BILL NUMBER: AB 527 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 30, 2003
INTRODUCED BY Assembly Member Leno
FEBRUARY 18, 2003
An act to amend Section 12693.90 of the Insurance Code,
relating to insurance. An act to add Part 6.25
(commencing with Section 12694) to Division 2 of the Insurance Code,
relating to health insurance.
LEGISLATIVE COUNSEL'S DIGEST
AB 527, as amended, Leno. Healthy families: advisory
panel Native American Tribal Casino Employee Health
Protection and Portability Act of 2003 .
Existing law does not require employers to provide health care
coverage for employees and dependents, other than coverage provided
as part of the workers' compensation system for work-related employee
injuries. Existing law provides for the creation of various
programs to provide health care services to persons who have limited
incomes and meet various eligibility requirements. These programs
include the Healthy Families Program administered by the Managed Risk
Medical Insurance Board and the Medi-Cal program administered by the
State Department of Health Services. Existing law provides for the
regulation of health care service plans by the Department of Managed
Health Care and health insurers by the Department of Insurance.
This bill would establish the Native American Tribal Casino
Employee Health Protection and Portability Program in the Health and
Welfare Agency, to be managed by the Native American Tribal Casino
Employee Health Board, which would consist of 11 members. The bill
would establish a process where tribal gaming casino employers may
provide health care coverage to the employees and dependents through
a purchasing pool administered through the program. Fees paid by
employers would be collected by the Employment Development Department
and deposited in the Native American Tribal Casino Employee Health
Fund, a continuously appropriated fund, along with various other
potential revenues. The bill would enact other related provisions.
Existing law establishes the Healthy Families Program,
administered by the Managed Risk Medical Insurance Board, to arrange
for the provision of health care, dental, and vision coverage to
eligible children meeting certain household income requirements.
Existing law requires the board to appoint a 15-member advisory panel
to advise the board on policies, regulations, operations, and
implementation of the program. Under existing law, the Healthy
Families Program becomes inoperative on January 1, 2004.
This bill would increase the panel to 16 members by adding one
member from organized labor.
Vote: majority. Appropriation: no yes
. Fiscal committee: yes. State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 12693.90 of the Insurance Code is
SECTION 1. The Legislature finds and declares all of the
following:
(a) That through the execution of compacts between Native American
tribes and the State of California, tribal gaming casinos have been
established throughout California.
(b) That the Native American tribal casino gaming industry is
rapidly expanding in California and that those gaming enterprises
provide gainful employment for tens of thousands of residents of the
State of California.
(c) That Native American tribal casinos are very profitable
business enterprises and have permitted gaming tribes to achieve
unprecedented economic wealth and independence.
(d) That the sovereign immunity enjoyed by Native American tribes
exempts their gaming operations from the payment of all state and
federal income tax.
(e) That the cost of providing health care coverage to the
employees of sovereign nations should be financed by their employers
and not by the taxpayers of the State of California.
(f) That the State of California currently faces a deep and
pronounced fiscal crisis necessitating reductions in the financial
support of health care programs for its residents.
(g) That several studies have indicated that a large percentage of
the employees of tribal gaming casinos receive their dependent
health care coverage through the Healthy Families Program, Medi-Cal,
and other taxpayer financed health care programs, at a cost to the
State of California estimated to be as high as $21 million in the
2002-03 fiscal year.
(h) That a mechanism should exist by which gaming tribes may
exercise the full measure of their sovereignty by voluntarily
participating in a program with the State of California to ensure
that their employees and their families receive health care coverage
that is fully financed by the profits of tribal gaming operations and
that permits portability of that coverage between tribal gaming
casino operations.
SEC. 2. Part 6.25 (commencing with Section 12694) is added to
Division 2 of the Insurance Code, to read:
PART 6.25. NATIVE AMERICAN TRIBAL CASINO EMPLOYEE HEALTH
PROTECTION AND PORTABILITY ACT OF 2003
Chapter 1. General Provisions
12694. (a) This part shall be known as the Native American Tribal
Casino Employee Health Protection and Portability Act of 2003.
(b) (1) The Native American Tribal Casino Employee Health
Protection and Portability Program is hereby created in the Health
and Welfare Agency. The program shall be managed by the Native
American Tribal Casino Employee Health Board.
(2) The board shall consist of 11 members.
(3) The Governor shall appoint five members, subject to
confirmation by the Senate. Of the five appointees by the Governor,
four shall represent tribal casino employees and one shall represent
providers of health care to tribal casino employees. At least two of
the employee members shall be members of a bona fide labor
organization that represents tribal casino employees. The tribal
chairperson or a designee of the tribal chairperson of the six tribes
that employ the largest number of tribal casino employees shall
serve on the board. The chairperson of the board shall be elected by
a majority of the board but shall be chosen from among the members
who are tribal chairpersons or their designees. The members
appointed by the Governor shall serve four year terms.
(4) The Secretary of Business, Transportation, and Housing, or his
or her designee, and the Secretary of Health and Welfare, or his or
her designee, shall serve on the board as ex officio, nonvoting
members.
(c) The board shall appoint an executive director for the board,
who shall serve at the pleasure of the board. The executive director
shall receive the salary established by the Department of Personnel
Administration for exempt officials. The executive director shall
administer the affairs of the board as directed by the board, and
shall direct the staff of the board. The executive director may
appoint, with the approval of the board, staff necessary to carry out
the provisions of this part.
12694.01. The Native American Tribal Casino Employee Health
Protection and Portability Program established pursuant to Section
12694 shall be eligible for receipt of funds from the Indian Gaming
Special Distribution established pursuant to Section 12012.85 of the
Government Code.
12694.02. This part shall not be construed to diminish any
protection already provided pursuant to collective bargaining
agreements or employer-sponsored plans that are more favorable to the
employees than the health care coverage required by this part.
Chapter 2. Definitions
12694.03. Unless the context requires otherwise, the definitions
set forth in this section shall govern the construction and meaning
of the terms and phrases used in this part.
(a) "Health plan" means any insurer, health care service plan,
self-funded employer-sponsored plan, multiple employer trust, or
Taft-Hartley Trust as defined by federal law, authorized to pay for
health care services in this state.
(b) "Dependent" means the spouse, minor child, permanently
disabled child, or legally dependent parent of a covered employee.
(c) "Tribal gaming casino" means a gaming establishment authorized
by a compact executed between the State of California and a Native
American tribe and executed pursuant to the Tribal Government Gaming
and Economic Self-Sufficiency Act of 1998 (Chapter 1 (commencing with
Section 98000) of Title 16 of the Government Code).
(d) "Tribal gaming casino employee" means an employee of a tribal
gaming casino, other than a member of that tribe.
(e) "Employment" has the meaning as defined in Article 1
(commencing with Section 601) of Chapter 3 of Part 1 of Division 1 of
the Unemployment Insurance Code.
(f) "Principal employer" means the employer for whom any employee
works the largest number of hours in any month.
(g) "Wages" means all remuneration for services from whatever
source, including commissions, bonuses, and tips and gratuities paid
directly to any individual by a customer or his or her employer.
(h) "Applicant" means any person, including an employee or their
dependent, on whose behalf an employer has paid a fee pursuant to
subdivision (c) of Section 12694.05.
(i) "Enrollee" means an applicant who has provided to the program
enrollment information as prescribed by the program in accordance
with Section 12694.30.
(j) "Board" means the Native American Tribal Casino Employee
Health Board.
(k) "Community provider plan" means that participating health plan
in each geographic area that has been designated by the Major Risk
Medical Insurance Board as having the highest percentage of
traditional and safety net providers in its provider network.
(l) "County organized health system" means a health care
organization that contracts with the State Department of Health
Services to provide comprehensive health care to all eligible
Medi-Cal beneficiaries residing in the county, and that is operated
directly by a public entity established by a county government
pursuant to Section 14087.51 or 14087.54 of the Welfare and
Institutions Code, or Chapter 3 (commencing with Section 101675) of
Part 4 of Division 101 of the Health and Safety Code.
(m) "Applicable contribution" means the cost to an applicant to
enable herself or himself or an eligible dependent to enroll in and
participate in the program. Applicable contribution does not include
copayments for insured services. The applicable contribution may be
paid by a contribution sponsor.
(n) "Value package" means the participating health plan available
to enrollees in each geographic area offering the lowest prices to
the program. The board may define the value package to include not
only the participating health plans offering the absolute lowest
price to the program but also the combination of health plans within
a fixed percentage or dollar amount of the absolute lowest price.
(o) "Fund" means the Native American Tribal Casino Employee Health
Fund.
(p) "Local initiative" means a prepaid health plan that is
organized by, or designated by, a county government or county
governments, or organized by stakeholders, of a region designated by
the department to provide comprehensive health care to eligible
Medi-Cal beneficiaries. The entities established pursuant to the
following sections of the Welfare and Institutions Code are local
initiatives: Sections 14018.7, 14087.31, 14087.35, 14087.36,
14087.38, and 14087.96.
(q) "Program" means the Native American Tribal Casino Employee
Health Program, which includes a purchasing pool providing health
coverage for Tribal Casino employees and their dependents for which
their Tribal Casino employer pays a fee rather than purchasing health
coverage.
(r) "Geographic managed care plan" means an entity that is
operating pursuant to a contract entered into under Article 2.91
(commencing with Section 14089) of Chapter 7 of Part 3 of Division 9
of the Welfare and Institutions Code.
(s) "Contribution sponsor" means a person or entity that pays the
applicable contribution on behalf of an applicant for any period of
12 consecutive months. If the sponsor is paying for the initial 12
months of eligibility, the payment for 12 months shall be made with
the application.
Chapter 3. Coverage
12694.04. Tribal gaming casino employers may provide health care
coverage to each employee pursuant to this part. Employers may also
provide health care coverage to the dependents of each employee in
the event that those dependents are not receiving coverage from a
different employer. An employer may provide health care coverage to
the dependent spouse or domestic partner of an employee who is
eligible for coverage from another employer.
12694.05. Tribal gaming casino employers may do any of the
following:
(a) Select coverage from any health plan.
(b) Provide coverage through self-funded employer-sponsored plans.
(c) Pay a fee to Native American Tribal Casino Employee Health
Protection and Portability Program for purposes of providing
coverage.
12694.06. Health care benefits provided by the program in
accordance with this part shall be equivalent to those provided
pursuant to Chapter 5 (commencing with Section 12693.60) of Part 6.2.
12694.07. No employer shall request or otherwise seek to obtain
information concerning income or other eligibility requirement for
public health benefits program regarding any employee, dependent or
other family member of an employee other than that information about
the employee's employment status otherwise known to the employer
consistent with existing state and federal law and regulation. For
these purposes, public health benefits programs include, but are not
limited to, Medi-Cal, Healthy Families, Managed Risk Medical
Insurance Program, and Access for Infants and Mothers. A violation
of this section shall constitute a violation of the Fair Employment
and Housing Act.
12694.08. The board may do all of the following consistent with
the standards in this part:
(a) Determine eligibility criteria for the program.
(b) Determine the participation requirements of applicants,
subscribers, and participating health, dental, and vision plans.
(c) Determine when subscribers' coverage begins and the extent and
scope of coverage.
(d) Assure that family contribution amount schedules are
consistent with those required under Part 6.2 (commencing with
Section 12693) and collect the contributions.
(e) Determine who may be a family contribution sponsor and provide
a mechanism for sponsorship.
(f) Provide or make available subsidized coverage through
participating health, dental, and vision plans, in a purchasing pool.
(g) Provide for the processing of applications and the enrollment
of subscribers.
(h) Determine and approve the benefit designs and copayments
required by health, dental, or vision plans participating in the
purchasing pool component program, consistent with Part 6.2
(commencing with Section 12693).
(i) Enter into contracts.
(j) Sue and be sued.
(k) Employ necessary staff.
(l) Authorize expenditures from the fund to pay program expenses
that exceed subscriber contributions, and to administer the program
as necessary.
(m) Maintain enrollment and expenditures to ensure that
expenditures do not exceed amounts available in the fund and if
sufficient funds are not available to cover the estimated cost of
program expenditures, the board shall institute appropriate measures
to increase fees paid by tribal casino employers.
(n) Issue rules and regulations, as necessary. Until January 1,
2005, any rules and regulations issued pursuant to this subdivision
may be adopted as emergency regulations in accordance with the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code).
The adoption of these regulations shall be deemed an emergency and
necessary for the immediate preservation of the public peace, health,
and safety or general welfare. The regulations shall become
effective immediately upon filing with the Secretary of State.
(o) Exercise all powers reasonably necessary to carry out the
powers and responsibilities expressly granted or imposed by this
part.
12694.09. The board shall arrange coverage for employers who pay
a fee pursuant to subdivision (c) of Section 12694.05 by establishing
and maintaining a purchasing pool for coverage of program enrollees
to enable applicants without access to affordable and comprehensive
employer-sponsored coverage to receive health benefits. The board
shall negotiate separate contracts with participating health plans
for the benefit package described in this part.
12694.10. The program shall be administered without regard to
gender, race, creed, color, sexual orientation, health status,
disability, or occupation.
12694.11. (a) Employee contributions shall be consistent with
those required pursuant to Part 6.2 (commencing with Section 12693).
(b) Health plans that are more expensive to the program than the
highest cost value package may be offered to and selected by
applicants. However, the cost to the program of those combinations
that exceeds the price to the program of the highest cost value
package shall be paid by the applicant as part of the applicable
contribution.
(c) The board shall provide a contribution discount to those
applicants who select the health plan in a geographic area that has
been designated as the Community Provider Plan. The discount shall
reduce the portion of the applicable contribution described in
subdivision (a).
12694.12. The applicable employee contribution shall be paid
concurrently with the employer fee, pursuant to subdivision (c) of
Section 12694.05. The employer may agree to pay any applicable
employee contribution.
12694.13. (a) The board shall assure that the required enrollee
copayment levels for specific benefits, including total annual
copayments, are consistent with those required pursuant to Part 6.2
(commencing with Section 12693). The board shall instruct
participating health plans to work with their provider networks to
provide for extended payment plans for enrollees utilizing a
significant number of health services for which copayments are
charged. The board shall track the number of enrollees who meet the
copayment maximum in each year and make adjustments in the amount if
a significant number of enrollees reach the copayment maximum.
(b) No deductibles or other out-of-pocket costs other than
copayments in accordance with this section shall be charged to
enrollees for health benefits.
(c) Coverage provided to enrollees shall not contain any
preexisting condition exclusion requirements.
(d) No participating health plan shall exclude any enrollee on the
basis of any actual or expected health condition or claims
experience of that enrollee or a member of that enrollee's family.
(e) There shall be no variations in rates charged to enrollees
including premiums and copayments, on the basis of any actual or
expected health condition or claims experience of any enrollee or
enrollee's family member. The only variation in rates charged to
enrollees, including copayments and premiums, that shall be permitted
is that expressly authorized by Section 12694.11.
(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) In no case shall an enrollee be required to pay more than one
thousand dollars ($1,000) per annum in out-of-pocket expenses.
12694.14. The board shall use appropriate and efficient means to
notify employees and their dependents of the availability of health
coverage from the program.
(a) The board shall assure that written enrollment information
issued or provided by the program is available to program enrollees
and applicants in each of the languages identified pursuant to
Chapter 17.5 (commencing with Section 7290) of Division 7 of Title 1
of the Government Code.
(b) The board shall assure that phone services provided to program
enrollees and applicants by the program are available in all of the
languages identified pursuant to Chapter 17.5 (commencing with
Section 7290) of Division 7 of Title 1 of the Government Code.
(c) The board shall assure that interpreter services are available
between enrollees and contracting plans. The board shall assure
that enrollees are provided information within provider network
directories of available linguistically diverse providers.
(d) The board shall assure that participating health plans provide
documentation on how they provide linguistically and culturally
appropriate services, including marketing materials, to enrollees.
12694.16. No participating health plan shall, in an area served
by the program, directly, or through an employee, agent, or
contractor, provide an applicant, or an enrollee with any marketing
material relating to benefits or rates provided under the program
unless the material has been both reviewed and approved by the board.
Chapter 5. Employer Fee
12694.17. The board shall annually determine the level of the fee
to be paid by employers who chose to participate in the program. In
determining the level of the fee, the board shall take into account
the wages of the employees for whom coverage will be purchased as
well as other relevant factors.
12694.18. The board shall provide notice to the Employment
Development Department of the amount of the fee in a time and manner
that permits the Employment Development Department to provide notice
to all employers of the estimated fee for the budget year.
Chapter 6. Participating Health Plans
12694.19. (a) The board may establish geographic areas within
which participating health plans may offer coverage to enrollees.
(b) Nothing in this section shall restrict a county organized
health system or a local initiative from providing service to program
enrollees in their licensed geographic service area.
12694.20. Participating health plans shall have, but need not be
limited to, all of the following operating characteristics
satisfactory to the board in consultation with the plan's licensing
or regulatory oversight agency:
(a) Strong financial condition, including the ability to assume
the risk of providing and paying for covered services. A
participating plan may utilize reinsurance, provider risk sharing,
and other appropriate mechanisms to share a portion of the risk.
(b) Adequate administrative management.
(c) A satisfactory grievance procedure.
(d) Participating plans or providers that contract with or employ
health care providers shall have mechanisms to accomplish all of the
following, in a manner satisfactory to the board:
(1) Review the quality of care covered.
(2) Review the appropriateness of care covered.
(3) Provide accessible health care services.
(e) (1) Before the effective date of the contract, the
participating health plan shall have devised a system for identifying
in a simple and clear fashion both in its own records and in the
medical records of enrollees the fact that the services provided are
provided under the program.
(2) Throughout the duration of the contract, the plan shall use
the system described in paragraph (1).
(f) Plans licensed by the Department of Managed Health Care shall
be deemed to meet the requirements of subdivisions (a) to (d),
inclusive, of this section.
12694.22. (a) Notwithstanding any other provision of law, the
board shall not be subject to licensure or regulation by the
Department of Insurance or the Department of Managed Health Care, as
the case may be.
(b) Participating health plans that contract with the program and
are regulated by either the Insurance Commissioner or the Department
of Managed Health Care shall be licensed and in good standing with
their respective licensing agencies. In their application to the
program, those entities shall provide assurance of their standing
with the appropriate licensing entity.
12694.23. (a) The board shall contract with a broad range of
health plans in an area, if available, to ensure that enrollees have
a choice from among a reasonable number and types of competing health
plans and providers. The board shall develop and make available
objective criteria for health plan selection and provide adequate
notice of the application process to permit all health plans and
providers a reasonable and fair opportunity to participate. The
criteria and application process shall allow participating health
plans to comply with their state and federal licensing and regulatory
obligations, except as otherwise provided in this chapter. Health
plan selection shall be based on the criteria developed by the board.
(b) (1) In its selection of participating plans the board shall
take all reasonable steps to assure the range of choices available to
each applicant shall include plans that include in their provider
networks and have signed contracts with traditional and safety net
providers.
(2) Participating health plans shall be required to submit to the
board on an annual basis a report summarizing their provider network.
The board shall give priority to those plans, on a county-by-county
basis, that demonstrate that they have included in their prospective
plan networks significant numbers of providers in these geographic
areas.
(c) In each geographic area, the board shall designate a community
provider plan that is the participating health plan which has the
highest percentage of traditional and safety net providers in its
network. Enrollees selecting such a plan shall be given an
applicable contribution discount as described in Section 12694.11.
(d) The board shall establish reasonable limits on health plan
administrative costs.
12694.24. The
board may adjust payments made to a participating health plan if the
board finds that the plan has a significantly disproportionate share
of high- or low-risk enrollees. Prior to making this finding, the
program shall obtain validated data from participating health plans.
Reporting requirements shall be administratively compatible with the
methods of operation of the health plans. Any adjustments to
payments shall utilize demographic and other factors which are
actuarially related to risk.
12694.25. The board may negotiate or arrange for stop-loss
insurance coverage that limits the program's fiscal responsibility
for the total costs of health services provided to program enrollees,
or arrange for participating health plans to share or assure the
financial risk for a portion of the total cost of health care
services to program enrollees, or both.
Chapter 7. Cost Containment
12694.26. The board shall develop and utilize appropriate cost
containment measures to maximize the cost-effectiveness of coverage
offered under the program. Those measures may include limiting the
expenditure of state funds for this purpose to the price to the state
for the lowest cost plan contracting with the program and creation
of program rules that restrict the ability of employers or applicants
to drop existing coverage in order to qualify for the program. The
board may obtain information sufficient to assist it in determining
whether the price paid for coverage is appropriate to assure access
to quality care and whether a different price may be appropriate.
Chapter 8. Enrollee Grievances and Plan Transfers
12694.27. (a) When an applicant is dissatisfied with any action
or inaction of a participating plan in which an enrollee is enrolled
through the purchasing pool, the applicant shall first attempt to
resolve the dispute with the participating plan according to its
established policies and procedures.
(b) The board shall assure that all participating health plans
make enrollees aware of the regulatory oversight available to the
applicant by the participating health plan's licensing or state
oversight entity.
(c) The board shall assure that all participating health plans
report to the board, at least once a year, the number and types of
benefit grievances filed by applicants on behalf of enrollees in the
program. This information shall be available to applicants upon
request in a format determined by the board.
12694.28. (a) Notwithstanding any other provision of this part, a
new enrollee in the program shall be allowed to switch his or her
choice of health plan once within the first three months of coverage
for any reason. Transfer of enrollment from one participating health
plan to another may otherwise be made by an enrollee at times and
under conditions as may be prescribed by regulations of the board.
(b) The board shall provide for the transfer of coverage of any
enrollee to another participating plan (1) if a contract with any
participating plan under which the enrollee receives coverage is
canceled or not renewed and (2) at least once a year upon request in
a manner as determined by the board, and (3) if a enrollee moves to
an area that the current health plan does not serve.
Chapter 9. Other Public Programs
12694.30. (a) The employer who has chosen to pay a fee to the
program shall provide information to the program regarding potential
enrollees as prescribed by the program.
(b) In no case shall the program require or permit the employer to
obtain from the potential enrollee information about the family
income or other eligibility requirements for Medi-Cal, Healthy
Families, or other public programs other than that information about
the employee's employment status otherwise known to the employer
consistent with existing state and federal law and regulation.
(c) The program shall obtain from enrollment information from
potential enrollees to be covered by the program.
(d) The enrollee shall be covered by the program from the date
that the program receives enrollment information from the enrollee.
(e) The program shall seek to assure continuity of coverage for
those enrollees continuing to be covered by the program. No enrollee
shall cease to be covered unless the program can document that the
enrollee received notice 30 days prior to the termination of
coverage.
12694.31. (a) Upon the effective date of coverage of a child
eligible for the program, the board shall arrange for payment of
providers who participate in the Child Health and Disability
Prevention Program pursuant to Article 6 (commencing with Section
124025) of Chapter 3 of Part 2 of Division 106 of the Health and
Safety Code, for well-child health assessments, immunizations, and
initial treatment provided up to 90 days prior to the effective date
of coverage.
(b) The board shall pay only for those services that are eligible
for federal financial participation under Section 2105 of Title XXI
of the Social Security Act and that are approved in the required
state plan under that title, except as specified in Section 12693.76.
(c) (1) Child Health and Disability Prevention Program providers
shall submit charges for the services under subdivision (a) on the
form or in the format specified by the department for the Child
Health and Disability Prevention Program. Those providers shall be
reimbursed at the rates established for these services by the Child
Health and Disability Prevention Program once coverage under the
program is established.
(2) Those providers shall submit charges for services reimbursable
under Medi-Cal on the form or in the format specified by the
department for Medi-Cal. Those providers shall be reimbursed at the
rates established for these services by Medi-Cal once coverage under
Medi-Cal is established.
(d) (1) The board may use the state fiscal intermediary for
Medicaid to process the payments authorized in subdivision (a).
(2) The board shall be exempt from the requirements of Chapter 7
(commencing with Section 11700) of Division 3 of Title 2 of the
Government Code and Chapter 3 (commencing with Section 12100) of Part
2 of Division 2 of the Public Contract Code as those requirements
apply to the use of contractual claims processing services by the
state fiscal intermediary.
12694.33. The following provisions apply for enrollees who have
been identified by the participating health plans as potentially
seriously emotionally disturbed.
(a) Participating plans, to the extent feasible, shall develop
memoranda of understanding, consistent with criteria established by
the board in consultation with the State Department of Mental Health,
for referral of enrollees 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 enrollees 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 Mental Health in accordance with
Sections 5705, 5716, 5718, 5720, 5724, and 5778 of the Welfare and
Institutions Code. The actual amount reimbursed by the board shall
be the federal share of the cost of the enrollee.
(c) This section shall only become operative with 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 enrollee.
12694.34. Notwithstanding any other provision of law, for an
enrollee 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 enrollee 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 enrollee.
12694.35. A child enrolled in the program who has a medical
condition that is eligible for services pursuant to the California
Children's Services Program, and whose family is not financially
eligible for the California Children's Services Program, shall have
the medically necessary treatment services for their California
Children's Services Program eligible medical condition authorized and
paid for by the California Children's Services Program. County
expenditures for the payment of services for the child shall be
waived and these expenditures shall be paid for by the state from
Title XXI funds that are applicable and state general funds.
12694.36. The board shall encourage all plans that provide
services under the program to have viable protocols for screening and
referring persons needing supplemental services outside of the scope
of the screening, preventive, and medically necessary and
therapeutic services covered by the contract to public programs
providing such supplemental services for which they may be eligible,
as well as for coordination of care between the plan and the public
programs. The public programs for which plans may be required to
develop screening, referral, and care coordination protocols may
include the California Children's Services Program, the regional
centers, county mental health programs, programs administered by the
Department of Alcohol and Drug Programs, and programs administered by
local education agencies.
Chapter 10. Administration
12694.40. A contract entered pursuant to this part shall be
exempt from any provision of law relating to competitive bidding, and
shall be exempt from the review or approval of any division of the
Department of General Services. The board shall not be required to
specify the amounts encumbered for each contract, but may allocate
funds to each contract based on the projected or actual enrollee
enrollments to a total amount not to exceed the amount appropriate
for the program including applicable contributions.
12694.41. (a) There is hereby created in the State Treasury the
Native American Tribal Casino Employee Health Fund which is,
notwithstanding Section 13340 of the Government Code, continuously
appropriated to the board for the purposes specified in this part.
(b) The board shall authorize the expenditure from the fund of any
federal funds or applicable contributions deposited into the fund.
This shall include the authority for the board to authorize the State
Department of Health Services to transfer federal funds appropriated
to the department for the program to the Native American Tribal
Casino Employee Health Board Fund, and to also deposit those funds
in, and to disburse those funds from, the Native American Tribal
Casino Employee Health Board Fund.
Chapter 11. Protection Against Substitution of Benefits
12694.45. (a) It shall constitute an unfair labor practice
contrary to public policy, and enforceable under Section 95 of the
Labor Code, for any employer to refer an individual employee or
employee's dependent to the program, or to arrange for an individual
employee or employee's dependent to apply to the program, for the
purpose of separating that employee or employee's dependent from
group health coverage provided in connection with the employee's
employment.
(b) To ensure compliance with this section, the board shall obtain
from each enrollee information about the principal employer of the
enrollee or the parent of the enrollee. amended to
read:
12693.90. (a) The board shall appoint a 16-member advisory panel
to advise the board, the chair of which may serve as an ex officio,
nonvoting member of the board. The panel shall be appointed and
ready to perform its duties by no later than February 1, 1998.
(b) The membership of the advisory panel shall be composed of all
of the following:
(1) Three representatives from the subscriber population.
(2) One physician and surgeon who is board certified in
pediatrics.
(3) One physician and surgeon who is board certified in the area
of family practice medicine.
(4) One member who is a licensed, practicing dentist.
(5) One representative from a licensed nonprofit primary care
clinic.
(6) One representative from a licensed hospital that is on the
disproportionate share list maintained by the State Department of
Health Services.
(7) One representative of the mental health provider community.
(8) One representative of the substance abuse provider community.
(9) One representative of the county public health provider
community.
(10) One representative from the education community.
(11) One representative from the health plan community.
(12) One representative from the business community.
(13) One representative from an eligible family with children with
special needs.
(14) One representative of organized labor.
(c) The advisory board members shall have demonstrated expertise
in the provision of health-related services to children aged 18 years
and under, as applicable.
(d) The advisory board members shall be composed of
representatives of the geographic, cultural, economic, and other
social factors of the state.
(e) The panel shall elect, from among its members, its chair.
(f) The panel shall have all of the following powers and duties:
(1) To advise the board on all policies, regulations, operations,
and implementation of the program.
(2) To consider all written recommendations of the panel and
respond in writing when the board rejects the advice of the panel.
(3) To meet at least quarterly, unless deemed unnecessary by the
chair.
(g) The members of the panel shall be reimbursed for all necessary
travel expenses associated with the activities of the panel.
(h) The members of the panel who represent the subscriber
population may receive per diem compensation if they are otherwise
economically unable to meet panel responsibilities.