Bill Text: CA SB311 | 2009-2010 | Regular Session | Amended

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

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Bill Title: Healthy Families Program: prospective payment system.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2010-02-01 - Returned to Secretary of Senate pursuant to Joint Rule 56. [SB311 Detail]

Download: California-2009-SB311-Amended.html

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BILL NUMBER: SB 311	AMENDED
	BILL TEXT

	AMENDED IN SENATE  APRIL 16, 2009

INTRODUCED BY   Senator Alquist

                        FEBRUARY 25, 2009

    An act to amend Section 14459.5 of the Welfare and
Institutions Code, relating to Medi-Cal.   An act to add
Section 12693.265 to the Insurance Code, relating to health care
coverage. 



	LEGISLATIVE COUNSEL'S DIGEST


   SB 311, as amended, Alquist.  Medi-Cal: managed care.
  Healthy Families Program: dental-only coverage. 

   Existing law, the federal Children's Health Insurance Program
Reauthorization Act of 2009, authorizes states with a separate
Children's Health Insurance Program to provide dental-only
supplemental coverage to children who are enrolled in group health
care coverage or health insurance coverage offered through an
employer and who would otherwise satisfy the requirements for being a
targeted low-income child, as specified.  
   Existing law creates the Healthy Families Program, administered by
the Managed Risk Medical Insurance Board, to arrange for the
provision of health, dental, and vision benefits to eligible children
pursuant to the federal Children's Health Insurance Program. 

   This bill would, contingent on the receipt and appropriation of
funds, require the board to provide dental-only coverage consistent
with the federal Children's Health Insurance Program Reauthorization
Act of 2009, as specified, and would authorize the board to adopt
regulations to implement that requirement.  
   The bill would also state the intent of the Legislature to enact
legislation that would implement other provisions of the federal
Children's Health Insurance Program Reauthorization Act of 2009.
 
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which health care services are provided to qualified low-income
persons.  
   Existing law, the Waxman-Duffy Prepaid Health Plan Act, allows the
department to contract with prepaid health plans to provide the
benefits authorized under Medi-Cal, providing Medi-Cal beneficiaries
the opportunity to enroll as regular subscribers in prepaid health
plans, as specified.  
   Under existing law, the department has responsibility for
monitoring the quality of all Medicaid services provided in the
state.  
   This bill would require the department to establish minimum
quality standards, in accordance with a prescribed timeframe, for the
provision of primary, preventive, and acute health care services, as
prescribed. It would permit the department to impose penalties for
violation of the standards, and would require that any savings
derived from these penalties be allocated to plans demonstrating
superior performance, as specified. 
   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.    The Legislature hereby finds and
declares all of the following:  
   (a) Congress and the President have reauthorized the federal
Children's Health Insurance Program, which provides funding for the
state's Healthy Families Program.  
   (b) The reauthorization legislation has provided additional
funding for children's health insurance and additional flexibility to
states to improve and expand health care coverage for children.
 
   (c) Although more than nine of every 10 children in California
have health care coverage, about 683,000 children in the state are
without health care coverage according to 2007 data from the Center
for Health Policy Research at the University of California at Los
Angeles.  
   (d) It is imperative that the state act to take advantage of the
increased federal funding and enhanced flexibility in administering
the federal Children's Health Insurance Program.  
   (e) It is the intent of the Legislature to enact legislation that
would implement the key elements of the federal Children's Health
Insurance Program Reauthorization Act of 2009, including receiving
federal matching funds for enrolling eligible immigrant children,
implementing changes to citizen documentation requirements, ensuring
parity in state coverage, establishing new payment methods for
clinics participating in the Healthy Families Program, measuring
quality of care within public programs, and taking advantage of the
increased federal funding that is available to California, including
bonuses and targeted grant programs, such as performance bonuses and
outreach funding. 
   SEC. 2.    Section 12693.265 is added to the 
 Insurance Code   , to read:  
   12693.265.  (a) Subject to subdivisions (b) and (c), the board
shall provide dental-only coverage as authorized by Section 501 of
the Children's Health Insurance Program Reauthorization Act of 2009
(Public Law 111-3). To be eligible to receive this coverage, a child
shall be an eligible child, as described in subdivision (a) of
Section 12693.70, except that the child shall be enrolled in
employer-sponsored coverage that does not provide dental benefits or
cost sharing that meets the requirements of Section 12693.63 and its
implementing regulations.
   (b) The board may adopt, and may only one time readopt,
regulations to implement subdivision (a). The adoption and one-time
readoption of a regulation authorized by this subdivision is deemed
to address an emergency, for purposes of Sections 11346.1 and 11349.6
of the Government Code, and the board is hereby exempted for this
purpose from the requirements of subdivision (b) of Section 11346.1
of the Government Code.
   (c) This section shall be implemented only if and to the extent
that federal financial participation is obtained and only if and to
the extent that funds are appropriated by the Legislature for
purposes of this section in the annual Budget Act or in another
statute.  
  SECTION 1.    Section 14459.5 of the Welfare and
Institutions Code is amended to read:
   14459.5.  (a) As delegated by the federal government, the
department has responsibility for monitoring the quality of all
Medicaid services provided in the state. A key component of this
monitoring function is the performance of annual, independent,
external reviews of the quality of services furnished under each
state contract with a health maintenance organization, as specified
by the federal Health Care Financing Administration.
   (b) (1) The department shall establish minimum quality standards
for the provision of primary, preventive, and acute health care
services provided by the health maintenance organizations under
contract with the department. These standards shall be based on the
Healthcare Effectiveness Data and Information Set (HEDIS) measures
for the External Accountability Set that each plan is required to
report annually to the department. The External Accountability Set
shall include a sufficient number of measures to adequately monitor
the managed care plans' provision of services to its full range of
enrollees, including, but not limited to, children, women,
individuals with a disability, and adults with chronic conditions.
The department shall require the External Quality Review Organization
that produces the annual Performance Measures For Medi-Cal Managed
Care Members report to prepare the report in full compliance with the
conventions of the National Committee for Quality Assurance.
   (2) In implementing this subdivision, it is the intent of the
Legislature that the department establish policies that will result
in all Medi-Cal managed care plans performing at no less than the
50th percentile level of HEDIS by January 1, 2015, based on the most
recent national Medicaid rates for any measure reported to the
department.
   (3) The minimum standards established by the department shall
include, but not be limited to, the following:
   (A) Prior to July 1, 2012, managed care plans shall be required to
perform at no less than the 25th percentile of HEDIS, based on the
most recent national Medicaid rates for all measures reported to the
department.
   (i) Commencing no later than April 1, 2010, the department shall
annually identify plans that perform below the 25th percentile of
HEDIS, based on the most recent national Medicaid rates for any
measure reported to the department. The department shall require
these managed care plans to develop a corrective action plan that
identifies specific interventions that will improve performance.
   (ii) Commencing January 1, 2012, a Medi-Cal managed care plan that
has submitted a corrective action plan and continues to perform
below the 25th percentile of HEDIS, based on the most recent national
Medicaid rates for any measure reported to the department, shall not
be eligible for the assignment of new Medi-Cal enrollees who have
not selected a managed care plan and would otherwise be enrolled in
that plan by the department through the default algorithm.
Additionally, the 10 percent cap that limits the number of defaulted
beneficiaries that a plan can lose from the prior year shall be
lifted for the managed care plans performing below the 25th
percentile of HEDIS.
   (iii) Commencing July 1, 2014, the department may impose a
financial penalty by withholding up to 5 percent of a Medi-Cal
managed care plan's contract rate, if that plan continues to perform
below the 25th percentile of HEDIS for any measure reported to the
department.
   (B) Prior to July 1, 2015, managed care plans shall be required to
perform at no less than the 50th percentile of HEDIS, based on the
most recent national Medicaid rates for all measures reported to the
department.
   (i) Commencing no later than April 1, 2013, the department shall
annually identify managed care plans that perform below the 50th
percentile of HEDIS, based on the most recent national Medicaid rates
for any measure reported to the department. The department shall
require these managed care plans to develop a corrective action plan
that identifies specific interventions that will improve performance.

   (ii) Commencing January 1, 2015, a Medi-Cal managed care plan that
has submitted a corrective action plan and continues to perform
below the 50th percentile of HEDIS, based on the most recent national
Medicaid rates for any measure reported to the department, shall not
be eligible for the assignment of new Medi-Cal enrollees who have
not selected a managed care plan and would otherwise be enrolled in
that plan by the department through the default algorithm.
Additionally, the 10 percent cap that limits the number of defaulted
beneficiaries that a plan can lose from the prior year shall be
lifted for the managed care plans performing below the 50th
percentile of HEDIS.
   (iii) Commencing July 1, 2017, the department may impose a
financial penalty by withholding up to 5 percent of a Medi-Cal
managed care plan's contract rate, if that plan continues to perform
below the 50th percentile of HEDIS for any measure reported to the
department.
   (4) The department shall allocate any savings derived from
penalties imposed pursuant to paragraph (3) to plans that have
demonstrated superior performance, as indicated by either performance
above the 75th percentile of, or substantial improvement in, HEDIS,
based on the most recent national Medicaid rates for any measure
reported to the department.
   (c) The Legislature finds and declares that the final report
obtained from the external reviews will provide valid and reliable
information regarding health care outcomes and the overall quality of
care delivered by the managed care plans.
   (d) The department shall make only the final report of each
external review available, within 30 calendar days of completion, to
the fiscal and health policy committees of the Legislature, and shall
make only the final report available for public viewing upon request
by any individual or organization.