This page is part of the CalCare AB2200 Reading Group project.
| Bill Text | Notes |
|---|---|
| CHAPTER 6. Program StandardsArticle 1. Standard of Care100660. CalCare shall establish a single standard of safe, therapeutic, and effective care for all residents of the state by the following means: | Standard of care is a medical term used to delineate what basic good care is in a community. |
| (a) The board shall establish requirements and standards, by regulation, for CalCare and health care providers, consistent with this title and consistent with the applicable professional practice and licensure standards of health care providers and health care professionals established pursuant to the Business and Professions Code, the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code, including requirements and standards for, as applicable:(1) The scope, quality, and accessibility of health care items and services.(2) Relations between participating providers and members.(3) Relations between institutional providers, group practices, and individual health care organizations, including credentialing for participation in CalCare and clinical and admitting privileges, and terms, methods, and rates of payment. | The standards they adopt will be based or consistent with on those in the healthcare providers and Healthcare professionals codes like the business and professions code, the health and safety Code, the insurance code. What is in the scope of practice, what are the ethics and legal guidelines for how participating providers and members are together, including rates of payment. ??? |
| (b) The board shall establish requirements and standards, bBy regulation, under CalCare that include provisions to promote all of the following:(1) Simplification, transparency, uniformity, and fairness in the following:(A) Health care provider credentialing for participation in CalCare.(B) Health care provider clinical and admitting privileges in health care facilities.(C) Clinical placement for educational purposes, including clinical placement for prelicensure registered nursing students without regard to degree type, that prioritizes nursing students in public education programs.(D) Payment procedures and rates.(E) Claims processing. | Health care provider credentialing should be simple, fair and transparent. So should payment and rates. |
| (2) In-person primary and preventive care, efficient and effective health care items and services, quality assurance, and promotion of public, environmental, and occupational health.(3) Elimination of health care disparities.(4) Nondiscrimination pursuant to Section 100631.(5) Accessibility of health care items and services, including accessibility for people with disabilities and people with limited ability to speak or understand English.(6) Providing health care items and services in a culturally, linguistically, and structurally competent manner.(7) Prevention-oriented care. | All aspects of care to be taken into consideration. Eliminate Health Care disparities, and discrimination, and have good accessibility of healthcare items for the people with disabilities and people with limited understanding of English. Be culturally competent. Prevention oriented care is valued and should be promoted. |
| (c) The board shall establish requirements and standards, to the extent authorized by federal law, by regulation, for replacing and merging with CalCare health care items and services and ancillary services currently provided by other programs, including Medicare, the Affordable Care Act, and federally matched public health programs.(d) A participating provider shall furnish information as required by the Department of Health Care Access and Information pursuant to Sections 100617 and 100641, and to Division 107 (commencing with Section 127000) of the Health and Safety Code, and permit examination of that information by the board as reasonably required for purposes of reviewing accessibility and utilization of health care items and services, quality assurance, cost containment, the making of payments, and statistical or other studies of the operation of CalCare or for protection and promotion of public, environmental, and occupational health. | Regulations to incorporate existing healthcare federal programs? A participating provider shall furnish information for the purposes of quality assurance, cost containment, etc. |
| (e) The board shall use the data furnished under this title to ensure that clinical practices meet the utilization, quality, and access standards of CalCare. The board shall not use a standard developed under this chapter for the purposes of establishing a payment incentive or adjustment under CalCare.(f) To develop requirements and standards and making other policy determinations under this chapter, the board shall consult with representatives of members, health care providers, health care organizations, labor organizations representing health care employees, and other interested parties. | The board shall use this data to make sure that Healthcare Services follow the standard of care. In order to help with the requirements and standards under this chapter, the board shall consult with representatives of members, healthcare providers and Healthcare orgs, labor organizations, etc. |
| (g) The board shall coordinate with the Office of Health Equity, the Department of Health Care Access and Information, and the Department of Managed Health Care to do both of the following:(1) Monitor participating providers for, and establish procedures related to, compliance with the requirements and standards established under this section.(2) Establish programs, including special projects under Section 100677, to ensure or manage CalCare member access to in-person primary and preventive care, efficient and effective health care items and services, and quality care. | The board shall coordinate with the office of Health equity and some other offices in order to monitor participating providers and establish programs. |
| 100661. (a) (1) As part of a health care practitioner’s duty to advocate for medically appropriate health care for their patients pursuant to Sections 510 and 2056 of the Business and Professions Code, a participating provider has a duty to act in the exclusive interest of the patient.(2) The duty described in paragraph (1) applies to a health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare.(b) Consistent with subdivision (a) and with Sections 510 and 2056 of the Business and Professions Code:(1) An individual’s treating physician, or other health care professional who is authorized to diagnose the individual in accordance with all applicable scope of practice and other license requirements and is treating the individual, is responsible for the determination of the medically necessary or appropriate care for the individual.(2) A participating provider or health care professional who may be employed by a participating provider or otherwise receive compensation or payment for health care items and services furnished under CalCare from a participating provider or other person participating in CalCare shall use reasonable care and diligence in safeguarding an individual under the care of the provider or professional and shall not impair an individual’s treating physician or other health care provider treating the individual from advocating for medically necessary or appropriate care under this section. | Duty of provider to act in the exclusive interest of the patient. Providers must advocate for medically necessary care. |
| (c) A health care provider or health care professional described in subdivision (a) violates the duty established under this section for any of the following:(1) Having a pecuniary interest or relationship, including an interest or relationship disclosed under subdivision (d), that impairs the provider’s ability to provide medically necessary or appropriate care.(2) Accepting a bonus, incentive payment, or compensation based on any of the following:(A) A patient’s utilization of services.(B) The financial results of another health care provider with which the participating provider has a pecuniary interest or contractual relationship, including employment or other compensation-based relationship, or of a person that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.(C) The financial results of an institutional provider, group practice, or person that contracts with, provides health care items or services under, or otherwise receives payment from CalCare.(3) Having a board member, executive, or administrator that receives compensation from, owns stock or has other financial investments in, or serves as a board member of an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider. | Things that violate the duty established above: Having a relationship that impairs the provider’s ability to provide medically necessary care, Accepting the bonus or other compensation based on various factors. |
| (d) To evaluate and review compliance with this section, a participating provider shall report, at least annually, to the Department of Health Care Access and Information all of the following:(1) A beneficial interest required to be disclosed to a patient pursuant to Section 654.2 of the Business and Professions Code.(2) A membership, proprietary interest, coownership, or profit-sharing arrangement, required to be disclosed to a patient pursuant to Section 654.1 of the Business and Professions Code.(3) A subcontract entered into that contains incentive plans that involve general payments, including capitation payments or shared risk agreements, that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions.(4) Bonus or other incentive arrangements used in compensation agreements with another health care provider or an entity that contracts with or provides health care items or services, including pharmaceutical products and medical devices or equipment, to the provider.(5) An offer, delivery, receipt, or acceptance of rebates, refunds, commission, preference, patronage dividend, discount, or other consideration for a referral made in exception to Section 650 of the Business and Professions Code. | Provider must report at least annually to the Department of Healthcare access and information all of the following: A beneficial interest required to be disclosed to a patient, A membership, proprietary interest, etc required to be disclosed to a patient, A subcontract entered into that contains incentive plans, general payments, capitation payments that are not tied to any specific medical decisions involving specific members. Other situations are listed. |
| (e) The board may adopt regulations as necessary to implement and enforce this section and may adopt regulations to expand reporting requirements under this section.(f) For purposes of this section, “person” means an individual, partnership, corporation, limited liability company, or other organization, or any combination thereof, including a medical group practice, independent practice association, preferred provider organization, foundation, hospital medical staff and governing body, or payer. | Definitions. |
| 100662. (a) An individual’s treating physician, nurse, or other health care professional, in implementing a patient’s medical or nursing care plan and in accordance with their scope of practice and licensure, may override health information technology or clinical practice guidelines, including standards and guidelines implemented by a participating provider through the use of health information technology, including electronic health record technology, clinical decision support technology, and computerized order entry programs. | Health Care professionals May override health information or standards of care if they’re following some kind of health technology. |
| (b) An override described in subdivision (a) shall, in the independent professional judgment of the treating physician, nurse, or other health care professional, meet all of the following requirements:(1) The override is consistent with the treating physician’s, nurse’s, or other health care professional’s determination of medical necessity or appropriateness or nursing assessment.(2) The override is in the best interest of the patient.(3) The override is consistent with the patient’s wishes. | Conditions of that override. |
| Article 2. Health Equity100665. (a) There is hereby established, within CalCare, the Office of Health Equity. The Director of the Department of Health Care Access and Information shall be the director of the office and shall carry out all functions of that position, including enforcement.(b) The office shall be responsible for coordination and collaboration across the programs and activities of CalCare and the California Health and Human Services Agency with respect to ensuring health equity under CalCare and other health programs of the California Health and Human Services Agency. | Health equity Establishing the office of Health equity. The director of the Department of Healthcare access and information shall be the director of The office. The office will coordinate and collaborate across programs to ensure Health equity. |
| (c) The office shall do all of the following:(1) Support the board through data collection and analysis of, and recommendations to address, all of the following:(A) The disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, disability, sex, including gender identity and sexual orientation, geographic location, socioeconomic status, incarceration, housing status, and other population-based characteristics.(B) Barriers to health, including barriers relating to income, education, housing, food insecurity, employment status, working conditions, and conditions related to the physical environment.(C) Barriers to health care access, including lack of trust and awareness, lack of transportation, geography, hospital and service closures, lack of health care infrastructure and facilities, lack of health care professional staffing and recruitment, disparities in quality of care received, and disparities in utilization of care.(D) Inequitable distribution of health care services, including health care professional shortage areas, medically underserved areas, medically underserved populations, and trends in hospital closures and service reductions.(E) Discrimination in health care settings and the use of racially biased or other discriminatory practice guidelines, health care technologies, and algorithms.(F) Increasing access to high-quality primary health care, particularly in medically underserved areas and for medically underserved populations | The office shall do all of the following: Data collection and analysis including the disproportionate burden of disease and death by race, ethnicity, national origin, primary language use, immigration status, age, etc. Barriers to health are listed: income, education, housing, food and security, employment status, working conditions, physical environment. More barriers to Health Access are listed. Inequitable distribution of healthcare services pertaining to medically underserved populations. Discrimination in healthcare settings and the use of racially biased guidelines, algorithms come etc. Increase access to primary Health care, particularly in medically underserved populations and areas. |
| (2) Ensure that analysis and data collected under this section are made publicly available and allow for the analysis of cross-sectional information on people’s identities.(3) Support the board through the development and coordination of programs and recommendations to enhance health equity in California, including programs and recommendations on all of the following:(A) Improving the provision of culturally, linguistically, and structurally competent care.(B) Increasing diversity in the health care workforce.(C) Ensuring sufficient health care professionals and facilities to meet the health care needs across the state.(D) Ensuring equitable access and distribution of needs across the state.(E) Recruitment and retention of a health care workforce that meets the cultural, linguistic, and other needs of Californians.(F) Recruitment and retention of a health care workforce in rural and medically underserved areas. | Make the data and analysis publicly available. Report to the board recommendations to enhance Health equity including: Improving culturally competent care Increasing diversity in the healthcare workforce Ensuring efficient professionals and facilities to meet the healthcare needs across the state Workforce that meets the cultural linguistic and other needs of California’s Healthcare workforce in rural and medically underserved areas. |
| (4) Develop, coordinate, and provide recommendations on programs that expand the number of primary health care providers and practitioners, including primary care physicians, registered nurses, and dentists, in the state.(5) Develop, coordinate, and provide recommendations on targeted programs and resources for federally qualified health centers, rural health centers, community health centers, and other community-based organizations that provide primary care in the state.(6) Conduct ongoing research and evaluation on health equity and access to primary care in California. | Increase providers including primary Care physicians, registered nurses, and dentist by developing, coordinating and recommending programs that expand these numbers. Conduct ongoing research and evaluation on Health equity and access to primary Care. |
| (7) Support the board and the CalCare Public Advisory Committee through data collection and analysis and recommendations to develop, propose, and review special projects under Section 100677.(8) Adopt and promulgate regulations for the purpose of carrying out this chapter.(9) Establish advisory or technical committees, as necessary. | Support data collection and analysis. Adopt and promulgate regulations for the purpose of carrying out this chapter. Establish advisory or technical committees as needed. |
| (d) For purposes of implementing this section, including hiring staff and consultants, through the procurement authority and processes of the department, facilitating and conducting meetings, conducting research and analysis, and developing the required reports, the office may enter into exclusive or nonexclusive contracts on a bid or negotiated basis. Until January 1, 2026, contracts entered into or amended pursuant to this chapter are exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and are exempt from the review or approval of any division of the Department of General Services. | The office may enter into contracts which are exempt from chapter 6 until January 1, 2026. |
| Article 3. Consumer Protections 100667. (a) It is the intent of the Legislature that all existing consumer protections related to health care service plans, including network adequacy, timely access, and language access, apply to CalCare. (b) It is the intent of the Legislature that all existing patient rights and protections in the delivery and provision of health care items and services apply to CalCare and participating providers in CalCare. (c) This title does not diminish or eliminate any protections consumers have under existing state and federal law, including health care spending targets and data collection required by the Office of Health Care Affordability. (d) For purposes of the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), the CalCare program is a health care service plan, including for purposes of the Independent Medical Review System established in Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code. (e) This title does not diminish or eliminate any of the rights and protections afforded to Californians by the Medicare and Medicaid programs under state and federal law or the Lanterman-Petris-Short Act (Part 1 (commencing with Section 5000) of Division 5 of the Welfare and Institutions Code). | Existing consumer protections are carried over into CalCare. |
This page is part of the CalCare AB2200 Reading Group project.