Bill Text: CA SB1236 | 2009-2010 | Regular Session | Amended
Bill Title: Medi-Cal: utilization controls.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Engrossed - Dead) 2010-08-13 - Set, second hearing. Held in committee and under submission. [SB1236 Detail]
Download: California-2009-SB1236-Amended.html
BILL NUMBER: SB 1236 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 10, 2010
AMENDED IN SENATE MAY 20, 2010
AMENDED IN SENATE APRIL 21, 2010
INTRODUCED BY Senator Alquist
(Coauthor: Assembly Member Beall)
FEBRUARY 19, 2010
An act to add and repeal Section 14133.55 of the Welfare and
Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 1236, as amended, Alquist. Medi-Cal: utilization controls.
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 establishes a program in Alameda County in which
utilization controls shall not be required when, pursuant to federal
law under the Medicare Program, a county hospital based utilization
review committee has been established to determine the level of
authorization for payment under Medi-Cal and a utilization plan has
been filed with, and approved by, the department.
This bill would establish a program, whereby state utilization
controls shall not be required for inpatient hospitalization
at hospital services provided by designated
public hospitals, as defined, with participation being optional for
each hospital. The bill would require the department to consult with
designated public hospitals in the development of the program.
The bill would require the nonfederal share of expenditures
for inpatient hospitalization at designated public hospitals
submitted to the federal Centers for Medicare and Medicaid Services
for purposes of claiming federal financial participation pursuant to
the above-described provisions to be comprised of only those funds
that are paid and certified by designated public hospitals in
accordance with applicable state and federal requirements. The bill
would, to the extent the program increases the net costs to the
state, require the participating designated public hospitals to agree
to pay the state's additional administrative costs through an
intergovernmental transfer of funds. This bill would
require the department, as part of the above-described program, to
seek any necessary federal approvals, including waivers and state
plan amendments, for an alternative utilization control system, as
specified. The bill would provide that an alternative utilization
control system established for inpatient hospital services shall
apply only to the extent that the nonfederal share of expenditures
for the services is incurred by the designated public hospital or
governmental entity with which it is affiliated, or is otherwise
funded with public funds that are transferred to the state from the
hospital or governmental entity.
This bill would provide that the above-described provisions shall
become inoperative on the date the Director of Health Care Services
executes a declaration specifying that either the
nonfederal share of expenditures for inpatient hospitalization at
designated public hospitals used for purposes of claiming federal
financial participation is not comprised of funds that are paid and
certified by designated public hospitals in accordance with
applicable state and federal requirements or the above-described
program will result in increased costs to the General Fund .
This bill would require the department to seek any necessary
federal approvals, including waivers and state plan amendments, for
implementing the above-described program, as specified.
Under existing law, one of the utilization controls to which
services are subject under the Medi-Cal program is the treatment
authorization request (TAR) process, which is approval by a
department consultant of a specified service in advance of the
rendering of that service based upon a determination of medical
necessity. Existing law requires the department to pursue additional
means to improve and streamline the TAR process.
In addition to the above-described program providing designated
public hospitals with the option of not using state utilization
controls, the bill would authorize the department to utilize any
process or program, including any pilot project, that is established
or authorized pursuant to the above-described provisions authorizing
the department to pursue additional means to improve and streamline
the TAR process, that is modified or developed to meet the needs of
the particular designated public hospital.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14133.55 is added to the Welfare and
Institutions Code, to read:
14133.55. (a) (1) There shall be
established a program whereby state utilization controls shall not be
required for inpatient hospitalization at
hospital services provided by designated public hospitals, as
defined in subdivision (d) of Section 14166.1. The
14166.1. The department shall consult with designated
public hospitals in the development of the program established
pursuant to this subdivision. Each designated public hospital shall
have the option to participate in the program established pursuant to
this subdivision.
(2) (A) In addition to the program established pursuant to
paragraph (1), the department may utilize any process or program,
including any pilot project, established or authorized pursuant to
Section 14133.01, that is modified or developed to meet the needs of
the particular designated public hospital.
(B) In utilizing a process or program pursuant to subparagraph
(A), the department shall consult with a designated public hospital
choosing to participate in that process or program.
(b) The As part of the program established
pursuant to subdivision (a), the department shall seek any
necessary federal approvals, including waivers and state plan
amendments, for implementing the program established
pursuant to subdivision (a) in a manner an alternative
utilization control system that will comply with applicable
federal Medicaid requirements and allow designated public hospitals
to obtain federal financial participation for inpatient
hospitalization at hospital services provided by
designated public hospitals.
(c) The nonfederal share of expenditures for inpatient
hospitalization at designated public hospitals submitted to the
federal Centers for Medicare and Medicaid Services for purposes of
claiming federal financial participation pursuant to this section
shall be comprised of only those funds that are paid and certified by
designated public hospitals in accordance with applicable state and
federal requirements.
(c) An alternative utilization control system that is established
for inpatient hospital services pursuant to subdivision (a) shall
apply only to the extent that the nonfederal share of expenditures
for services is incurred by the designated public hospital or
governmental entity with which it is affiliated, or is otherwise
funded with public funds that are transferred to the state from the
designated public hospital or governmental entity with which it is
affiliated.
(d) This section shall become inoperative and be repealed
on the date the Director of Health Care Services executes a
declaration specifying that the either of the
following:
(1) The nonfederal share of
expenditures for inpatient hospitalization at
hospital services provided by designated public hospitals used
for purposes of claiming federal financial participation is not
comprised of funds that are paid and certified
incurred by designated public hospitals or the
governmental entities with which they are affiliated, or i
s not otherwise funded with public funds that are transferred to the
state from the designated public hospitals or governmental entities
with which they are affiliated in accordance with applicable
state and federal requirements, and as of that date is
repealed. requirements.
(2) The program established pursuant to subdivision (a) will
result in increased costs to the General Fund.
(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of policy letters or
similar instructions, without taking further regulatory action.
(f) To the extent that the program established pursuant to
subdivision (a) increases the net costs to the state, the
participating designated public hospitals shall agree to pay the
state's additional administrative costs through an intergovernmental
transfer of funds.
(g)
(f) This section shall be implemented only to the
extent federal financial participation is available.
