This page is part of the CalCare AB2200 Reading Group project.
Link to write notes on Section 2 Chapter 3.
| Bill Text | Notes |
|---|---|
| CHAPTER 3. Eligibility and Enrollment100630. (a) Every resident of the state shall be eligible and entitled to enroll as a member of CalCare.(b) (1) A member shall not be required to pay a fee, payment, or other charge for enrolling in or being a member of CalCare.(2) A member shall not be required to pay a premium, copayment, coinsurance, deductible, or any other form of cost sharing for all covered benefits under CalCare.(c) A college, university, or other institution of higher education in the state may purchase coverage under CalCare for a student, or a student’s dependent, who is not a resident of the state.(d) An individual entitled to benefits through CalCare may obtain health care items and services from any institution, agency, or individual participating provider.(e) The board shall establish a process for automatic CalCare enrollment at the time of birth in California. | b) No premium. (But there is a payroll tax.) No copay, or deductible. c) Out of state college students can get covered with the same terms. d) Single provider network. e) Cradle to grave coverage. |
| 100631. (a) All residents of this state, no matter what their sex, race, color, religion, ancestry, national origin, disability, age, previous or existing medical condition, genetic information, marital status, familial status, military or veteran status, sexual orientation, gender identity or expression, pregnancy, pregnancy-related medical condition, including termination of pregnancy, citizenship, primary language, or immigration status, are entitled to full and equal accommodations, advantages, facilities, privileges, or services in all health care providers participating in CalCare. | Non-discrimination. This codifies that everyone we can imagine is in. If you are not in the list, contact the organizers and legislators. |
| (b) Subdivision (a) prohibits a participating provider, or an entity conducting, administering, or funding a health program or activity pursuant to this title, from discriminating based upon the categories described in subdivision (a) in the provision, administration, or implementation of health care items and services through CalCare. | Providers must also be non-discriminatory. |
| (c) Discrimination prohibited under this section includes the following:(1) Exclusion of a person from participation in or denial of the benefits of CalCare, except as expressly authorized by this title for the purposes of enforcing eligibility standards in Section 100630.(2) Reduction of a person’s benefits.(3) Any other discrimination by any participating provider or any entity conducting, administering, or funding a health program or activity pursuant to this title. | Discrimination includes exclusion from benefits, reduction of benefits, anything else. |
| (d) Section 52 of the Civil Code shall apply to discrimination under this section.(e) Except as otherwise provided in this section, a participating provider or entity is in violation of subdivision (b) if the complaining party demonstrates that any of the categories listed in subdivision (a) was a motivating factor for any health care practice, even if other factors also motivated the practice. | Section 52 talks about the liability for discrimination, amounts, legal costs, etc. |
| CHAPTER 4. Benefits | |
| 100635. (a) Individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to a participating provider for the health care items and services in subdivision (c), if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.(b) The determination of medical necessity or appropriateness shall be made by the member’s treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards established in Chapter 6 (commencing with Section 100660), and by the board, and other laws of the state. | Your doctor decides what treatment is necessary, and CalCare covers it. |
| (c) Covered health care benefits for members include all of the following categories of health care items and services:(1) Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services.(2) Inpatient and outpatient health care professional services and other ambulatory patient services.(3) Primary and preventive services, including chronic disease management.(4) Prescription drugs, biological products, and all contraceptive items approved by the United States Food and Drug Administration.(5) Medical devices, equipment, appliances, and assistive technology.(6) Mental health and substance abuse treatment services, including inpatient and outpatient care.(7) Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.(8) Comprehensive reproductive care, including abortion, contraception, and | A broad range of benefits, including: Chronic disease management Contraceptives Substance abuse treatment Mental health services Abortion Dental Vision Rehab Emergency transport Gender affirming care Disabled person transport Long term care |
| (d) The categories of covered health care items and services under subdivision (c) include all the following:(1) Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual.(2) Child and adult immunizations.(3) Hospice care.(4) Care in a skilled nursing facility.(5) Home health care, including health care provided in an assisted living facility.(6) Prenatal and postnatal care.(7) Podiatric care.(8) Blood and blood products.(9) Dialysis.(10) Community-based adult services as defined under Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code as of January 1, 2021.(11) Dietary and nutritional therapies determined appropriate by the board.(12) Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture.(13) Health care items and services previously covered by county integrated health and human services programs pursuant to Chapter 12.96 (commencing with Section 18990) and Chapter 12.991 (commencing with Section 18991) of Part 6 of Division 9 of the Welfare and Institutions Code.(14) Health care items and services previously covered by a regional center for persons with developmental disabilities pursuant to Chapter 5 (commencing with Section 4620) of Division 4.5 of the Welfare and Institutions Code.(15) Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers. | They also clarify that the following are included: Eyeglasses Hearing aids Prostheses Repair of these things Hospice care Nursing home Home health care Prenatal postnatal Podiatry Dialysis Adult services Nutritionists Some chiropractic and acupuncture Language interpretation services |
| (e) Covered health care items and services under CalCare include all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:(1) The federal Children’s Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).(2) Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(3) The federal Medicare | (I need to link these out.) Basically all Federal programs are covered. |
| 100636. (a) Subject to the other provisions of this title, individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this title, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:(1) Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living.(2) Is a disability, as defined in Section 12102(1)(A) of Title 42 of the United States Code, that substantially limits one or more of the member’s major life activities. | Disability rights:Based on “limitation” in “daily living” (rather than work)Also defined by the Federal definition of disability. |
| (b) The board shall adopt regulations that provide for the following:(1) The determination of individual eligibility for long-term services and supports under this section.(2) The assessment of the long-term services and supports needed for an eligible individual.(3) The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program established in Title II or Title XVI of the federal Social Security Act to the long-term services and supports under this section. | The Board will add regulations:To determine eligibility for long-term services. Unless the SSA makes a determination under SDI, in which case, you are eligible automatically. (This implies that the Board rules will be no more restrictive than the Federal.) |
| (c) Long-term services and supports provided pursuant to this section shall do all of the following:(1) Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting.(2) Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care.(3) Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the member’s maximum possible autonomy and the member’s maximum possible civic, social, and economic participation.(4) Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization.(5) Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipient’s type or level of disability, service need, or age.(6) Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the member’s needs.(7) Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity.(8) Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions.(9) Ensure that long-term services and supports provide recipients the option of self-direction of service, including under the Self-Directed Services Program described in Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code, from either the recipient or care coordinators of the recipient’s choosing.(d) In developing regulations to implement this section, the board shall consult the advisory commission established pursuant to Section 100614. | Long-term care includes: Nursing services Home based Community based Respite care Maximum autonomy for the patient. Prioritizes dignity. Prioritize home and community services. |
| 100637. (a) (1) The board shall, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.(2) In implementing this section, the board shall not remove or eliminate covered health care items and services under CalCare that are listed in this chapter.(b) The board shall establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare. | General rule to grow, rather than reduce, services. |
| (c) The board shall establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the Independent Medical Review System established in the Department of Managed Health Care pursuant to Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.(d) For the purposes of this chapter:(1) “Coverage decision” means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A “coverage decision” does not encompass a decision regarding a disputed health care item or service.(2) “Disputed health care item or service” means a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision. | Dispute Resolution rules |
This page is part of the CalCare AB2200 Reading Group project.