The bill will require California residents to maintain at least a minimum policy of health care coverage for themselves and their dependents unless a minimum policy costs more than 6.5% of the person's family income, or a person has a significant financial hardship.
The bill will require the Managed Risk Medical Insurance Board to determine the minimum policy of health care coverage.
Health insurance/plan offerings will be changed to 5 specified classes of approved health benefits available for each health service plan, with one HMO and one PPO in each class.
There will be standardized insurance plan summary descriptions.
There will be guaranteed issue of health insurance, with the only risk adjustment factors to be age, region, and family size; discounts can be offered for nonsmokers, people with demonstrated weight loss, or actively participating in a disease management program.
Insurance plans are to compete on the basis of price, quality, and service.
Subscribers can increase benefits by one level of health plan classes annually during their birth month or upon marriage, domestic partnership, divorce, death of spouse or domestic partner providing benefits, or birth or adoption of a child.
At any time, subscribers can decrease benefits.
Insurance coverage is to be effective within 31 days of application and payment. Insurance benefits can be terminated for non-payment of premiums or withdrawal of the plan or insurer from the individual health care market.
Health plans can use electronic communication with patients.
Drug formularies will be available electronically.
At least 85% of insurance premiums are to be spent on health care.
A Healthy Action Incentives and Rewards program can be offered by employers.
There are long, complicated, and confusing passages regarding eligibility for various state and federally supported programs, mostly increasing eligibility for free or subsidized care.
The bill would create the California Cooperative Health Insurance Purchasing Program (Cal-CHIPP), a statewide purchasing pool for health care, administered by the Managed Risk Medical Insurance Board. The bill will require health care service plans and health insurers with more than one million or more enrollees to submit a good faith bid to the board to be a participating plan in Cal-CHIPP. The bill specifies eligibility for Cal-CHIPP; the board will develop a variety of benefit plan designs, including the Cal-CHIPP Healthy Families plan for low-income persons. The employer can pay all or a part of the premium for their employees enrolled in Cal-CHIPP.
Employees and their families shall be eligible fro Cal-CHIPP if the employer has elected to pay into the California Health Trust Fund, or if the individual is eligible for a state tax credit for purchasing affordable health care coverage.
People without healthcare coverage for >63 days after losing employment based healthcare coverage will have the premium paid by the Managed Risk Medical Insurance Board for a minimum coverage plan through CHIPP, and recoup the cost from the person.
Family monthly payments for family value packages are (after 7/1/10):
$7/child, maximum $14/family up to 1.5xpoverty level
$9/child, maximum $27/family 1.5xpoverty level to 2xpoverty level.
$25/child, maximum $75/family 2.5xpoverty level to 3xpoverty level.
For 5 years, Medi-Cal will cover everyone with income at or under the federal poverty level.
Medi-Cal will expand eligibility to those 19 years or older with a family income at 100%- 250% of the federal poverty level, with a county share of cost.
Medi-Cal will exempt all assets tests for eligibility of recipients and reduce semiannual status reports to verification of address.
There is a proposal to increase ( by an unspecified amount) Medi-Cal payments to physicians subject to funding, federal approval, and partly linked to performance measures.
Schools can provide health insurance information to parents/guardians of students, including how to apply for government subsidized health plans.
Healthy Families Program will be expanded, including non-citizens with state-only funds. Family income from 2.5x-3x the poverty level will be disregarded for eligibility.
There would be an electronic personal health record for the Healthy Families program and for the PERS plan participants that will provide real-time patient-specific information regarding eligibility for covered benefits through an internet-based system. Enrolees may opt to include personal health information as well.
A physician will be able to supervise up to 6 nurse practioners and 6 physician assistants at one time.
Medical assistants, licensed or unlicensed, will be able to perform standard written procedures without on site monitoring by a licensed physician, nurse practitioner, nurse-midwife, physician assistant, or podiatrist.
Nurse practitioners will be able to prescribe Schedule II drugs without on site supervision by physician if physician is available by telephone.
A Task Force on Nurse Practitioner Scope of Practice consisting of the Director of Consumer Affairs, 3 members of the Medical Board of California (2 selected by the Governor and 1 by the Senate Committee on Rules), 3 members of the Board of Registered Nursing, and 2 non-voting representatives of an institution of higher education appointed by the Governor will recommend changes in scope of practice for nurse practitioners by June 30, 2009, that will be implemented by the Director of Consumer Affairs by July 1, 2010. The cost of implementing these changes will be paid by the Medical Board of California and the Board of Registered Nursing.
Electronic prescription capability will be required for all prescribers and pharmacies in California by January 1, 2010, with written receipts to patients.
This bill will require the California Health and Human Services Agency to develop of best practice standards for high-cost chronic diseases that state health care programs would be required to implemented upon their adoption. It will develop health care provider performance measurement benchmarks, and incorporate these benchmarks into a common pay-for-performance model for every state-administered health care program.
Smoking cessation programs will be supported, and the 10 largest insurers' programs will be monitored by the state.
Diabetes prevention and treatment programs will be established.
A Community Makeover Grant program will promote active living and healthy eating, and educate the public about obesity prevention.
This bill will create the California Health Care Cost and Quality Transparency Commission: 13 members, 7 appointed by the governor (1 each representatives of academia, hospitals, integrated multispeciality medical groups, physicians, large employers, labor unions, employers), 3 appointed by the Senate Committee on Rules (labor union, consumers, and health insurers), and 3 appointed by the Assembly Speaker (consumers, small employers, and nonprofit), with non voting ex officio members. The commission will develop and regularly update a health care quality and cost containment plan. They will require any data source to submit data necessary to implement the health care cost and quality transparency plan. They will distribute data on quality, safety, outcomes, cost, and utilization, and allow comparison of health plans, insurers, individual facilities, physicians, and other health care providers. They will utilize a unique patient identifier to find " inadequate quality of care, such as hospital readmissions and repetitive service utilization".
The commission will impose fees on data sources and data users (but minimal charges to academia, and no charges to the public to access the data), and to impose penalties of $100-$1,000 per day on data sources that fail to file any report required by the commission. The fees generated by the program will pay for the program.
Hospitals will be unable to bill patients with non-contracted insurance beyond co-payments/share of cost amounts for emergency services and post-stabilization care.
The bill will create the California Health Benefits Service governed by a board appointed by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly (3 representatives of local initiatives, 2 representatives of county health systems, a representative of health care purchasers, a representative of health care consumers, a representative of health care providers, and a representative of organized labor) to create joint ventures licensed as Knox-Keene health care service plans between certain county-organized health plans and 22 designated public hospitals, county health clinics, and community clinics.
Risk-adjusted outcome reports will be issued re: outcome for percutaneous coronary interventions.
The cost of the this bill is to be borne by increased federal support of Medicaid and S-CHIP, taxes on employers (2-6.5% of total payroll if equivalent amount not already spent on healthcare), hospitals (4% of patient revenues), premium payments in publicly subsidized coverage, and tobacco ($2/pack of cigarettes; fees on other products), and savings in existing health care programs.
From January 1, 2008 to December 31, 2011, adoption of regulations by the Managed Risk Medical Insurance Board shall be deemed to be an emergency and necessary for the immediate preservation of public peace, health, and safety, or the general welfare.
There is expressed flexibility in the act to modify requirements, categories, or populations in order to maximize federal financial participation, but not to decrease health coverage or benefits, and not to increase cost-sharing amounts specified in the act.
Violation of the bill's requirements would be a crime.
-Len Doberne, MD