Health Benefits And Copayments - Healthy Families - Insurance - CA

Section § 12693.60

This law section explains that the health coverage provided to subscribers must meet federal standards under the Social Security Act and generally match the health benefits provided to state employees. An exception is made for mental health inpatient care, allowing for a flexible approach where one inpatient day can substitute for more outpatient care days. Additionally, any regulations adopted or revised due to changes in this section are considered an emergency, allowing them to bypass certain governmental procedural requirements to ensure public well-being.

(a) Coverage provided to subscribers shall meet the federal coverage requirements in Section 2103 of Title XXI of the Social Security Act. Except as otherwise provided in this part, the covered health benefits provided to subscribers shall be equivalent to those provided to state employees through the Public Employees’ Retirement System for the most recent plan year preceding the applicable program plan year, except that the plans may provide a mechanism for inpatient hospital care provided under the mental health benefit through which applicants may agree to a treatment plan in which each inpatient day may be substituted for two residential treatment days or three day treatment program days.

(b) The adoption and readoption, by the Managed Risk Medical Insurance Board, of regulations to implement the changes made to this section by the act that added this subdivision, shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that it describe facts showing the need for immediate action and from review by the Office of Administrative Law.

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Section § 12693.61

This law applies to health plan subscribers identified as potentially seriously emotionally disturbed. Participating health plans are encouraged to collaborate with county mental health departments to assist these individuals. While referrals to county mental health departments are allowed, the health plans must still provide the mental health coverage outlined in their contracts, including assessment and treatment plans. County mental health departments can offer some or all of the mental health services.

The state board will set up a system so counties can claim federal reimbursement for services they provide to these subscribers, with reimbursement rates determined by the State Department of Health Care Services. This law takes effect only if approved by the federal government.

If counties agree to work with health plans, they are responsible for covering the nonfederal share of the costs for these subscribers.

The following provisions apply for subscribers who have been identified by the participating health plans as potentially seriously emotionally disturbed.

(a) Participating plans, to the extent feasible, including plans receiving purchasing credits shall develop memoranda of understanding, consistent with criteria established by the board in consultation with the State Department of Health Care Services, for referral of subscribers who are seriously emotionally disturbed to a county mental health department. This referral does not relieve a participating plan from providing the mental health coverage specified in its contract, including assessment of, and development of, a treatment plan for serious emotional disturbance. Plans may contract with county mental health departments to provide for all, or a portion of, the services provided under the program’s mental health benefit.

(b) The board shall establish an accounting process under which counties providing services to subscribers who have been determined to be seriously emotionally disturbed pursuant to Section 5600.3 of the Welfare and Institutions Code can claim federal reimbursement for the services. The board shall reimburse counties pursuant to the rates set by the State Department of Health Care Services in accordance with Sections 5705, 14705.7, 14705, 14708, 14711, and 14718 of the Welfare and Institutions Code. The actual amount reimbursed by the board shall be the federal share of the cost of the subscriber.

(c) This section shall only become operative with federal approval of the State Child Health Plan and the approval of federal financial participation.

(d) Counties choosing to enter into a memorandum of understanding pursuant to subdivision (a) shall provide the nonfederal share of cost for the subscriber.

seriously emotionally disturbed health plans collaboration county mental health departments ...

Section § 12693.62

This section explains how insurance coverage works for children with certain medical conditions that qualify them for the California Children's Services Program. If a child is eligible for these services, their regular health insurance plan doesn't cover the specific treatments covered by the program. Instead, the program itself handles those treatments and payments. Insurance plans must refer children who might need these services to the program. Once enrolled, treatments are provided by program-approved doctors and centers, following approved plans, while other non-related health services are still covered by the child's usual insurance.

Notwithstanding any other provision of law, for a subscriber who is determined by the California Children’s Services Program to be eligible for benefits under the program pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, a participating plan shall not be responsible for the provision of, or payment for, the particular services authorized by the California Children’s Services Program for the particular subscriber for the treatment of a California Children’s Services Program eligible medical condition. Participating plans shall refer a child who they reasonably suspect of having a medical condition that is eligible for services under the California Children’s Services Program to the California Children’s Services Program. The California Children’s Services Program shall provide case management and authorization of services if the child is found to be medically eligible for the California Children’s Services Program. Diagnosis and treatment services that are authorized by the California Children’s Services Program shall be performed by paneled providers for that program and approved special care centers of that program in accordance with treatment plans approved by the California Children’s Services Program. All other services provided under the participating plan shall be available to the subscriber.

California Children's Services Program eligible medical condition participating plan responsibilities ...

Section § 12693.615

This section outlines rules for copayments and coverage for subscribers under a specific insurance program. Copayments for subscribers can't be higher than those for California state employees and are capped at $250 per family each year. Health plans must offer extended payment plans for those with frequent copayments, and no deductibles or preexisting condition exclusions are allowed.

Coverage can't vary based on a subscriber's health status or claims history, and there are no copayments for preventive services. Additionally, there are no annual or lifetime benefit caps. Emergency room visits have a $50 copayment, waived if hospitalization follows, while inpatient stays have a $100 copayment per day, up to $200 per admission.

Changes to copayments depend on federal approval and must align with changes for children in the Medi-Cal program. Regulations to implement these changes are considered urgent for public health and safety and bypass typical review processes.

(a) The board shall establish the required subscriber copayment levels for specific benefits consistent with the limitations of Section 2103 of Title XXI of the Social Security Act. The copayment levels established by the board shall, to the extent possible, reflect the copayment levels established for state employees, effective January 1, 1998, through the Public Employees’ Retirement System. Except as otherwise provided in this section, under no circumstances shall copayments exceed the copayment level established for state employees for the most recent plan year preceding the applicable program plan year through the Public Employees’ Retirement System. Total annual copayments charged to subscribers shall not exceed two hundred fifty dollars ($250) per family. The board shall instruct participating health plans to work with their provider networks to provide for extended payment plans for subscribers utilizing a significant number of health services for which copayments are charged. The board shall track the number of subscribers who meet the copayment maximum in each year and make adjustments in the amount if a significant number of subscribers reach the copayment maximum.

(b) No deductibles shall be charged to subscribers for health benefits.

(d) No participating health, dental, or vision plan shall exclude any subscriber on the basis of any actual or expected health condition or claims experience of that subscriber or a member of that subscriber’s family.

(e) There shall be no variations in rates charged to subscribers including premiums and copayments, on the basis of any actual or expected health condition or claims experience of any subscriber or subscriber’s family member. The only variation in rates charged to subscribers, including copayments and premiums, that shall be permitted is that which is expressly authorized by Section 12693.43.

(f) There shall be no copayments for preventive services as defined in Section 1367.35 of the Health and Safety Code.

(g) There shall be no annual or lifetime benefit maximums in any of the coverage provided under the program.

(h) Plans that receive purchasing credits pursuant to Section 12693.39 shall comply with subdivisions (b), (c), (d), (e), (f), and (g).

(i)

(1) Effective October 1, 2011, or the first day of the month following 120 days after the federal approval required by subparagraphs (A) and (B) of paragraph (3), whichever occurs later, copayments for emergency room and inpatient hospital services shall be set by the board as follows:

(A) Fifty dollars ($50) for outpatient emergency room services. The copayment shall be waived if the subscriber is hospitalized.

(B) One hundred dollars ($100) for each hospital inpatient day up to a maximum of two hundred dollars ($200) per admission.

(2) The changes made to the copayments in paragraph (1) shall not increase the maximum annual copayment of two hundred fifty dollars ($250) per family described in subdivision (a).

(3) The changes made to the copayments in paragraph (1) shall be implemented only if, and to the extent that, both of the following occur:

(A) The state receives prior federal authorization to implement the copayments in the form of an approved amendment to the state plan under Title XXI of the federal Social Security Act or a waiver of one or more requirements of Title XXI of the federal Social Security Act.

(B) The state receives prior federal authorization for, and implements, copayments in the same amounts for all children enrolled in the Medi-Cal program through an approved amendment to the state plan under Title XIX of the federal Social Security Act or a waiver of one or more requirements of Title XIX of the federal Social Security Act.

(4) Notwithstanding paragraph (1), the state shall not implement the copayments otherwise required by this subdivision at an earlier date than the state implements copayments in the same amounts for all children in the Medi-Cal program.

(5) The adoption and readoption, by the Managed Risk Medical Insurance Board, of regulations to implement the changes made to this section by the act that added this subdivision, shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the board is hereby exempted from the requirement that it describe facts showing the need for immediate action and from review by the Office of Administrative Law.

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