HomeMy WebLinkAboutCouncil Reading File - SB562 Text-As AmendedAMENDED IN SENATE MAY 26, 2017
AMENDED IN SENATE APRIL 17, 2017
AMENDED IN SENATE MARCH 29, 2017
SENATE BILL No. 562
Introduced by Senators Lara and Atkins
(Principal coauthors: Senators Galgiani and Wiener)
(Principal coauthors: Assembly Members Bonta and Gomez)
(Coauthors: Senators Allen, McGuire, and Skinner)
(Coauthors: Assembly Members Chiu, Friedman, Kalra, McCarty,
Nazarian, Mark Stone, and Thurmond)
February 17, 2017
An act to add Title 22.2 (commencing with Section 100600) to the
Government Code, relating to health care coverage, and making an
appropriation therefor.
legislative counsel’s digest
SB 562, as amended, Lara. The Healthy California Act.
Existing federal law, the federal Patient Protection and Affordable
Care Act (PPACA), enacted various health care coverage market reforms
that took effect January 1, 2014. PPACA required each state, by January
1, 2014, to establish an American Health Benefit Exchange to facilitate
the purchase of qualified health benefit plans by qualified individuals
and qualified small employers. PPACA defines a “qualified health plan”
as a plan that, among other requirements, provides an essential health
benefits package. Existing state law creates the California Health Benefit
Exchange, also known as Covered California, to facilitate the purchase
of qualified health plans by qualified individuals and qualified small
employers.
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Existing law, the Knox-Keene Health Care Service Plan Act of 1975
(Knox-Keene), provides for the licensure and regulation of health care
service plans by the Department of Managed Health Care. Existing law
provides for the regulation of health insurers by the Department of
Insurance. Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid program provisions.
This bill, the Healthy California Act, would create the Healthy
California program to provide comprehensive universal single-payer
health care coverage and a health care cost control system for the benefit
of all residents of the state. The bill, among other things, would provide
that the program cover a wide range of medical benefits and other
services and would incorporate the health care benefits and standards
of other existing federal and state provisions, including, but not limited
to, the state’s Children’s Health Insurance Program (CHIP), Medi-Cal,
ancillary health care or social services covered by regional centers for
persons with developmental disabilities, Knox-Keene, and the federal
Medicare program. The bill would require the board to seek all necessary
waivers, approvals, and agreements to allow various existing federal
health care payments to be paid to the Healthy California program,
which would then assume responsibility for all benefits and services
previously paid for with those funds.
This bill would also provide for the participation of health care
providers in the program, require care coordination for members, provide
for payment for health care services and care coordination, and specify
program standards. The bill would state the intent of the Legislature to
enact legislation that would develop a revenue plan, taking into
consideration anticipated federal revenue available for the Healthy
California program. The bill would create the Healthy California Trust
Fund in the State Treasury, as a continuously appropriated fund,
consisting of any federal and state moneys received for the purposes of
the act. Because the bill would create a continuously appropriated fund,
it would make an appropriation.
This bill would create the Healthy California Board to govern the
program, made up of 9 members with demonstrated and acknowledged
expertise in health care, and appointed as provided. The bill would
provide the board with all the powers and duties necessary to establish
the Healthy California program, including, but not limited to,
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determining when individuals may start enrolling into the program,
employing necessary staff, and negotiating and entering into any
necessary contracts. The bill would also require the Secretary of
California Health and Human Services to establish a public advisory
committee to advise the board on all matters of policy for the Healthy
California program.
This bill would prohibit health care service plans and health insurers
from offering health benefits or covering any service for which coverage
is offered to individuals under the program, except as provided. The
bill would authorize health care providers, as defined, to collectively
negotiate rates of payment for health care services, rates of payment
for prescription and nonprescription drugs, and payment methodologies
using a 3rd-party representative, as provided.
This bill would prohibit this act from becoming operative until the
Secretary of California Health and Human Services gives written notice
to the Secretary of the Senate and the Chief Clerk of the Assembly that
the Healthy California Trust Fund has the revenues to fund the costs
of implementing the act. The California Health and Human Services
Agency would be required to publish a copy of the notice on its Internet
Web site.
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.
Vote: majority. Appropriation: yes. Fiscal committee: yes.
State-mandated local program: no.
The people of the State of California do enact as follows:
line 1 SECTION 1. (a) The Legislature finds and declares all of the
line 2 following:
line 3 (1) All residents of this state have the right to health care. While
line 4 the federal Patient Protection and Affordable Care Act (PPACA)
line 5 brought many improvements in health care and health care
line 6 coverage, it still leaves many Californians without coverage or
line 7 with inadequate coverage.
line 8 (2) Californians, as individuals, employers, and taxpayers, have
line 9 experienced a rise in the cost of health care and health care
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line 1 coverage in recent years, including rising premiums, deductibles,
line 2 and copays, as well as restricted provider networks and high
line 3 out-of-network charges.
line 4 (3) Businesses have also experienced increases in the costs of
line 5 health care benefits for their employees, and many employers are
line 6 shifting a larger share of the cost of coverage to their employees
line 7 or dropping coverage entirely.
line 8 (4) Individuals often find that they are deprived of affordable
line 9 care and choice because of decisions by health benefit plans guided
line 10 by the plan’s economic needs rather than consumers’ health care
line 11 needs.
line 12 (5) To address the fiscal crisis facing the health care system and
line 13 the state, and to ensure Californians can exercise their right to
line 14 health care, comprehensive health care coverage needs to be
line 15 provided.
line 16 (6) It is the intent of the Legislature to establish a comprehensive
line 17 universal single-payer health care coverage program and a health
line 18 care cost control system for the benefit of all residents of the state.
line 19 (b) (1) It is further the intent of the Legislature to establish the
line 20 Healthy California (HC) program to provide universal health
line 21 coverage for every Californian based on his or her ability to pay
line 22 and funded by broad-based revenue.
line 23 (2) It is the intent of the Legislature for the state to work to
line 24 obtain waivers and other approvals relating to Medi-Cal, the state’s
line 25 Children’s Health Insurance Program, Medicare, the PPACA, and
line 26 any other federal programs so that any federal funds and other
line 27 subsidies that would otherwise be paid to the State of California,
line 28 Californians, and health care providers would be paid by the federal
line 29 government to the State of California and deposited in the Healthy
line 30 California Trust Fund.
line 31 (3) Under those waivers and approvals, those funds would be
line 32 used for health coverage that provides health benefits equal to or
line 33 exceeded by those programs as well as other program
line 34 modifications, including elimination of cost sharing and insurance
line 35 premiums.
line 36 (4) Those programs would be replaced and merged into the HC
line 37 program, which will operate as a true single-payer program.
line 38 (5) If any necessary waivers or approvals are not obtained, it is
line 39 the intent of the Legislature that the state use state plan
line 40 amendments and seek waivers and approvals to maximize, and
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line 1 make as seamless as possible, the use of federally matched public
line 2 health programs and federal health programs in the HC program.
line 3 (6) Thus, even if other programs such as Medi-Cal or Medicare
line 4 may contribute to paying for care, it is the goal of this act that the
line 5 coverage be delivered by the HC program, and, as much as
line 6 possible, that the multiple sources of funding be pooled with other
line 7 HC program funds and not be apparent to HC program members
line 8 or participating providers.
line 9 (c) This act does not create any employment benefit, nor does
line 10 it require, prohibit, or limit the providing of any employment
line 11 benefit.
line 12 (d) (1) It is the intent of the Legislature not to change or impact
line 13 in any way the role or authority of any licensing board or state
line 14 agency that regulates the standards for or provision of health care
line 15 and the standards for health care providers as established under
line 16 current law, including, but not limited to, the Business and
line 17 Professions Code, the Health and Safety Code, the Insurance Code,
line 18 and the Welfare and Institutions Code, as applicable.
line 19 (2) This act would in no way authorize the Healthy California
line 20 Board, the Healthy California program, or the Secretary of
line 21 California Health and Human Services to establish or revise
line 22 licensure standards for health care providers.
line 23 (e) It is the intent of the Legislature that neither health
line 24 information technology nor clinical practice guidelines limit the
line 25 effective exercise of the professional judgment of physicians and
line 26 registered nurses. Physicians and registered nurses shall be free to
line 27 override health information technology and clinical practice
line 28 guidelines if, in their professional judgment, it is in the best interest
line 29 of the patient and consistent with the patient’s wishes.
line 30 (f) (1) It is the intent of the Legislature to prohibit the HC
line 31 program, a state agency, a local agency, or a public employee
line 32 acting under color of law from providing or disclosing to anyone,
line 33 including, but not limited to, the federal government, any
line 34 personally identifiable information obtained, including, but not
line 35 limited to, a person’s religious beliefs, practices, or affiliation,
line 36 national origin, ethnicity, or immigration status, for law
line 37 enforcement or immigration purposes.
line 38 (2) This act would also prohibit law enforcement agencies from
line 39 using the HC program’s funds, facilities, property, equipment, or
line 40 personnel to investigate, enforce, or assist in the investigation or
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line 1 enforcement of any criminal, civil, or administrative violation or
line 2 warrant for a violation of any requirement that individuals register
line 3 with the federal government or any federal agency based on
line 4 religion, national origin, ethnicity, or immigration status.
line 5 (g) It is the further intent of the Legislature to address the high
line 6 cost of prescription drugs and ensure they are affordable for
line 7 patients.
line 8 SEC. 2. Title 22.2 (commencing with Section 100600) is added
line 9 to the Government Code, to read:
line 10
line 11 TITLE 22.2. THE HEALTHY CALIFORNIA ACT
line 12
line 13 Chapter 1. General Provisions
line 14
line 15 100600. This title shall be known, and may be cited, as the
line 16 Healthy California Act.
line 17 100601. There is hereby established in state government the
line 18 Healthy California program to be governed by the Healthy
line 19 California Board pursuant to Chapter 2 (commencing with Section
line 20 100610).
line 21 100602. For the purposes of this title, the following definitions
line 22 apply:
line 23 (a) “Affordable Care Act” or “PPACA” means the federal
line 24 Patient Protection and Affordable Care Act (Public Law 111-148),
line 25 as amended by the federal Health Care and Education
line 26 Reconciliation Act of 2010 (Public Law 111-152), and any
line 27 amendments to, or regulations or guidance issued under, those
line 28 acts.
line 29 (b) “Allied health practitioner” means a group of health
line 30 professionals who apply their expertise to prevent disease
line 31 transmission, diagnose, treat, and rehabilitate people of all ages
line 32 and in all specialties. Together with a range of technical and
line 33 support staff, they may deliver direct patient care, rehabilitation,
line 34 treatment, diagnostics, and health improvement interventions to
line 35 restore and maintain optimal physical, sensory, psychological,
line 36 cognitive, and social functions. Examples include, but are not
line 37 limited to, audiologists, occupational therapists, social workers,
line 38 and radiographers.
line 39 (c) “Board” means the Healthy California Board described in
line 40 Section 100610.
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line 1 (d) “Care coordination” means services provided by a care
line 2 coordinator under Section 100637.
line 3 (e) “Care coordinator” means an individual or entity approved
line 4 by the board to provide care coordination under Section 100637.
line 5 (f) “Carrier” means either a private health insurer holding a
line 6 valid outstanding certificate of authority from the Insurance
line 7 Commissioner or a health care service plan, as defined under
line 8 subdivision (f) of Section 1345 of the Health and Safety Code,
line 9 licensed by the Department of Managed Health Care.
line 10 (g) “Committee” means the public advisory committee
line 11 established pursuant to Section 100611.
line 12 (h) “Essential community providers” means persons or entities
line 13 acting as safety net clinics, safety net health care providers, or
line 14 rural hospitals.
line 15 (i) “Federally matched public health program” means the state’s
line 16 Medi-Cal program under Title XIX of the federal Social Security
line 17 Act (42 U.S.C. Sec. 1396 et seq.) and the state’s Children’s Health
line 18 Insurance Program (CHIP) under Title XXI of the federal Social
line 19 Security Act (42 U.S.C. Sec. 1397aa et seq.).
line 20 (j) “Fund” means the Healthy California Trust Fund established
line 21 under Section 100655.
line 22 (k) “Health care organization” means an entity that is approved
line 23 by the board under Section 100640 to provide health care services
line 24 to members under the program.
line 25 (l) “Health care service” means any health care service,
line 26 including care coordination, that is included as a benefit under the
line 27 program.
line 28 (m) “Healthy California” or “HC” means the Healthy California
line 29 program established in Section 100601.
line 30 (n) “Implementation period” means the period under subdivision
line 31 (f) of Section 100612 during which the program is subject to
line 32 special eligibility and financing provisions until it is fully
line 33 implemented under that section.
line 34 (o) “Integrated health care delivery system” means a provider
line 35 organization that meets both of the following criteria:
line 36 (1) Is fully integrated operationally and clinically to provide a
line 37 broad range of health care services, including preventive care,
line 38 prenatal and well-baby care, immunizations, screening diagnostics,
line 39 emergency services, hospital and medical services, surgical
line 40 services, and ancillary services.
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line 1 (2) Is compensated by Healthy California using capitation or
line 2 facility budgets for the provision of health care services.
line 3 (p) “Long-term care” means long-term care, treatment,
line 4 maintenance, or services not covered under the state’s Children’s
line 5 Health Insurance Program, as appropriate, with the exception of
line 6 short-term rehabilitation, and as defined by the board.
line 7 (q) “Medicaid” or “medical assistance” means a program that
line 8 is one of the following:
line 9 (1) The state’s Medi-Cal program under Title XIX of the federal
line 10 Social Security Act (42 U.S.C. Sec. 1396 et seq.).
line 11 (2) The state’s Children’s Health Insurance Program under Title
line 12 XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et
line 13 seq.).
line 14 (r) “Medicare” means Title XVIII of the federal Social Security
line 15 Act (42 U.S.C. Sec. 1395 et seq.) and the programs thereunder.
line 16 (s) “Member” means an individual who is enrolled in the
line 17 program.
line 18 (t) “Out-of-state health care service” means a health care service
line 19 provided in person to a member while the member is physically
line 20 located out of the state under either of the following circumstances:
line 21 (1) It is medically necessary that the health care service be
line 22 provided while the member physically is out of the state.
line 23 (2) It is clinically appropriate and necessary, and cannot be
line 24 provided in the state, because the health care service can only be
line 25 provided by a particular health care provider physically located
line 26 out of the state. However, any health care service provided to an
line 27 HC member by a health care provider qualified under Section
line 28 100635 that is located outside the state shall not be considered an
line 29 out-of-state service and shall be covered as otherwise provided in
line 30 this title.
line 31 (u) “Participating provider” means any individual or entity that
line 32 is a health care provider qualified under Section 100635 that
line 33 provides health care services to members under the program, or a
line 34 health care organization.
line 35 (v) “Prescription drugs” means prescription drugs as defined in
line 36 subdivision (n) of Section 130501 of the Health and Safety Code.
line 37 (w) “Program” means the Healthy California program
line 38 established in Section 100601.
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line 1 (x) “Resident” means an individual whose primary place of
line 2 abode is in the state, without regard to the individual’s immigration
line 3 status.
line 4 100603. This title does not preempt any city, county, or city
line 5 and county from adopting additional health care coverage for
line 6 residents in that city, county, or city and county that provides more
line 7 protections and benefits to California residents than this title.
line 8 100604. To the extent any provision of California law is
line 9 inconsistent with this title or the legislative intent of the Healthy
line 10 California Act, this title shall apply and prevail, except when
line 11 explicitly provided otherwise by this title.
line 12
line 13 Chapter 2. Governance
line 14
line 15 100610. (a) The Healthy California Board shall be an
line 16 independent public entity not affiliated with an agency or
line 17 department. The board shall be governed by an executive board
line 18 consisting of nine members who are residents of California. Of
line 19 the members of the board, four shall be appointed by the Governor,
line 20 two shall be appointed by the Senate Committee on Rules, and
line 21 two shall be appointed by the Speaker of the Assembly. The
line 22 Secretary of California Health and Human Services or his or her
line 23 designee shall serve as a voting, ex officio member of the board.
line 24 (b) Members of the board, other than an ex officio member,
line 25 shall be appointed for a term of four years. Appointments by the
line 26 Governor shall be subject to confirmation by the Senate. A member
line 27 of the board may continue to serve until the appointment and
line 28 qualification of his or her successor. Vacancies shall be filled by
line 29 appointment for the unexpired term. The board shall elect a
line 30 chairperson on an annual basis.
line 31 (c) (1) Each person appointed to the board shall have
line 32 demonstrated and acknowledged expertise in health care.
line 33 (2) Appointing authorities shall also consider the expertise of
line 34 the other members of the board and attempt to make appointments
line 35 so that the board’s composition reflects a diversity of expertise in
line 36 the various aspects of health care.
line 37 (3) Appointments to the board by the Governor, the Senate
line 38 Committee on Rules, and the Speaker of the Assembly shall be
line 39 composed of:
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line 1 (A) At least one representative of a labor organization
line 2 representing registered nurses.
line 3 (B) At least one representative of the general public.
line 4 (C) At least one representative of a labor organization.
line 5 (D) At least one representative of the medical provider
line 6 community.
line 7 (d) Each member of the board shall have the responsibility and
line 8 duty to meet the requirements of this title, the Affordable Care
line 9 Act, and all applicable state and federal laws and regulations, to
line 10 serve the public interest of the individuals, employers, and
line 11 taxpayers seeking health care coverage through the program, and
line 12 to ensure the operational well-being and fiscal solvency of the
line 13 program.
line 14 (e) In making appointments to the board, the appointing
line 15 authorities shall take into consideration the cultural, ethnic, and
line 16 geographical diversity of the state so that the board’s composition
line 17 reflects the communities of California.
line 18 (f) (1) A member of the board or of the staff of the board shall
line 19 not be employed by, a consultant to, a member of the board of
line 20 directors of, affiliated with, or otherwise a representative of, a
line 21 health care provider, a health care facility, or a health clinic while
line 22 serving on the board or on the staff of the board. A member of the
line 23 board or of the staff of the board shall not be a member, a board
line 24 member, or an employee of a trade association of health facilities,
line 25 health clinics, or health care providers while serving on the board
line 26 or on the staff of the board. A member of the board or of the staff
line 27 of the board shall not be a health care provider unless he or she
line 28 receives no compensation for rendering services as a health care
line 29 provider and does not have an ownership interest in a health care
line 30 practice.
line 31 (2) A board member shall not receive compensation for his or
line 32 her service on the board, but may receive a per diem and
line 33 reimbursement for travel and other necessary expenses, as provided
line 34 in Section 103 of the Business and Professions Code, while
line 35 engaged in the performance of official duties of the board.
line 36 (3) For purposes of this subdivision, “health care provider”
line 37 means a person licensed or certified pursuant to Division 2
line 38 (commencing with Section 500) of the Business and Professions
line 39 Code, or licensed pursuant to the Osteopathic Act or the
line 40 Chiropractic Act.
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line 1 (g) A member of the board shall not make, participate in making,
line 2 or in any way attempt to use his or her official position to influence
line 3 the making of a decision that he or she knows, or has reason to
line 4 know, will have a reasonably foreseeable material financial effect,
line 5 distinguishable from its effect on the public generally, on him or
line 6 her or a member of his or her immediate family, or on either of
line 7 the following:
line 8 (1) Any source of income, other than gifts and other than loans
line 9 by a commercial lending institution in the regular course of
line 10 business on terms available to the public without regard to official
line 11 status aggregating two hundred fifty dollars ($250) or more in
line 12 value provided to, received by, or promised to the member within
line 13 12 months prior to the time when the decision is made.
line 14 (2) Any business entity in which the member is a director,
line 15 officer, partner, trustee, employee, or holds any position of
line 16 management.
line 17 (h) There shall not be liability in a private capacity on the part
line 18 of the board or a member of the board, or an officer or employee
line 19 of the board, for or on account of an act performed or obligation
line 20 entered into in an official capacity, when done in good faith,
line 21 without intent to defraud, and in connection with the
line 22 administration, management, or conduct of this title or affairs
line 23 related to this title.
line 24 (i) The board shall hire an executive director to organize,
line 25 administer, and manage the operations of the board. The executive
line 26 director shall be exempt from civil service and shall serve at the
line 27 pleasure of the board.
line 28 (j) The board shall be subject to the Bagley-Keene Open Meeting
line 29 Act (Article 9 (commencing with Section 11120) of Chapter 1 of
line 30 Part 1 of Division 3 of Title 2), except that the board may hold
line 31 closed sessions when considering matters related to litigation,
line 32 personnel, contracting, and rates.
line 33 (k) The board may adopt rules and regulations as necessary to
line 34 implement and administer this title in accordance with the
line 35 Administrative Procedure Act (Chapter 3.5 (commencing with
line 36 Section 11340) of Part 1 of Division 3 of Title 2).
line 37 100611. (a) The Secretary of California Health and Human
line 38 Services shall establish a public advisory committee to advise the
line 39 board on all matters of policy for the program.
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line 1 (b) The members of the committee shall include all of the
line 2 following:
line 3 (1) Four physicians, all of whom shall be board certified in their
line 4 fields, and at least one of whom shall be a psychiatrist. The Senate
line 5 Committee on Rules and the Governor shall each appoint one
line 6 member. The Speaker of the Assembly shall appoint two of these
line 7 members, both of whom shall be primary care providers.
line 8 (2) Two registered nurses, to be appointed by the Senate
line 9 Committee on Rules.
line 10 (3) One licensed allied health practitioner, to be appointed by
line 11 the Speaker of the Assembly.
line 12 (4) One mental health care provider, to be appointed by the
line 13 Senate Committee on Rules.
line 14 (5) One dentist, to be appointed by the Governor.
line 15 (6) One representative of private hospitals, to be appointed by
line 16 the Governor.
line 17 (7) One representative of public hospitals, to be appointed by
line 18 the Governor.
line 19 (8) One representative of an integrated health care delivery
line 20 system, to be appointed by the Governor.
line 21 (9) Four consumers of health care. The Governor shall appoint
line 22 two of these members, one of whom shall be a member of the
line 23 disabled community. The Senate Committee on Rules shall appoint
line 24 a member who is 65 years of age or older. The Speaker of the
line 25 Assembly shall appoint the fourth member.
line 26 (10) One representative of organized labor, to be appointed by
line 27 the Speaker of the Assembly.
line 28 (11) One representative of essential community providers, to
line 29 be appointed by the Senate Committee on Rules.
line 30 (12) One member of organized labor, to be appointed by the
line 31 Senate Committee on Rules.
line 32 (13) One representative of small business, which is a business
line 33 that employs less than 25 people, to be appointed by the Governor.
line 34 (14) One representative of large business, which is a business
line 35 that employs more than 250 people, to be appointed by the Speaker
line 36 of the Assembly.
line 37 (15) One pharmacist, to be appointed by the Speaker of the
line 38 Assembly.
line 39 (c) In making appointments pursuant to this section, the
line 40 Governor, the Senate Committee on Rules, and the Speaker of the
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line 1 Assembly shall make good faith efforts to ensure that their
line 2 appointments, as a whole, reflect, to the greatest extent feasible,
line 3 the social and geographic diversity of the state.
line 4 (d) Any member appointed by the Governor, the Senate
line 5 Committee on Rules, or the Speaker of the Assembly shall serve
line 6 a four-year term. These members may be reappointed for
line 7 succeeding four-year terms.
line 8 (e) Vacancies that occur shall be filled within 30 days after the
line 9 occurrence of the vacancy, and shall be filled in the same manner
line 10 in which the vacating member was initially selected or appointed.
line 11 The Secretary of California Health and Human Services shall notify
line 12 the appropriate appointing authority of any expected vacancies on
line 13 the public advisory committee.
line 14 (f) Members of the committee shall serve without compensation,
line 15 but shall be reimbursed for actual and necessary expenses incurred
line 16 in the performance of their duties to the extent that reimbursement
line 17 for those expenses is not otherwise provided or payable by another
line 18 public agency or agencies, and shall receive one hundred dollars
line 19 ($100) for each full day of attending meetings of the committee.
line 20 For purposes of this section, “full day of attending a meeting”
line 21 means presence at, and participation in, not less than 75 percent
line 22 of the total meeting time of the committee during any particular
line 23 24-hour period.
line 24 (g) The public advisory committee shall meet at least six times
line 25 per year in a place convenient to the public. All meetings of the
line 26 committee shall be open to the public, pursuant to the
line 27 Bagley-Keene Open Meeting Act (Article 9 (commencing with
line 28 Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2).
line 29 (h) The public advisory committee shall elect a chairperson who
line 30 shall serve for two years and who may be reelected for an
line 31 additional two years.
line 32 (i) Appointed committee members shall have worked in the
line 33 field they represent on the committee for a period of at least two
line 34 years prior to being appointed to the committee.
line 35 (j) It is unlawful for the committee members or any of their
line 36 assistants, clerks, or deputies to use for personal benefit any
line 37 information that is filed with, or obtained by, the committee and
line 38 that is not generally available to the public.
line 39 100612. (a) The board shall have all powers and duties
line 40 necessary to establish and implement Healthy California under
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line 1 this title. The program shall provide comprehensive universal
line 2 single-payer health care coverage and a health care cost control
line 3 system for the benefit of all residents of the state.
line 4 (b) The board shall, to the maximum extent possible, organize,
line 5 administer, and market the program and services as a single-payer
line 6 program under the name “HC,” “Healthy California,” or any other
line 7 name as the board determines, regardless of which law or source
line 8 the definition of a benefit is found, including, on a voluntary basis,
line 9 retiree health benefits. In implementing this title, the board shall
line 10 avoid jeopardizing federal financial participation in the programs
line 11 that are incorporated into Healthy California and shall take care
line 12 to promote public understanding and awareness of available
line 13 benefits and programs.
line 14 (c) The board shall consider any matter to effectuate the
line 15 provisions and purposes of this title. The board shall have no
line 16 executive, administrative, or appointive duties except as otherwise
line 17 provided by law.
line 18 (d) The board shall employ necessary staff and authorize
line 19 reasonable expenditures, as necessary, from the Healthy California
line 20 Trust Fund to pay program expenses and to administer the program.
line 21 (e) The board may do all of the following:
line 22 (1) Negotiate and enter into any necessary contracts, including,
line 23 but not limited to, contracts with health care providers, integrated
line 24 health care delivery systems, and care coordinators.
line 25 (2) Sue and be sued.
line 26 (3) Receive and accept gifts, grants, or donations of moneys
line 27 from any agency of the federal government, any agency of the
line 28 state, and any municipality, county, or other political subdivision
line 29 of the state.
line 30 (4) Receive and accept gifts, grants, or donations from
line 31 individuals, associations, private foundations, and corporations,
line 32 in compliance with the conflict-of-interest provisions to be adopted
line 33 by the board by regulation.
line 34 (5) Share information with relevant state departments, consistent
line 35 with the confidentiality provisions in this title, necessary for the
line 36 administration of the program.
line 37 (f) The board shall determine when individuals may begin
line 38 enrolling in the program. There shall be an implementation period
line 39 that begins on the date that individuals may begin enrolling in the
line 40 program and ends on a date determined by the board.
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line 1 (g) A carrier may not offer benefits or cover any services for
line 2 which coverage is offered to individuals under the program, but
line 3 may, if otherwise authorized, offer benefits to cover health care
line 4 services that are not offered to individuals under the program.
line 5 However, this title does not prohibit a carrier from offering either
line 6 of the following:
line 7 (1) Any benefits to or for individuals, including their families,
line 8 who are employed or self-employed in the state but who are not
line 9 residents of the state.
line 10 (2) Any benefits during the implementation period to individuals
line 11 who enrolled or may enroll as members of the program.
line 12 (h) After the end of the implementation period, a person shall
line 13 not be a board member unless he or she is a member of the
line 14 program, except the ex officio member.
line 15 (i) No later than two years after the effective date of this section,
line 16 the board shall develop the following proposals:
line 17 (1) The board shall develop a proposal, consistent with the
line 18 principles of this title, for provision by the program of long-term
line 19 care coverage, including the development of a proposal, consistent
line 20 with the principles of this title, for its funding. In developing the
line 21 proposal, the board shall consult with an advisory committee,
line 22 appointed by the chairperson of the board, including representatives
line 23 of consumers and potential consumers of long-term care, providers
line 24 of long-term care, members of organized labor, and other interested
line 25 parties.
line 26 (2) The board shall develop proposals for both of the following:
line 27 (A) Accommodating employer retiree health benefits for people
line 28 who have been members of HC but live as retirees out of the state.
line 29 (B) Accommodating employer retiree health benefits for people
line 30 who earned or accrued those benefits while residing in the state
line 31 prior to the implementation of HC and live as retirees out of the
line 32 state.
line 33 (3) The board shall develop a proposal for HC coverage of health
line 34 care services currently covered under the workers’ compensation
line 35 system, including whether and how to continue funding for those
line 36 services under that system and whether and how to incorporate an
line 37 element of experience rating.
line 38 100613. The board may contract with not-for-profit
line 39 organizations to provide both of the following:
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SB 562— 15 —
line 1 (a) Assistance to consumers with respect to selection of a care
line 2 coordinator or health care organization, enrolling, obtaining health
line 3 care services, disenrolling, and other matters relating to the
line 4 program.
line 5 (b) Assistance to health care providers providing, seeking, or
line 6 considering whether to provide health care services under the
line 7 program, with respect to participating in a health care organization
line 8 and interacting with a health care organization.
line 9 100614. The board shall provide grants from funds in the
line 10 Healthy California Trust Fund or from funds otherwise
line 11 appropriated for this purpose to health planning agencies
line 12 established pursuant to Section 127155 of the Health and Safety
line 13 Code to support the operation of those health planning agencies.
line 14 100615. The board shall provide funds from the Healthy
line 15 California Trust Fund or funds otherwise appropriated for this
line 16 purpose to the Secretary of Labor and Workforce Development
line 17 for a program for retraining and assisting job transition for
line 18 individuals employed or previously employed in the fields of health
line 19 insurance, health care service plans, and other third-party payments
line 20 for health care or those individuals providing services to health
line 21 care providers to deal with third-party payers for health care, whose
line 22 jobs may be or have been ended as a result of the implementation
line 23 of the program, consistent with otherwise applicable law.
line 24 100616. (a) The board shall provide for the collection and
line 25 availability of all of the following data to promote transparency,
line 26 assess adherence to patient care standards, compare patient
line 27 outcomes, and review utilization of health care services paid for
line 28 by the program:
line 29 (1) Inpatient discharge data, including acuity and risk of
line 30 mortality.
line 31 (2) Emergency department and ambulatory surgery data,
line 32 including charge data, length of stay, and patients’ unit of
line 33 observation.
line 34 (3) Hospital annual financial data, including all of the following:
line 35 (A) Community benefits by hospital in dollar value.
line 36 (B) Number of employees and classification by hospital unit.
line 37 (C) Number of hours worked by hospital unit.
line 38 (D) Employee wage information by job title and hospital unit.
line 39 (E) Number of registered nurses per staffed bed by hospital unit.
line 40 (F) Type and value of healthy information technology.
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line 1 (G) Annual spending on health information technology,
line 2 including purchases, upgrades, and maintenance.
line 3 (b) The board shall make all disclosed data collected under
line 4 subdivision (a) publicly available and searchable through an
line 5 Internet Web site and through the Office of Statewide Health
line 6 Planning and Development public data sets.
line 7 (c) The board shall, directly and through grants to not-for-profit
line 8 entities, conduct programs using data collected through the Healthy
line 9 California program to promote and protect public, environmental,
line 10 and occupational health, including cooperation with other data
line 11 collection and research programs of the Office of Statewide Health
line 12 Planning and Development and the California Health and Human
line 13 Services Agency, consistent with this title and otherwise applicable
line 14 law.
line 15 (d) Prior to full implementation of the program, the board shall
line 16 provide for the collection and availability of data on the number
line 17 of patients served by hospitals and the dollar value of the care
line 18 provided, at cost, for all of the following categories of Office of
line 19 Statewide Health Planning and Development data items:
line 20 (1) Patients receiving charity care.
line 21 (2) Contractual adjustments of county and indigent programs,
line 22 including traditional and managed care.
line 23 (3) Bad debts.
line 24 100617. (a) Notwithstanding any other law, Healthy California,
line 25 any state or local agency, or a public employee acting under color
line 26 of law shall not provide or disclose to anyone, including, but not
line 27 limited to, the federal government any personally identifiable
line 28 information obtained, including, but not limited to, a person’s
line 29 religious beliefs, practices, or affiliation, national origin, ethnicity,
line 30 or immigration status for law enforcement or immigration purposes.
line 31 (b) Notwithstanding any other law, law enforcement agencies
line 32 shall not use Healthy California moneys, facilities, property,
line 33 equipment, or personnel to investigate, enforce, or assist in the
line 34 investigation or enforcement of any criminal, civil, or
line 35 administrative violation or warrant for a violation of any
line 36 requirement that individuals register with the federal government
line 37 or any federal agency based on religion, national origin, ethnicity,
line 38 or immigration status.
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line 1 Chapter 3. Eligibility and Enrollment
line 2
line 3 100620. (a) Every resident of the state shall be eligible and
line 4 entitled to enroll as a member under the program.
line 5 (b) (1) A member shall not be required to pay any fee, payment,
line 6 or other charge for enrolling in or being a member under the
line 7 program.
line 8 (2) A member shall not be required to pay any premium,
line 9 copayment, coinsurance, deductible, and any other form of cost
line 10 sharing for all covered benefits.
line 11 (c) A college, university, or other institution of higher education
line 12 in the state may purchase coverage under the program for a student,
line 13 or a student’s dependent, who is not a resident of the state.
line 14
line 15 Chapter 4. Benefits
line 16
line 17 100630. (a) Covered health care benefits under the program
line 18 include all medical care determined to be medically appropriate
line 19 by the member’s health care provider.
line 20 (b) Covered health care benefits for members shall include, but
line 21 are not limited to, all of the following:
line 22 (1) Licensed inpatient and licensed outpatient medical and health
line 23 facility services.
line 24 (2) Inpatient and outpatient professional health care provider
line 25 medical services.
line 26 (3) Diagnostic imaging, laboratory services, and other diagnostic
line 27 and evaluative services.
line 28 (4) Medical equipment, appliances, and assistive technology,
line 29 including prosthetics, eyeglasses, and hearing aids and the repair,
line 30 technical support, and customization needed for individual use.
line 31 (5) Inpatient and outpatient rehabilitative care.
line 32 (6) Emergency care services.
line 33 (7) Emergency transportation.
line 34 (8) Necessary transportation for health care services for persons
line 35 with disabilities or who may qualify as low income.
line 36 (9) Child and adult immunizations and preventive care.
line 37 (10) Health and wellness education.
line 38 (11) Hospice care.
line 39 (12) Care in a skilled nursing facility.
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line 1 (13) Home health care, including health care provided in an
line 2 assisted living facility.
line 3 (14) Mental health services.
line 4 (15) Substance abuse treatment.
line 5 (16) Dental care.
line 6 (17) Vision care.
line 7 (18) Prescription drugs.
line 8 (19) Pediatric care.
line 9 (20) Prenatal and postnatal care.
line 10 (21) Podiatric care.
line 11 (22) Chiropractic care.
line 12 (23) Acupuncture.
line 13 (24) Therapies that are shown by the National Institutes of
line 14 Health, National Center for Complementary and Integrative Health
line 15 to be safe and effective.
line 16 (25) Blood and blood products.
line 17 (26) Dialysis.
line 18 (27) Adult day care.
line 19 (28) Rehabilitative and habilitative services.
line 20 (29) Ancillary health care or social services previously covered
line 21 by county integrated health and human services programs pursuant
line 22 to Chapter 12.96 (commencing with Section 18986.60) and Chapter
line 23 12.991 (commencing with Section 18986.86) of Part 6 of Division
line 24 9 of the Welfare and Institutions Code.
line 25 (30) Ancillary health care or social services previously covered
line 26 by a regional center for persons with developmental disabilities
line 27 pursuant to Chapter 5 (commencing with Section 4620) of Division
line 28 4.5 of the Welfare and Institutions Code.
line 29 (31) Case management and care coordination.
line 30 (32) Language interpretation and translation for health care
line 31 services, including sign language and Braille or other services
line 32 needed for individuals with communication barriers.
line 33 (33) Health care and long-term supportive services currently
line 34 covered under Medi-Cal or the state’s Children’s Health Insurance
line 35 Program.
line 36 (34) Covered benefits for members shall also include all health
line 37 care services required to be covered under any of the following
line 38 provisions, without regard to whether the member would otherwise
line 39 be eligible for or covered by the program or source referred to:
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SB 562— 19 —
line 1 (A) The state’s Children’s Health Insurance Program (Title XXI
line 2 of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
line 3 (B) Medi-Cal (Chapter 7 (commencing with Section 14000) of
line 4 Part 3 of Division 9 of the Welfare and Institutions Code).
line 5 (C) The federal Medicare program pursuant to Title XVIII of
line 6 the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
line 7 (D) Health care service plans pursuant to the Knox-Keene Health
line 8 Care Service Plan Act of 1975 (Chapter 2.2 (commencing with
line 9 Section 1340) of Division 2 of the Health and Safety Code).
line 10 (E) Health insurers, as defined in Section 106 of the Insurance
line 11 Code, pursuant to Part 2 (commencing with Section 10110) of
line 12 Division 2 of the Insurance Code.
line 13 (F) Any additional health care services authorized to be added
line 14 to the program’s benefits by the program.
line 15 (G) All essential health benefits mandated by the Affordable
line 16 Care Act as of January 1, 2017.
line 17
line 18 Chapter 5. Delivery of Care
line 19
line 20 Article 1. Health Care Providers
line 21
line 22 100635. (a) (1) Any health care provider who is licensed to
line 23 practice in California and is otherwise in good standing is qualified
line 24 to participate in the program as long as the health care provider’s
line 25 services are performed within the State of California.
line 26 (2) The board shall establish and maintain procedures and
line 27 standards for recognizing health care providers located out of the
line 28 state for purposes of providing coverage under the program for
line 29 members who require out-of-state health care services while the
line 30 member is temporarily located out of the state.
line 31 (b) Any health care provider qualified to participate under this
line 32 section may provide covered health care services under the
line 33 program, as long as the health care provider is legally authorized
line 34 to perform the health care service for the individual and under the
line 35 circumstances involved.
line 36 (c) A member may choose to receive health care services under
line 37 the program from any participating provider, consistent with
line 38 provisions of this title, the willingness or availability of the
line 39 provider, subject to provisions of this title relating to
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line 1 discrimination, and the appropriate clinically relevant
line 2 circumstances.
line 3 (d) A person who chooses to enroll with an integrated health
line 4 care delivery system, group medical practice, or essential
line 5 community provider that offers comprehensive services, shall
line 6 retain membership for at least one year after an initial three-month
line 7 evaluation period during which time the person may withdraw for
line 8 any reason.
line 9 (1) The three-month period shall commence on the date when
line 10 a member first sees a primary care provider.
line 11 (2) A person who wants to withdraw after the initial three-month
line 12 period shall request a withdrawal pursuant to the dispute resolution
line 13 procedures established by the board and may request assistance
line 14 from the patient advocate, which shall be provided for in the
line 15 dispute resolution procedures, in resolving the dispute. The dispute
line 16 shall be resolved in a timely fashion and shall not have an adverse
line 17 effect on the care a patient receives.
line 18
line 19 Article 2. Care Coordination
line 20
line 21 100637. (a) Care coordination shall be provided to the member
line 22 by his or her care coordinator. A care coordinator may employ or
line 23 utilize the services of other individuals or entities to assist in
line 24 providing care coordination for the member, consistent with
line 25 regulations of the board and with the statutory requirements and
line 26 regulations of the care coordinator’s licensure.
line 27 (b) Care coordination includes administrative tracking and
line 28 medical recordkeeping services for members, except as otherwise
line 29 specified for integrated health care delivery systems.
line 30 (c) Care coordination administrative tracking and medical
line 31 recordkeeping services for members shall not be required to utilize
line 32 a certified electronic health record, meet any other requirements
line 33 of the federal Health Information Technology for Economic and
line 34 Clinical Health, Health Act, enacted under the federal American
line 35 Recovery and Reinvestment Act of 2009 (Public Law 111-5), or
line 36 meet certification requirements of the federal Centers for Medicare
line 37 and Medicaid Services’ Electronic Health Records Incentive
line 38 Programs, including meaningful use requirements.
line 39 (d) The care coordinator shall comply with all federal and state
line 40 privacy laws, including, but not limited to, the federal Health
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SB 562— 21 —
line 1 Insurance Portability and Accountability Act (HIPAA; 42 U.S.C.
line 2 Sec. 1320d et seq.) and its implementing regulations, the
line 3 Confidentiality of Medical Information Act (Part 2.6 (commencing
line 4 with Section 56) of Division 1 of the Civil Code), the Insurance
line 5 Information and Privacy Protection Act (Article 6.6 (commencing
line 6 with Section 791) of Chapter 1 of Part 2 of Division 1 of the
line 7 Insurance Code), and Section 1798.81.5 of the Civil Code.
line 8 (e) Referrals from a care coordinator are not required for a
line 9 member to see any eligible provider.
line 10 (f) A care coordinator may be an individual or entity that is
line 11 approved by the program that is any of the following:
line 12 (1) A health care practitioner that is any of the following:
line 13 (A) The member’s primary care provider.
line 14 (B) The member’s provider of primary gynecological care.
line 15 (C) At the option of a member who has a chronic condition that
line 16 requires specialty care, a specialist health care practitioner who
line 17 regularly and continually provides treatment to the member for
line 18 that condition.
line 19 (2) An entity licensed pursuant to any of the following
line 20 provisions:
line 21 (A) Health facility, Chapter 2 (commencing with Section 1250)
line 22 of Division 2 of the Health and Safety Code.
line 23 (B) Health care service plan, Knox-Keene Health Care Service
line 24 Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340)
line 25 of Division 2 of the Health and Safety Code).
line 26 (C) Long-term health care facility, as defined in Section 1418
line 27 of the Health and Safety Code, or a program developed pursuant
line 28 to paragraph (1) of subdivision (i) of Section 100612, or a
line 29 long-term health care facility with respect to a member who
line 30 receives mental health care services.
line 31 (D) County medical facility, Chapter 2.5 (commencing with
line 32 Section 1440) of Division 2 of the Health and Safety Code.
line 33 (E) Residential care facility for persons with chronic,
line 34 life-threatening illness, Chapter 3.01 (commencing with Section
line 35 1568.01) of Division 2 of the Health and Safety Code.
line 36 (F) Alzheimer’s day care resource center, Chapter 3.1
line 37 (commencing with Section 1568.15) of Division 2 of the Health
line 38 and Safety Code.
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line 1 (G) Residential care facility for the elderly, Chapter 3.2
line 2 (commencing with Section 1569) of Division 2 of the Health and
line 3 Safety Code.
line 4 (H) Home health agency, Chapter 8 (commencing with Section
line 5 1725) of Division 2 of the Health and Safety Code.
line 6 (I) Private duty nursing agency, Chapter 8.3 (commencing with
line 7 Section 1743) of Division 2 of the Health and Safety Code.
line 8 (J) Hospice, Chapter 8.5 (commencing with Section 1745) of
line 9 Division 2 of the Health and Safety Code.
line 10 (K) Pediatric day health and respite care facility, Chapter 8.6
line 11 (commencing with Section 1760) of Division 2 of the Health and
line 12 Safety Code.
line 13 (L) Home care service, Chapter 13 (commencing with Section
line 14 1796.10) of Division 2 of the Health and Safety Code.
line 15 (M) Mental health care provider, pursuant to Division 4
line 16 (commencing with Section 4000 4000) of the Welfare and
line 17 Institutions Code). Code.
line 18 (3) A health care organization.
line 19 (4) A Taft-Hartley health and welfare fund, with respect to its
line 20 members and their family members. This provision does not
line 21 preclude a Taft-Hartley health and welfare fund from becoming a
line 22 care coordinator under paragraph (5) or a health care organization
line 23 under Section 100640.
line 24 (5) Any not-for-profit or governmental entity approved by the
line 25 program.
line 26 (g) (1) A health care provider shall only be reimbursed for
line 27 services if the member is enrolled with a care coordinator at the
line 28 time the health care service is provided.
line 29 (2) Every member shall be encouraged to enroll with a care
line 30 coordinator that agrees to provide care coordination prior to
line 31 receiving health care services to be paid for under the program. If
line 32 a member receives health care services before choosing a care
line 33 coordinator, the program shall assist the member, when appropriate,
line 34 with choosing a care coordinator.
line 35 (3) The member shall remain enrolled with that care coordinator
line 36 until the member becomes enrolled with a different care coordinator
line 37 or ceases to be a member. Members have the right to change their
line 38 care coordinators on terms at least as permissive as Medi-Cal
line 39 (Chapter 7 (commencing with Section 14000) of Part 3 of Division
line 40 9 of the Welfare and Institutions Code) relating to an individual
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SB 562— 23 —
line 1 changing his or her primary care provider or managed care
line 2 provider.
line 3 (h) A health care organization may establish rules relating to
line 4 care coordination for members in the health care organization that
line 5 are different from this section but otherwise consistent with this
line 6 title and other applicable laws.
line 7 (i) This section does not authorize any individual to engage in
line 8 any act in violation of the provisions of Division 2 (commencing
line 9 with Section 500) of the Business and Professions Code.
line 10 (j) An individual or entity may not be a care coordinator unless
line 11 the services included in care coordination are within the
line 12 individual’s professional scope of practice or the entity’s legal
line 13 authority.
line 14 (k) (1) The board shall develop and implement procedures and
line 15 standards, by regulation, for an individual or entity to be approved
line 16 as a care coordinator in the program, including, but not limited to,
line 17 procedures and standards relating to the revocation, suspension,
line 18 limitation, or annulment of approval on a determination that the
line 19 individual or entity is incompetent to be a care coordinator or has
line 20 exhibited a course of conduct that is inconsistent with program
line 21 standards and regulations, or that exhibits an unwillingness to meet
line 22 those standards and regulations, or is a potential threat to the public
line 23 health or safety.
line 24 (2) The procedures and standards adopted by the board shall be
line 25 consistent with professional practice, licensure standards, and
line 26 regulations established pursuant to the Business and Professions
line 27 Code, the Health and Safety Code, the Insurance Code, and the
line 28 Welfare and Institutions Code, as applicable.
line 29 (3) In developing and implementing standards of approval of
line 30 care coordinators for individuals receiving chronic mental health
line 31 care services, the board shall consult with the Mental Health
line 32 Services Division of the State Department of Health Care Services
line 33 and the Director of Developmental Services.
line 34 (l) To maintain approval under the program, a care coordinator
line 35 shall do all of the following:
line 36 (1) Renew its status every three years pursuant to regulations
line 37 adopted by the board.
line 38 (2) Provide to the program any data required by the Office of
line 39 Statewide Health Planning and Development pursuant to Division
line 40 107 (commencing with Section 127000) of the Health and Safety
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line 1 Code that would enable the board to evaluate the impact of care
line 2 coordinators on quality, outcomes, and cost of health care.
line 3
line 4 Article 3. Payment for Health Care Services and Care
line 5 Coordination
line 6
line 7 100639. (a) The board shall adopt regulations regarding
line 8 contracting for, and establishing payment methodologies for,
line 9 covered health care services and care coordination provided to
line 10 members under the program by participating providers, care
line 11 coordinators, and health care organizations. There may be a variety
line 12 of different payment methodologies, including those established
line 13 on a demonstration basis. All payment rates under the program
line 14 shall be reasonable and reasonably related to the cost of efficiently
line 15 providing the health care service and ensuring an adequate and
line 16 accessible supply of health care services.
line 17 (b) Health care services provided to members under the program,
line 18 except for care coordination, shall be paid for on a fee-for-service
line 19 basis unless and until another payment methodology is established
line 20 by the board.
line 21 (c) Notwithstanding subdivision (b), integrated health care
line 22 delivery systems, essential community providers, and group
line 23 medical practices that provide comprehensive, coordinated services
line 24 may choose to be reimbursed on the basis of a capitated system
line 25 operating budget or a noncapitated system operating budget that
line 26 covers all costs of providing health care services.
line 27 (d) The program shall engage in good faith negotiations with
line 28 health care providers’ representatives under Chapter 8
line 29 (commencing with Section 100660), including, but not limited to,
line 30 in relation to rates of payment for health care services, rates of
line 31 payment for prescription and nonprescription drugs, and payment
line 32 methodologies. Those negotiations shall be through a single entity
line 33 on behalf of the entire program for prescription and nonprescription
line 34 drugs.
line 35 (e) (1) Payment for health care services established under this
line 36 title shall be considered payment in full.
line 37 (2) A participating provider shall not charge any rate in excess
line 38 of the payment established under this title for any health care
line 39 service provided to a member under the program and shall not
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SB 562— 25 —
line 1 solicit or accept payment from any member or third party for any
line 2 health care service, except as provided under a federal program.
line 3 (3) However, this section does not preclude the program from
line 4 acting as a primary or secondary payer in conjunction with another
line 5 third-party payer when permitted by a federal program.
line 6 (f) The program may adopt, by regulation, payment
line 7 methodologies for the payment of capital-related expenses for
line 8 specifically identified capital expenditures incurred by
line 9 not-for-profit or governmental entities that are health facilities
line 10 pursuant to Chapter 2 (commencing with Section 1250) of Division
line 11 2 of the Health and Safety Code. Any capital-related expense
line 12 generated by a capital expenditure that requires prior approval
line 13 shall have received that approval in order to be paid by the
line 14 program. That approval shall be based on achievement of the
line 15 program standards described in Chapter 6 (commencing with
line 16 Section 100645).
line 17 (g) Payment methodologies and payment rates shall include a
line 18 distinct component of reimbursement for direct and indirect
line 19 graduate medical education.
line 20 (h) The board shall adopt, by regulation, payment methodologies
line 21 and procedures for paying for health care services provided to a
line 22 member while the member is located out of the state.
line 23
line 24 Article 4. Health Care Organizations
line 25
line 26 100640. (a) A member may choose to enroll with and receive
line 27 program care coordination and ancillary health care services from
line 28 a health care organization.
line 29 (b) A health care organization shall be a not-for-profit or
line 30 governmental entity that is approved by the board that is either of
line 31 the following:
line 32 (1) A county integrated health and human services program
line 33 under Chapter 12.96 (commencing with Section 18986.60) and
line 34 Chapter 12.991 (commencing with Section 18986.86) of Part 6 of
line 35 Division 9 of the Welfare and Institutions Code.
line 36 (2) A regional center for persons with developmental disabilities
line 37 under Chapter 5 (commencing with Section 4620) of Division 4.5
line 38 of the Welfare and Institutions Code.
line 39 (c) (1) The board shall develop and implement procedures and
line 40 standards, by regulation, for an entity to be approved as a health
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line 1 care organization in the program, including, but not limited to,
line 2 procedures and standards relating to the revocation, suspension,
line 3 limitation, or annulment of approval on a determination that the
line 4 entity is incompetent to be a health care organization or has
line 5 exhibited a course of conduct that is inconsistent with program
line 6 standards and regulations, or that exhibits an unwillingness to meet
line 7 those standards and regulations, or is a potential threat to the public
line 8 health or safety.
line 9 (2) The procedures and standards adopted by the board shall be
line 10 consistent with professional practice and licensure standards
line 11 established pursuant to the Business and Professions Code, the
line 12 Health and Safety Code, the Insurance Code, and the Welfare and
line 13 Institutions Code, as applicable.
line 14 (3) In developing and implementing standards of approval of
line 15 health care organizations, the board shall consult with the Mental
line 16 Health Services Division of the State Department of Health Care
line 17 Services and the Director of Developmental Services.
line 18 (d) To maintain approval under the program, a health care
line 19 organization shall do both of the following:
line 20 (1) Renew its status at a frequency determined by the board.
line 21 (2) Provide data to the California Health and Human Services
line 22 Agency, as required by the board, to enable the board to evaluate
line 23 the health care organization in relation to the quality of health care
line 24 services, health care outcomes, and cost.
line 25 (e) The board may adopt narrowly focused regulations relating
line 26 solely to health care organizations for the sole and specific purpose
line 27 of ensuring consistent compliance with this title.
line 28 (f) This title may not be construed to alter in any way the
line 29 professional practice of health care providers or their licensure
line 30 standards established pursuant to Division 2 (commencing with
line 31 Section 500) of the Business and Professions Code.
line 32 (g) Health care organizations shall not use health information
line 33 technology or clinical practice guidelines that limit the effective
line 34 exercise of the professional judgment of physicians and registered
line 35 nurses. Physicians and registered nurses shall be free to override
line 36 health information technology and clinical practice guidelines if,
line 37 in their professional judgment, it is in the best interest of the patient
line 38 and consistent with the patient’s wishes.
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SB 562— 27 —
line 1 Chapter 6. Program Standards
line 2
line 3 100645. Healthy California shall establish a single standard of
line 4 safe, therapeutic care for all residents of the state by the following
line 5 means:
line 6 (a) The board shall establish requirements and standards, by
line 7 regulation, for the program and for health care organizations, care
line 8 coordinators, and health care providers, consistent with this title
line 9 and consistent with the applicable professional practice and
line 10 licensure standards of health care providers and health care
line 11 professionals established pursuant to the Business and Professions
line 12 Code, the Health and Safety Code, the Insurance Code, and the
line 13 Welfare and Institutions Code, including requirements and
line 14 standards for, as applicable:
line 15 (1) The scope, quality, and accessibility of health care services.
line 16 (2) Relations between health care organizations or health care
line 17 providers and members.
line 18 (3) Relations between health care organizations and health care
line 19 providers, including credentialing and participation in the health
line 20 care organization, and terms, methods, and rates of payment.
line 21 (b) The board shall establish requirements and standards, by
line 22 regulation, under the program that include, but are not limited to,
line 23 provisions to promote all of the following:
line 24 (1) Simplification, transparency, uniformity, and fairness in
line 25 health care provider credentialing and participation in health care
line 26 organization networks, referrals, payment procedures and rates,
line 27 claims processing, and approval of health care services, as
line 28 applicable.
line 29 (2) In-person primary and preventive care, care coordination,
line 30 efficient and effective health care services, quality assurance, and
line 31 promotion of public, environmental, and occupational health.
line 32 (3) Elimination of health care disparities.
line 33 (4) Consistent with the Unruh Civil Rights Act (Section 51 of
line 34 the Civil Code), nondiscrimination with respect to members and
line 35 health care providers on the basis of race, color, ancestry, national
line 36 origin, religion, citizenship, immigration status, primary language,
line 37 mental or physical disability, age, sex, gender, sexual orientation,
line 38 gender identity or expression, medical condition, genetic
line 39 information, marital status, familial status, military or veteran
line 40 status, or source of income; however, health care services provided
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line 1 under the program shall be appropriate to the patient’s clinically
line 2 relevant circumstances.
line 3 (5) Accessibility of care coordination, health care organization
line 4 services, and health care services, including accessibility for people
line 5 with disabilities and people with limited ability to speak or
line 6 understand English.
line 7 (6) Providing care coordination, health care organization
line 8 services, and health care services in a culturally competent manner.
line 9 (c) The board shall establish requirements and standards, to the
line 10 extent authorized by federal law, by regulation, for replacing and
line 11 merging with the Healthy California program health care services
line 12 and ancillary services currently provided by other programs,
line 13 including, but not limited to, Medicare, the Affordable Care Act,
line 14 and federally matched public health programs.
line 15 (d) Any participating provider or care coordinator that is
line 16 organized as a for-profit entity shall be required to meet the same
line 17 requirements and standards as entities organized as not-for-profit
line 18 entities, and payments under the program paid to those entities
line 19 shall not be calculated to accommodate the generation of profit,
line 20 revenue for dividends, or other return on investment or the payment
line 21 of taxes that would not be paid by a not-for-profit entity.
line 22 (e) Every participating provider shall furnish information as
line 23 required by the Office of Statewide Health Planning and
line 24 Development pursuant to Division 107 (commencing with Section
line 25 127000) of the Health and Safety Code and permit examination
line 26 of that information by the program as may be reasonably required
line 27 for purposes of reviewing accessibility and utilization of health
line 28 care services, quality assurance, cost containment, the making of
line 29 payments, and statistical or other studies of the operation of the
line 30 program or for protection and promotion of public, environmental,
line 31 and occupational health.
line 32 (f) In developing requirements and standards and making other
line 33 policy determinations under this chapter, the board shall consult
line 34 with representatives of members, health care providers, care
line 35 coordinators, health care organizations, labor organizations
line 36 representing health care employees, and other interested parties.
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line 1 Chapter 7. Funding
line 2
line 3 Article 1. Federal Health Programs and Funding
line 4
line 5 100650. (a) The board shall seek all federal waivers and other
line 6 federal approvals and arrangements and submit state plan
line 7 amendments as necessary to operate the program consistent with
line 8 this title.
line 9 (b) (1) The board shall apply to the United States Secretary of
line 10 Health and Human Services or other appropriate federal official
line 11 for all waivers of requirements, and make other arrangements,
line 12 under Medicare, any federally matched public health program, the
line 13 Affordable Care Act, and any other federal programs that provide
line 14 federal funds for payment for health care services that are necessary
line 15 to enable all Healthy California members to receive all benefits
line 16 under the program through the program, to enable the state to
line 17 implement this title, and to allow the state to receive and deposit
line 18 all federal payments under those programs, including funds that
line 19 may be provided in lieu of premium tax credits, cost-sharing
line 20 subsidies, and small business tax credits, in the State Treasury to
line 21 the credit of the Healthy California Trust Fund, created pursuant
line 22 to Section 100655, and to use those funds for the program and
line 23 other provisions under this title.
line 24 (2) To the fullest extent possible, the board shall negotiate
line 25 arrangements with the federal government to ensure that federal
line 26 payments are paid to Healthy California in place of federal funding
line 27 of, or tax benefits for, federally matched public health programs
line 28 or federal health programs.
line 29 (3) The board may require members or applicants to provide
line 30 information necessary for the program to comply with any waiver
line 31 or arrangement under this title. Information provided by members
line 32 to the board for the purposes of this subdivision shall not be used
line 33 for any other purpose.
line 34 (4) The board may take any additional actions necessary to
line 35 effectively implement Healthy California to the maximum extent
line 36 possible as a single-payer program consistent with this title.
line 37 (c) The board may take actions consistent with this article to
line 38 enable the program to administer Medicare in California, and the
line 39 program shall be a provider of supplemental insurance coverage
line 40 (Medicare Part B) and shall provide premium assistance drug
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line 1 coverage under Medicare Part D for eligible members of the
line 2 program.
line 3 (d) The board may waive or modify the applicability of any
line 4 provisions of this section relating to any federally matched public
line 5 health program or Medicare, as necessary, to implement any waiver
line 6 or arrangement under this section or to maximize the federal
line 7 benefits to the program under this section, provided that the board,
line 8 in consultation with the Director of Finance, determines that the
line 9 waiver or modification is in the best interest of the state and
line 10 members affected by the action.
line 11 (e) The board may apply for coverage for, and enroll, any
line 12 eligible member under any federally matched public health program
line 13 or Medicare. Enrollment in a federally matched public health
line 14 program or Medicare shall not cause any member to lose any health
line 15 care service provided by the program or diminish any right the
line 16 member would otherwise have.
line 17 (f) (1) Notwithstanding any other law, the board, by regulation,
line 18 shall increase the income eligibility level, increase or eliminate
line 19 the resource test for eligibility, simplify any procedural or
line 20 documentation requirement for enrollment, and increase the
line 21 benefits for any federally matched public health program and for
line 22 any program in order to reduce or eliminate an individual’s
line 23 coinsurance, cost-sharing, or premium obligations or increase an
line 24 individual’s eligibility for any federal financial support related to
line 25 Medicare or the Affordable Care Act.
line 26 (2) The board may act under this subdivision, upon a finding
line 27 approved by the Director of Finance and the board that the action
line 28 does all of the following:
line 29 (A) Will help to increase the number of members who are
line 30 eligible for and enrolled in federally matched public health
line 31 programs, or for any program to reduce or eliminate an individual’s
line 32 coinsurance, cost-sharing, or premium obligations or increase an
line 33 individual’s eligibility for any federal financial support related to
line 34 Medicare or the Affordable Care Act.
line 35 (B) Will not diminish any individual’s access to any health care
line 36 service or right the individual would otherwise have.
line 37 (C) Is in the interest of the program.
line 38 (D) Does not require or has received any necessary federal
line 39 waivers or approvals to ensure federal financial participation.
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line 1 (3) Actions under this subdivision shall not apply to eligibility
line 2 for payment for long-term care.
line 3 (g) To enable the board to apply for coverage for, and enroll,
line 4 any eligible member under any federally matched public health
line 5 program or Medicare, the board may require that every member
line 6 or applicant provide the information necessary to enable the board
line 7 to determine whether the applicant is eligible for a federally
line 8 matched public health program or for Medicare, or any program
line 9 or benefit under Medicare.
line 10 (h) As a condition of continued eligibility for health care services
line 11 under the program, a member who is eligible for benefits under
line 12 Medicare shall enroll in Medicare, including Parts A, B, and D.
line 13 (i) The program shall provide premium assistance for all
line 14 members enrolling in a Medicare Part D drug coverage plan under
line 15 Section 1860D of Title XVIII of the federal Social Security Act
line 16 (42 U.S.C. Sec. 1395w-101 et seq.), limited to the low-income
line 17 benchmark premium amount established by the federal Centers
line 18 for Medicare and Medicaid Services and any other amount the
line 19 federal agency establishes under its de minimis premium policy,
line 20 except that those payments made on behalf of members enrolled
line 21 in a Medicare advantage plan may exceed the low-income
line 22 benchmark premium amount if determined to be cost effective to
line 23 the program.
line 24 (j) If the board has reasonable grounds to believe that a member
line 25 may be eligible for an income-related subsidy under Section
line 26 1860D-14 of Title XVIII of the federal Social Security Act (42
line 27 U.S.C. Sec. 1395w-114), the member shall provide, and authorize
line 28 the program to obtain, any information or documentation required
line 29 to establish the member’s eligibility for that subsidy; however, the
line 30 board shall attempt to obtain as much of the information and
line 31 documentation as possible from records that are available to it.
line 32 (k) The program shall make a reasonable effort to notify
line 33 members of their obligations under this section. After a reasonable
line 34 effort has been made to contact the member, the member shall be
line 35 notified in writing that he or she has 60 days to provide the required
line 36 information. If the required information is not provided within the
line 37 60-day period, the member’s coverage under the program may be
line 38 terminated. Information provided by members to the board for the
line 39 purposes of this section shall not be used for any other purpose.
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line 1 (l) The board shall assume responsibility for all benefits and
line 2 services paid for by the federal government with those funds.
line 3
line 4 Article 2. The Healthy California Trust Fund
line 5
line 6 100655. (a) The Healthy California Trust Fund is hereby
line 7 created in the State Treasury for the purposes of this title.
line 8 Notwithstanding Section 13340, all moneys in the fund shall be
line 9 continuously appropriated without regard to fiscal year for the
line 10 purposes of this title. Any moneys in the fund that are unexpended
line 11 or unencumbered at the end of a fiscal year may be carried forward
line 12 to the next succeeding fiscal year.
line 13 (b) Notwithstanding any other law, moneys deposited in the
line 14 fund shall not be loaned to, or borrowed by, any other special fund
line 15 or the General Fund, or a county general fund or any other county
line 16 fund.
line 17 (c) The board shall establish and maintain a prudent reserve in
line 18 the fund.
line 19 (d) The board or staff of the board shall not utilize any funds
line 20 intended for the administrative and operational expenses of the
line 21 board for staff retreats, promotional giveaways, excessive executive
line 22 compensation, or promotion of federal or state legislative or
line 23 regulatory modifications.
line 24 (e) Notwithstanding Section 16305.7, all interest earned on the
line 25 moneys that have been deposited into the fund shall be retained
line 26 in the fund and used for purposes consistent with the fund.
line 27 (f) The fund shall consist of all of the following:
line 28 (1) All moneys obtained pursuant to legislation enacted as
line 29 proposed under Section 100657.
line 30 (2) Federal payments received as a result of any waiver of
line 31 requirements granted or other arrangements agreed to by the United
line 32 States Secretary of Health and Human Services or other appropriate
line 33 federal officials for health care programs established under
line 34 Medicare, any federally matched public health program, or the
line 35 Affordable Care Act.
line 36 (3) The amounts paid by the State Department of Health Care
line 37 Services that are equivalent to those amounts that are paid on behalf
line 38 of residents of this state under Medicare, any federally matched
line 39 public health program, or the Affordable Care Act for health
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line 1 benefits that are equivalent to health benefits covered under Healthy
line 2 California.
line 3 (4) Federal and state funds for purposes of the provision of
line 4 services authorized under Title XX of the federal Social Security
line 5 Act (42 U.S.C. Sec. 1397 et seq.) that would otherwise be covered
line 6 under Healthy California.
line 7 (5) State moneys that would otherwise be appropriated to any
line 8 governmental agency, office, program, instrumentality, or
line 9 institution that provides health care services for services and
line 10 benefits covered under Healthy California. Payments to the fund
line 11 pursuant to this section shall be in an amount equal to the money
line 12 appropriated for those purposes in the fiscal year beginning
line 13 immediately preceding the effective date of this title.
line 14 (g) All federal moneys shall be placed into the Healthy
line 15 California Federal Funds Account, which is hereby created within
line 16 the Healthy California Trust Fund.
line 17 (h) Moneys in the fund shall only be used for the purposes
line 18 established in this title.
line 19
line 20 Article 3. Healthy California Financing
line 21
line 22 100657. (a) It is the intent of the Legislature to enact legislation
line 23 that would develop a revenue plan, taking into consideration
line 24 anticipated federal revenue available for the program. In developing
line 25 the revenue plan, it is the intent of the Legislature to consult with
line 26 appropriate officials and stakeholders.
line 27 (b) It is the intent of the Legislature to enact legislation that
line 28 would require all state revenues from the program to be deposited
line 29 in an account within the Healthy California Trust Fund to be
line 30 established and known as the Healthy California Trust Fund
line 31 Account.
line 32
line 33 Chapter 8. Collective Negotiation by Health Care
line 34 Providers with Healthy California
line 35
line 36 Article 1. Definitions
line 37
line 38 100660. For purposes of this chapter, the following definitions
line 39 apply:
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line 1 (a) (1) “Health care provider” means a person who is licensed,
line 2 certified, registered, or authorized to practice a health care
line 3 profession pursuant to Division 2 (commencing with Section 500)
line 4 of the Business and Professions Code and who is any of the
line 5 following:
line 6 (A) An individual who practices that profession as a health care
line 7 provider or as an independent contractor.
line 8 (B) An owner, officer, shareholder, or proprietor of a health
line 9 care provider.
line 10 (C) An entity that employs or utilizes health care providers to
line 11 provide health care services, including, but not limited to, a health
line 12 facility licensed pursuant to Chapter 2 (commencing with Section
line 13 1250) of Division 2 of the Health and Safety Code.
line 14 (2) A health care provider under Division 2 (commencing with
line 15 Section 500) of the Business and Professions Code who practices
line 16 as an employee of a health care provider is not a health care
line 17 provider for purposes of this chapter.
line 18 (b) “Health care providers’ representative” means a third party
line 19 that is authorized by health care providers to negotiate on their
line 20 behalf with Healthy California over terms and conditions affecting
line 21 those health care providers.
line 22 (c) “Healthy California” or “HC” means the Healthy California
line 23 program established in Section 100601.
line 24
line 25 Article 2. Collective Negotiation Authorized
line 26
line 27 100662. (a) Health care providers may meet and communicate
line 28 for the purpose of collectively negotiating with Healthy California
line 29 on any matter relating to Healthy California, including, but not
line 30 limited to, rates of payment for health care services, rates of
line 31 payment for prescription and nonprescription drugs, and payment
line 32 methodologies.
line 33 (b) This chapter shall not be construed to allow or authorize an
line 34 alteration of the terms of the internal and external review
line 35 procedures set forth in law.
line 36 (c) This chapter shall not be construed to allow a strike of
line 37 Healthy California by health care providers related to the collective
line 38 negotiations.
line 39 (d) This chapter shall not be construed to allow or authorize
line 40 terms or conditions that would impede the ability of Healthy
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SB 562— 35 —
line 1 California to obtain or retain accreditation by the National
line 2 Committee for Quality Assurance or a similar body, or to comply
line 3 with applicable state or federal law.
line 4
line 5 Article 3. Collective Negotiation Requirements
line 6
line 7 100664. (a) Collective negotiation rights granted by this
line 8 chapter shall meet all of the following requirements:
line 9 (1) Health care providers may communicate with other health
line 10 care providers regarding the terms and conditions to be negotiated
line 11 with HC.
line 12 (2) Health care providers may communicate with health care
line 13 providers’ representatives.
line 14 (3) A health care providers’ representative is the only party
line 15 authorized to negotiate with HC on behalf of the health care
line 16 providers as a group.
line 17 (4) A health care provider can be bound by the terms and
line 18 conditions negotiated by the health care providers’ representatives.
line 19 (5) In communicating or negotiating with the health care
line 20 providers’ representative, HC is entitled to offer and provide
line 21 different terms and conditions to individual competing health care
line 22 providers.
line 23 (b) This chapter does not affect or limit the right of a health care
line 24 provider or group of health care providers to collectively petition
line 25 a governmental entity for a change in a law, rule, or regulation.
line 26 (c) This chapter does not affect or limit collective action or
line 27 collective bargaining on the part of a health care provider with his
line 28 or her employer or any other lawful collective action or collective
line 29 bargaining.
line 30 100666. (a) Before engaging in collective negotiations with
line 31 HC on behalf of health care providers, a health care providers’
line 32 representative shall file with the board, in the manner prescribed
line 33 by the board, information identifying the representative, the
line 34 representative’s plan of operation, and the representative’s
line 35 procedures to ensure compliance with this chapter.
line 36 (b) Each person who acts as the representative of negotiating
line 37 parties under this chapter shall pay a fee to the board to act as a
line 38 representative. The board, by regulation, shall set fees in amounts
line 39 deemed reasonable and necessary to cover the costs incurred by
line 40 the board in administering this chapter.
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line 1 Article 4. Prohibited Collective Action
line 2
line 3 100668. (a) This chapter does not authorize competing health
line 4 care providers to act in concert in response to a health care
line 5 providers’ representative’s discussions or negotiations with HC,
line 6 except as authorized by other law.
line 7 (b) A health care providers’ representative shall not negotiate
line 8 any agreement that excludes, limits the participation or
line 9 reimbursement of, or otherwise limits the scope of services to be
line 10 provided by any health care provider or group of health care
line 11 providers with respect to the performance of services that are within
line 12 the health care provider’s scope of practice, license, registration,
line 13 or certificate.
line 14
line 15 Chapter 9. Operative Date
line 16
line 17 100670. (a) Notwithstanding any other law, this title shall not
line 18 become operative until the date the Secretary of California Health
line 19 and Human Services notifies the Secretary of the Senate and the
line 20 Chief Clerk of the Assembly in writing that he or she has
line 21 determined that the Healthy California Trust Fund has the revenues
line 22 to fund the costs of implementing this title.
line 23 (b) The California Health and Human Services Agency shall
line 24 publish a copy of the notice on its Internet Web site.
line 25 SEC. 3. The provisions of this act are severable. If any
line 26 provision of this act or its application is held invalid, that invalidity
line 27 shall not affect other provisions or applications that can be given
line 28 effect without the invalid provision or application.
line 29 SEC. 4. The Legislature finds and declares that Section 2 of
line 30 this act, which adds Sections 100610 and 100617 to the
line 31 Government Code, imposes a limitation on the public’s right of
line 32 access to the meetings of public bodies or the writings of public
line 33 officials and agencies within the meaning of Section 3 of Article
line 34 I of the California Constitution. Pursuant to that constitutional
line 35 provision, the Legislature makes the following findings to
line 36 demonstrate the interest protected by this limitation and the need
line 37 for protecting that interest:
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SB 562— 37 —
line 1 In order to protect private, confidential, and proprietary
line 2 information, it is necessary for that information to remain
line 3 confidential.
O
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