and Transparency Report to the department.(2) This report shall include the following data and information that shall be submitted in a form, manner, and in accordance with timelines prescribed by the department:
(A) The county’s annual allocation of state and federal behavioral health funds, by category.
(B) The county’s annual expenditure of state and federal behavioral health funds, by category.
(C) The amounts of annual and cumulative unspent state and federal behavioral health funds, including funds in a reserve account, by category.
(D) The county’s annual expenditure of county general funds and other funds, by category, on mental health or substance use disorder treatment services.
(E) The sources and amounts spent annually as the nonfederal share for Medi-Cal specialty mental health services and Medi-Cal substance use disorder treatment services, by category.
(F) All administrative costs, by category.
(G) All contracted services, and the cost of those contracted services, by category.
(H) Information on behavioral
health services provided to persons not covered by Medi-Cal, including, but not limited to, those who are uninsured or covered by Medicare or commercial insurance, by category.
(I) Other data and information, which shall include, but is not limited to, information on spending on children and youth, service utilization data, performance outcome measures across all behavioral health delivery systems, and data and information pertaining to populations with identified disparities in behavioral health outcomes, as specified by the department. This shall include data through the lens of health equity to identify racial, ethnic, age, gender, and other demographic disparities and inform disparity reduction efforts. Other data and information may include the number of people who are eligible adults and older adults, as defined in Section 5892, who are incarcerated, experiencing homelessness, inclusive of the availability of housing, the number of
eligible children and youth, as defined in Section 5892, who access evidence based early psychosis and mood disorder detection and intervention programs.
(J) Data and information on workforce measures and metrics, including, but not limited to, all of the following:
(i) Vacancies and efforts to fill vacancies.
(ii) The number of county employees providing direct clinical behavioral health services.
(iii) Whether there is a net change in the number of county employees providing direct clinical behavioral health services compared to the prior year and an explanation for that change.
(b) The department shall establish metrics, in consultation with counties, stakeholders, and the Behavioral
Health Services Oversight and Accountability Commission to measure and evaluate the quality and efficacy of the behavioral health services and programs listed in paragraph (1) of subdivision (c) of Section 5963.02. The metrics shall be used to identify demographic and geographic disparities in the quality and efficacy of behavioral health services and programs listed in paragraph (1) of subdivision (c) of Section 5963.02.
(c) Each county’s board of supervisors shall attest that the County Behavioral Health Outcomes, Accountability, and Transparency Report is complete and accurate before it is submitted to the department.
(d) Each year, the department shall post on its internet website a statewide County Behavioral Health Outcomes, Accountability, and Transparency Report.
(e) (1) The department
may require a county or Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101, to revise its integrated plan or annual update pursuant to Section 5963.02 if the department determines the plan or update fails to adequately address local needs pursuant to paragraph (2) of subdivision (b) of Section 5963.02.
(2) The department may impose a corrective action plan or require a county or Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101, to revise its integrated plan or annual update pursuant to Section 5963.02 if the department determines that the county or delivery system fails to make adequate progress in meeting the metrics established by the department pursuant to subdivision (b).
(3) (A) (i) If a county or Medi-Cal behavioral health delivery system
fails to submit the data and information specified in subdivision (a) by the required deadline, or as otherwise required by the department, fails to allocate funding pursuant to Section 5892, fails to comply with the expenditure requirements of subdivisions (b) and (c) of Section 5892.2 or fails to follow the process pursuant to Section 5963.03, the department may impose a corrective action plan, monetary sanctions, or temporarily withhold payments to the county or Medi-Cal behavioral health delivery system, pursuant to Section 14197.7.
(ii) Subject to the guidance issued pursuant to Section 5963.05, if a county’s actual expenditures of its allocations from the Behavioral Health Services Fund significantly varies from its budget in Section 5963.02, the department may impose a corrective action plan, monetary sanctions, or temporarily
withhold payments to the county pursuant to Section 14197.7.
(iii) Notwithstanding subdivision (o) of Section 14197.7, temporarily withheld payments shall be withheld from the Behavioral Health Services Fund.
(B) (i) Notwithstanding subdivision (q) of Section 14197.7, monetary sanctions collected pursuant to this section shall be deposited in the Behavioral Health Services Act Accountability Fund, which is hereby created in the State Treasury.
(ii) Subject to the department’s guidance issued pursuant to Section 5963.05, all monies in the Behavioral Health Services Act Accountability Fund shall be continuously appropriated and allocated and distributed to the county that paid the monetary sanction upon the department’s determination that the county has come into compliance.
(C) The department shall temporarily withhold amounts it deems necessary to ensure the county or Medi-Cal behavioral health delivery system comes into compliance.
(D) The department shall release the temporarily withheld funds when it determines the county or Medi-Cal behavioral health delivery system has come into compliance.
(f) This section shall be read in conjunction with, and apply in addition to, any other applicable law that authorizes the department to impose sanctions or otherwise take remedial actions against a county and Medi-Cal behavioral health delivery system.
(g) This section shall become operative on July 1, 2026, if amendments to the Mental Health Services Act are approved by the voters at the March 5, 2024, statewide primary
election.
SEC. 68.
Section 14005.62 of the Welfare and Institutions Code is amended to read:14005.62.
(a) (1) Notwithstanding any other law, for an applicant or beneficiary whose eligibility is not determined using the modified adjusted gross income (MAGI)-based financial methods, as specified in Section 1396a(e)(14) of Title 42 of the United States Code, the department shall seek federal approval to implement a disregard of one hundred thirty thousand dollars ($130,000) in nonexempt property for a case with one member and sixty-five thousand dollars ($65,000) for each additional household member, up to a maximum of 10 members.(2) This subdivision shall be implemented only after the director determines that systems have been programmed for the disregards specified in paragraph (1) and they communicate that determination in writing to
the Department of Finance and no sooner than January 1, 2026.
(b) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of county letters, provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action. Such instructions shall include a list of all exempt property for use until such time that regulations are adopted.
(2) Within two years of implementing the requirements set forth in this subdivision, the department shall do both of the following:
(A) Adopt, amend, or repeal regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code and
this section.
(B) Update its notices and forms to reflect the consideration of assets and resources as described in subdivision (a).
(c) Upon operation of subdivision (a), the department shall make available, on a quarterly basis data, the number of Medi-Cal enrollees who lost eligibility due to the asset limit. The department shall consult with stakeholders to determine the appropriate data elements and level of detail, including, but not limited to, the reasons for termination.
(d) This section shall only be implemented to the extent consistent with federal law, upon the department obtaining any necessary federal approvals, and to the extent federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.
(e)This section shall become operative on January 1, 2026.
(e) This section shall become inoperative on July 1, 2027, and, as of January 1, 2028, is repealed.
SEC. 69.
Section 14005.62 is added to the Welfare and Institutions Code, to read:14005.62.
(a) (1) Notwithstanding any other law, for an applicant or beneficiary whose eligibility is not determined using the modified adjusted gross income (MAGI)-based financial methods, as specified in Section 1396a(e)(14) of Title 42 of the United States Code, the department shall seek federal approval to implement a resource limit of twenty-one thousand dollars ($21,000) in nonexempt property for a household with one member, thirty-one thousand dollars ($31,000) in nonexempt property for a household with two members, and one thousand five hundred fifty dollars ($1,550) for each additional household member, up to a maximum of 10 members.(2) This subdivision shall be implemented only after the director determines that
systems have been programmed for the limits specified in paragraph (1) and they communicate that determination in writing to the Department of Finance, and no sooner than July 1, 2027.
(b) For beneficiaries enrolled as of the operative date of this section, subdivision (a) shall apply beginning with the beneficiary’s first annual redetermination conducted on or after the operative date of this section.
(c) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of county letters, provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action.
(2) Within two years of implementing the requirements set forth in this section, the
department shall do both of the following:
(A) Adopt, amend, or repeal regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code and this section.
(B) Update its notices and forms to reflect the consideration of assets and resources as described in subdivision (a).
(d) Upon operation of subdivision (a), the department shall make available, on a quarterly basis data, the number of Medi-Cal enrollees who lost eligibility due to the asset limit. The department shall consult with stakeholders to determine the appropriate data elements and level of detail, including, but not limited to, the reasons for termination.
(e) This section shall only be implemented to the
extent consistent with federal law, upon the department obtaining any necessary federal approvals, and to the extent federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.
(f) This section shall become operative on July 1, 2027.
SEC. 70.
Section 14005.11 of the Welfare and Institutions Code, as amended by Section 52 of Chapter 21 of the Statutes of 2025, is amended to read:14005.11.
(a) To the extent required by federal law for qualified beneficiaries enrolled in the federal Medicare Program, the department shall pay the premiums, deductibles, and coinsurance for elderly and disabled persons entitled to benefits under Title XVIII of the federal Social Security Act, whose income does not exceed the federal poverty level and whose resources do not exceed the amount specified in subdivision (a) of Section 14005.62.(b) The department shall pay, in addition to subdivision (a), applicable additional premiums, deductibles, and coinsurance for drug coverage extended to qualified beneficiaries enrolled in the federal Medicare Program.
(c) The deductible payments required by
subdivision (b) may be covered by providing the same drug coverage as offered to categorically needy recipients, as defined in Section 14050.1.
(d) As specified in this section, it is the intent of the Legislature to assist in the payment of Medicare Part B premiums for qualified low-income Medi-Cal beneficiaries who are ineligible for federal sharing or federal contribution for the payment of those premiums.
(e) For a Medi-Cal beneficiary who has a spend down of excess income but who is ineligible for the assistance provided pursuant to subdivision (a), or who is ineligible for any other federally funded assistance for the payment of the beneficiary’s Medicare Part B premium, the department shall pay for the beneficiary’s Medicare Part B premium in the month following each month that the beneficiary’s spend down of excess income has been met.
(f) When a county is informed that an applicant or beneficiary is eligible for benefits under the federal Medicare Program, the county shall determine whether that individual is eligible under the Qualified Medicare Beneficiary program, the Specified Low-Income Medicare Beneficiary program, or the Qualifying Individual program, and shall enroll the applicant or beneficiary in the appropriate program.
(g) (1) The department shall enter into a Medicare Part A buy-in agreement for qualified Medicare beneficiaries with the federal Centers for Medicare and Medicaid Services by submitting a state plan amendment with a proposed effective date in accordance with paragraph (2).
(2) Subject to paragraph (3), the Medicare Part A buy-in agreement described in this subdivision shall be effective on January 1,
2025, or the date the department communicates to the Department of Finance in writing that systems have been programmed for implementation of this subdivision, whichever date is later.
(3) This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and is not otherwise jeopardized.
(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, until the time regulations are adopted.
(5) For purposes of this subdivision, “Medicare Part A
buy-in agreement” means an agreement authorized by Section 1395v of Title 42 of the United States Code under which the state shall pay Medicare Part A premiums for qualified individuals who are enrolled in both the Medicare Program and the Medi-Cal program.
(h)This section shall become operative on January 1, 2026.
(h) This section shall become inoperative on January 1, 2027, and, as of January 1, 2028, is repealed.
SEC. 71.
Section 14005.11 is added to the Welfare and Institutions Code, to read:14005.11.
(a) To the extent required by federal law for qualified beneficiaries enrolled in the federal Medicare Program, the department shall pay the premiums, deductibles, and coinsurance for elderly and disabled persons entitled to benefits under Title XVIII of the federal Social Security Act, whose income does not exceed the federal poverty level and whose resources do not exceed the amount specified in subdivision (a) of Section 14005.62.(b) For beneficiaries enrolled as of the operative date of this section, subdivision (a) shall apply beginning with the beneficiary’s first annual redetermination conducted on or after the operative date of this section.
(c) The department shall
pay, in addition to subdivision (a), applicable additional premiums, deductibles, and coinsurance for drug coverage extended to qualified beneficiaries enrolled in the federal Medicare Program.
(d) The deductible payments required by subdivision (c) may be covered by providing the same drug coverage as offered to categorically needy recipients, as defined in Section 14050.1.
(e) As specified in this section, it is the intent of the Legislature to assist in the payment of Medicare Part B premiums for qualified low-income Medi-Cal beneficiaries who are ineligible for federal sharing or federal contribution for the payment of those premiums.
(f) For a Medi-Cal beneficiary who has a spend down of excess income but who is ineligible for the assistance provided pursuant to subdivision (a), or who is ineligible for any
other federally funded assistance for the payment of the beneficiary’s Medicare Part B premium, the department shall pay for the beneficiary’s Medicare Part B premium in the month following each month that the beneficiary’s spend down of excess income has been met.
(g) When a county is informed that an applicant or beneficiary is eligible for benefits under the federal Medicare Program, the county shall determine whether that individual is eligible under the Qualified Medicare Beneficiary program, the Specified Low-Income Medicare Beneficiary program, or the Qualifying Individual program, and shall enroll the applicant or beneficiary in the appropriate program.
(h) (1) The department shall enter into a Medicare Part A buy-in agreement for qualified Medicare beneficiaries with the federal Centers for Medicare and Medicaid Services by submitting a state plan
amendment with a proposed effective date in accordance with paragraph (2).
(2) Subject to paragraph (3), the Medicare Part A buy-in agreement described in this subdivision shall be effective on January 1, 2025, or the date the department communicates to the Department of Finance in writing that systems have been programmed for implementation of this subdivision, whichever date is later.
(3) This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and is not otherwise jeopardized.
(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this
subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, until the time regulations are adopted.
(5) For purposes of this subdivision, “Medicare Part A buy-in agreement” means an agreement authorized by Section 1395v of Title 42 of the United States Code under which the state shall pay Medicare Part A premiums for qualified individuals who are enrolled in both the Medicare Program and the Medi-Cal program.
(i) This section shall become operative on July 1, 2027.
SEC. 72.
Section 14005.36 of the Welfare and Institutions Code is amended to read:14005.36.
(a)(B) The outreach shall include information on how to comply with the
work or community engagement requirements, an explanation of the definition of an “applicable individual” as set forth in subsection (xx) of Section 1396a of Title 42 of the United States Code, and those beneficiaries who may be exempted, including any reporting requirements and processes to meet an exemption, and the consequences of noncompliance.
(C) The department shall provide an outreach notice to the beneficiary by mail, or an electronic format if elected by the individual, and by one or more additional formats. Additional formats may include telephone, text message, an internet website, other commonly available electronic means, and other formats that the United States Secretary of Health and Human Services determines appropriate.
(D) Beneficiary outreach and education shall be coordinated across public social services programs to help minimize barriers to administrative
disenrollments.
(E) The department shall solicit input from existing department-convened stakeholder workgroup meetings and member advisory boards, to the extent feasible, to help inform member communications and outreach strategies.
(2) (A) The county shall undertake outreach efforts to beneficiaries receiving benefits under this chapter, in order to maintain the most up-to-date home addresses, telephone numbers, and other necessary contact information, and to encourage and assist with timely submission of the annual reaffirmation form, and, when applicable, transitional Medi-Cal program reporting forms and to facilitate
the Medi-Cal redetermination process when one is required as provided in Section 14005.37.
process, including the requirements of Public Law 119-21. In implementing this subdivision, a county may shall make a good faith effort to collaborate with community-based organizations, provided that confidentiality is protected. A county shall exercise its discretion in determining which community-based organizations are best situated to assist in outreach efforts, particularly in efforts aimed at difficult-to-reach individuals and communities.
(B) The county outreach efforts shall meet cultural and linguistic
appropriateness standards, in alignment with the National Standards for Culturally and Linguistically Appropriate Services.
(b) The department shall encourage and facilitate efforts by managed care plans to report updated beneficiary contact information to counties.
(c) (1) The department and each county shall incorporate, in a timely manner, updated contact information received from managed care plans pursuant to subdivision (b) into the beneficiary’s Medi-Cal case file and into all systems used to inform plans of their beneficiaries’ enrollee status. Updated Medi-Cal beneficiary contact information shall be limited to the beneficiary’s telephone number, change of address information, and change of name.
(2) When a managed care plan obtains a beneficiary’s updated
contact information, the managed care plan shall ask the beneficiary for approval to provide the beneficiary’s updated contact information to the appropriate county. If the managed care plan does not obtain approval from the beneficiary to provide the appropriate county with the updated contact information, the county shall attempt to verify that the information that it receives from the plan is accurate, which may include, but is not limited to, making contact with the beneficiary, before updating the beneficiary’s case file. The contact shall first be attempted using the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(d) The
department shall share beneficiary redetermination data, including the date of redetermination, with applicable managed care plans to aid in managed care plans’ efforts to assist beneficiaries with retaining Medi-Cal coverage, including incorporation into the managed care plans’ outreach and education efforts described in Section 14197.81.
(d)
(e) This section shall be implemented only to the extent that federal financial participation under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) is available.
(e)
(f) To the extent otherwise required by Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall adopt emergency regulations implementing this section no later than July 1, 2015. The department may thereafter readopt the emergency regulations pursuant to that chapter. The adoption and readoption, by the department, of regulations implementing this section shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the department is hereby exempted from the requirement that it describe facts showing the need for immediate action and from review by the Office of Administrative Law.
SEC. 73.
Section 14005.365 is added to the Welfare and Institutions Code, immediately following Section 14005.36, to read:14005.365.
(a) It is the intent of the Legislature to develop a data dashboard to collect, track, analyze, and report on metrics related to the impact of federal H.R. 1 (Public Law 119-21) on Medi-Cal eligibility and enrollment.(b) The department, in collaboration with the California Health and Human Services Agency and in consultation with the California Health Benefit Exchange (Covered California), shall establish a data dashboard that provides data on applications, enrollment, redeterminations, disenrollments, and terminations, stratified by county and by demographic data, including age, race, ethnicity, language, and gender. The dashboard shall exclude any personally identifiable information.
(c) The dashboard shall track and report on the specific data for work or community engagement requirements and exemptions under Public Law 119-21, including all of the following:
(1) Enrollment totals of individuals receiving Medi-Cal coverage.
(2) (A) Outcomes of determinations and redetermination of Medi-Cal eligibility.
(B) Number of ex parte approvals, including procedural or administrative denials or terminations, and appeals data.
(3) Number of individuals subject to work or community engagement requirements and their compliance with the requirements.
(A) Of this group, the top five reasons that applications are denied and enrollees are terminated
or disenrolled based on work or community engagement requirements.
(B) Number of members who are specified excluded from work or community engagement.
(C) Number of members who receive mandatory exceptions, including the number of members who request and receive short-term hardships.
(d) (1) Commencing no later than January 1, 2028, the department shall operationalize the data dashboard and shall post the information described in subdivisions (a), (b), and (c) on a quarterly basis in a downloadable format.
(2) The department shall develop the dashboard in consultation with stakeholders, including consumers, advocates, Medi-Cal managed care plans, providers, counties, and the Legislature through the department-convened stakeholder
workgroup meetings to ensure that the dashboard is user-friendly and that the data relied on can be accessed by the public.
(e) In developing the dashboard, the department shall consider all of the following objectives, among others:
(1) To learn and document the impact of Public Law 119-21 on Californians who apply for, or are enrolled in, the Medi-Cal program.
(2) To allow the department and stakeholders to identify trends or problems with eligibility and enrollment in the Medi-Cal program based on the quarterly data reported, tracked, and analyzed over time to improve the program and address systemic or electronic application technology issues with the eligibility systems.
(3) To obtain reliable data that are collected and analyzed in a timely
fashion.
SEC. 74.
Section 14005.37 of the Welfare and Institutions Code is amended to read:14005.37.
(a) (1) Except as provided in paragraph (2) or as provided in Section 14005.39, a county shall perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months and shall promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstances that may affect eligibility for Medi-Cal benefits. The procedures for redetermining Medi-Cal eligibility described in this section shall apply to all Medi-Cal(2) Effective no sooner than March 1, 2027, notwithstanding paragraph (1), with respect to redeterminations of Medi-Cal eligibility scheduled on or after January 1, 2027, a county shall perform redeterminations once every six months for the following individuals:
(A) An individual enrolled under Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
(B) An individual who receives state-funded Medi-Cal coverage and who meets the same criteria described
in Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
(3) The requirements described in paragraph (2) shall not apply to any individual described in Section 1396a(xx)(9)(A)(ii)(II) of Title 42 of the United States Code.
(b) Loss of eligibility for cash aid under that program shall not result in a redetermination under this section unless the reason for the loss of eligibility is one that would result in the need for a redetermination for a person whose eligibility for Medi-Cal under Section 14005.30 was determined without a concurrent determination of eligibility for cash aid under the CalWORKs program.
(c) A loss of contact, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no
forwarding address, shall require a prompt redetermination according to the procedures set forth in this section.
(d) Except as otherwise provided in this section, Medi-Cal eligibility shall continue during the redetermination process described in this section and a beneficiary’s Medi-Cal eligibility shall not be terminated under this section until the county makes a specific determination based on facts clearly demonstrating that the beneficiary is no longer eligible for Medi-Cal benefits under any basis and due process rights guaranteed under this division have been met. For the purposes of this subdivision, for a beneficiary who is subject to the use of MAGI-based financial methods, the determination of whether the beneficiary is eligible for Medi-Cal benefits under any basis shall include, but is not limited to, a determination of eligibility for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods only
if either of the following occurs:
(1) The county assesses the beneficiary as being potentially eligible under a program that is exempt from the use of MAGI-based financial methods, including, but not limited to, on the basis of age, blindness, disability, or the need for long-term care services and supports.
(2) The beneficiary requests that the county determine whether the beneficiary is eligible for Medi-Cal benefits on a basis that is exempt from the use of MAGI-based financial methods.
(e) (1) For purposes of acquiring information necessary to conduct the eligibility redeterminations described in this section, a county shall gather information available to the county that is relevant to the beneficiary’s Medi-Cal eligibility prior to contacting the beneficiary. Sources for these efforts
shall include information contained in the beneficiary’s file or other information, including more recent information available to the county, including, but not limited to, Medi-Cal, CalWORKs, and CalFresh case files of the beneficiary or of any of their immediate family members, which are open, or were closed within the last 90 days, information accessed through any databases accessed under Sections 435.948, 435.949, and 435.956 of Title 42 of the Code of Federal Regulations, and, wherever feasible, other sources of relevant information reasonably available to the county or to the county via the department.
(2) In the case of an annual or six-month redetermination, if, based upon information obtained pursuant to paragraph (1), the county is able to make a determination of continued eligibility, the county shall notify the beneficiary of
both of the following:
(A) The eligibility determination and the information it is based on.
(B) That the beneficiary is required to inform the county via the internet, by telephone, by mail, in person, or through other commonly available electronic means, in counties where such electronic communication is available, if any information contained in the notice is inaccurate but that the beneficiary is not required to sign and return the notice if all information provided on the notice is accurate.
(3) The county shall make all reasonable efforts not to send multiple notices during the same time period about eligibility. The notice of eligibility renewal shall contain other related information such as if the beneficiary is in a new Medi-Cal program.
(4) In the case of a redetermination due to a change in circumstances, if a county determines that the change in circumstances does not affect the beneficiary’s eligibility status, the county shall not send the beneficiary a notice unless required to do so by federal law.
(f) (1) In the case of an annual or six-month eligibility redetermination, if the county is unable to determine continued eligibility based on the information obtained pursuant to paragraph (1) of subdivision (e), the beneficiary shall be so informed and shall be provided with an annual or six-month renewal form, at least 60 days before the beneficiary’s annual
or six-month
redetermination date, that is prepopulated with information that the county has obtained and that identifies any additional information needed by the county to determine eligibility. The form shall include all of the following:
(A) The requirement that the beneficiary provide any necessary information to the county within 60 days of the date that the form is sent to the beneficiary.
(B) That the beneficiary may respond to the county via the internet, by mail, by telephone, in person, or through other commonly available electronic means if those means are available in that county.
(C) That if the beneficiary chooses to return the form or renewal information to the county in person or via mail,
person, by telephone, online, via mail, or through commonly available electronic means, the beneficiary shall sign the form in order for it to be considered complete. A county shall accept electronic signatures, including telephonically recorded signatures, signatures obtained through an online application, handwritten signatures transmitted via other commonly available electronic means, if those means are available in that county, and electronic signatures initiated or collected by third parties through one of the software programs approved by the department as meeting the criteria of Section 16.5 of the Government Code.
(D) The telephone number to call in order to obtain more information.
(2) The county shall attempt to contact
the beneficiary via the internet, by telephone, or through other commonly available electronic means, if those means are available in that county, during the 60-day period after the prepopulated form is mailed to the beneficiary to collect the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response.
(3) If the beneficiary has not provided any response to the written request for information sent pursuant to paragraph (1) within 60 days from the date the form is sent, the county shall terminate the beneficiary’s eligibility for Medi-Cal benefits following the provision of timely notice.
(4) If the beneficiary responds to the written request for information during the 60-day period pursuant to paragraph (1) but the information provided is incomplete, the county shall follow the procedures set forth in
paragraph (3) of subdivision (g) to work with the beneficiary to complete the information.
(5) (A) The form required by this subdivision shall be developed by the department in consultation with the counties and representatives of eligibility workers and consumers.
(B) For beneficiaries whose eligibility is not determined using MAGI-based financial methods, the county may use existing renewal forms until the state develops prepopulated renewal forms to provide to beneficiaries. The department shall develop prepopulated renewal forms for use with beneficiaries whose eligibility is not determined using MAGI-based financial methods by January 1, 2015.
(g) (1) In the case of a redetermination due to change in circumstances, if a county cannot obtain sufficient information to
redetermine eligibility pursuant to subdivision (e), the county shall send to the beneficiary a form that states the information needed to redetermine eligibility. The county shall only request information related to the change in circumstances. The county shall not request information or documentation that has been previously provided by the beneficiary, that is not absolutely necessary to complete the eligibility determination, or that is not subject to change. The county shall only request information for nonapplicants necessary to make an eligibility determination or for a purpose directly related to the administration of the state Medicaid plan. The form shall advise the individual to provide any necessary information to the county via the internet, by telephone, by mail, in person, or through other commonly available electronic means. The beneficiary is not required to sign or return the form. The form shall include a telephone number to call in order to obtain more information. Future revisions to the
form shall be developed by the department in consultation with the counties, representatives of consumers, and eligibility workers. A Medi-Cal beneficiary shall have 30 days from the date the form is mailed pursuant to this subdivision to respond.
(2) If the purpose for a redetermination under this section is a loss of contact with the Medi-Cal beneficiary, as evidenced by the return of mail marked in such a way as to indicate that it could not be delivered to the intended recipient or that there was no forwarding address, a return of the form described in this subdivision marked as undeliverable shall result in an immediate notice of action terminating Medi-Cal eligibility.
(3) During the 30-day period after the date of mailing of a form to the Medi-Cal beneficiary pursuant to this subdivision, the county shall attempt to contact the beneficiary by telephone, in writing, or other
commonly available electronic means, in counties where such electronic communication is available, to request the necessary information if the beneficiary has not responded to the request for additional information or has provided an incomplete response. If the beneficiary does not supply the necessary information to the county within the 30-day limit, a 10-day notice of termination of Medi-Cal eligibility shall be sent.
(h) Beneficiaries shall be required to report any change in circumstances that may affect their eligibility within 10 calendar days following the date the change occurred.
(i) (1) If, within 90 days of a Medi-Cal beneficiary’s eligibility termination date or a change in eligibility status due to the beneficiary’s failure to provide
needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. The beneficiary shall be entitled to request a Medi-Cal eligibility determination for any of the three months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019. This paragraph shall become inoperative on January 1, 2027.
(2) Beginning on January 1, 2027, for Medi-Cal beneficiaries described in subparagraph (A) or (B) of paragraph (2) of subdivision (a), if, within 90 days of the beneficiary’s eligibility
termination date or a change in eligibility status due to the beneficiary’s failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. The beneficiary shall be entitled to request a Medi-Cal eligibility determination for the month immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(3) Beginning on January 1, 2027, for all Medi-Cal beneficiaries not described in paragraph (2), if, within 90 days of a Medi-Cal beneficiary’s eligibility termination date or a change in eligibility status due to the beneficiary’s failure to provide needed information, the discontinued beneficiary submits to the county a signed and completed form or otherwise
provides the needed information to the county, eligibility shall be redetermined in a timely manner by the county without requiring a new application. The beneficiary shall be entitled to request a Medi-Cal eligibility determination for either of the two months immediately prior to the month in which the beneficiary provided the needed information to the county, in accordance with Section 14019.
(j) If the information available to the county pursuant to the redetermination procedures of this section does not indicate a basis of eligibility, Medi-Cal benefits may be terminated so long as due process requirements have otherwise been met.
(k) The department shall, with the counties and representatives of consumers, including those with disabilities, and Medi-Cal eligibility workers, develop a timeframe for redetermination of Medi-Cal eligibility based upon
disability, including ex parte review, the redetermination forms described in subdivisions (f) and (g), timeframes for responding to county or state requests for additional information, and the forms and procedures to be used. The forms and procedures shall be as consumer-friendly as possible for people with disabilities. The timeframe shall provide a reasonable and adequate opportunity for the Medi-Cal beneficiary to obtain and submit medical records and other information needed to establish eligibility for Medi-Cal based upon disability.
(l) The county shall consider blindness as continuing until the reviewing physician determines that a beneficiary’s vision has improved beyond the applicable definition of blindness contained in the plan.
(m) The county shall consider disability as continuing until the review team determines that a beneficiary’s disability no longer meets
the applicable definition of disability contained in the plan.
(n) In the case of a redetermination due to a change in circumstances, if a county determines that the beneficiary remains eligible for Medi-Cal benefits, the county shall begin a new 12-month or 6-month eligibility period.
(o) For individuals determined ineligible for Medi-Cal by a county following the redetermination procedures set forth in this section, the county shall determine eligibility for other insurance affordability programs, and, if the individual is found to be eligible, the county shall, as appropriate, transfer the individual’s electronic account to other insurance affordability programs via a secure electronic interface.
(p) Any
renewal form or notice shall be accessible to persons who are limited-English proficient and persons with disabilities consistent with all federal and state requirements.
(q) The requirements to provide information in subdivisions (e) and (g), and to report changes in circumstances in subdivision (h), may be provided through any of the modes of submission allowed in Section 435.907(a) of Title 42 of the Code of Federal Regulations, including an internet website identified by the department, telephone, mail, in person, and other commonly available electronic means as authorized by the department.
(r) Forms required to be signed by a beneficiary pursuant to this section shall be signed under penalty of perjury. Electronic signatures, telephonic signatures, and handwritten signatures transmitted by electronic transmission shall be accepted.
(s) For purposes of this section, “MAGI-based financial methods” means income calculated using the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, and as added by the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any subsequent amendments.
(t) When contacting a beneficiary under paragraphs (2) and (4) of subdivision (f), and paragraph (3) of subdivision (g), a county shall first attempt to use the method of contact identified by the beneficiary as the preferred method of contact, if a method has been identified.
(u)The department shall seek federal approval to extend the annual redetermination date under this section for a three-month period for those Medi-Cal beneficiaries whose annual redeterminations are scheduled to occur between January 1, 2014, and March 31,
2014.
(v)
(u) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
updated.
(v) Paragraphs (2) and (3) of subdivision (a) and paragraphs (2) and (3) of subdivision (i) shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation.
(w) This section shall be implemented only if and to the extent that federal financial participation is available and not otherwise jeopardized and if any necessary federal approvals have been obtained.
(x)This section shall become operative on January 1, 2014.
SEC. 75.
Section 14005.69 is added to the Welfare and Institutions Code, immediately following Section 14005.68, to read:14005.69.
(a) It is the intent of the Legislature that the department implement work or community engagement requirements set forth in Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of federal H.R. 1 (Public Law 119-21)) to ensure that all eligible Medi-Cal applicants and beneficiaries obtain and maintain coverage in ways that are least administratively burdensome to applicants and beneficiaries.(b) For purposes of this section, the following definitions apply:
(1) “Applicable individual” means an individual, other than a specified excluded individual as defined in paragraph (2), who is eligible to enroll, or is enrolled, in the Medi-Cal program and is any of
the following:
(A) An individual whose Medi-Cal eligibility is pursuant to Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
(B) An individual who receives state-funded Medi-Cal coverage and who meets the same criteria described in Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code.
(C) An individual who has attained 19 years of age and is under 65 years of age, is not pregnant, and is not entitled to, or enrolled for, benefits under federal Medicare Part A (42 U.S.C. Sec. 1395c et seq.), or eligible for, or enrolled for, benefits under federal Medicare Part B (42 U.S.C. Sec. 1395j et seq.).
(2) “Specified excluded individual” means any of the following individuals, as determined in accordance with criteria
established by federal regulation or directive from the federal Centers for Medicare and Medicaid Services:
(A) An individual who is described in Section 1396a(a)(10)(A)(i)(IX) of Title 42 of the United States Code.
(B) An Indian or an Urban Indian, as defined in paragraphs (13) and (28) of Section 1603 of Title 25 of the United States Code, respectively.
(C) A California Indian, as described in Section 1679(a) of Title 25 of the United States Code.
(D) An individual who has otherwise been determined eligible as an Indian for the federal Indian Health Service under regulations promulgated by the United States Secretary of Health and Human Services.
(E) The parent, guardian, caretaker
relative, or family caregiver of a dependent child 13 years of age or younger or a disabled individual.
(F) The parent, guardian, caretaker relative, or family caregiver of an individual with a chronic or other health condition, disability, or functional limitation.
(G) A veteran with a disability rated as total under Section 1155 of Title 38 of the United States Code.
(H) An individual who is medically frail or otherwise has special medical needs, as defined by the United States Secretary of Health and Human Services, including any of the following individuals:
(i) An individual who is blind or disabled, as defined in Section 1382c of Title 42 of the United States Code.
(ii) An individual
with a substance use disorder.
(iii) An individual with a disabling mental disorder.
(iv) An individual with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living.
(v) An individual with a serious or complex medical condition.
(I) An individual in compliance with the work requirements under the federal Temporary Assistance for Needy Families (TANF).
(J) A member of a household that receives Supplemental Nutrition Assistance Program (SNAP) benefits under the federal Food and Nutrition Act of 2008 (Public Law 110-246) and is not exempt from a work requirement under that act.
(K) An individual participating in a drug addiction or alcoholic treatment and rehabilitation program, as defined in Section 2012(h) of Title 7 of the United States Code.
(L) An inmate or former inmate of a public institution released at any point during the three-month period ending on the first day of that month.
(M) An individual who is pregnant or entitled to postpartum medical assistance under paragraph (5) or (16) of Section 1396(e) of Title 42 of the United States Code.
(N) Foster youth or former foster youth under 26 years of age.
(3) “Educational program” includes both of the following:
(A) An institution of higher
education, as defined in Section 1001 of Title 20 of the United States Code.
(B) A program of career and technical education, as defined in Section 2302 of Title 20 of the United States Code.
(4) “Work program” has the meaning as set forth in Section 2015(o)(1) of Title 7 of the United States Code, which includes, among other programs, certain employment and training programs described in paragraph (4) of subdivision (d) of that section, subject to the exclusions described in paragraph (1) of subdivision (o) of that section.
(c) The department shall confirm that systems are programmed to maintain coverage with minimal information requests to an applicant or beneficiary by doing both of the following:
(1) Verifying compliance through interfaces with data
sources that include, but are not limited to, wage data, Medi-Cal eligibility aid codes, Medi-Cal claims and encounter data, and data from the State Department of Social Services.
(2) Allowing individuals the option to add, through consent-based verification platforms and any other means, information to their application or renewal for purposes of verifying compliance.
(d) No sooner than January 1, 2027, pursuant to the requirements set forth in Section 1396a(xx) of Title 42 of the United States Code, as a condition of Medi-Cal eligibility, and following the department’s confirmation that systems are programmed to maintain coverage with minimal data requests to an applicable individual, an applicable individual shall demonstrate work or community engagement.
(1) An applicable individual who applies for the Medi-Cal
program shall demonstrate work or community engagement for one month immediately preceding the month during which the individual applies for the Medi-Cal program.
(2) An applicable individual enrolled and receiving Medi-Cal services shall demonstrate work or community engagement for any one month during the period between the individual’s most recent determination or redetermination, as applicable, of eligibility and their next regularly scheduled redetermination of eligibility as described in Section 14005.37.
(e) Subject to this subdivision and subdivision (f), an applicable individual demonstrates work or community engagement for a month if they meet one or more of the following conditions with respect to that month, as determined in accordance with criteria established by federal regulation or directives from the federal Centers for Medicare and Medicaid Services:
(1) The individual works no less than 80 hours.
(2) The individual completes no less than 80 hours of community service.
(3) The individual participates in a work program for no less than 80 hours.
(4) The individual is enrolled in an educational program at least half-time.
(5) The individual engages in any combination of the activities described in paragraphs (1) to (4), inclusive, for a total of no less than 80 hours.
(6) The individual has a total monthly income, including, but not limited to, earned income, unemployment benefits, state disability insurance, retirement income, or dividends, that is no less than the applicable
minimum wage requirement under Section 206 of Title 29 of the United States Code, multiplied by 80 hours.
(7) The individual had an average monthly income, including, but not limited to, earned income, unemployment benefits, state disability insurance, retirement income, or dividends, over the preceding six months that is no less than the applicable minimum wage requirement under Section 206 of Title 29 of the United States Code, multiplied by 80 hours, and is a seasonal worker, as described in Section 45R(d)(5)(B) of the federal Internal Revenue Code of 1986.
(f) An applicable individual is deemed to have demonstrated work or community engagement under subdivision (d) for a month if, for part or all of the month, the individual either is a specified excluded individual, as defined in paragraph (2) of subdivision (b), or is any of the following:
(1) An individual under 19 years of age.
(2) An individual entitled to, or enrolled for, benefits under federal Medicare Part A (42 U.S.C. Sec. 1395c et seq.), or enrolled for benefits under federal Medicare Part B (42 U.S.C. Sec. 1395j et seq.).
(3) An individual described in any of subclauses (I) through (VII) of Section 1396a(a)(10)(A)(i) of Title 42 of the United States Code.
(4) An inmate of a public institution at any point during the three-month period ending on the first day of that month.
(5) An individual excluded based on any other federally required or approved exemptions outlined in the state plan or waivers.
(g) An
applicable individual may be found compliant with work or community engagement under subdivision (b) for that month if they experience a short-term hardship, a short-term hardship is applicable to the individual, and they are otherwise eligible for the short-term hardship.
(h) For purposes of this section, and in accordance with applicable federal law, an applicable individual experiences a short-term hardship event during a month if, for part or all of that month, any of the following is met, as determined in accordance with criteria established by federal regulation or directives from the federal Centers for Medicare and Medicaid Services:
(1) The individual receives inpatient hospital services, nursing facility services, services in an intermediate care facility for individuals with intellectual disabilities, inpatient psychiatric hospital services, or other services of similar
acuity, including outpatient care relating to other services specified in this paragraph, as determined by the United States Secretary of Health and Human Services, and the individual requests a short-term hardship exemption.
(2) The individual resides in a county in which an emergency or disaster was declared by the President of the United States pursuant to the federal National Emergencies Act (50 U.S.C. Sec. 1601 et seq.) or the federal Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. Sec. 5121 et seq.).
(3) The individual resides in a county with an unemployment rate that is at or above the lesser of 8 percent or 1.5 times the national unemployment rate, subject to a request from the department to the United States Secretary of Health and Human Services.
(4) The individual or their
dependent must travel outside of their community for an extended period of time to receive medical services necessary to treat a serious or complex medical condition, as described in Section 1396a(xx)(9)(A)(ii)(V)(ee) of Title 42 of the United States Code, that are not available within their community of residence, and the individual requests a short-term hardship exemption.
(i) For purposes of verifying that an applicable individual has met the requirement to demonstrate work or community engagement under subdivision (e), or determining that the individual is deemed to have demonstrated work or community engagement under subdivision (f) or (g), or determining that the individual is a specified excluded individual under paragraph (2) of subdivision (b), the department shall establish processes and use available and reliable information without requiring, where possible and only when sufficient verification has been submitted, the applicable
individual to submit additional information.
(j) If a county is unable to verify that an applicable individual either has met the requirement to demonstrate work or community engagement under subdivision (e) or was deemed to have demonstrated work or community engagement under subdivision (f) or (g), the county shall do all of the following:
(1) Provide the applicable individual with the notice of noncompliance described in subdivision (k).
(2) Provide the applicable individual with a period of 30 calendar days, beginning on the date on which the notice of noncompliance is received by the individual, to do any of the following:
(A) Make a satisfactory showing of compliance with the requirement for community engagement under subdivision (d).
(B) Make a satisfactory showing that the applicable individual was deemed to have demonstrated work or community engagement under subdivision (f) or (g).
(C) Make a satisfactory showing that the work or community engagement requirement does not apply to the individual on the basis that the individual does not meet the definition of an applicable individual under paragraph (1) of subdivision (b).
(3) Continue to provide the applicable individual with Medi-Cal services during the 30-calendar-day period if the applicable individual is enrolled in the Medi-Cal program.
(4) Deny the applicable individual’s application for the Medi-Cal program, or disenroll the individual from the Medi-Cal program, if no satisfactory showing is made pursuant to paragraph (2) and
the applicable individual is not a specified excluded individual as defined in paragraph (2) of subdivision (b), no later than the end of the month following the month in which the 30-calendar-day period ends.
(5) Before denying the applicable individual’s application or disenrolling the individual, the county shall first do both of the following:
(A) Determine whether there is any other basis for eligibility for the Medi-Cal program or for another insurance affordability program for the individual.
(B) Provide written notice and grant the individual an opportunity for a fair hearing.
(k) The notice of noncompliance provided to an applicable individual shall be on a form prescribed by the department and shall include the name and telephone number of the
county department worker, county department call center, or other appropriate county department contact that is available to assist applicants and beneficiaries with questions about their notice, and the date the form was completed. A copy of the notice shall be placed in the case file. The notice shall include all of the following information:
(1) How to make a satisfactory showing of compliance with the work or community engagement requirement, including which months will be assessed for work or community engagement, how to show that the beneficiary demonstrated work or community engagement, and how to show that the individual should be deemed to have demonstrated work or community engagement.
(2) How to make a satisfactory showing that the work or community engagement requirement does not apply to the individual on the basis that the individual does not meet the definition of
an applicable individual, including because the individual meets the criteria for one or more of the categories of a specified excluded individual.
(3) The deadline for providing the information.
(4) A description of how the information should be submitted to the county.
(5) A description of the consequences of noncompliance with work or community engagement requirements and failure to respond to the notice of noncompliance.
(6) How the individual may reapply for the Medi-Cal program if their application is denied or the individual is disenrolled.
(7) Information about short-term hardship events.
(8) The applicable
individual’s right to request a state hearing, including the procedures for requesting a state hearing and the time limits within which a state hearing must be requested.
(9) The circumstances under which aid will be continued if a state hearing is requested.
(l) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, until regulations are adopted.
(2) The department shall adopt regulations by July 1, 2029, for purposes of this section, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code.
(m) This section shall remain operative only as long as Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of federal H.R. 1 (Public Law 119-21)) is operative.
(n) (1) This section shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation of this section.
(2) This section shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and not otherwise jeopardized.
SEC. 76.
Section 14007.12 is added to the Welfare and Institutions Code, immediately following Section 14007.1, to read:14007.12.
(a) No later than January 1, 2027, the department shall establish a process to regularly obtain address information for individuals enrolled in the Medi-Cal program in accordance with Section 1396a(vv) of Title 42 of the United States Code for the purpose of preventing simultaneous enrollment under Medicaid state plans or waivers of multiple states.(b) (1) The process described in subdivision (a) to regularly obtain address information for individuals enrolled in the Medi-Cal program shall obtain address information from reliable data sources described in paragraph (2) and take actions as the United States Secretary of Health and Human Services specifies with respect to any changes to the address based on the
information.
(2) For purposes of this subdivision, the following are reliable data sources:
(A) Mail returned to the state by the United States Postal Service with a forwarding address.
(B) The National Change of Address Database maintained by the United States Postal Service.
(C) A managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, or prepaid inpatient health plan or prepaid ambulatory health plan, as these terms are defined in Section 1396b(m)(9)(D) of Title 42 of the United States Code, that has a contract under the Medi-Cal program if the address information is provided to the entity or plan directly from, or verified by the entity or plan directly with, the individual.
(D) Other data sources as identified by the department and approved by the United States Secretary of Health and Human Services.
(c) Beginning January 1, 2027, each contract under the Medi-Cal program with a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, or with a prepaid inpatient health plan or prepaid ambulatory health plan, as these terms are defined in Section 1396b(m)(9)(D) of Title 42 of the United States Code, shall provide that the entity or plan shall promptly transmit to the county any address information for an individual enrolled with the entity or plan that is provided to the entity or plan directly from, or verified by the entity or plan directly with, the individual.
(d) At least 10 days before terminating Medi-Cal eligibility, the department shall send
residency verification letters to members requesting that members contact the department to verify their residency and receipt of benefits only in California, informing members about the methods to report this information, and that they shall be granted the 90-day cure period.
(e) (1) This section shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation of this section.
(2) This section shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and not otherwise jeopardized.
SEC. 77.
Section 14007.5 of the Welfare and Institutions Code is amended to read:14007.5.
(a) Persons who are not citizens or nationals of the United States shall be eligible for Medi-Cal, whether federally funded or state-funded, only to the same extent as permitted under federal law and regulations for receipt of federal financial participation under Title XIX of the federal Social Security Act, except as otherwise provided in this section and elsewhere in this chapter.(b)In accordance with Section 1903(v)(1) of the federal Social Security Act (42 U.S.C. Sec. 1396b(v)(1)), a person who is not a citizen or a national of the United States shall only be eligible for the full scope of Medi-Cal benefits if the person has an immigration status described in Section 1641(b) of Title 8 of the United States Code. For purposes of this section, persons who
are not citizens or nationals of the United States and who are “permanently residing in the United States under color of law” shall be interpreted to include all persons who are not citizens or nationals of the United States residing in the United States with the knowledge and permission of the United States Department of Homeland Security and whose departure the United States Department of Homeland Security does not contemplate enforcing and with respect to whom federal financial participation is not available under Title XIX of the federal Social Security Act.
(c)A person who has an immigration status described in Section 1641(b) of Title 8 of the United States Code, but who is subject to the limitation described in Section 1613(a) of Title 8 of the United States Code, or a person who is otherwise permanently residing in the United States under color of law, shall be eligible for the full
scope of Medi-Cal benefits, subject to the service limitations described in subdivision (l).
(b) (1) Until October 1, 2026, an individual who is not a citizen or a national of the United States who has the immigration status described in Section 1641(b) of Title 8 of the United States Code shall be eligible for the full scope of Medi-Cal benefits.
(2) Beginning October 2, 2026, and until June 30, 2027, an individual described in paragraph (1) shall be eligible for the full scope of Medi-Cal state-funded benefits, subject to the service limitations described in subdivision (m).
(c) Beginning July 1, 2027, an individual who has an immigration status described in Section 1641(b) of Title 8 of the United States Code, but is not described in Section 1396b(v)(5) of Title 42 of the United States Code shall only be eligible for medically necessary pregnancy-related services, and care and services necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law.
(d) (1) Beginning October 1, 2026, a person who has an immigration status described in subdivision (b), but who is subject to the limitation described in Section 1613(a) of Title 8 of the United States Code, shall be eligible for the full scope of Medi-Cal benefits, subject to the service limitations
described in subdivision (m).
(2) An individual who is not described in subdivision (b) or (c), but who is permanently residing in the United States under color of law, shall be eligible for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivision (m). For purposes of this section, persons who are not citizens or nationals of the United States and who are “permanently residing in the United States under color of law” shall be interpreted to include all persons who are not citizens or nationals of the United States residing in the United States with the knowledge and permission of the United States Department of Homeland Security and whose departure the United States Department of Homeland Security does not contemplate enforcing and with respect to whom federal financial participation is not
available under Title XIX of the federal Social Security Act.
(d)
(e) Any person who is not a citizen or national of the United States who is otherwise eligible for Medi-Cal services, but who does not meet the requirements under subdivision (b) or (c), (b), (c), or (d), shall only be eligible for care and services that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law,
except as described in Sections 14007.65, 14007.7, and 14007.8. For purposes of this section, the term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(1) Placing the patient’s health in serious jeopardy.
(2) Serious impairment to bodily functions.
(3) Serious dysfunction to any bodily organ or part. It is the intent of this section to entitle eligible individuals to inpatient and outpatient services that are necessary for the treatment of the emergency medical condition in the same manner as administered by the department through regulations and provisions of federal law.
(e)
(f) (1) (A) No sooner than July 1, 2027, all individuals described in subdivisions (c) and (d), except for those individuals described in subparagraph (B), shall be required to pay a monthly premium as a condition of eligibility for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivision (l), (m), if they are otherwise eligible for benefits under this chapter.
(B) The following individuals are not subject to the monthly premium requirements described in subparagraph (A):
(i) Individuals under 19 years of age.
(ii) Individuals over 59 years of age.
(iii) Individuals who are pregnant. pregnant or entitled to postpartum medical assistance.
(2)Monthly premiums imposed under this subdivision shall be thirty dollars ($30) per beneficiary.
(iv) Individuals enrolled in the county or state Medi-Cal Inmate Eligibility Program.
(2) No sooner than May 14, 2027, the Governor’s 2027–28 May Revision shall include the level of monthly premiums imposed under this subdivision, which shall be no less than thirty dollars ($30) and no greater than fifty dollars ($50) per beneficiary.
(3) An individual required to pay premiums pursuant to this subdivision, after no more than 90 days of nonpayment of the monthly premium, is only eligible for medically necessary pregnancy-related services, and care and services necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law. All outstanding premium balances shall be paid in full as a condition of continued eligibility for
the full scope of Medi-Cal benefits.
(4) The monthly premium requirements and service limitations described in paragraphs (1), (2), and (3) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal benefits until their 26th birthday.
(f)
(g) Pursuant to Section 14001.2, each county department shall require that each applicant for, or beneficiary of, Medi-Cal, including a child, shall provide their social security number
account number, or numbers, if they have more than one social security number.
(g)
(h) (1) In order to be eligible for benefits under subdivision (b) or (c), (b), (c), or (d), an applicant or beneficiary shall present United States Citizenship and Immigration Services registration documentation or other proof of satisfactory immigration status from the United States Citizenship and Immigration Services.
(2) Any person who meets all other program requirements but who lacks documentation of United States Citizenship and Immigration Services registration or other proof of satisfactory immigration status shall be provided a reasonable opportunity to submit the evidence. For purposes of this paragraph, “reasonable opportunity” means 30 90 days or the time it actually takes the county to process the Medi-Cal application, whichever is longer.
(3) During the reasonable opportunity period under paragraph (2), the county department shall process the applicant’s application for medical assistance in a manner that conforms to its normal processing procedures and timeframes.
(h)
(i) (1) The county department shall grant only the Medi-Cal benefits set forth in subdivision (d) (e) of this section or in Section 14007.65, 14007.7, or 14007.8 to any individual who, after 30 calendar days or the time it actually takes the county to process the Medi-Cal application, whichever is longer, has failed to submit documents constituting reasonable evidence indicating a satisfactory immigration status for Medi-Cal purposes, or who is reported by the United States Citizenship and Immigration Services to lack a satisfactory immigration status for Medi-Cal purposes.
(2) If a person who is not a citizen or national of the United States has been receiving Medi-Cal benefits based on eligibility established prior to the effective date of this section and that individual, upon redetermination of eligibility for benefits, fails to submit documents constituting reasonable evidence indicating a satisfactory immigration status for Medi-Cal purposes, the county department shall discontinue the Medi-Cal benefits, except for the care and services set forth in subdivision (d) (e) of this section or in Section 14007.65, 14007.7, or 14007.8. The county department shall provide adequate notice to the individual of any adverse action and shall accord the individual an opportunity for a fair hearing if the individual requests one.
(i)
(j) To the extent permitted by federal law and regulations, a person who is not a citizen or national of the United States applying for services under subdivisions (b) and (c) (b), (c), or (d) shall be granted eligibility for the scope of services to which they would otherwise be entitled if, at the time the county department makes the determination about their eligibility, the person meets either of the following requirements:
(1) The person has not had a reasonable opportunity to submit documents constituting reasonable evidence indicating satisfactory immigration status.
(2) The person has provided documents constituting reasonable evidence indicating a satisfactory immigration status, but the county department has not received timely verification of the person’s immigration status from the United States Citizenship and Immigration Services.
(3) The verification process shall protect the privacy of all participants. A person’s immigration status shall be subject to verification by the United States Citizenship and Immigration Services, to the extent required for receipt of federal financial participation in the Medi-Cal program.
(j)
(k) If a person does not declare status as a lawful permanent resident or person permanently residing under color of law, or as a person legalized under Section 210, 210A, or 245A of the federal Immigration and Nationality Act (Public Law 82-414), Medi-Cal coverage under subdivision (d) (e) of this section or in Section 14007.65, 14007.7, or 14007.8 shall be provided to the individual if they are otherwise eligible.
(k)
(l) If a person subject to this section is not fluent
in English, the county department shall provide an understandable explanation of the requirements of this section in a language in which the person is fluent.
(l)
(m) (1) No sooner than July 1, 2026, 2027, all individuals described in subdivisions (c) and (d) and (e) who are
19 years of age or older shall not be eligible for dental services set forth in this chapter, except for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law.
(2) Paragraph (1) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal benefits until their 26th birthday.
(m)
(n) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement, interpret, or make specific this section, in whole or in part, by means of plan or county letter, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action.
(n)
(o) Subdivisions (e) and (l) (d) and (m) shall be implemented only after the director determines, and communicates in writing to the Department of Finance,
that systems have been programmed for implementation.
SEC. 78.
Section 14007.65 of the Welfare and Institutions Code is amended to read:14007.65.
(a) Persons who are not citizens or nationals of the United States who were receiving long-term care services under the authority of subdivision (f) of Section 1 of Chapter 1441 of the Statutes of 1988 on the day prior to the effective date of this section shall continue to receive those long-term care services.(b) On or after the effective date of this section, any applicant who is not lawfully present in the United States, who is otherwise eligible for Medi-Cal services, but who does not meet the requirements under subdivision (b) (b), (c), or (d) of Section 14007.5,
would be eligible to receive federally reimbursable long-term care services pursuant to the Medicaid program provided for pursuant to Title 19 of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.), shall be eligible to receive long-term care services to the extent that funding is made available for this purpose in the annual Budget Act. In no event shall expenditures for this program exceed the amount necessary to serve 110 percent of the 1999–2000 estimated eligible population without further authorization by the Legislature.
SEC. 79.
Section 14007.8 of the Welfare and Institutions Code is amended to read:14007.8.
(a) (1) An individual who is 25 years of age or younger, and who does not have satisfactory immigration status or is unable to establish satisfactory immigration status as required by Section 14011.2, shall be eligible for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivisions (b), (c), and (k), if they are otherwise eligible for benefits under this chapter.(2) (A) After the director determines, and communicates that determination in writing to the Department of Finance, that systems have been programmed for implementation of this subparagraph, but no sooner than May 1, 2022, an individual who is 50 years of age or older, and who does not have satisfactory immigration
status or is unable to establish satisfactory immigration status as required by Section 14011.2, shall be eligible for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivisions (b), (c), and (k), if they are otherwise eligible for benefits under this chapter.
(B) After the director determines, and communicates that determination in writing to the Department of Finance, that systems have been programmed for implementation of this subparagraph, but no later than January 1, 2024, an individual who is 26 to 49 years of age, inclusive, and who does not have satisfactory immigration status as required by Section 14011.2, shall be eligible for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivisions (b), (c), and (k), if they are otherwise eligible for benefits under this chapter.
(b) (1) No sooner than January 1, 2026, an individual who is 19 years of age or older, who does not have satisfactory immigration status as required by Section 14011.2, who is otherwise eligible for Medi-Cal services pursuant to subdivision (d) of Section 14007.5, and who applies for Medi-Cal on or after January 1, 2026, shall only be eligible for medically necessary pregnancy-related services, and care and services necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law.
(2) Notwithstanding paragraph (1), an individual who is 19 years of age or older, who does not have satisfactory immigration status as required by Section 14011.2, who was enrolled in full-scope Medi-Cal and was not pregnant, but loses coverage for full-scope Medi-Cal, shall be eligible to reenroll in full-scope Medi-Cal within three months from the date of disenrollment for full-scope
Medi-Cal, pregnancy-only Medi-Cal, or postpartum Medi-Cal. Payment of outstanding premium balances prior to the initiation of the three-month cure period shall be a condition of reenrollment under this subdivision for individuals disenrolled from Medi-Cal due to nonpayment of premiums. For purposes of this paragraph, “full-scope Medi-Cal” means the full scope of Medi-Cal benefits, subject to the service limitations described in subdivision (k).
(3) Paragraphs (1) and (2) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal benefits until their 26th birthday.
(c) (1) No sooner than January 1, 2026, if an individual described in subdivision (a) who is 19 years of age
or older loses eligibility for full-scope Medi-Cal on or after January 1, 2026, the individual shall only be eligible for medically necessary pregnancy-related services, and care and services necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law.
(2) No sooner than January 1, 2026, notwithstanding paragraph (1), if an individual described in subdivision (a) who is 19 years of age or older loses eligibility for full-scope Medi-Cal while pregnant, the individual shall remain eligible for the full scope of Medi-Cal benefits, subject to the service limitations described in subdivision (k), throughout the pregnancy and for 12 months after the pregnancy ends.
(3) Paragraphs (1) and (2) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration
status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal benefits until their 26th birthday.
(d) The department shall provide monthly updates to the appropriate policy and fiscal committees of the Legislature on the status of the implementation of this section.
(e)To the extent permitted by state and federal law, an individual eligible for full-scope Medi-Cal pursuant to subdivision (a) shall be required to enroll in a Medi-Cal managed care health plan. Enrollment in a Medi-Cal managed care health plan shall not preclude a beneficiary from being enrolled in any other children’s Medi-Cal specialty program that they would otherwise be eligible for.
(e) Effective no sooner than January 1, 2027, to the extent permitted by state and federal law, an individual eligible for the Medi-Cal program pursuant to this section shall be eligible for services in the Medi-Cal fee-for-service delivery system.
(f) (1) The department shall maximize federal financial participation in implementing this section to the extent allowable. For purposes of implementing this section, the department shall claim federal financial participation to the extent that the department determines it is available.
(2) To the extent that federal financial participation is unavailable, the department shall implement this section using state funds appropriated for this purpose.
(g) This section
shall be implemented only to the extent it is in compliance with Section 1621(d) of Title 8 of the United States Code.
(h) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time any necessary regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(2) Notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance
with Section 9795 of the Government Code, until regulations have been adopted.
(i) In implementing this section, the department may contract, as necessary, on a bid or nonbid basis. This subdivision establishes an accelerated process for issuing contracts pursuant to this section. Those contracts, and any other contracts entered into pursuant to this subdivision, may be on a noncompetitive bid basis and shall be exempt from both of the following:
(1) Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and any policies, procedures, or regulations authorized by that part.
(2) Review or approval of contracts by the Department of General Services.
(j) (1) (A) No sooner than July 1,
2027, all individuals described in subdivision (a), except for those individuals described in subparagraph (B), shall be required to pay a monthly premium as a condition of eligibility for Medi-Cal benefits, if they are otherwise eligible for benefits under this chapter.
(B) The following individuals are not subject to the monthly premium requirements described in subparagraph (A):
(i) Individuals under 19 years of age.
(ii) Individuals over 59 years of age.
(iii) Individuals who are pregnant.
pregnant or entitled to postpartum medical assistance.
(2)Monthly premiums imposed under this section shall be thirty dollars ($30) per beneficiary.
(iv) Individuals enrolled in the county or state Medi-Cal Inmate Eligibility Program.
(2) No sooner than May 14, 2027, the Governor’s 2027–28 May Revision shall include the level of monthly premiums imposed under this subdivision, which shall be no less than thirty dollars ($30) and no greater than fifty dollars ($50) per beneficiary.
(3) An individual described in paragraph (1), after no more than 90 days of nonpayment of the monthly premium, will only be eligible for medically necessary pregnancy-related services, and care and services necessary for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law. All outstanding premium balances shall be paid in full as a condition of continued eligibility for full-scope Medi-Cal coverage, subject to the service limitations described in subdivision (k).
(4) The monthly premium requirements and service limitations described in paragraphs (1), (2), and (3) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal
benefits until their 26th birthday.
(k) (1) No sooner than July 1, 2026,
2027, an individual who is 19 years of age or older, who is eligible for Medi-Cal benefits pursuant to subdivision (a), shall not be eligible for dental services set forth in this chapter, except for the treatment of an emergency medical condition and medical care directly related to the emergency, as defined in federal law.
(2) Paragraph (1) shall not apply to nonminor dependents, as defined in Section 11400, and individuals who but for their immigration status are eligible for Medi-Cal pursuant to Section 14005.28. These individuals shall remain eligible for the full scope of Medi-Cal benefits until their 26th birthday.
(l) Subdivisions (b), (c), (j), and (k) shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for
implementation.
SEC. 80.
Section 14016.2 of the Welfare and Institutions Code is amended to read:14016.2.
(a) If a person who is incapable of acting onThe provisions of this section
(b) A provision of subdivision (a)
shall become inoperative to the extent that they are
it is found to conflict with federal requirements governing federal reimbursements of state Medicaid costs.
SEC. 81.
Section 14019 of the Welfare and Institutions Code is amended to read:14019.
(a) (1) Notwithstanding(2) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by an applicant described in Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code, or by an applicant for state-funded Medi-Cal coverage who meets the same criteria described in that federal provision, Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during the month immediately prior
to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018.
(3) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by any applicant except those described in paragraph (2), Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during either of the two months immediately prior to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018.
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan
or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action.
(c) (1) Paragraphs (2) and (3) of subdivision (a) shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation of this section.
(2) Paragraphs (2) and (3) of subdivision (a) shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and not otherwise jeopardized.
SEC. 82.
Section 14019.6 of the Welfare and Institutions Code is amended to read:14019.6.
Notwithstanding any other provision of law, no person, whose property reserve exceeds the property limit, may establish eligibility forSEC. 83.
Section 14043.26 of the Welfare and Institutions Code is amended to read:14043.26.
(a) (1) On and after January 1, 2004, an applicant that currently is not enrolled in the Medi-Cal program, or a provider applying for continued enrollment, upon written notification from the department that enrollment for continued participation of all providers in a specific provider of service category or subgroup of that category to which the provider belongs will occur, or, except as provided in subdivisions (b) and (e), a provider not currently enrolled at a location where the provider intends to provide services, goods, supplies, or merchandise to a Medi-Cal beneficiary, shall submit a complete application package for enrollment, continuing enrollment, or enrollment at a new location or a change in location.(2) Clinics licensed by
the department pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section.
(3) Health facilities licensed by the department pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section.
(4) Adult day health care providers licensed pursuant to Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section.
(5) Home health agencies licensed pursuant to Chapter 8 (commencing with Section 1725) of Division
2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section.
(6) Hospices licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section.
(b) A physician and surgeon licensed by the Medical Board of California or the Osteopathic Medical Board of California, or a dentist licensed by the Dental Board of California, practicing as an individual physician practice or as an individual dentist practice, as defined in Section 14043.1, who is enrolled and in good standing in the Medi-Cal program, and who is changing locations of that individual physician practice or individual dentist practice within the same county, shall be eligible to continue enrollment at
the new location by filing a change of location form to be developed by the department. The form shall comply with all minimum federal requirements related to Medicaid provider enrollment. Filing this form shall be in lieu of submitting a complete application package pursuant to subdivision (a).
(c) (1) Except as provided in paragraph (2), within 30 days after receiving an application package submitted pursuant to subdivision (a), the department shall provide written notice that the application package has been received and, if applicable, that there is a moratorium on the enrollment of providers in the specific provider of service category or subgroup of the category to which the applicant or provider belongs. This moratorium shall bar further processing of the application package.
(2) Within 15 days after receiving an application package from a physician,
or a group of physicians, licensed by the Medical Board of California or the Osteopathic Medical Board of California, or a change of location form pursuant to subdivision (b), the department shall provide written notice that the application package or the change of location form has been received.
(d) (1) If the application package submitted pursuant to subdivision (a) is from an applicant or provider who meets the criteria listed in paragraph (2), the applicant or provider shall be considered a preferred provider and shall be granted preferred provisional provider status pursuant to this section and for a period of no longer than 18 months, effective from the date on the notice from the department. The ability to request consideration as a preferred provider and the criteria necessary for the consideration shall be publicized to all applicants and providers. An applicant or provider who desires consideration as a
preferred provider pursuant to this subdivision shall request consideration from the department by making a notation to that effect on the application package, by cover letter, or by other means identified by the department in a provider bulletin. Request for consideration as a preferred provider shall be made with each application package submitted in order for the department to grant the consideration. An applicant or provider who requests consideration as a preferred provider shall be notified within 60 days whether the applicant or provider meets or does not meet the criteria listed in paragraph (2). If an applicant or provider is notified that the applicant or provider does not meet the criteria for a preferred provider, the application package submitted shall be processed in accordance with the remainder of this section.
(2) To be considered a preferred provider, the applicant or provider shall meet all of the following criteria:
(A) Hold a current license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California, which license shall not have been revoked, whether stayed or not, suspended, placed on probation, or subject to other limitation.
(B) Be a current faculty member of a teaching hospital or a children’s hospital, as defined in Section 10727, accredited by the Joint Commission or the American Osteopathic Association, or be credentialed by a health care service plan that is licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or county organized health system, or be a current member in good standing of a group that is credentialed by a health care service plan that is licensed under the Knox-Keene Act.
(C) Have full, current, unrevoked, and unsuspended privileges at a Joint Commission or American Osteopathic Association accredited general acute care hospital.
(D) Not have any adverse entries in the federal Healthcare Integrity and Protection Data Bank.
(3) The department may recognize other providers as qualifying as preferred providers if criteria similar to those set forth in paragraph (2) are identified for the other providers. The department shall consult with interested parties and appropriate stakeholders to identify similar criteria for other providers so that they may be considered as preferred providers.
(e) (1) If a Medi-Cal applicant meets the criteria listed in paragraph (2), the applicant shall be enrolled in the Medi-Cal
program after submission and review of a short form application to be developed by the department. The form shall comply with all minimum federal requirements related to Medicaid provider enrollment. The department shall notify the applicant that the department has received the application within 15 days of receipt of the application. The department shall enroll the applicant or notify the applicant that the applicant does not meet the criteria listed in paragraph (2) within 90 days of receipt of the application.
(2) Notwithstanding any other provision of law, an applicant or provider who meets all of the following criteria shall be eligible for enrollment in the Medi-Cal program pursuant to this subdivision, after submission and review of a short form application:
(A) The applicant’s or provider’s practice is based in one or more of the following: a general acute care hospital, a
rural general acute care hospital, or an acute psychiatric hospital, as defined in subdivisions (a) and (b) of Section 1250 of the Health and Safety Code.
(B) The applicant or provider holds a current, unrevoked, or unsuspended license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California. An applicant or provider shall not be in compliance with this subparagraph if a license revocation has been stayed, the licensee has been placed on probation, or the license is subject to any other limitation.
(C) The applicant or provider does not have an adverse entry in the federal Healthcare Integrity and Protection Data Bank.
(3) An applicant shall be granted provisional provider status under this subdivision for a period of 12 months.
(f) Except as provided in subdivision (g), within 180 days after receiving an application package submitted pursuant to subdivision (a), or from the date of the notice to an applicant or provider that the applicant or provider does not qualify as a preferred provider under subdivision (d), the department shall give written notice to the applicant or provider that any of the following applies, or shall on the 181st day grant the applicant or provider provisional provider status pursuant to this section for a period no longer than 12 months, effective from the 181st day:
(1) The applicant or provider is being granted provisional provider status for a period of 12 months, effective from the date on the notice.
(2) The application package is incomplete. The notice shall identify additional information or documentation that
is needed to complete the application package.
(3) The department is exercising its authority under Section 14043.37, 14043.4, or 14043.7, and is conducting background checks, preenrollment inspections, or unannounced visits.
(4) The application package is denied for any of the following reasons:
(A) Pursuant to Section 14043.2 or 14043.36.
(B) For lack of a license necessary to perform the health care services or to provide the goods, supplies, or merchandise directly or indirectly to a Medi-Cal beneficiary, within the applicable provider of service category or subgroup of that category.
(C) The period of time during which an applicant or provider has been barred from reapplying has not
passed.
(D) For other stated reasons authorized by law.
(E) For failing to submit fingerprints as required by federal Medicaid regulations.
(F) For failing to pay an application fee as required by federal Medicaid regulations.
(5) The application package is withdrawn by request of the applicant or provider and the department’s review is canceled pursuant to subdivision (n).
(g) Notwithstanding subdivision (f), within 90 days after receiving an application package submitted pursuant to subdivision (a) from a physician or physician group licensed by the Medical Board of California or the Osteopathic Medical Board of California, or from the date of the notice to that physician or physician
group that does not qualify as a preferred provider under subdivision (d), or within 90 days after receiving a change of location form submitted pursuant to subdivision (b), the department shall give written notice to the applicant or provider that either paragraph (1), (2), (3), (4), or (5) of subdivision (f) applies, or shall on the 91st day grant the applicant or provider provisional provider status pursuant to this section for a period no longer than 12 months, effective from the 91st day.
(h) (1) If the application package that was noticed as incomplete under paragraph (2) of subdivision (f) is resubmitted with all requested information and documentation, and received by the department within 60 days of the date on the notice, the department shall, within 60 days of the resubmission, send a notice that any of the following applies:
(A) The applicant or
provider is being granted provisional provider status for a period of 12 months, effective from the date on the notice.
(B) The application package is denied for any other reasons provided for in paragraph (4) of subdivision (f).
(C) The department is exercising its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits.
(D) The application package is withdrawn by request of the applicant or provider and the department’s review is canceled pursuant to subdivision (n).
(2) (A) If the application package that was noticed as incomplete under paragraph (2) of subdivision (f) is not resubmitted with all requested information and documentation and received by
the department within 60 days of the date on the notice, the application package shall be denied by operation of law. The applicant or provider may reapply by submitting a new application package that shall be reviewed de novo.
(B) If the failure to resubmit is by a currently enrolled provider as defined in Section 14043.1, including providers applying for continued enrollment, the failure may make the provider also subject to deactivation of the provider’s number and all of the business addresses used by the provider to provide services, goods, supplies, or merchandise to Medi-Cal beneficiaries.
(C) Notwithstanding subparagraph (A), if the notice of an incomplete application package included a request for information or documentation related to grounds for denial under Section 14043.2 or 14043.36, the applicant or provider shall not reapply for enrollment or continued enrollment
in the Medi-Cal program or for participation in any health care program administered by the department or its agents or contractors for a period of three years.
(i) (1) If the department exercises its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits, the applicant or provider shall receive notice, from the department, after the conclusion of the background check, preenrollment inspection, or unannounced visit of either of the following:
(A) The applicant or provider is granted provisional provider status for a period of 12 months, effective from the date on the notice.
(B) Discrepancies or failure to meet program requirements, as prescribed by the department, have been found to exist during the preenrollment
period.
(2) (A) The notice shall identify the discrepancies or failures, and whether remediation can be made or not, and if so, the time period within which remediation must be accomplished. Failure to remediate discrepancies and failures as prescribed by the department, or notification that remediation is not available, shall result in denial of the application by operation of law. The applicant or provider may reapply by submitting a new application package that shall be reviewed de novo.
(B) If the failure to remediate is by a currently enrolled provider as defined in Section 14043.1, including providers applying for continued enrollment, the failure may make the provider also subject to deactivation of the provider’s number and all of the business addresses used by the provider to provide services, goods, supplies, or merchandise to Medi-Cal
beneficiaries.
(C) Notwithstanding subparagraph (A), if the discrepancies or failure to meet program requirements, as prescribed by the director, included in the notice were related to grounds for denial under Section 14043.2 or 14043.36, the applicant or provider shall not reapply for three years.
(j) If provisional provider status or preferred provisional provider status is granted pursuant to this section, a provider number shall be used by the provider for each business address for which an application package has been approved. This provider number shall be used exclusively for the locations for which it was approved, unless the practice of the provider’s profession or delivery of services, goods, supplies, or merchandise is such that services, goods, supplies, or merchandise are rendered or delivered at locations other than the provider’s business address and this practice
or delivery of services, goods, supplies, or merchandise has been disclosed in the application package approved by the department when the provisional provider status or preferred provisional provider status was granted.
(k) Except for providers subject to subdivision (c) of Section 14043.47, a provider currently enrolled in the Medi-Cal program at one or more locations who has submitted an application package for enrollment at a new location or a change in location pursuant to subdivision (a), or filed a change of location form pursuant to subdivision (b), may submit claims for services, goods, supplies, or merchandise rendered at the new location until the application package or change of location form is approved or denied under this section, and shall not be subject, during that period, to deactivation, or be subject to any delay or nonpayment of claims as a result of billing for services rendered at the new location as herein authorized.
However, the provider shall be considered during that period to have been granted provisional provider status or preferred provisional provider status and be subject to termination of that status pursuant to Section 14043.27. A provider that is subject to subdivision (c) of Section 14043.47 may come within the scope of this subdivision upon submitting documentation in the application package that identifies the physician providing supervision for every three locations. If a provider submits claims for services rendered at a new location before the application for that location is received by the department, the department may deny the claim.
(l) An applicant or a provider whose application for enrollment, continued enrollment, or a new location or change in location has been denied pursuant to this section, may appeal the denial in accordance with Section 14043.65.
(m) (1) Upon receipt of a complete and accurate claim for an individual nurse provider, the department shall adjudicate the claim within an average of 30 days.
(2) During the budget proceedings of the 2006–07 fiscal year, and each fiscal year thereafter, the department shall provide data to the Legislature specifying the timeframe under which it has processed and approved the provider applications submitted by individual nurse providers.
(3) For purposes of this subdivision, “individual nurse providers” are providers authorized under certain home- and community-based waivers and under the state plan to provide nursing services to Medi-Cal recipients in the recipients’ own homes rather than in institutional settings.
(n) (1) Except as provided in paragraph (2), an applicant or provider
may request to withdraw an application package submitted pursuant to this section at any time, at which point the department’s review shall be canceled.
(2) The department’s review shall not be canceled if, at the time the applicant or provider requests to withdraw the application package, the department has already initiated its review under Section 14043.37, 14043.4, or 14043.7.
(o) (1) For the period beginning on July 1, 2026, and ending on June 30, 2027, an applicant or provider shall not be granted provisional or preferred provisional enrollment status in the Medi-Cal program as a result of the department’s failure to act within any of the following statutory timeframes:
(A) The 90-day determination period
described in subdivision (e).
(B) The 90-day determination period described in subdivision (g).
(C) The 180-day extended determination period described in subdivision (f).
(D) The 60-day determination period for supplemental information described in subdivision (h).
(2) During the period described in paragraph (1), the department’s failure to issue a determination within the applicable timeframe shall not result in approval by default, and the application shall remain pending unless and until the department issues a written determination consistent with all applicable state and federal Medicaid screening requirements.
(3) Nothing in this subdivision limits the department’s authority to
deny, terminate, or otherwise act upon an application under this article during the review period.
(4) This subdivision shall become inoperative on July 1, 2027.
SEC. 84.
Section 14132.100 of the Welfare and Institutions Code, as amended by Section 103 of Chapter 21 of the Statutes of 2025, is amended to read:14132.100.
(a) The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.(b) The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of “visit” set forth in subdivision (g).
(d) Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural
health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2) Subject to the conditions set
forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A) The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B) A change in service due to amended regulatory requirements or rules.
(C) A change in service resulting from relocating or remodeling an FQHC or RHC.
(D) A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in the types of
patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G) Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3) A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A) The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(C) The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC’s or RHC’s rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. “Net change” means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any approved increase or decrease in the provider’s rate shall be retroactive to the beginning of the FQHC’s or RHC’s fiscal year in which the
request is submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHC’s or RHC’s prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, “significantly lower” means an average per-visit rate decrease in excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved scope-of-service
change or changes were initially implemented on or after the first day of an FQHC’s or RHC’s fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHC’s or RHC’s fiscal year ending in 2003.
(7) All references in this subdivision to “fiscal year” shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a
supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHC’s or RHC’s PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a
supplemental payment is not warranted.
(2) The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A) A presentation of data to demonstrate reasons for the FQHC’s or RHC’s request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facility’s total costs, whichever is less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6) The department shall notify the provider of the department’s discretionary decision in writing.
(g) (1) An FQHC or RHC “visit” means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plan’s definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.
(B) Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services
of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHC’s or RHC’s rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHC’s or RHC’s application for, or the department’s approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other
FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the provider’s rate shall be made within six months after the date of receipt of the department’s rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist or dental hygienist in alternative practice services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3) Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist.
(4) (A) (i) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent
the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when
services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable
standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv) (I) An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II) Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia) Notwithstanding the prohibition in subclause (I)
and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) (s) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib) Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific
requirements and consistent with federal and state laws, regulations, and guidance.
(v) An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I) The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
(II) The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III) The FQHC or RHC determines that the billing
provider is able to meet the applicable standard of care.
(IV) An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B) (i) Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice.
(ii) The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHC’s or RHC’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii) Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I) Offer those services via in-person, face-to-face contact.
(II) Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
(iv) In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, in writing or verbally, on at
least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I) The FQHC or RHC shall document in the
patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received.
(II) The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C) The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D) This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be
construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F) Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G) Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained
in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5) For purposes of this section, “physician” shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services’ Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(h) If FQHC or RHC services are partially reimbursed by a third-party payer, such as
a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i) (1) Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A) An entity that first
qualifies as an FQHC or RHC in 2001 or later.
(B) A newly licensed facility at a new location added to an existing FQHC or RHC.
(C) An entity that is an existing FQHC or RHC that is relocated to a new site.
(2) (A) An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i) The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHC’s or RHC’s existing licensee.
(ii) The FQHC or RHC submits the change in scope of service request within 90 days after the FQHC’s or RHC’s first full fiscal year.
(B) The FQHC’s or RHC’s single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:
(i) An audit in accordance with Section 14170.
(ii) Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in
Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii) Any approved increase or decrease in the provider’s rate shall be retroactive to the beginning of the FQHC’s or RHC’s fiscal year in which the request is submitted.
(C) Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, prior to January 1, 2017.
(3) If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the
following methods at the election of the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C) At a new entity’s one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the
projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D) The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4) In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual
utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5) The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the
applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHC’s or RHC’s prospective payment rate at that time.
(j) (1) Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined in subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic
license by the State Department of Public Health prior to January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added prior to January 1, 2017.
(2) If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health prior to January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHC’s or RHC’s primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3) This subdivision does not preclude or
otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHC’s or RHC’s clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l) Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1) An
FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2) (A) For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHC’s or RHC’s per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHC’s or RHC’s clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B) If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services,
the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHC’s or RHC’s building, that are or were previously calculated as part of the clinic’s base PPS rate.
(3) If the costs associated with providing Drug Medi-Cal services are within the FQHC’s or RHC’s clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHC’s or RHC’s per-visit PPS rate as a change in scope of service.
(A) An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHC’s or RHC’s clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding
subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B) An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C) The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to
paragraph (4).
(D) Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHC’s or RHC’s projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E) Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F) For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the
actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G) After the department approves the adjustment to the FQHC’s or RHC’s clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H) An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4) Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A) In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B) In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC,
the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5) The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6) For purposes of this subdivision, the following definitions apply:
(A) “Drug Medi-Cal organized delivery system” or “DMC-ODS” means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B) “Special
Terms and Conditions” has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m) Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1) An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plan’s network.
(2) (A) For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHC’s or RHC’s per-visit PPS rate. For
purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHC’s or RHC’s clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B) If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHC’s or RHC’s building, that are or were previously calculated as part of the clinic’s base PPS rate.
(3) If the costs associated with providing specialty mental health services are within the FQHC’s or
RHC’s clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHC’s or RHC’s per-visit PPS rate as a change in scope of service.
(A) An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHC’s or RHC’s clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B) An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first
day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C) The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D) Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHC’s or RHC’s projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E) Rate changes based on a request for scope-of-service change
under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F) For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G) After the department approves the adjustment to the FQHC’s or RHC’s clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H) An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4) The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n) The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and a psychological associate, associate professional clinical
counselor, associate clinical social worker, or associate marriage and family therapist when all of the following conditions are met:
(1) The psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist is supervised by the designated licensed behavioral health practitioner, as required by their applicable clinical licensing board.
(2) The behavioral health visit is billed under the supervising licensed practitioner of the FQHC or RHC, pursuant to paragraph (1).
(3) The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o) FQHCs and RHCs may appeal a grievance or complaint
concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p) The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q) The department shall implement this section only to the extent that federal financial participation is available.
(r) Notwithstanding any other
law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of this section, including all of the following:
(1) Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).
(2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or
change.
(3) Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4) Providing at least 60 days advance notice of the effective date of the proposed action or change.
(s) This section shall become inoperative on July 1, 2026, 2027, and, as of January 1, 2027,
2028, is repealed.
SEC. 85.
Section 14132.100 of the Welfare and Institutions Code, as added by Section 104 of Chapter 21 of the Statutes of 2025, is amended to read:14132.100.
(a) The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.(b) The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health clinic services that are eligible for federal financial participation shall be reimbursed on a per-visit basis in accordance with the definition of “visit” set forth in subdivision (g).
(d) Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law,
federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A) The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B) A change in service due to amended regulatory requirements or rules.
(C) A change in service resulting from relocating or remodeling an FQHC or RHC.
(D) A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G) Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of
providing teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3) A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A) The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination thereof.
(D) The net change in the FQHC’s or RHC’s rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. “Net change” means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any approved increase or decrease in the provider’s rate shall be retroactive to
the beginning of the FQHC’s or RHC’s fiscal year in which the request is submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHC’s or RHC’s prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, “significantly lower” means an average per-visit rate decrease in excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHC’s or RHC’s fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHC’s or RHC’s fiscal year ending in 2003.
(7) All references in this subdivision to “fiscal year” shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHC’s or RHC’s PPS rate is sufficient to cover its overall costs,
including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2) The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A) A presentation of data to demonstrate reasons for the FQHC’s or RHC’s request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facility’s total costs, whichever is less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6) The department shall notify the provider of the department’s discretionary decision in writing.
(g) (1) An FQHC or RHC “visit” means a face-to-face encounter between an FQHC or
RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, or a visiting nurse that is eligible for federal financial participation. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plan’s definition of an FQHC or RHC visit that is eligible for federal financial participation.
(2) (A) A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist that is
eligible for federal financial participation.
(B) Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHC’s or RHC’s rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHC’s or RHC’s application for, or the department’s approval of, a rate adjustment pursuant to this
subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the provider’s rate shall be made within six months after the date of receipt of the department’s rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist or dental hygienist in alternative
practice services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3) Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist that is eligible for federal financial participation.
(4) (A) (i) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage
and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified
nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii) Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical
psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv) (I) An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II) Notwithstanding
subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia) Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) (s) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib) Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(v) An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I) The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the
service is performed.
(II) The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III) The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
(IV) An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B) (i) Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care
services via video synchronous interaction to preserve beneficiary choice.
(ii) The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHC’s or RHC’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii) Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I) Offer those services via in-person, face-to-face contact.
(II) Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a
different provider to arrange for that care.
(iv) In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical
transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I) The FQHC or RHC shall document in the patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received.
(II) The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C) The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal
approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D) This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F) Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G) Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5) For purposes of this section, “physician” shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services’ Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to
the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(h) If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i) (1) Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A) An entity that first qualifies as an FQHC or RHC in 2001 or later.
(B) A newly licensed facility at a new location added to an existing FQHC or RHC.
(C) An entity that is an existing FQHC or RHC that is relocated to a new site.
(2) (A) An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section
1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i) The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHC’s or RHC’s existing licensee.
(ii) The FQHC or RHC submits the change in scope of service request within 90 days after the FQHC’s or RHC’s first full fiscal year.
(B) The FQHC’s or RHC’s single PPS rate for those locations shall be calculated
based on the total costs and total visits of those locations and shall be determined based on the following:
(i) An audit in accordance with Section 14170.
(ii) Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii) Any approved increase or decrease in the provider’s rate shall be retroactive to the beginning of the FQHC’s or RHC’s fiscal year in which the request is submitted.
(C) Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of
Public Health, whether by a regional district office or the centralized application unit, prior to January 1, 2017.
(3) If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit
rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C) At a new entity’s one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4) In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or
RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5) The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHC’s or RHC’s prospective payment rate at that time.
(j) (1) Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined in subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health prior to January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added prior to January 1, 2017.
(2) If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health prior to January 1, 2017, applies for
an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHC’s or RHC’s primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3) This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHC’s or RHC’s clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to
account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l) Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1) An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2) (A) For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHC’s or RHC’s per-visit PPS rate.
For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHC’s or RHC’s clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B) If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHC’s or RHC’s building, that are or were previously calculated as part of the clinic’s base PPS rate.
(3) If the costs associated with providing Drug Medi-Cal services are within the FQHC’s or RHC’s clinic base PPS rate, as determined by the
department, the Drug Medi-Cal services costs shall be adjusted out of the FQHC’s or RHC’s per-visit PPS rate as a change in scope of service.
(A) An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHC’s or RHC’s clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B) An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement
for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C) The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D) Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHC’s or RHC’s projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E) Rate changes based on a request for scope-of-service change under this
subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F) For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G) After the department approves the adjustment to the FQHC’s or RHC’s clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H) An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4) Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A) In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county
designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B) In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5) The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6) For purposes of this subdivision, the following
definitions apply:
(A) “Drug Medi-Cal organized delivery system” or “DMC-ODS” means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B) “Special Terms and Conditions” has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m) Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1) An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health
services to Medi-Cal beneficiaries as part of the mental health plan’s network.
(2) (A) For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHC’s or RHC’s per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHC’s or RHC’s clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B) If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner
determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHC’s or RHC’s building, that are or were previously calculated as part of the clinic’s base PPS rate.
(3) If the costs associated with providing specialty mental health services are within the FQHC’s or RHC’s clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHC’s or RHC’s per-visit PPS rate as a change in scope of service.
(A) An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHC’s or RHC’s clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the
scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B) An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHC’s or RHC’s fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C) The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D) Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHC’s or RHC’s projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E) Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F) For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center
services or rural health center services and specialty mental health services.
(G) After the department approves the adjustment to the FQHC’s or RHC’s clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H) An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4) The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference
between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n) The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and a psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist when all of the following conditions are met:
(1) The psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist is supervised by the designated licensed behavioral health practitioner, as required by their applicable clinical licensing board.
(2) The behavioral health visit is billed under the supervising licensed practitioner of the FQHC or RHC, pursuant to paragraph (1).
(3) The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o) FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p) The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or
requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q) The department shall implement this section only to the extent that federal financial participation is available.
(r) Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of this section, including all of the following:
(1) Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).
(2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3) Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4) Providing at least 60 days advance notice of the effective date of the proposed action or change.
(s) This section shall become operative on July 1, 2026. 2027.
SEC. 86.
Section 14132.14 is added to the Welfare and Institutions Code, to read:14132.14.
(a) Federal Food and Drug Administration-approved treatments for menopausal symptoms are covered benefits under the Medi-Cal program, subject to medical necessity. These include all of the following:(1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss.
(2) Low-dose antidepressants.
(3) Anticonvulsants.
(4) Medications to prevent or treat osteoporosis.
(5) Nonhormonal medications for vasomotor-related symptoms.
(b) The department shall establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall consider current clinical care recommendations from the Menopause Society or other nationally recognized professional association, and shall identify billing codes for services commonly used to treat symptoms resulting from menopause.
(c) Coverage pursuant to this subdivision shall be provided without discrimination on the basis of gender expression or identity.
(d) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause.
(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(f) This section shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
SEC. 87.
Section 14154 of the Welfare and Institutions Code is amended to read:14154.
(a) (1) The department shall establish and maintain a plan whereby costs for county administration of the determination of eligibility for benefits under this chapter will be effectively controlled within the amounts annually appropriated for that administration. The plan, to be known as the County Administrative Cost Control Plan, shall establish standards and performance criteria, including workload, productivity, and support services standards, to which counties shall adhere. The plan shall include standards for controlling eligibility determination costs that are incurred by performing eligibility determinations at county hospitals, or that are incurred due to the outstationing of any other eligibility function. Except as provided in Section 14154.15, reimbursement to a county for outstationed eligibility functions shall be based solely on productivity standards applied to that county’s welfare department office.(2) (A) The plan shall delineate both of the following:
(i) The process for determining county administration base costs, which include salaries and benefits, support costs, and staff development.
(ii) The process for determining funding for caseload changes, cost-of-living adjustments, and program and other changes.
(B) The annual county budget survey document utilized under the plan shall be constructed to enable the counties to provide sufficient detail to the department to support their budget requests.
(3) The plan shall be part of a single
state plan, jointly developed by the department and the State Department of Social Services, in conjunction with the counties, for administrative cost control for the California Work Opportunity and Responsibility to Kids (CalWORKs), CalFresh, and Medical Assistance (Medi-Cal) programs. Allocations shall be made to each county and shall be limited by and determined based upon the County Administrative Cost Control Plan. In administering the plan to control county administrative costs, the department shall not allocate state funds to cover county cost overruns that result from county failure to meet requirements of the plan. The department and the State Department of Social Services shall budget, administer, and allocate state funds for county administration in a uniform and consistent manner.
(4) The department and county welfare departments shall develop procedures to ensure the data clarity, consistency, and reliability of information
contained in the county budget survey document submitted by counties to the department. These procedures shall include the format of the county budget survey document and process, data submittal and its documentation, and the use of the county budget survey documents for the development of determining county administration costs. Communication between the department and the county welfare departments shall be ongoing as needed regarding the content of the county budget surveys and any potential issues to ensure the information is complete and well understood by involved parties. Any changes developed pursuant to this section shall be incorporated within the state’s annual budget process by no later than the 2011–12 fiscal year.
(5) The department shall provide a clear narrative description along with fiscal detail in the Medi-Cal estimate package, submitted to the Legislature in January and May of each year, of each component of the county
administrative funding for the Medi-Cal program. This shall describe how the information obtained from the county budget survey documents was utilized and, if applicable, modified and the rationale for the changes.
(6) Notwithstanding any other law, the department shall develop and implement, in consultation with county program and fiscal representatives, a new budgeting methodology for Medi-Cal county administrative costs that reflects the impact of PPACA implementation on county administrative work. The new budgeting methodology shall be used to reimburse counties for eligibility processing and case maintenance for applicants and beneficiaries.
(A) The budgeting methodology may include, but is not limited to, identification of the costs of eligibility determinations for applicants, and the costs of eligibility redeterminations and case maintenance activities for recipients, for
different groupings of cases, based on variations in time and resources needed to conduct eligibility determinations. The calculation of time and resources shall be based on the following factors: complexity of eligibility rules, ongoing eligibility requirements, and other factors as determined appropriate by the department. The development of the new budgeting methodology may include, but is not limited to, county survey of costs, time and motion studies, in-person observations by department staff, data reporting, and other factors deemed appropriate by the department.
(B) The new budgeting methodology shall be clearly described, state the necessary data elements to be collected from the counties, and establish the timeframes for counties to provide the data to the state.
(C) The new budgeting methodology developed pursuant to this paragraph shall be implemented no sooner than
the 2015–16 fiscal year. The department may develop a process for counties to phase in the requirements of the new budgeting methodology.
(D) The department shall provide the new budgeting methodology to the legislative fiscal committees by March 1 of the fiscal year immediately preceding the first fiscal year of implementation of the new budgeting methodology.
(E) To the extent that the funding for the county budgets developed pursuant to the new budget methodology is not fully appropriated in any given fiscal year, the department, with input from the counties, shall identify and consider options to align funding and workload responsibilities.
(F) For purposes of this paragraph, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments.
(G) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this paragraph by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time any necessary regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the implementation of the new budgeting methodology pursuant to this paragraph, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until
regulations have been adopted.
(b) Nothing in this section, Section 15204.5, or Section 18906 shall be construed to limit the administrative or budgetary responsibilities of the department in a manner that would violate Section 14100.1, and thereby jeopardize federal financial participation under the Medi-Cal program.
(c) (1) The Legislature finds and declares that
that, in order for counties to do the work that is expected of them, it is necessary that they receive adequate funding, including adjustments for reasonable annual cost-of-doing-business increases. The Legislature further finds and declares that linking appropriate funding for county Medi-Cal administrative operations, including annual cost-of-doing-business adjustments, with performance standards will give counties the incentive to meet the performance standards and enable them to continue to do the work they do on behalf of the state. It is therefore the Legislature’s intent, upon an appropriation by the Legislature for this purpose, to provide appropriate funding to the counties for the effective administration of the Medi-Cal program at the local level to ensure that counties can reasonably meet the purposes of the performance measures as contained in this section.
(2) It is the intent of the
Legislature to not appropriate funds for the cost-of-doing-business adjustment for the 2008–09, 2009–10, 2010–11, 2011–12, 2012–13, 2014–15, 2015–16, 2016–17, and 2017–18 fiscal years and the 2024–25 to 2027–28, inclusive, 2017–18, 2024–25, and 2025–26 fiscal years.
(d) The department is responsible for the Medi-Cal program in accordance with state and federal law. A county shall determine Medi-Cal eligibility in accordance with state and federal law. If in the course of its duties the department becomes aware of accuracy problems in any county, the department shall, within available resources, provide training and technical assistance as appropriate. This section shall not be interpreted to eliminate any remedy otherwise available to the department to
enforce accurate county administration of the program. In administering the Medi-Cal eligibility process, each county shall meet the following performance standards each fiscal year:
(1) Complete eligibility determinations as follows:
(A) Ninety percent of the general applications without applicant errors and are complete shall be completed within 45 days.
(B) Ninety percent of the applications for Medi-Cal based on disability shall be completed within 90 days, excluding delays by the state.
(2) (A) The department shall establish best-practice guidelines for expedited enrollment of newborns into the Medi-Cal program, preferably with the goal of enrolling newborns within 10 days after the county is informed of the birth. The
department, in consultation with counties and other stakeholders, shall work to develop a process for expediting enrollment for all newborns, including those born to mothers receiving CalWORKs assistance.
(B) Upon the development and implementation of the best-practice guidelines and expedited processes, the department and the counties may develop an expedited enrollment timeframe for newborns that is separate from the standards for all other applications, to the extent that the timeframe is consistent with these guidelines and processes.
(3) Perform timely annual redeterminations, as follows:
(A) Ninety percent of the annual redetermination forms shall be mailed to the recipient by the anniversary date.
(B) Ninety percent of the annual redeterminations
shall be completed within 60 days of the recipient’s annual redetermination date for those redeterminations based on forms that are complete and have been returned to the county by the recipient in a timely manner.
(C) Ninety percent of those annual redeterminations where the redetermination form has not been returned to the county by the recipient shall be completed by sending a notice of action to the recipient within 45 days after the date the form was due to the county.
(e) The department shall develop procedures in collaboration with the counties and stakeholder groups for determining county review cycles, sampling methodology and procedures, and data reporting.
(f) On January 1 of each year, each applicable county, as determined by the department, shall report to the department on the county’s results in
meeting the performance standards specified in this section. The report shall be subject to verification by the department. County reports shall be provided to the public upon written request.
(g) If the department finds that a county is not in compliance with one or more of the standards set forth in this section, the county shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the county shall take to improve its performance on the standard or standards with which the county is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the county in order to avoid a sanction.
(h) (1) If a county does not meet the performance standards for completing eligibility determinations and redeterminations as
specified in this section, the department may, at its sole discretion, reduce the allocation of funds to that county in the following year by 2 percent. Any funds so reduced may be restored by the department if, in the determination of the department, sufficient improvement has been made by the county in meeting the performance standards during the year for which the funds were reduced. If the county continues not to meet the performance standards, the department may reduce the allocation by an additional 2 percent for each year thereafter in which sufficient improvement has not been made to meet the performance standards.
(2) No reduction of the allocation of funds to a county shall be imposed pursuant to this subdivision for failure to meet performance standards during any period of time in which the cost-of-doing-business increase is suspended.
(i) Notwithstanding Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and except as provided in subparagraph (G) of paragraph (6) of subdivision (a), the department shall, without taking any further regulatory action, implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of all-county letters or similar instructions.
SEC. 88.
Section 14184.101 of the Welfare and Institutions Code is amended to read:14184.101.
For purposes of this article, and elsewhere in law where specified, the following definitions shall apply:(a) “CalAIM” or “CalAIM initiative” means the respective components of the California Advancing and Innovating Medi-Cal initiative authorized by this article and approved by the federal Centers for Medicare and Medicaid Services in the CalAIM Terms and Conditions.
(b) “CalAIM term” means the entire period during which an applicable component of the CalAIM initiative is in effect, as approved by the federal Centers for Medicare and Medicaid Services, including any applicable extension period.
(c) “CalAIM Terms and Conditions” means those terms and
conditions issued and approved by the federal Centers for Medicare and Medicaid Services, including any attachments, appendices, or similar documents, and subsequent amendments thereto, that govern implementation of the respective components of the CalAIM initiative pursuant to this article. CalAIM Terms and Conditions shall include, at a minimum, any terms and conditions specified in the following:
(1) California Advancing and Innovating Medi-Cal Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services pursuant to Section 1315 of Title 42 of the United States Code, effective for the period from January 1, 2022, to December 31, 2026, 2031, inclusive, and any applicable extension period, or for any period
otherwise approved therein.
(2) Any associated Medicaid Waivers as approved by the federal Centers for Medicare and Medicaid Services pursuant to Section 1396n of Title 42 of the United States Code that are necessary to implement a CalAIM component, effective for the period from January 1, 2022, to December 31, 2026, 2031, inclusive, and any applicable extension period, or for any period otherwise specified in the CalAIM Terms and Conditions.
(3) Any associated Medi-Cal State Plan amendments approved by the federal Centers for Medicare and Medicaid Services that are necessary to implement a CalAIM component.
(4) Any provision of
a comprehensive risk contract, nonrisk contract, or other similar managed care arrangement, including an intergovernmental agreement, approved by the federal Centers for Medicare and Medicaid Services to implement the authorities described in paragraph (1), (2), or (3).
(d) “CalAIM year” or “Initiative Year” means the applicable effective period identified in the CalAIM Terms and Conditions that corresponds to a specific period of time as set forth in paragraphs (1) to (5), (10), inclusive. Individual programs or components under the CalAIM Initiative may be operated on program years that differ from the CalAIM years identified in paragraphs (1) to (5),
(10), inclusive, or may be operated without regard to program years, as applicable.
(1) Initiative year 1 corresponds to the period of January 1, 2022, to December 31, 2022, inclusive.
(2) Initiative year 2 corresponds to the period of January 1, 2023, to December 31, 2023, inclusive.
(3) Initiative year 3 corresponds to the period of January 1, 2024, to December 31, 2024, inclusive.
(4) Initiative year 4 corresponds to the period of January 1, 2025, to December 31, 2025, inclusive.
(5) Initiative year 5 corresponds to the period of January 1, 2026, to December 31, 2026, inclusive.
(6) Initiative year 6 corresponds to the period of January 1, 2027, to December 31, 2027, inclusive.
(7) Initiative year 7 corresponds to the period of January 1, 2028, to December 31, 2028, inclusive.
(8) Initiative year 8 corresponds to the period of January 1, 2029, to December 31, 2029, inclusive.
(9) Initiative year 9 corresponds to the period of January 1, 2030, to December 31, 2030, inclusive.
(10) Initiative year 10 corresponds to the period of January 1, 2031, to December 31, 2031, inclusive.
(e) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the
Code of Federal Regulations.
(f) “Designated public hospital” means any one of the hospitals identified in subdivision (f) of Section 14184.10, and any successor, including any restructured, reorganized, or differently named hospital, that is operated by a county, a city and county, the University of California, or a special hospital authority described in Chapter 5 (commencing with Section 101850) or Chapter 5.5 (commencing with Section 101852) of Part 4 of Division 101 of the Health and Safety Code, or any additional public hospital to the extent identified as a “designated public hospital” in the CalAIM Terms and Conditions.
(g) “Federal disproportionate share hospital allotment” means the amount specified for California under Section 1396r-4(f) of Title 42 of the United States Code for a federal fiscal year.
(h) “Federal medical assistance percentage” means the federal medical assistance percentage applicable for federal financial participation purposes for medical assistance under the Medi-Cal State Plan pursuant to Section 1396b(a)(1) of Title 42 of the United States Code.
(i) “Medi-Cal behavioral health delivery system” means an entity or local agency that contracts with the department to provide covered behavioral health Medi-Cal benefits pursuant to Article 3.2 (commencing with Section 14124.20), or Section 14184.400 and Chapter 8.9 (commencing with Section 14700), or a county Drug Medi-Cal Organized Delivery System pilot authorized under the CalAIM Terms and Conditions and described in Section 14184.401 or authorized under the Medi-Cal 2020 Demonstration Project Act pursuant to Article 5.5 (commencing with Section 14184).
(j) “Medi-Cal managed care plan” means any
individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to any provision of this chapter or Chapter 8 (commencing with Section 14200).
(k) “Nonrisk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations.
(l) “Nonfederal share percentage” means the difference between 100 percent and the applicable federal medical assistance percentage.
(m) “Total computable disproportionate share hospital allotment” means the federal disproportionate share hospital allotment for a federal fiscal year, divided by the applicable federal medical assistance percentage with respect to that same federal fiscal
year.
SEC. 89.
Section 14184.102 of the Welfare and Institutions Code is amended to read:14184.102.
(a) Consistent with federal law, the department shall seek federal approval for, and implement, the CalAIM initiative, including, but not limited to, all of the following components:(1) Continuation of the Medi-Cal Managed Care program, described in part in Sections 14184.200 to 14184.208, inclusive, and, elsewhere in this chapter and Chapter 8 (commencing with Section 14200), and which includes any comprehensive risk contract between the department and an individual, organization, or entity to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to any provision of this chapter or Chapter 8 (commencing with Section 14200).
(2) Continuation of the Global
Payment Program, described in Section 14184.40, as amended by the act that added this section, and Section 14184.300.
(3) Continuation of the Medi-Cal Specialty Mental Health Services Program, as described in part in Section 14184.400.
(4) Continuation of the Drug Medi-Cal organized delivery system program, as described in part in Section 14184.401.
(5) Behavioral Health Medical Necessity Changes, Payment Reform, Administrative Simplification, and Behavioral Health Quality Improvement Program, as described in Sections 14184.402, 14184.403, 14184.404, and 14184.405.
(6) The State Plan Dental Improvement Program, as described in Section 14184.500.
(7) Enhancing County Oversight and
Monitoring, as described in Section 14184.600.
(8) Providing Access and Transforming Health (PATH) Supports, as described in Section 14184.700.
(9) Targeted Pre-Release Medi-Cal Benefits for Qualified Inmates, as described in Section 14184.800.
(10) Employment Supports and BridgeCare, as described in Section 14184.900.
(b) The department shall report to the Legislature any conflicts between this article and the CalAIM Terms and Conditions, including identification of the specific conflicts and recommendations for conforming language.
(c) The department, as appropriate and to the
extent practicable, shall consult with interested stakeholders with regard to implementation of applicable components of CalAIM under subdivision (a) in which they will participate, including, but not limited to, the issuance of departmental guidance pursuant to subdivision (d). Interested stakeholders may include, but need not be limited to, designated public hospitals, district and municipal public hospitals, other local governmental agencies, consumer representatives, and Medi-Cal managed care plans.
(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article or the CalAIM Terms and Conditions, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar instructions, without taking any further regulatory action. The department shall make use of
appropriate processes to ensure that affected stakeholders are timely informed of, and have access to, applicable guidance issued pursuant to this authority, and that this guidance remains publicly available until all payments related to the applicable CalAIM component are finalized.
(e) For purposes of implementing this article or the CalAIM Terms and Conditions, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis, and may implement changes to existing information technology systems. Notwithstanding any other law, contracts entered into or amended, or changes to existing information technology systems, pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract
Code, and shall be exempt from the review or approval of any division of the Department of General Services.
(f) The department shall seek any federal approvals it deems necessary to implement CalAIM under this article and other provisions of law amended by the act that added this subdivision. This shall include, but need not be limited to, approval of any amendment, addition, or technical correction to the CalAIM Terms and Conditions, as the department deems necessary. This article shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(g) Consistent with subdivision (b), the director shall report to the Legislature on any recommended amendments to any provision, process, or methodology specified in this article, Article 5.4 (commencing with Section 14180),
Article 5.5 (commencing with Section 14184), or other sections of law amended by the act that added this subdivision, to the extent necessary to comply with federal law or the CalAIM Terms and Conditions, to obtain or maintain federal approval, or to ensure federal financial participation is available and not otherwise jeopardized, if the amendment is consistent with the goals set forth in this article and its individual components, and does not significantly alter the relative level of support for participating entities. If the director, after consulting with those entities participating in the applicable CalAIM component and that would be affected by that amendment, determines that the potential amendment would be consistent with the goals set forth in this article and would not significantly alter the relative level of support for affected participating entities, the amendment shall be submitted to the Legislature for its consideration.
(h) During the course of the CalAIM term, the department may develop and implement successor payment methodologies or programs to continue to support entities participating in one or more components of CalAIM following the expiration of the CalAIM term and that further the goals set forth in this article. The department shall consult with the entities participating in the payment methodologies or program components under CalAIM, affected stakeholders, and the Legislature in the development of any successor payment methodologies or program components pursuant to this subdivision.
(i) The department may seek to extend the payment methodologies or programs described in this article, or in the CalAIM Terms and Conditions, including modification thereto, through the CalAIM term or to subsequent time periods by way of amendment or extension of the relevant CalAIM Terms and Conditions, amendment to the Medi-Cal State Plan, or any
combination thereof, consistent with the applicable federal requirements. This subdivision shall only be implemented after consultation with the entities participating in, or affected by, those methodologies or programs, and only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(j) Notwithstanding any other state or local law, including, but not limited to, Section 5328 of this code, and Sections 11812 and 11845.5 of the Health and Safety Code, the sharing of health, social services, housing, and criminal justice information, records, and other data with and among the department, other state departments, including the State Department of Public Health and the State Department of Social Services, Medi-Cal managed care plans, Medi-Cal behavioral health delivery systems, counties, health care providers, social services organizations, care coordination
and case management teams, and other authorized provider or plan entities, and contractors of all of those entities, shall be permitted to the extent necessary to implement applicable CalAIM components described in this article and the CalAIM Terms and Conditions, and to the extent consistent with federal law. The department shall issue guidance identifying permissible data-sharing arrangements to implement CalAIM.
(k) (1) Notwithstanding any other law, and to the extent authorized by the CalAIM Terms and Conditions, the department may claim federal financial participation for expenditures associated with the designated state health programs identified in the CalAIM Terms and Conditions for use solely by the department as specified in this subdivision.
(2) Any federal financial participation claimed pursuant to paragraph (1) shall be used to offset applicable
General Fund expenditures. These amounts are hereby appropriated to the department and shall be available for transfer to the General Fund for this purpose.
(3) An amount of General Fund moneys equal to the federal financial participation that may be claimed pursuant to paragraph (1) is hereby appropriated to the Health Care Deposit Fund for use by the department for purposes of implementing this article.
(4) (A) Notwithstanding any other law, the department shall maintain reimbursement rates in the Medi-Cal program for primary care, obstetric care, and behavioral health services, and shall increase reimbursement rates for those service codes, as necessary to meet federally imposed minimum requirements specified in the CalAIM Terms and Conditions for dates of service on or after January 1, 2024, to the extent required by the federal Centers for Medicare and
Medicaid Services as a condition of claiming federal financial participation for designated state health programs as described in this subdivision.
(B) To the extent required by the CalAIM Terms and Conditions, subparagraph (A) shall apply to claims for the identified codes paid by the department in fee-for-service and to claims paid by a Medi-Cal managed care plan.
SEC. 90.
Section 14184.200 of the Welfare and Institutions Code is amended to read:14184.200.
(a) Notwithstanding any other law, the department may standardize those populations that are subject to mandatory enrollment in a Medi-Cal managed care plan across all aid code groups and Medi-Cal managed care models statewide, subject to a Medi-Cal managed care plan readiness, continuity of care transition plan, and disenrollment process developed in consultation with stakeholders, in accordance with the CalAIM Terms and Conditions and as described in this section.(1) (A) The department shall ensure the Medi-Cal managed care plan’s readiness for network adequacy includes a geographic access review of rural ZIP Codes to ensure time or distance standards are met, or alternative access standard requests are approved, as applicable, and
the plan’s ability to meet existing federal and state mandatory provider type requirements, where available.
(B) The department shall not require a population to enroll in managed care if Medi-Cal managed care plans fail to meet the Medi-Cal managed care plan readiness requirements detailed in this paragraph for that population.
(2) The Medi-Cal managed care plan shall comply with the continuity of care requirements in Section 1373.96 of the Health and Safety Code and shall be consistent with and no more restrictive than existing or future policy and guidance issued by the department, including All Plan Letter 22-032, any superseding all plan letter, and related guidance.
(3) The disenrollment process for an enrollee in any county shall be consistent with and no more restrictive than existing federal and state
statutes and regulations, including Section 53889 and subdivision (c) of Section 53891 of Title 22 of the California Code of Regulations. The beneficiary may request a medical exemption from mandatory enrollment in a Medi-Cal managed care plan in accordance with Section 53887 of Title 22 of the California Code of Regulations and may disenroll or be exempted from mandatory enrollment under the limited circumstances set forth in subdivision (c) of Section 53891 of Title 22 of the California Code of Regulations. That disenrollment or exemption from mandatory enrollment in a Medi-Cal managed care plan shall be consistent with subsection (c) of Section 438.56 of Title 42 of the Code of Federal Regulations and applicable state law.
(b) (1) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January
1, 2022, and subject to subdivision (f) of Section 14184.102, a non-dual-eligible beneficiary, except a beneficiary identified in paragraph (2), shall be required to enroll, or shall continue to be required to enroll, in a Medi-Cal managed care plan for purposes of their receipt of covered Medi-Cal benefits.
(2) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January 1, 2022, or as otherwise specified in this paragraph, subject to subdivision (f) of Section 14184.102, the following dual and non-dual beneficiary groups, as identified by the department, shall be exempt from mandatory enrollment in a Medi-Cal managed care plan:
(A) A
beneficiary eligible for only restricted-scope Medi-Cal benefits, as described in subdivision (d) (e) of Section 14007.5 and Sections 14005.65 and 14007.7.
(B) A beneficiary made eligible on the basis of a share of cost, including, but not limited to, a non-dual-eligible beneficiary residing in a county that is authorized to operate a county organized health system (COHS), as described in Article 2.8 (commencing with Section 14087.5), except for a non-dual-eligible beneficiary that is eligible on the basis of their need for long-term care services with a share of cost, as identified by the department.
(C) A beneficiary made eligible on the basis of a federally approved Medi-Cal Presumptive
Eligibility program, as determined by the department, but only during the relevant period of presumptive eligibility.
(D) An eligible beneficiary who is an inmate of a public institution, or who is released pursuant to Section 26605.6 or 26605.7 of the Government Code.
(E) A beneficiary with satisfactory immigration status, including a noncitizen that is lawfully present, who is eligible for only pregnancy-related Medi-Cal coverage and who received services through the Medi-Cal fee-for-service delivery system prior to January 1, 2022, as identified by the department, but only through the end of the postpartum period.
(F) A beneficiary without satisfactory immigration status or who is unable to establish satisfactory immigration status as required by Section 14011.2, who is eligible for only pregnancy-related Medi-Cal
coverage, excluding a beneficiary enrolled in the Medi-Cal Access Program described in Chapter 2 (commencing Section 15810) of Part 3.3.
(G) A non-dual-eligible beneficiary who is an Indian, as defined in subdivision (a) of Section 438.14 of Title 42 of the Code of Federal Regulations, and who elects to forego voluntary enrollment in a Medi-Cal managed care plan.
(H) A non-dual-eligible beneficiary eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who elects to forego voluntary enrollment in a Medi-Cal managed care plan, except for a non-dual beneficiary described in this subparagraph who resides in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), or, effective January 1, 2025, in a county operating a Single Plan model of managed care
established under Article 2.7 (commencing with Section 14087.3) and Article 2.8 (commencing with Section 14087.5). For the purpose of this subdivision, the following requirements shall apply to non-dual-eligible beneficiaries eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who are transitioning to mandatory enrollment in a Medi-Cal managed care plan in a county operating a Single Plan model of managed care:
(i) Medi-Cal managed care plans shall comply with the access requirements in Section 14197 and in accordance with All Plan Letter 23-001, any superseding all plan letter, and any related guidance.
(ii) The department shall use the Intercounty Transfer process as outlined in All County Welfare Directors Letter 18-02E to provide for immediate access to care and treatment services in the month of
enrollment when a beneficiary moves from one county to another.
(iii) The department shall issue guidance with input from stakeholders, including county child welfare departments.
(I) A non-dual-eligible beneficiary enrolled with an entity with a contract with the department pursuant to the Program of All-Inclusive Care for the Elderly (PACE), as described in Chapter 8.75 (commencing with Section 14591).
(J) Any other non-dual-eligible beneficiary, as identified by the department, for whom federal law prohibits mandatory enrollment in a Medi-Cal managed care plan.
(K) A beneficiary residing in one of the Veterans’ Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(L) Commencing no sooner than January 1, 2027, and subject to subdivision (f) of Section 14184.102, a beneficiary without satisfactory immigration status or who is unable to establish satisfactory immigration status as required by Section 14011.2, who is eligible pursuant to Section 14007.8 for the full-scope of Medi-Cal benefits, and who is subject to the service limitations described in subdivisions (b), (c), and (k) of Section 14007.8.
(c) (1) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January 1, 2023, and subject to subdivision (f) of Section 14184.102, a dual eligible beneficiary, except as provided in paragraph (2) of subdivision (b) or paragraph (2) of this subdivision, shall be required to
enroll, or shall continue to be required to enroll, in a Medi-Cal managed care plan for purposes of their receipt of covered Medi-Cal benefits.
(2) The following dual eligible beneficiary groups, as identified by the department, shall be exempt from mandatory enrollment in Medi-Cal managed care as described in paragraph (1):
(A) A dual eligible beneficiary made eligible on the basis of a share of cost, including, but not limited to, a dual eligible beneficiary residing in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), except for a dual eligible beneficiary who is eligible on the basis of their need for long-term care services with a share of cost, as determined by the department.
(B) A dual eligible beneficiary enrolled with an entity with a contract with
the department pursuant to PACE as described in Chapter 8.75 (commencing with Section 14591).
(C) A dual eligible beneficiary enrolled with an entity with a Senior Care Action Network (SCAN) contract with the department.
(D) A dual eligible beneficiary who is an Indian, as defined in subsection (a) of Section 438.14 of Title 42 of the Code of Federal Regulations, and who elects to forego voluntary enrollment in a Medi-Cal managed care plan.
(E) A dual eligible beneficiary with HIV/AIDS who elects to forego voluntary enrollment in a Medi-Cal managed care plan.
(F) A dual eligible beneficiary eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who elects to forego voluntary
enrollment in a Medi-Cal managed care plan, except for a dual beneficiary described in this subparagraph who resides in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), or, effective January 1, 2025, in a county operating a Single Plan model of managed care established under Article 2.7 (commencing with Section 14087.3) and Article 2.8 (commencing with Section 14087.5). For the purpose of this subdivision, the following requirements shall apply to non-dual-eligible beneficiaries eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who are transitioning to mandatory enrollment in a Medi-Cal managed care plan in a county operating a Single Plan model of managed care:
(i) Medi-Cal managed care plans shall comply with the access requirements in Section 14197 and in accordance with All Plan Letter 23-001, any
superseding all plan letter, and any related guidance.
(ii) The department shall use the Intercounty Transfer process as outlined in All County Welfare Directors Letter 18-02E to provide for immediate access to care and treatment services in the month of enrollment when a beneficiary moves from one county to another.
(iii) The department shall issue guidance with input from stakeholders, including county child welfare departments.
(G) A dual eligible beneficiary residing in one of the Veterans’ Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(H) Any other dual eligible beneficiary, as identified by the department, for whom federal law prohibits mandatory enrollment in a
Medi-Cal managed care plan.
(d) (1) This section shall not prohibit a Medi-Cal beneficiary from receiving covered benefits on a temporary basis through the Medi-Cal fee-for-service delivery system pending enrollment into an individual Medi-Cal managed care plan in accordance with this section and the CalAIM Terms and Conditions.
(2) This section shall not prohibit certain Medi-Cal beneficiaries eligible for full-scope benefits under the Medi-Cal State plan, as identified by the department, from voluntarily enrolling in a Medi-Cal managed care plan, in accordance with the CalAIM Terms and Conditions.
(e) (1) No later than January 1, 2023, in all non-County Organized Health System counties, in areas where a PACE plan is available, the PACE plan shall be presented as an
enrollment option, included in enrollment materials, and made available to an applicable beneficiary whenever enrollment choices and options are presented. Outreach and enrollment materials shall enable a Medi-Cal beneficiary to understand what PACE provides, that, if eligible, they may be assessed for PACE eligibility and enroll in PACE, and how they can receive additional information and request to be assessed for PACE eligibility. A person meeting the age qualifications for PACE and who chooses PACE shall not be assigned to a Medi-Cal managed care plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for PACE. A person enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE plan pursuant to the three-way agreement between the PACE plan, the department, and the federal Centers for Medicare and Medicaid Services.
(2) In areas of the state where a
presentation on Medi-Cal managed care plan enrollment options is unavailable, the department, or its contracted vendor, shall provide informational, outreach, and enrollment materials about the PACE program.
(f) For purposes of this section, the following definitions apply:
(1) “Dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or both, and is eligible for medical assistance under the Medi-Cal State Plan. For purposes of this article, “dual eligible beneficiary” shall include both a “full-benefit dual eligible beneficiary” and a “partial-benefit dual eligible beneficiary,” as those terms are defined in this subdivision.
(2) “Full-benefit dual eligible beneficiary”
means an individual 21 years or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), Medicare Part B (42 U.S.C. Sec. 1395j et seq.), and Medicare Part D (42 U.S.C. Sec. 1395w-101), and is eligible for medical assistance under the Medi-Cal State Plan.
(3) “Non-dual-eligible beneficiary” means an individual eligible for medical assistance under the Medi-Cal State plan, as determined by the department, that is not eligible for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.).
(4) “Partial-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), but not Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or who is enrolled for Medicare Part B (42 U.S.C. Sec. 1395j et seq.), but not
Medicare Part A (42 U.S.C. Sec. 1395c et seq.), and is eligible for medical assistance under the Medi-Cal State Plan.
SEC. 91.
Section 14184.404 of the Welfare and Institutions Code is amended to read:14184.404.
(a) Notwithstanding any other law, commencing January 1, 2027, subject to subdivision (f) of Section 14184.102, an individual county, or counties acting jointly, shall provide and administer covered behavioral health Medi-Cal benefits under a single Medi-Cal behavioral health delivery system(b) During the CalAIM term, the department, in
consultation with counties, shall conduct any planning activities
that it deems necessary and issue related guidance pursuant to subdivision (d) of Section 14184.102 to facilitate implementation of subdivision (a).
(c) The department may authorize a noncounty organization that it contracts with pursuant to Section 14712 or Section 14124.21 to provide and administer covered behavioral health Medi-Cal benefits under a single Medi-Cal behavioral health delivery system contract, in accordance with the CalAIM Terms and Conditions.
SEC. 92.
Section 14184.900 is added to the Welfare and Institutions Code, to read:14184.900.
(a) Commencing no sooner than January 1, 2027, in accordance with the CalAIM Terms and Conditions and subdivision (f) of Section 14184.102, the department shall implement Employment Supports.(b) Commencing no sooner than January 1, 2027, in accordance with the CalAIM Terms and Conditions and subdivision (f) of Section 14184.102, the department shall implement BridgeCare to provide home- and community-based services and caregiver supports to individuals enrolled in the federal Medicare Program who meet the near dual eligibility criteria outlined in the CalAIM Terms and Conditions.
SEC. 93.
Section 14197.2 of the Welfare and Institutions Code is amended to read:14197.2.
(a) This section implements the state option in subsection (j) of Section 438.8 of Title 42 of the Code of Federal Regulations.(b) Commencing July 1, 2019, a Medi-Cal managed care plan shall comply with a minimum 85 percent medical loss ratio (MLR) consistent with Section 438.8 of Title 42 of the Code of Federal Regulations. The ratio shall be calculated and reported for each MLR reporting year by the Medi-Cal managed care plan consistent with Section 438.8 of Title 42 of the Code of Federal Regulations.
(c) (1) Effective for contract rating periods commencing on or after July 1, 2023, a Medi-Cal managed care plan shall provide a remittance for an MLR reporting year if the
ratio for that MLR reporting year does not meet the minimum MLR standard of 85 percent. The department shall determine the remittance amount on a plan-specific basis for each rating region of the plan and shall calculate the federal and nonfederal share amounts associated with each remittance.
(2) After the department returns the requisite federal share amounts associated with any remittance funds collected in any applicable fiscal year to the federal Centers for Medicare and Medicaid Services, the remaining amounts remitted by a Medi-Cal managed care plan pursuant to this section shall be transferred to the Medi-Cal Loan Repayment Program Special Fund for the purposes of the Medi-Cal Physicians and Dentists Loan Repayment Program as described in Section 14114. deposited in the
General Fund.
(d) Except as otherwise required under this section, and until June 30, 2022, the requirements under this section do not apply to a health care service plan under a subcontract with a Medi-Cal managed care plan to provide covered health care services to Medi-Cal beneficiaries enrolled in the Medi-Cal managed care plan. This subdivision shall be inoperative on July 1, 2022.
(e) The department shall post on its internet website all of the following information:
(1) The aggregate MLR of all Medi-Cal managed care plans.
(2) The MLR of each Medi-Cal managed care plan, and, as applicable, the MLR of each subcontractor plan or other delegated entity, under contract with the Medi-Cal managed care plan, that is required to
report an MLR pursuant to the CalAIM Terms and Conditions.
(3) Any required remittances owed by each Medi-Cal managed care plan, and, as applicable, any required remittances owed by each subcontractor plan or other delegated entity to that Medi-Cal managed care plan pursuant to the CalAIM Terms and Conditions.
(f) For purposes of this section, the following definitions apply:
(1) “Medical loss ratio (MLR) reporting year” shall have the same meaning as that term is defined in Section 438.8 of Title 42 of the Code of Federal Regulations.
(2) (A)“Medi-Cal managed care plan”
means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:
(i)
(A) Article 2.7 (commencing with Section 14087.3).
(ii)
(B) Article 2.8 (commencing with Section 14087.5).
(iii)
(C) Article 2.81 (commencing with Section 14087.96).
(iv)
(D) Article 2.82 (commencing with Section 14087.98).
(v)
(E) Article 2.91 (commencing with Section 14089).
(vi)
(F) Article 1 (commencing with Section 14200) of Chapter 8.
(vii)
(G) Article 7 (commencing with Section 14490) of Chapter 8.
(B)For purposes of the remittance requirement described in subdivision (c), “Medi-Cal managed care plan” does not include dental managed care plans that contract with the department pursuant to this chapter or Chapter 8 (commencing with Section 14200). This subparagraph shall be inoperative on January 1, 2024.
(3) “CalAIM Terms and Conditions” shall have the same meaning as that term is defined in subdivision (c) of Section 14184.101.
(g) The department shall seek any federal approvals it deems necessary to implement this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
SEC. 94.
Section 15926 of the Welfare and Institutions Code is amended to read:15926.
(a) The following definitions apply for purposes of this part:(1) “Accessible” means in compliance with Section 11135 of the Government Code, Section 1557 of the PPACA, and regulations or guidance adopted pursuant to these statutes.
(2) “Limited-English-proficient” means not speaking English as one’s primary language and having a limited ability to read, speak, write, or understand English.
(3) “Insurance affordability program” means a program that is one of the following:
(A) The Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396
et seq.).
(B) The state’s children’s health insurance program (CHIP) under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).
(C) A program that makes available to qualified individuals coverage in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code.
(D) A program that makes available coverage in a qualified health plan through the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code with cost-sharing reductions established under Section 1402 of PPACA and any subsequent amendments to that act.
(b) An individual shall have the option to apply for insurance affordability programs in person, by mail, online, by telephone, or by other commonly available electronic means.
means, including a mobile-friendly internet website.
(c) (1) A single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs shall be developed by the department, in consultation with the board governing the Exchange, as part of the stakeholder process described in subdivision (b) of Section 15925. The application shall be used by all entities authorized to make an eligibility determination for any of the insurance affordability programs and by their agents.
(2) The department may develop and require the use of supplemental forms to collect additional information needed to determine eligibility on a basis other than the financial methodologies described in Section 1396a(e)(14) of Title 42 of the United States Code, as added by the federal Patient Protection and
Affordable Care Act (Public Law 111-148), and as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments, as provided under Section 435.907(c) of Title 42 of the Code of Federal Regulations. Regulations, and as amended by federal H.R. 1 (Public Law 119-21).
(3) The application shall be tested and
application, or any amendments thereto, as required to comply with Public Law 119-21, shall be user-tested for accuracy and readability in all Medi-Cal threshold languages and shall be operational by the date as required by the federal Secretary of Health and Human Services. Services, including prior to the effective date of any applicable changes required pursuant to Public Law 119-21.
(4) The application form form, or any amendments thereto,
shall, to the extent not inconsistent consistent with federal statutes, regulations, and guidance, satisfy all of the following criteria:
(A) The form form, or any supplements thereto, shall include simple, user-friendly language and instructions.
(B) The form
form, or any amendments and supplemental forms thereto, may not ask for information related to a nonapplicant that is not necessary to determine eligibility in the applicant’s particular circumstances.
(C) The form form, or any amendments and supplemental forms thereto, may require only information necessary to support the eligibility and enrollment processes for insurance affordability programs.
(D) The form
form, or any amendments and supplemental forms thereto, may be used for, but shall not be limited to, screening. screening and enrollment into an insurance affordability program.
(E) The form may ask, or be used otherwise to identify, if the mother of an infant applicant under one year of age had coverage through an insurance affordability program for the infant’s birth, for the purpose of automatically enrolling the infant into the applicable program without the family having to complete the application process for the infant.
(F) The form may include questions that are voluntary for applicants to answer regarding demographic data categories,
including race, ethnicity, primary language, disability status, and other categories recognized by the federal Secretary of Health and Human Services under Section 4302 of the PPACA.
(G) Notwithstanding subparagraphs (B) and (C), on or before January 1, 2027, the form shall include an optional question for an applicant to identify whether they are experiencing homelessness.
(H)Until January 1, 2016, the department shall instruct counties to not reject an application that was in existence prior to January 1, 2014, but to accept the application and request any additional information needed from the applicant in order to complete the eligibility determination process. The department shall work with counties and consumer advocates to develop the supplemental questions.
(H) The form may be used, to the extent possible, to determine compliance with work or community engagement requirements set forth in Section 1396a(xx) of Title 42 of the United States Code (Section 71119 of Public Law 119-21), as described in Section 14005.69, including any exemptions to those requirements, without seeking additional information.
(d) Nothing in this section shall preclude the use of a provider-based application form or enrollment procedures for insurance affordability programs or other health programs that differs from the application form described in subdivision (c), and related enrollment procedures. Nothing in this section shall preclude the use of a joint application, developed by the department and the State Department of Social Services, that allows for an application to be made for multiple programs, including, but not limited to,
CalWORKs, CalFresh, and insurance affordability programs.
(e) The entity making the eligibility determination shall grant eligibility immediately whenever possible and with the consent of the applicant in accordance with the state and federal rules governing insurance affordability programs.
(f) (1) If the eligibility, enrollment, and retention system has the ability to prepopulate an application form for insurance affordability programs with personal information from available electronic databases, an applicant shall be given the option, with their informed consent, to have the application form prepopulated. Before a prepopulated application is submitted to the entity authorized to make eligibility determinations, the individual shall be given the opportunity to provide additional eligibility information and to correct any information retrieved from a
database.
(2) All insurance affordability programs may accept self-attestation, instead of requiring an individual to produce a document, for age, date of birth, family size, household income, state residence, pregnancy, work or community engagement activities or exemptions to those requirements, and any other applicable criteria needed to determine the eligibility of an applicant or recipient, to the extent permitted by state and federal law.
(3) An applicant or recipient shall have their information electronically verified in the manner required by the PPACA PPACA, Public Law 119-21,
and implementing federal regulations and guidance and state law.
(4) Before an eligibility determination is made, the individual shall be given the opportunity to provide additional eligibility information and to correct information.
(5) The eligibility of an applicant shall not be delayed beyond the timeliness standards as provided in Section 435.912 of Title 42 of the Code of Federal Regulations or denied for any insurance affordability program unless the applicant is given a reasonable opportunity, of at least the kind provided for under the Medi-Cal program pursuant to Section 14007.5 and paragraph (7) of subdivision (e) of Section 14011.2, to resolve discrepancies concerning any information provided by a verifying entity.
entity, including the opportunity to provide information to demonstrate compliance with work or community engagement requirements pursuant to Section 14005.69.
(6) To the extent federal financial participation is available, an applicant shall be provided benefits in accordance with the rules of the insurance affordability program, as implemented in federal regulations and guidance, for which the applicant otherwise qualifies until a determination is made that the applicant is not eligible and all applicable notices have been provided. Nothing in this section shall be interpreted to grant presumptive eligibility if it is not otherwise required by state law, and, if so required, then only to the extent permitted by federal law.
(g) The eligibility, enrollment, and retention system shall offer an applicant and recipient assistance with their
application or renewal for an insurance affordability program in person, over the telephone, by mail, online, or through other commonly available electronic means and in a manner that is accessible to individuals with disabilities and those who are limited English proficient.
(h) (1) During the processing of an application, renewal, or a transition due to a change in circumstances, an entity making eligibility determinations for an insurance affordability program shall ensure that an eligible applicant and recipient of insurance affordability programs that meets all program eligibility requirements and complies with all necessary requests for information moves between programs without any breaks in coverage and without being required to provide any forms, documents, or other information or undergo verification that is duplicative or otherwise unnecessary. The individual shall be informed about how to obtain information
about the status of their application, renewal, or transfer to another program at any time, and the information shall be promptly provided when requested.
(2) The application or case of an individual screened as not eligible for Medi-Cal on the basis of Modified Adjusted Gross Income (MAGI) household income or noncompliance with the requirements of Section 14005.69, but who may be eligible on the basis of being 65 years of age or older, or on the basis of blindness or disability, shall be forwarded to the Medi-Cal program for an eligibility determination. During the period this application or case is processed for a non-MAGI Medi-Cal eligibility determination, if the applicant or recipient is otherwise eligible for an insurance affordability program, the applicant or recipient shall be determined eligible for that program.
(3) Renewal procedures shall include all available methods for reporting renewal information, including, but not limited to, face-to-face, telephone, mail, and online renewal or renewal through other commonly available electronic means.
(4) An applicant who is not eligible for an insurance affordability program for a reason other than income eligibility, including work or community engagement requirements, or for any reason in the case of applicants and recipients residing in a county that offers a health coverage program for individuals with income above the maximum allowed for the Exchange premium tax credits, shall be
provided application information and referred to the county health coverage program in their county of residence.
(i) Notwithstanding subdivisions (e), (f), and (j), before an online applicant who appears to be eligible for the Exchange with a premium tax credit or reduction in cost sharing, or both, may be enrolled in the Exchange, both of the following shall occur:
(1) The applicant shall be informed of the overpayment penalties under the federal Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 (Public Law 112-9), if the individual’s annual family income increases by a specified amount or more, calculated on the basis of the individual’s current family size and current income, and that penalties are avoided by prompt reporting of income increases throughout the year.
(2) The applicant shall be informed of the penalty for failure to have minimum essential health coverage.
(j) The department shall, in coordination with the Exchange board, streamline and coordinate all eligibility rules and requirements among insurance affordability programs using the least restrictive rules and requirements permitted by federal and state law. This process shall include the consideration of methodologies for determining income levels, assets, rules for household size, citizenship and immigration status, work or community engagement and related exemptions, and self-attestation and verification requirements.
(k) (1) Forms and notices developed pursuant to this section shall be
accessible and standardized, as appropriate, and shall comply with federal and state laws, regulations, and guidance prohibiting discrimination.
(2) Forms and notices developed pursuant to this section shall be developed using plain language and shall be provided in a manner that affords meaningful access to limited-English-proficient individuals, in accordance with applicable state and federal law, and at a minimum, provided in the same threshold languages as required for Medi-Cal managed care plans.
(l) The department, the California Health and Human Services Agency, and the Exchange board shall establish a process for receiving and acting on stakeholder suggestions regarding the functionality of the eligibility systems supporting
and concerns regarding the Exchange, including the activities of all entities providing eligibility screening to ensure the correct eligibility rules and requirements are being used. This process shall include consumers and their advocates, be conducted no less than quarterly, and include the recording, review, and analysis of potential defects or enhancements of the eligibility systems. systems through regular user-testing and user-centered design sessions. The process shall also include regular updates on the work to analyze, prioritize, and implement corrections to confirmed defects and proposed enhancements, and to monitor screening.
enhancements to the eligibility systems and to monitor screening and evaluation for Medi-Cal eligibility.
(m) In designing and implementing the eligibility, enrollment, and retention system, the department and the Exchange board shall ensure that all privacy and confidentiality rights under the PPACA PPACA, Public Law 119-21, and other federal and state laws are incorporated and followed, including responses to security breaches.
SEC. 95.
To the extent that these activities are an allowable use of the AIDS Drug Assistance Program Rebate Fund, this section authorizes the State Department of Public Health to spend up to $134,840,000 in fiscal year 2026–27, $134,490,000 in fiscal year 2027–28, $126,590,000 in fiscal year 2028–29, and $130,090,000 in fiscal year 2029–30, from the AIDS Drug Assistance Program Rebate Fund to implement the following programs, consistent with Sections 120955, 120956, 120960, 120972, 120972.1, and 120972.2 of the Health and Safety Code:(a) For the 2026–27
fiscal year, beginning July 1, 2026, the following applies:
(1) $33,800,000 shall be available on a one-time basis, commencing July 1, 2026, for preexposure and postexposure prophylaxis initiation and retention projects. Funds shall be encumbered or expended no later than June 30, 2030.
(2) $14,500,000 shall be available on a one-time basis, commencing July 1, 2026, for rapid antiretroviral therapy projects. Funds shall be encumbered or expended no later than June 30, 2030.
(3) $14,100,000 shall be available on a one-time basis, commencing July 1, 2026, for HIV and aging projects. Funds shall be encumbered or expended no later than June 30, 2030.
(4) $30,000,000 shall be available on a one-time basis, commencing July 1, 2026, for emergency department
syndemic screening projects. Funds shall be encumbered or expended no later than June 30, 2029.
(5) $550,000 shall be available on a one-time basis, commencing July 1, 2026, to fund Hepatitis C testing training.
(6) $25,000,000 shall be available on a one-time basis, commencing July 1, 2026, to provide housing support for individuals living with HIV. Funds shall be encumbered or expended no later than June 30, 2030.
(7) $640,000 shall be available annually for four years commencing July 1, 2026, to support state operations personnel to implement this section.
(8) $16,250,000 shall be available annually for four years, commencing July 1, 2026, to support the California Overdose Prevention and Harm Reduction Initiative (COPHRI).
(b) For the 2027–28 fiscal year, beginning July 1, 2027, the following applies:
(1) $30,000,000 shall be available on a one-time basis, commencing July 1, 2027, for the Syphilis and Congenital Syphilis Outbreak Strategy. Funds shall be encumbered or expended no later than June 30, 2032.
(2) $10,000,000 shall be available annually for three years, commencing July 1, 2027, for the Harm Reduction Supply Clearinghouse. Funds allocated for this purpose may be used to support costs associated with the distribution of supplies.
(3) $5,000,000 shall be available annually for three years, commencing July 1, 2027, for the Two-Spirit, Transgender, Gender Nonconforming, and Intersex (2TGI) Wellness and Equity Fund.
(4) $3,400,000 shall be available on a one-time basis, commencing July 1, 2027, to implement strategies to maintain HIV viral suppression among state prison inmates released to the community. Funds shall be encumbered or expended no later than June 30, 2031.
(5) $200,000 shall be available annually for three years, commencing July 1, 2027, for the TakeMeHome program to allow the program to offer delivery of home test kits for HIV, sexually transmitted infections (STIs), and hepatitis C through delivery services in addition to the mail.
(6) $19,000,000 shall be available on a one-time basis, commencing July 1, 2027, to provide housing support for individuals living with HIV.
(7) $25,000,000 shall be available annually for three years, commencing July 1, 2027, to supplement federal Centers for Disease
Control and Prevention HIV prevention funding for the State Department of Public Health and local public health departments. The State Department of Public Health shall set aside portions of these funds and competitively award them for efforts to conduct outreach to migrant farmworkers.
(8) $25,000,000 shall be available annually for three years, commencing July 1, 2027, to supplement Ryan White HIV/AIDS Program funding, including funding for the department’s HIV Care Program as well as funding for Ryan White Eligible Metropolitan Areas and Transitional Grant Areas.
(c) For the 2028–29 fiscal year, beginning July 1, 2028, the following applies:
(1) $18,000,000 shall be available for two years, commencing July 1, 2028, to provide housing support for individuals living with HIV.
(2) $10,000,000 shall be available on a one-time basis, commencing July 1, 2028, to support investments to end the epidemic of hepatitis C, pursuant to Section 122440 of the Health and Safety Code. Funds shall be encumbered or expended no later than June 30, 2033.
(3) $8,000,000 shall be available on a one-time basis, commencing July 1, 2028, to establish demonstration projects to allow for innovative, evidence-informed approaches to improve the health and well-being of the most vulnerable and underserved Californians living with or at risk for hepatitis B virus infection, to the extent that these activities are an allowable use of the ADAP Rebate Fund and in consultation with the Office of AIDS of the State Department of Public Health. Funds shall be encumbered or expended no later than June 30, 2033.
(4) $8,500,000
shall be available on a one-time basis, commencing July 1, 2028, to distribute funding to one or more community-based organizations to make internal and external condoms available, aimed at preventing the transmission of HIV and STIs.
(d) For the 2029–30 fiscal year, beginning July 1, 2029, $30,000,000 shall be available on a one-time basis, commencing July 1, 2029, for emergency department syndemic screening projects. Funds shall be encumbered or expended no later than June 30, 2032.
(e) The department may make awards or grants to help expedite the expenditure or encumbrance process.
(f) The department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with
Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services.
(g) The department may also, in consultation with the Department of Finance, use an alternative local fiscal agent that is not identified in this section, if necessary, to achieve the intended legislative purpose.
SEC. 96.
(a) In fiscal year 2026–27, the State Department of Public Health may spend up to $50,000,000 from the AIDS Drug Assistance Program Rebate Fund to support state or local agencies, or community-based organizations providing federally funded Ryan White HIV/AIDS Program Part A and federal Centers for Disease Control and Prevention high-impact HIV prevention and surveillance services and programs for which federal funding has been delayed, reduced, canceled, or eliminated as a result of federal policy actions. These funds shall be available for encumbrance or expenditure until June 30, 2027.(1) (A) (i) To support timely processing of requests, entities requesting funds due to a delay in receipt of federal funds or an expected Notice of Award shall notify the department no later than 45 days before the federal funding is due to lapse and may request no more than three months of the delayed expected funding. Entities shall submit subsequent requests for subsequent three month periods, and shall do so no later than 30 days before the prior three-month period is due to end, but shall not request funds beyond the time remaining on the original federal award. Entities may submit requests fewer than 45 days before the federal funding is due to lapse, but those requests might not be processed in time to avoid a lapse of funds.
(ii) For purposes of this subparagraph, the nonreceipt of a federal Notice of Award by 45 days prior
to the date federal funding is due to lapse shall constitute sufficient evidence of a federal funding delay, and written notice or confirmation from the federal government shall not be required.
(B) Entities requesting funds due to federal action to reduce, cancel, or eliminate funding shall notify the department as soon as practicable following the federal action. For each federal funding stream that has been reduced, canceled, or eliminated, entities may request no more than the amount that was reduced, canceled, or eliminated for the one-year period beginning from the lapse or federal action. Those requests might not be processed in time for planned programming to continue uninterrupted.
(2) (A) Upon notification to the department of federal action, or the nonreceipt of a federal Notice of Award, that results in delay of, reductions to, cancellation of, or
elimination of federal funding for those services, programs, or initiatives, the department shall notify the Department of Finance.
(B) The Department of Finance may authorize funding allocations that are equivalent to the amounts requested pursuant to paragraph (1), to the extent these amounts are within the amount of funds appropriated for this purpose, and correspond to services that would have otherwise been funded by the delayed, reduced, canceled, or eliminated federal funds as soon as practicable, but no later than 30 days following notification from the department.
(3) If federal funding that was delayed, reduced, or otherwise adversely changed is restored at the federal level, funding made available under this item up to the amount that has been restored, not inclusive of any unfunded shortfall resulting from reduced federal award, shall be repaid to the AIDS Drug
Assistance Program Rebate Fund within 90 days of receipt of funds from the federal government. The entity may request an extension of up to an additional 90 days, subject to approval by the department.
(b) The department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services.
(c) The department may also, in consultation with the Department of Finance, use an alternative local fiscal agent
that is not identified in this section, if necessary, to achieve the intended legislative purpose.
SEC. 97.
The Legislature finds and declares that a special statute is necessary and that a general statute cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances of the County of Lake with regard to access to perinatal services. Residents of the county do not have adequate access to perinatal services, but they could have access to hospitals with capacity to provide services using a standby perinatal model. A special statute applied to the county would expedite implementation of that model.SEC. 98.
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution for certain costs that may be incurred by a local agency or school district because, in that regard, this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.However, if the Commission on State Mandates determines that this act contains other costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made pursuant to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of the Government Code.
SEC. 99.
The Legislature finds and declares that Sections 44 and 46 of this act, which amend Sections 127632 and 127634 of the Health and Safety Code, impose a limitation on the public’s right of access to the meetings of public bodies or the writings of public officials and agencies within the meaning of Section 3 of Article I of the California Constitution. Pursuant to that constitutional provision, the Legislature makes the following findings to demonstrate the interest protected by this limitation and the need for protecting that interest:In order to protect
confidential and personal medical information, the safety of medical providers, and access to reproductive health, family planning, and gender-affirming care services, it is necessary that grants, contracts, and related information created or obtained pursuant to this provision are exempt from disclosure.
SEC. 100.
The Legislature finds and declares that Section 49 of this act, which adds Section 127772 to the Health and Safety Code, imposes a limitation on the public’s right of access to the meetings of public bodies or the writings of public officials and agencies within the meaning of Section 3 of Article I of the California Constitution. Pursuant to that constitutional provision, the Legislature makes the following findings to demonstrate the interest protected by this limitation and the need for protecting that interest:The Department of Health Care Access
and Information will have access to personal information and, as such, it is crucial that the information in its possession not be available to the public.
SEC. 101.
This act is a bill providing for appropriations related to the Budget Bill within the meaning of subdivision (e) of Section 12 of Article IV of the California Constitution, has been identified as related to the budget in the Budget Bill, and shall take effect immediately.It is the intent of the Legislature to enact statutory changes relating to the Budget Act of 2025.
