Bill Text: CA SB494 | 2013-2014 | Regular Session | Chaptered
Bill Title: Health care providers.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2013-10-09 - Chaptered by Secretary of State. Chapter 684, Statutes of 2013. [SB494 Detail]
Download: California-2013-SB494-Chaptered.html
BILL NUMBER: SB 494 CHAPTERED
BILL TEXT
CHAPTER 684
FILED WITH SECRETARY OF STATE OCTOBER 9, 2013
APPROVED BY GOVERNOR OCTOBER 9, 2013
PASSED THE SENATE SEPTEMBER 12, 2013
PASSED THE ASSEMBLY SEPTEMBER 11, 2013
AMENDED IN ASSEMBLY SEPTEMBER 6, 2013
AMENDED IN ASSEMBLY SEPTEMBER 3, 2013
AMENDED IN ASSEMBLY AUGUST 19, 2013
AMENDED IN ASSEMBLY AUGUST 5, 2013
AMENDED IN SENATE MAY 28, 2013
AMENDED IN SENATE APRIL 3, 2013
INTRODUCED BY Senator Monning
(Principal coauthor: Senator Hernandez)
FEBRUARY 21, 2013
An act to add and repeal Section 1375.9 of the Health and Safety
Code, to add Section 10133.4 to the Insurance Code, and to amend
Sections 14087.48, 14088, and 14254 of the Welfare and Institutions
Code, relating to health care providers.
LEGISLATIVE COUNSEL'S DIGEST
SB 494, Monning. Health care providers.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
This bill would, until January 1, 2019, require a health care
service plan to ensure that there is at least one full-time
equivalent primary care physician for every 2,000 enrollees. This
bill would, until January 1, 2019, authorize the assignment of up to
an additional 1,000 enrollees, as specified, to a primary care
physician for each full-time equivalent nonphysician medical
practitioner, as defined, supervised by that physician. By imposing
new requirements on health care service plans, the willful violation
of which would be a crime, this bill would impose a state-mandated
local program.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services. Prior
to a Medi-Cal managed care plan commencing operations, existing law
requires the department to evaluate, among other things, the extent
to which the plan has an adequate provider network, including the
location, office hours, and language capabilities of the plan's
primary care physicians. Existing law defines primary care provider
for these purposes as an internist, general practitioner,
obstetrician-gynecologist, pediatrician, family practice physician,
or, as specified, types of clinics and defines primary care physician
as a physician who has the responsibility, among other duties, for
providing initial and primary care to patients.
This bill would require that the department evaluate the location,
office hours, and language capabilities of a plan's primary care
physicians and, if applicable, nonphysician medical practitioners.
The bill would add nonphysician medical practitioners to the
definition of a primary care provider and would define nonphysician
medical practitioner, as specified. The bill would make conforming
changes.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1375.9 is added to the Health and Safety Code,
to read:
1375.9. (a) A health care service plan shall ensure there is at
least one full-time equivalent primary care physician for every 2,000
enrollees of the plan. The number of enrollees per primary care
physician may be increased by up to 1,000 additional enrollees for
each full-time equivalent nonphysician medical practitioner
supervised by that primary care physician.
(b) This section shall not require a primary care physician to
accept an assignment of enrollees by a health care service plan
without his or her approval, or that would be contrary to paragraph
(2) of subdivision (b) of Section 1375.7.
(c) Nothing in this section shall be interpreted to modify
subdivision (e) of Section 2836.1 of the Business and Professions
Code or subdivision (b) of Section 3516 of the Business and
Professions Code.
(d) For purposes of this section, a primary care provider includes
a "nonphysician medical practitioner," which is defined as a
physician assistant performing services under the supervision of a
primary care physician in compliance with Chapter 7.7 (commencing
with Section 3500) of Division 2 of the Business and Professions Code
or a nurse practitioner performing services in collaboration with a
physician pursuant to Chapter 6 (commencing with Section 2700) of
Division 2 of the Business and Professions Code.
(e) This section shall remain in effect only until January 1,
2019, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2019, deletes or extends
that date.
SEC. 2. Section 10133.4 is added to the Insurance Code, to read:
10133.4. (a) For purposes of insurers who contract with providers
for alternate rates pursuant to Section 10133, a primary care
provider includes a "nonphysician medical practitioner," which is
defined as a physician assistant performing services under the
supervision of a primary care physician in compliance with Chapter
7.7 (commencing with Section 3500) of Division 2 of the Business and
Professions Code or a nurse practitioner performing services in
collaboration with a physician pursuant to Chapter 6 (commencing with
Section 2700) of Division 2 of the Business and Professions Code.
(b) This section shall not require a primary care provider to
accept the assignment of a number of insureds that would exceed
standards of good health care as provided in Section 10133.5.
(c) Nothing in this section shall be interpreted to modify
subdivision (e) of Section 2836.1 of the Business and Professions
Code or subdivision (b) of Section 3516 of the Business and
Professions Code.
SEC. 3. Section 14087.48 of the Welfare and Institutions Code is
amended to read:
14087.48. (a) For purposes of this section, "Medi-Cal managed
care plan" means any individual, organization, or entity that enters
into a contract with the department pursuant to Article 2.7
(commencing with Section 14087.3), Article 2.8 (commencing with
Section 14087.5), Article 2.81 (commencing with Section 14087.96),
Article 2.9 (commencing with Section 14088), or Article 2.91
(commencing with Section 14089), or pursuant to Article 1 (commencing
with Section 14200), or Article 7 (commencing with Section 14490) of
Chapter 8.
(b) Before a Medi-Cal managed care plan commences operations based
upon an action of the director that expands the geographic area of
Medi-Cal managed care, the department shall perform an evaluation to
determine the readiness of any affected Medi-Cal managed care plan to
commence operations. The evaluation shall include, at a minimum, all
of the following:
(1) The extent to which the Medi-Cal managed care plan
demonstrates the ability to provide reliable service utilization and
cost data, including, but not limited to, quarterly financial
reports, audited annual reports, utilization reports of medical
services, and encounter data.
(2) The extent to which the Medi-Cal managed care plan has an
adequate provider network, including, but not limited to, the
location, office hours, and language capabilities of primary care
physicians and, if applicable, nonphysician medical practitioners,
specialists, pharmacies, and hospitals, that the types of specialists
in the provider network are based on the population makeup and
particular geographic needs, and that whether requirements will be
met for availability of services and travel distance standards, as
set forth in Sections 53852 and 53885, respectively, of Title 22 of
the California Code of Regulations.
(3) The extent to which the Medi-Cal managed care plan has
developed procedures for the monitoring and improvement of quality of
care, including, but not limited to, procedures for retrospective
reviews which include patterns of practice reviews and drug
prescribing practice reviews, utilization management mechanisms to
detect both under- and over-utilization of health care services, and
procedures that specify timeframes for medical authorization.
(4) The extent to which the Medi-Cal managed care plan has
demonstrated the ability to meet accessibility standards in
accordance with Section 1300.67.2 of Title 28 of the California Code
of Regulations, including, but not limited to, procedures for
appointments, waiting times, telephone procedures, after hours calls,
urgent care, and arrangement for the provision of unusual specialty
services.
(5) The extent to which the Medi-Cal managed care plan has met all
standards and guidelines established by the department that
demonstrate readiness to provide services to enrollees.
(6) The extent to which the Medi-Cal managed care plan has
submitted all required contract deliverables to the department,
including, but not limited to, quality improvement systems,
utilization management, access and availability, member services,
member grievance systems, and enrollments and disenrollments.
(7) The extent to which the Medi-Cal managed care plan's Evidence
of Coverage, Member Services Guide, or both, conforms to federal and
state statutes and regulations, is accurate, and is easily
understood.
(8) The extent to which the Medi-Cal managed care plan's primary
care and facility sites have been reviewed and evaluated by the
department.
SEC. 4. Section 14088 of the Welfare and Institutions Code is
amended to read:
14088. (a) It is the purpose of this article to ensure that the
Medi-Cal program shall be operated in the most cost-effective and
efficient manner possible with the optimum number of Medi-Cal
providers and shall ensure quality of care and known access to
services.
(b) For the purposes of this article, the following definitions
shall apply:
(1) "Primary care provider" means either of the following:
(A) Any internist, general practitioner,
obstetrician-gynecologist, pediatrician, family practice physician,
nonphysician medical practitioner, or any primary care clinic, rural
health clinic, community clinic or hospital outpatient clinic
currently enrolled in the Medi-Cal program, which agrees to provide
case management to Medi-Cal beneficiaries.
(B) A county or other political subdivision that employs,
operates, or contracts with, any of the primary care providers listed
in subparagraph (A), and that agrees to use that primary care
provider for the purposes of contracting under this article.
(2) "Primary care case management" means responsibility for the
provision of referral, consultation, ordering of therapy, admission
to hospitals, followup care, and prepayment approval of referred
services.
(3) "Designation form" or "form" means a form supplied by the
department to be executed by a Medi-Cal beneficiary and a primary
care provider or other entity eligible pursuant to this article who
has entered into a contract with the department pursuant to this
article, setting forth the beneficiary's choice of contractor and an
agreement to be limited by the case management decisions of that
contractor and the contractor's agreement to be responsible for that
beneficiary's case management and medical care, as specified in this
article.
(4) "Emergency services" means health care services rendered by an
eligible Medi-Cal provider to a Medi-Cal beneficiary for those
health services required for alleviation of severe pain or immediate
diagnosis and treatment of unforeseen medical conditions which if not
immediately diagnosed and treated could lead to disability or death.
(5) "Modified primary care case management" means primary care
case management wherein capitated services are limited to primary
care practitioner office visits only.
(6) "Service area" means an area designated by either a single
federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
(c) For purposes of Medi-Cal managed care plans, as defined in
subdivision (m) of Section 14016.5, "nonphysician medical
practitioner" means a physician assistant performing services under
physician supervision in compliance with Chapter 7.7 (commencing with
Section 3500) of Division 2 of the Business and Professions Code, a
certified nurse-midwife performing services under physician
supervision in compliance with Article 2.5 (commencing with Section
2746) of Chapter 6 of Division 2 of the Business and Professions
Code, or a nurse practitioner performing services in collaboration
with a physician pursuant to Chapter 6 (commencing with Section 2700)
of Division 2 of the Business and Professions Code.
SEC. 5. Section 14254 of the Welfare and Institutions Code is
amended to read:
14254. (a) "Primary care physician" is a physician who has the
responsibility for providing initial and primary care to patients,
for maintaining the continuity of patient care, and for initiating
referral for specialist care. A primary care physician shall be
either a physician who has limited his or her practice of medicine to
general practice or who is a board-certified or board-eligible
internist, pediatrician, obstetrician-gynecologist, or family
practitioner.
(b) A nonphysician medical practitioner, as defined in subdivision
(c) of Section 14088, who is supervised by a primary care physician,
has the responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and for
initiating referral for specialist care.
SEC. 6. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
