I have attached a copy (on which I have also provided comments) of California Assembly Constitutional Amendment (ACA) No. 11 (Kalra), January 5, 2022, which is “A resolution to propose to the people of the State of California an amendment to the Constitution of the State” to “impose an excise tax, payroll taxes, and a State Personal Income CalCare Tax . . . to fund comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of every resident of the state, as well as reserves deemed necessary to ensure payment, to be established in statute. The measure would [also] authorize the Legislature, upon an economic analysis determining insufficient amounts to fund these purposes, to increase any or all of these tax rates by a statute passed by majority vote of both houses of the Legislature.”
Obviously, health care, health care coverage (what care is provided and covered, or not), health care access, and health care costs are issues and can cause personal, financial, health, life and death, and quality of life uncertainties, concerns and problems for a lot of people (i.e., perhaps for most people). And these are issues that have been in the news and politics or politicized for years, and will continue to be so. Improvements are needed. I’m all ears if someone has solutions or improvements, and provides the details for evaluation. A risk management approach is needed, in my view. I have attached a copy of ACA No. 11 (Kalra) with some of my initial comments which are from a risk management approach – responses and answers from the Legislators would be helpful and constructive for dialogue and evaluation. Below I have also provided a link to a useful article in the L.A. Times, which discusses some of the issues and problems, and what else needs to happen. And, I have also provided a link to California AB-1400, which is the legislation that contains some of the information about what the proposed health care system might and might not provide and cover, and how it might or might not work.
See also the blog post with my risk management process slide – https://ihaveadifferentview.com/2021/09/10/updated-simple-risk-management-and-related-decision-making-process-slide/
Here is the link to the L. A. Times article – it’s a useful article and provides additional information – https://www.yahoo.com/news/california-democrats-trying-again-universal-130011668.html
The following is a link to California AB-1400 Guaranteed Health Care for All – this is the legislation that contains the detail about what the health care would cover, or not, and how it would be run and operated, or not. However, even that information is broad and general, and lacks specifics. In other words, neither the elected legislator representatives who are voting on this and related legislation, or anyone else, know what will or will not be covered, what it will cost (and those costs are guaranteed to rise), or how it will be run and be operated. Note, for example, Chapter 4 (copied and pasted below) provides the detail about what benefits are covered – for my preference, this is way too general and lacking in detail. Again, I’m all ears for improvements – but let’s get the detail resolved instead of doing legislature as normal. Or, have each legislator tell us what she or he believes, in detail, will be covered and what it will cost now and in the future years.
Here is the link to California AB-1400 – https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220AB1400
Here is a copy and paste of AB-1400, Chapter 4, re benefits and coverage, or not, including section 100627(d) at the very end discussing “Coverage decision” and “Disputed health care item or service” definitions and situations:
CHAPTER 4. Benefits
100625. (a) Individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to a participating provider for the health care items and services in subdivision (c), if medically necessary or appropriate for the maintenance of health or for the prevention, diagnosis, treatment, or rehabilitation of a health condition.
(b) The determination of medical necessity or appropriateness shall be made by the member’s treating physician or by a health care professional who is treating that individual and is authorized to make that determination in accordance with the scope of practice, licensing, the program standards established in Chapter 6 (commencing with Section 100650) and by the board, and other laws of the state.
(c) Covered health care benefits for members include all of the following categories of health care items and services:
(1) Inpatient and outpatient medical and health facility services, including hospital services and 24-hour-a-day emergency services.
(2) Inpatient and outpatient health care professional services and other ambulatory patient services.
(3) Primary and preventive services, including chronic disease management.
(4) Prescription drugs and biological products.
(5) Medical devices, equipment, appliances, and assistive technology.
(6) Mental health and substance abuse treatment services, including inpatient and outpatient care.
(7) Diagnostic imaging, laboratory services, and other diagnostic and evaluative services.
(8) Comprehensive reproductive, maternity, and newborn care.
(10) Oral health, audiology, and vision services.
(11) Rehabilitative and habilitative services and devices, including inpatient and outpatient care.
(12) Emergency services and transportation.
(13) Early and periodic screening, diagnostic, and treatment services as defined in Section 1396d(r) of Title 42 of the United States Code.
(14) Necessary transportation for health care items and services for persons with disabilities or who may qualify as low income.
(15) Long-term services and supports described in Section 100626, including long-term services and supports covered under Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code) or the federal Children’s Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.))
(16) Any additional health care items and services the board authorizes to be added to CalCare benefits.
(d) The categories of covered health care items and services under subdivision (c) include all the following:
(1) Prosthetics, eyeglasses, and hearing aids and the repair, technical support, and customization needed for their use by an individual.
(2) Child and adult immunizations.
(3) Hospice care.
(4) Care in a skilled nursing facility.
(5) Home health care, including health care provided in an assisted living facility.
(6) Prenatal and postnatal care.
(7) Podiatric care.
(8) Blood and blood products.
(10) Community-based adult services as defined under Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code as of January 1, 2021.
(11) Dietary and nutritional therapies determined appropriate by the board.
(12) Therapies that are shown by the National Center for Complementary and Integrative Health in the National Institutes of Health to be safe and effective, including chiropractic care and acupuncture.
(13) Health care items and services previously covered by county integrated health and human services programs pursuant to Chapter 12.96 (commencing with Section 18990) and Chapter 12.991 (commencing with Section 18991) of Part 6 of Division 9 of the Welfare and Institutions Code.
(14) Health care items and services previously covered by a regional center for persons with developmental disabilities pursuant to Chapter 5 (commencing with Section 4620) of Division 4.5 of the Welfare and Institutions Code.
(15) Language interpretation and translation for health care items and services, including sign language and braille or other services needed for individuals with communication barriers.
(e) Covered health care items and services under CalCare include all health care items and services required to be covered under the following provisions, without regard to whether the member would be eligible for or covered by the source referred to:
(1) The federal Children’s Health Insurance Program (Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.)).
(2) Medi-Cal (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(3) The federal Medicare program pursuant to Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(4) Health care service plans pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
(5) Health insurers, as defined in Section 106 of the Insurance Code, pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code.
(6) All essential health benefits mandated by the federal Patient Protection and Affordable Care Act as of January 1, 2017.
(f) Health care items and services covered under CalCare shall not be subject to prior authorization or a limitation applied through the use of step therapy protocols.
100626. (a) Subject to the other provisions of this title, individuals enrolled for benefits under CalCare are entitled to have payment made by CalCare to an eligible provider for long-term services and supports, in accordance with the standards established in this title, for care, services, diagnosis, treatment, rehabilitation, or maintenance of health related to a medically determinable condition, whether physical or mental, of health, injury, or age, that either:
(1) Causes a functional limitation in performing one or more activities of daily living or in instrumental activities of daily living.
(2) Is a disability, as defined in Section 12102(1)(A) of Title 42 of the United States Code, that substantially limits one or more of the member’s major life activities.
(b) The board shall adopt regulations that provide for the following:
(1) The determination of individual eligibility for long-term services and supports under this section.
(2) The assessment of the long-term services and supports needed for an eligible individual.
(3) The automatic entitlement of an individual who receives or is approved to receive disability benefits from the federal Social Security Administration under the federal Social Security Disability Insurance program established in Title II or Title XVI of the federal Social Security Act to the long-term services and supports under this section.
(c) Long-term services and supports provided pursuant to this section shall do all of the following:
(1) Include long-term nursing services for a member, whether provided in an institution or in a home- and community-based setting.
(2) Provide coverage for a broad spectrum of long-term services and supports, including home- and community-based services, other care provided through noninstitutional settings, and respite care.
(3) Provide coverage that meets the physical, mental, and social needs of a member while allowing the member the member’s maximum possible autonomy and the member’s maximum possible civic, social, and economic participation.
(4) Prioritize delivery of long-term services and supports through home- and community-based services over institutionalization.
(5) Unless a member chooses otherwise, ensure that the member receives home- and community-based long-term services and supports regardless of the recipient’s type or level of disability, service need, or age.
(6) Have the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the member’s needs.
(7) Be provided in a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity.
(8) Provide long-term services and supports that are of equal quality and equitably accessible across geographic regions.
(9) Ensure that long-term services and supports provide recipients the option of self-direction of service, including under the Self-Directed Services Program described in Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code, from either the recipient or care coordinators of the recipient’s choosing.
(d) In developing regulations to implement this section, the board shall consult the advisory commission established pursuant to Section 100614.
(a) (1) The board shall, on a regular basis and at least annually, evaluate whether the benefits under CalCare should be expanded or adjusted to promote the health of members and California residents, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science.
(2) In implementing this section, the board shall not remove or eliminate covered health care items and services under CalCare that are listed in this chapter.
(b) The board shall establish a process by which health care professionals, other clinicians, and members may petition the board to add or expand benefits to CalCare.
(c) The board shall establish a process by which individuals may bring a disputed health care item or service or a coverage decision for review to the Independent Medical Review System established in the Department of Managed Health Care pursuant to Article 5.55 (commencing with Section 1374.30) of Chapter 2.2 of Division 2 of the Health and Safety Code.
(d) For the purposes of this chapter:
(1) “Coverage decision” means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A “coverage decision” does not encompass a decision regarding a disputed health care item or service.
(2) “Disputed health care item or service” means a health care item or service eligible for coverage and payment under CalCare that has been denied, modified, or delayed by a decision of a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for health care items and services furnished under CalCare from a participating provider, in whole or in part, due to a finding that the service is not medically necessary or appropriate. A decision regarding a disputed health care item or service relates to the practice of medicine, including early discharge from an institutional provider, and is not a coverage decision.
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Best to you. David Tate, Esq. (and inactive CPA)
Remember, every case and situation is different. It is important to obtain and evaluate all of the evidence that is available, and to apply that evidence to the applicable standards and laws. You do need to consult with an attorney and other professionals about your particular situation. This post is not a solicitation for legal or other services inside of or outside of California, and, of course, this post only is a summary of information that changes from time to time, and does not apply to any particular situation or to your specific situation. So . . . you cannot rely on this post for your situation or as legal or other professional advice or representation.
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