Bill Text: CA SB1098 | 2015-2016 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: dental services: utilization rate: report.

Spectrum:

Status: (Passed) 2016-09-25 - Chaptered by Secretary of State. Chapter 630, Statutes of 2016. [SB1098 Detail]

Download: California-2015-SB1098-Introduced.html

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BILL NUMBER: SB 1098	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Cannella

                        FEBRUARY 17, 2016

   An act to amend Section 14089 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1098, as introduced, Cannella. Medi-Cal: geographic managed
care.
   Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income persons. The
Medi-Cal program is, in part, governed and funded by federal Medicaid
provisions. Existing law authorizes the department to provide health
care services to beneficiaries through various models of managed
care, including through a comprehensive program of managed health
care plan services for Medi-Cal recipients residing in clearly
defined geographical areas. Existing law specifies guidelines the
department is required to follow in selecting and entering into
contracts with managed care plans. Existing law requires the
department to give an eligible beneficiary specified notices for the
purpose of assisting the beneficiary in choosing a managed care plan,
and imposes requirements on the beneficiary and the department
regarding choice of, and enrollment in, a managed care plan.
   This bill would make technical, nonsubstantive changes to those
provisions.
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 14089 of the Welfare and Institutions Code is
amended to read:
   14089.  (a) The purpose of this article is to provide a
comprehensive program of managed health care plan services to
Medi-Cal recipients residing in clearly defined geographical areas.
It  is, further,   is further  the purpose
of this article to create maximum accessibility to health care
services by permitting Medi-Cal recipients the option of choosing
from among two or more managed health care plans or fee-for-service
managed case arrangements, including, but not limited to, health
maintenance organizations, prepaid health plans, and primary care
case management plans. Independent practice associations, health
insurance carriers, private foundations, and university medical
centers systems, not-for-profit clinics, and other primary care
providers, may be offered as choices to Medi-Cal recipients under
this article if they are organized and operated as managed care
plans, for the provision of preventive managed health care plan
services.
   (b) The department may seek proposals and then shall enter into
contracts based on relative costs, extent of coverage offered,
quality of health services to be provided, financial stability of the
health care plan or carrier, recipient access to services,
cost-containment strategies, peer and community participation in
quality control, emphasis on preventive and managed health care
services and the ability of the health plan to meet all requirements
for both of the following:
   (1) Certification, where legally required, by the Director of the
Department of Managed Health Care and the Insurance Commissioner.
   (2) Compliance with all of the following:
   (A) The health plan shall satisfy  all 
applicable state and federal legal requirements for participation as
a Medi-Cal managed care contractor.
   (B) The health plan shall meet  any  standards
established by the department for the implementation of this article.

   (C) The health plan receives the approval of the department to
participate in the pilot project under this article.
   (c) (1) (A) The proposals shall be for the provision of preventive
and managed health care services to specified eligible populations
on a capitated, prepaid, or postpayment basis.
   (B) Enrollment in a Medi-Cal managed health care plan under this
article shall be voluntary for beneficiaries eligible for the federal
Supplemental Security Income for the Aged, Blind, and Disabled
Program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of
Title 42 of the United States Code).
   (2) The cost of each program established under this section shall
not exceed the total amount that the department estimates it would
pay for all services and requirements within the same geographic area
under the fee-for-service Medi-Cal program.
   (d) (1) An eligible beneficiary shall be entitled to enroll in any
health care plan contracted for pursuant to this article that is in
effect for the geographic area in which he or she resides. The
department shall make available to recipients information summarizing
the benefits and limitations of each health care plan available
pursuant to this section in the geographic area in which the
recipient resides. A Medi-Cal or CalWORKs applicant or beneficiary
shall be informed of the health care options available regarding
methods of receiving Medi-Cal benefits. The county shall ensure that
each beneficiary is informed of these options and informed that a
health care options presentation is available.
   (2) No later than 30 days following the date a Medi-Cal or
CalWORKs recipient is informed of the health care options described
in paragraph (1), the recipient shall indicate his or her choice, in
writing, of one of the available health care plans and his or her
choice of primary care provider or clinic contracting with the
selected health care plan. Notwithstanding the 30-day deadline set
forth in this paragraph, if a beneficiary requests a directory for
the entire service area within 30 days of the date of receiving an
enrollment form, the deadline for choosing a plan shall be extended
an additional 30 days from the date of that request.
   (3) The health care options information described in this
subdivision shall include the following elements:
   (A) Each beneficiary or eligible applicant shall be provided, at a
minimum, with the name, address, telephone number, and specialty, if
any, of each primary care provider, by specialty or clinic
participating in each managed health care plan option through a
personalized provider directory for that beneficiary or applicant.
This information shall be presented under the geographic area
designations by the name of the primary care provider and clinic, and
shall be updated based on information electronically provided
monthly by the health care plans to the department, setting forth
changes in the health care plan provider network. The geographic
areas shall be based on the applicant's residence address, the minor
applicant's school address, the applicant's work address, or any
other factor deemed appropriate by the department, in consultation
with health plan representatives, legislative staff, and consumer
stakeholders. In addition, directories of the entire service area,
including, but not limited to, the name, address, and telephone
number of each primary care provider and hospital, of all Geographic
Managed Care health plan provider networks shall be made available to
beneficiaries or applicants who request them from the health care
options contractor. Each personalized provider directory shall
include information regarding the availability of a directory of the
entire service area, provide telephone numbers for the beneficiary to
request a directory of the entire service area, and include a
postage-paid mail card to send for a directory of the entire service
area. The personalized provider directory shall be implemented as a
pilot project in Sacramento County pursuant to this article, and in
Los Angeles County (Two-Plan Model) pursuant to Article 2.7
(commencing with Section  14087.305).  
14087.3).  The content, form, and geographic areas used shall be
determined by the department in consultation with a workgroup to
include health plan representatives, legislative staff, and consumer
stakeholders, with an emphasis on the inclusion of stakeholders from
Los Angeles and Sacramento Counties. The personalized provider
directories may include a section for each health plan. Prior to
implementation of the pilot project, the department, in consultation
with consumer stakeholders, legislative staff, and health plans,
shall determine the parameters, methodology, and evaluation process
of the pilot project. The pilot project shall thereafter be in effect
for a minimum of two years. Following two years of operation as a
pilot project in two counties, the department, in consultation with
consumer stakeholders, legislative staff, and health plans, shall
determine whether to implement personalized provider directories as a
permanent program statewide. If necessary, the pilot project shall
continue beyond the initial two-year period until this determination
is made. This pilot project shall only be implemented to the extent
that it is budget neutral to the department.
   (B) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating
provider is a primary care provider or clinic contracting with any of
the health plans available and has the available capacity and agrees
to continue to treat that beneficiary or eligible applicant.
   (C) Each beneficiary or eligible applicant shall be informed that
if he or she fails to make a choice, he or she shall be assigned to,
and enrolled in, a health care plan.
   (4) At the time the beneficiary or eligible applicant selects a
health care plan, the department shall, when applicable, encourage
the beneficiary or eligible applicant to also indicate, in writing,
his or her choice of primary care provider or clinic contracting with
the selected health care plan.
   (5) Commencing with the implementation of a geographic managed
care project in a designated county, a Medi-Cal or CalWORKs
beneficiary who does not make a choice of health care plans in
accordance with paragraph (2), shall be assigned to and enrolled in
an appropriate health care plan providing service within the area in
which the beneficiary resides.
   (6) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select a primary care
provider who is available, the health care plan selected by or
assigned to the beneficiary shall ensure that the beneficiary selects
a primary care provider or clinic within 30 days after enrollment or
is assigned to a primary care provider within 40 days after
enrollment.
   (7) A Medi-Cal or CalWORKs beneficiary dissatisfied with the
primary care provider or health care plan shall be allowed to select
or be assigned to another primary care provider within the same
health care plan. In addition, the beneficiary shall be allowed to
select or be assigned to another health care plan contracted for
pursuant to this article that is in effect for the geographic area in
which he or she resides in accordance with Section 1903(m)(2)(F)(ii)
of the Social Security Act.
   (8) The department or its contractor shall notify a health care
plan when it has been selected by or assigned to a beneficiary. The
health care plan that has been selected or assigned by a beneficiary
shall notify the primary care provider that has been selected or
assigned. The health care plan shall also notify the beneficiary of
the health care plan and primary care provider selected or assigned.
   (9) This section shall be implemented in a manner consistent with
any federal waiver that is required to be obtained by the department
to implement this section.
   (e) A participating county may include within the plan or plans
providing coverage pursuant to this section, employees of county
government, and others who reside in the geographic area and who
depend upon county funds for all or part of their health care costs.
   (f) Funds may be provided to prospective contractors to assist in
the design, development, and installation of appropriate programs.
The award of these funds shall be based on criteria established by
the department.
   (g) In implementing this article, the department may enter into
contracts for the provision of essential administrative and other
services. Contracts entered into under this subdivision may be on a
noncompetitive bid basis and shall be exempt from Chapter 2
(commencing with Section 10290) of Part 2 of Division 2 of the Public
Contract Code.
   (h) Notwithstanding any other  provision of  law,
on and after the effective date of the act adding this subdivision,
the department shall have exclusive authority to set the rates,
terms, and conditions of geographic managed care contracts and
contract amendments under this article. As of that date, all
references to this article to the negotiator or to the California
Medical Assistance Commission shall be deemed to mean the department.

   (i) Notwithstanding subdivision (q) of Section 6254 of the
Government Code, a contract or contract amendments executed by both
parties after the effective date of the act adding this subdivision
shall be considered a public record for purposes of the California
Public Records Act (Chapter 3.5 (commencing with Section 6250) of
Division 7 of Title 1 of the Government Code) and shall be disclosed
upon request. This subdivision includes contracts that reveal the
department's rates of payment for health care services, the rates
themselves, and rate manuals.