Amended IN Assembly May 01, 2019 Amended IN Assembly March 18, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 1249Introduced by Assembly Member MaienscheinFebruary 21, 2019 An act to add and repeal Section 1343.3 to the Health and Safety Code, relating to health care service plans. LEGISLATIVE COUNSEL'S DIGESTAB 1249, as amended, Maienschein. Health care service plans: regulations: exemptions. Existing federal law defines a voluntary employees beneficiary association as an organization comprised composed of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries. Existing federal law also provides for a trust fund established by a representative of an employers employees for the sole and exclusive benefit of the employees and their families and dependents.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also act and authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate. Existing law also exempts a health care service plan operated by a city, county, city and county, public entity, political subdivision, or public joint labor management trust that satisfies certain criteria, including that the plan requires providers to be reimbursed solely on a fee-for-service basis.This bill would require the director, by May 1, 2020, to authorize 2 pilot programs, one in northern California and one in southern California, under which a voluntary employees beneficiary association with enrollment of more than 100,000 lives, notwithstanding the fee-for-service requirement described above, or a trust fund as described above, would be exempt from licensure under the act for a period of 5 years, if the association or trust fund has entered into one or more contracts with a health care provider that uses risk-based or global risk payment and meets other criteria, including that the provider is registered with the department as a risk-based organization or limited or restricted licensee. The bill would require the association or trust fund and each health care provider participating in each pilot program to report to the department information regarding cost savings and clinical patient outcomes compared to a fee-for-service payment model, and would require the department to report those findings to the Legislature by June 1, 2026. The bill would repeal these provisions on January 1, 2029.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1343.3 is added to the Health and Safety Code, to read:1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
Amended IN Assembly May 01, 2019 Amended IN Assembly March 18, 2019 CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 1249Introduced by Assembly Member MaienscheinFebruary 21, 2019 An act to add and repeal Section 1343.3 to the Health and Safety Code, relating to health care service plans. LEGISLATIVE COUNSEL'S DIGESTAB 1249, as amended, Maienschein. Health care service plans: regulations: exemptions. Existing federal law defines a voluntary employees beneficiary association as an organization comprised composed of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries. Existing federal law also provides for a trust fund established by a representative of an employers employees for the sole and exclusive benefit of the employees and their families and dependents.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also act and authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate. Existing law also exempts a health care service plan operated by a city, county, city and county, public entity, political subdivision, or public joint labor management trust that satisfies certain criteria, including that the plan requires providers to be reimbursed solely on a fee-for-service basis.This bill would require the director, by May 1, 2020, to authorize 2 pilot programs, one in northern California and one in southern California, under which a voluntary employees beneficiary association with enrollment of more than 100,000 lives, notwithstanding the fee-for-service requirement described above, or a trust fund as described above, would be exempt from licensure under the act for a period of 5 years, if the association or trust fund has entered into one or more contracts with a health care provider that uses risk-based or global risk payment and meets other criteria, including that the provider is registered with the department as a risk-based organization or limited or restricted licensee. The bill would require the association or trust fund and each health care provider participating in each pilot program to report to the department information regarding cost savings and clinical patient outcomes compared to a fee-for-service payment model, and would require the department to report those findings to the Legislature by June 1, 2026. The bill would repeal these provisions on January 1, 2029.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
Amended IN Assembly May 01, 2019 Amended IN Assembly March 18, 2019
Amended IN Assembly May 01, 2019
Amended IN Assembly March 18, 2019
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION
Assembly Bill No. 1249
Introduced by Assembly Member MaienscheinFebruary 21, 2019
Introduced by Assembly Member Maienschein
February 21, 2019
An act to add and repeal Section 1343.3 to the Health and Safety Code, relating to health care service plans.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 1249, as amended, Maienschein. Health care service plans: regulations: exemptions.
Existing federal law defines a voluntary employees beneficiary association as an organization comprised composed of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries. Existing federal law also provides for a trust fund established by a representative of an employers employees for the sole and exclusive benefit of the employees and their families and dependents.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also act and authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate. Existing law also exempts a health care service plan operated by a city, county, city and county, public entity, political subdivision, or public joint labor management trust that satisfies certain criteria, including that the plan requires providers to be reimbursed solely on a fee-for-service basis.This bill would require the director, by May 1, 2020, to authorize 2 pilot programs, one in northern California and one in southern California, under which a voluntary employees beneficiary association with enrollment of more than 100,000 lives, notwithstanding the fee-for-service requirement described above, or a trust fund as described above, would be exempt from licensure under the act for a period of 5 years, if the association or trust fund has entered into one or more contracts with a health care provider that uses risk-based or global risk payment and meets other criteria, including that the provider is registered with the department as a risk-based organization or limited or restricted licensee. The bill would require the association or trust fund and each health care provider participating in each pilot program to report to the department information regarding cost savings and clinical patient outcomes compared to a fee-for-service payment model, and would require the department to report those findings to the Legislature by June 1, 2026. The bill would repeal these provisions on January 1, 2029.
Existing federal law defines a voluntary employees beneficiary association as an organization comprised composed of a voluntary association of employees that provides for the payment of life, sick, accident, or similar benefits to members or their dependents, or designated beneficiaries. Existing federal law also provides for a trust fund established by a representative of an employers employees for the sole and exclusive benefit of the employees and their families and dependents.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes the willful violation of the act a crime. Existing law exempts specified persons or plans from the requirements of the act, including persons organized and operating pursuant to a certificate issued by the Insurance Commissioner, as specified. Existing law also act and authorizes the Director of the Department of Managed Health Care to exempt additional specified persons or plans if the director finds, among other things, that the exemption is in the public interest. Under existing law, upon the request of the Director of Health Care Services, the director must exempt a county-operated pilot program contracting with the State Department of Health Care Services, and may exempt a noncounty-operated pilot program, or a mental health plan contractor, subject to any conditions the Director of Health Care Services deems appropriate. Existing law also exempts a health care service plan operated by a city, county, city and county, public entity, political subdivision, or public joint labor management trust that satisfies certain criteria, including that the plan requires providers to be reimbursed solely on a fee-for-service basis.
This bill would require the director, by May 1, 2020, to authorize 2 pilot programs, one in northern California and one in southern California, under which a voluntary employees beneficiary association with enrollment of more than 100,000 lives, notwithstanding the fee-for-service requirement described above, or a trust fund as described above, would be exempt from licensure under the act for a period of 5 years, if the association or trust fund has entered into one or more contracts with a health care provider that uses risk-based or global risk payment and meets other criteria, including that the provider is registered with the department as a risk-based organization or limited or restricted licensee. The bill would require the association or trust fund and each health care provider participating in each pilot program to report to the department information regarding cost savings and clinical patient outcomes compared to a fee-for-service payment model, and would require the department to report those findings to the Legislature by June 1, 2026. The bill would repeal these provisions on January 1, 2029.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1343.3 is added to the Health and Safety Code, to read:1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1343.3 is added to the Health and Safety Code, to read:1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
SECTION 1. Section 1343.3 is added to the Health and Safety Code, to read:
### SECTION 1.
1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.(A)The health care provider utilizes risk-based or global risk payment.(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.(B) A delegation agreement.(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.(ii) Basic health care services.(iii) Prescription drug benefits.(iv) Continuity of care.(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.(vi) Language assistance programs.(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.(viii) Prohibitions against deceptive marketing.(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.(x) Mechanisms for resolving provider disputes.(xi) Requirements regarding utilization review or utilization management.(3)(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.(4)(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.(5)(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.(b)(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.(c)(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.
1343.3. (a) The director, by May 1, 2020, shall authorize one pilot program in northern California, and one pilot program in southern California, under which a voluntary employees beneficiary association, as defined in Section 501(c)(9) of Title 26 of the United States Code, Code or in Section 1349.2, notwithstanding paragraph (3) of subdivision (a) of Section 1349.2, with enrollment of greater than 100,000 lives, or a trust fund described in Section 186(c)(5) to (8), inclusive, of Title 29 of the United States Code, shall be exempt from this chapter for the period of January 1, 2021, to December 31, 2025, inclusive, if all of the following criteria are met:
(1) The purpose of the pilot program is to demonstrate the control of costs for health care services and the improvement of health outcomes and quality of service when compared against a sole fee-for-service provider reimbursement model.
(2) The voluntary employees beneficiary association or trust fund has entered into a contract with one or more health care providers that meet all of the following: providers under which each provider agrees to accept risk-based or global risk payment from the voluntary employees beneficiary association or trust fund.
(A)The health care provider utilizes risk-based or global risk payment.
(B)The health care provider is currently registered with the department, or will become registered through the pilot program application, as a risk-bearing organization, limited licensee, or restricted licensee.
(C)The health care provider agrees to report on any payments within the normal course of reporting made by the provider to the department on a quarterly and annual basis.
(3) Each risk-bearing provider is registered as a risk-bearing organization pursuant to Section 1375.4 and applicable department regulations if the provider accepts professional capitation.
(4) Each global risk-bearing provider holds or agrees to obtain a limited or restricted license pursuant to Section 1349 or 1351 or Section 1300.49 of Title 28 of the California Code of Regulations.
(5) Each risk-bearing provider continues to comply with applicable financial solvency standards and audit requirements under this chapter, including, but not limited to, financial reporting on a quarterly basis, during the term of the pilot program.
(6) The contract between the voluntary employees beneficiary association or trust fund and each health care provider includes all of the following:
(A) Provisions dividing financial responsibility between the parties and defining which party is financially responsible for services rendered.
(B) A delegation agreement.
(C) Provisions regarding the process by which each party will determine the appropriateness of all of the following:
(i) Assurances that the risk-based organization, limited licensee, or restricted licensee, as applicable, has the organizational and administrative capacity to provide services to covered employees, and that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management.
(ii) Basic health care services.
(iii) Prescription drug benefits.
(iv) Continuity of care.
(v) Standards for network adequacy and timely access to care, including, but not limited to, access to specialty care.
(vi) Language assistance programs.
(vii) Procedures for filing consumer grievances and appeals, including, but not limited to, independent medical review.
(viii) Prohibitions against deceptive marketing.
(ix) Requirements regarding the submission of claims by providers and the timely processing of provider claims.
(x) Mechanisms for resolving provider disputes.
(xi) Requirements regarding utilization review or utilization management.
(3)
(7) The term of each contract between the voluntary employees beneficiary association or trust fund and a health care provider does not exceed the period of the pilot program.
(4)
(8) Each health care provider that has entered into a contract with the voluntary employees beneficiary association or trust fund is a party to the pilot program application submitted to the department. The application shall include a copy of each contract between the voluntary employees beneficiary association or trust fund and a participating health care provider.
(5)
(9) (A) The voluntary employees beneficiary association or trust fund and each health care provider participating in the pilot program agree to collect and report to the department, in each year of the pilot program, information regarding the comparative cost savings when compared to fee-for-service payment and payment, performance measurements for clinical patient outcomes. outcomes, and any other information required by the department.
(B) The department may authorize a public or private agency to receive the information specified in this paragraph and monitor the pilot project under the data standard applicable to an accountable care organization.
(b) This section does not exempt a health care provider that contracts with a voluntary employees beneficiary association or trust fund as part of a pilot program authorized by subdivision (a) from the financial solvency requirements of Section 1375.4 and related department regulations, Section 1349 or 1351, or Section 1300.49 of Title 28 of the California Code of Regulations, as applicable.
(b)
(c) The department, after the termination of both pilot programs, and before June 1, 2026, shall submit a report to the Legislature regarding the costs and clinical patient outcomes of the pilot programs compared to fee-for-service payment models. This report shall be submitted in compliance with Section 9795 of the Government Code.
(c)
(d) This section shall remain in effect only until January 1, 2029, and as of that date is repealed.