Robert F. Kennedy Farm Workers Medical Plan.

Assembly Member Ortega’s AB 499 would recalibrate the Robert F. Kennedy Farm Workers Medical Plan’s state reimbursement framework by lowering the per-episode eligibility threshold from $70,000 to $50,000 while preserving a $3 million annual cap, and by introducing a formal, CPA-verified data reporting and reimbursement process that runs on a defined annual cycle and carries a sunset date in early 2031.

Under the bill, the state would annually reimburse the plan for claim payments that exceed $50,000 per eligible employee or dependent for a single episode of care, with a cap of $3 million per year. Beginning after September 1, 2017, the plan must submit to the Department of Health Care Services completed data, verified by an independent certified public accountant, covering claims paid during the prior year from September 1 to August 31. If the department receives the data, it must analyze it to determine the total of claims exceeding $50,000, and reimburse the plan the determined amount no later than 60 days after data receipt, up to the annual cap.

The bill formalizes the reimbursement process and data workflow, creating a defined sequence: CPA-verified annual data submission, department analysis of eligible high-cost claims, and a 60-day payment timeline that is constrained by the $3 million cap. The annual data cycle and reimbursement timing are tied to a September–August reporting period, and the provision is set to expire on January 1, 2031 unless extended by later statute.

Fiscal and implementation considerations accompany the policy changes. The measure does not itself designate a new appropriation, leaving funding to the normal budgeting process, while creating ongoing administrative duties for both the RFK Plan and the department, including CPA verification of data and department-led analyses. Data specifications and definitions of a “single episode of care” are not detailed in the bill, suggesting that regulatory guidance may be needed to operationalize the framework. The sunset date provides a built-in expiration unless extended. The policy engages stakeholders—primarily the RFK Plan and its eligible members—through a more formal reimbursement mechanism and clearer reporting obligations, while preserving the overarching structure of state support through 2031 subject to extension.