Bill Text: CA SB986 | 2013-2014 | Regular Session | Amended

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

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Bill Title: Medi-Cal: managed care: exemption from plan enrollment.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Engrossed - Dead) 2014-08-14 - Set, second hearing. Held under submission. [SB986 Detail]

Download: California-2013-SB986-Amended.html

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BILL NUMBER: SB 986	AMENDED
	BILL TEXT

	AMENDED IN SENATE  APRIL 10, 2014

INTRODUCED BY   Senator Hernandez

                        FEBRUARY 11, 2014

   An act to  amend Section 14182 of   add
Section 14103.9   to  the Welfare and Institutions
Code, relating to Medi-Cal.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 986, as amended, Hernandez. Medi-Cal: managed care: 
seniors and persons with disabilities.   exemption from
plan enrollment. 
   Existing law provides for the Medi-Cal program, administered by
the State Department of Health Care Services, under which qualified
low-income individuals receive health care services. The Medi-Cal
program is, in part, governed and funded by federal Medicaid Program
provisions. One of the methods by which these services are provided
is pursuant to contracts with various types of managed care health
plans.  Existing law authorizes the department, in
furtherance of a specified waiver or demonstration project, to
require seniors and persons with disabilities who do not have other
health coverage to be assigned as mandatory enrollees into new or
existing managed care health plans. Existing law requires the
department, in exercising its authority pursuant to these provisions,
to, among other things, ensure that managed care health plans
participating in the demonstration project provide access to
out-of-network providers for new individual members and comply with
continuity of care requirements, as specified.  
   This bill would instead require the department to ensure that the
managed care health plans participating in the demonstration project
provide timely access to out-of-network providers for new individual
members and fully comply with the continuity of care requirements.
 
   This bill would require that a Medi-Cal beneficiary who has
received a medical exemption from enrollment in a Medi-Cal managed
care plan and who is to receive or has received specified
transplantations, including allogeneic bone marrow transplantation,
receive an extension of the medical exemption for up to 12 months if
the treating physician who provided or oversaw the transplantation or
who is providing the followup care determines that it is medically
necessary for the beneficiary to remain under the care of the
treating physician. The bill would require, at the end of the
extension, the treating physician to assess the beneficiary's
condition to determine whether the beneficiary's condition has
stabilized to a level that would enable the beneficiary to be safely
transferred to a physician within a Medi-Cal managed care health plan
without any deleterious effects to the beneficiary's health. If the
condition is not stable enough to transfer, the medical exemption
would be extended up to an additional 12 months. The bill would
prohibit a beneficiary meeting the criteria of these provisions from
being transitioned into a Medi-Cal managed care health plan until
appeals and other specified means of redress have been exhausted. The
bill would make related findings and declarations. 
   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 finds and declares all
of the following:  
   (a) Medi-Cal beneficiaries with severe conditions have
difficulties finding specialists and centers of excellence to treat
them. Even when they do find this care, Medi-Cal beneficiaries often
lose continuity of care with these providers due to regulations
pertaining to the medical exemption from enrollment in a Medi-Cal
managed care plan process, which leads to delays in obtaining care,
inability to maintain continuity with specialists with the knowledge
required to treat their conditions, and a painful and costly
worsening or relapse of their medical conditions.  
   (b) It is important that Medi-Cal beneficiaries maintain
continuity of care with their specialty care providers when the
beneficiary has been diagnosed with cancer or other life-threatening
blood disorders or undergone bone marrow, blood stem cell, cord
blood, or haploidentical transplantation.  
   (c) Bone marrow, blood stem cell, cord blood, and haploidentical
transplantation, particularly allogeneic transplants in which the
marrow or stem cells of an unrelated donor are used, can create
significant complications for the patient long after the initial
hospital stay. Medi-Cal beneficiaries on immunosuppressive
medications, if not properly monitored, can suffer significant
adverse reactions, including relapses of their original cancer or
blood disorder, graft versus host disease, and rare infections that
can be severe, disabling, and fatal. When these complications occur,
they are not only significantly painful and distressing to the
beneficiary and his or her loved ones, but add tremendous,
preventable costs to the Medi-Cal system.  
   (d) Therefore, the Legislature finds that it is in the best
interests of Medi-Cal beneficiaries who have undergone allogeneic
bone marrow, blood stem cell, cord blood, or haploidentical
transplantations to maintain continuity of care with these specialty
care providers when those providers certify the need for continuity
and can appropriately monitor and treat their conditions and
comorbidities. The Legislature also finds that it in the best
interests of the beneficiaries, the Medi-Cal system, and the
taxpayers of this state that this more cost-effective continuity of
care is maintained, thereby preventing costly, disabling, and even
fatal adverse reactions, relapses, and infection. 
   SEC. 2.    Section 14103.9 is added to the  
Welfare and Institutions Code   , to read:  
   14103.9.  (a) A Medi-Cal beneficiary who has received a medical
exemption from enrollment in a Medi-Cal managed care plan pursuant to
the medical exemption request process, as provided for in Section
53887 of Title 22 of the California Code of Regulations, and who is
to receive or has received an allogeneic bone marrow transplantation,
allogeneic blood stem cell transplantation, cord blood
transplantation, or haploidentical transplantation shall receive an
extension of the medical exemption beyond the initial 12-month
exemption period if the treating physician who provided or oversaw
the transplantation or who is providing the followup care to the
beneficiary determines that it is medically necessary for the
beneficiary to remain under the care of the treating physician. The
extension shall be provided for up to 12 months, after which the
treating physician who provided or oversaw the transplant, or who is
providing the followup care, shall assess the beneficiary's condition
to determine whether the beneficiary's medical condition has
stabilized to a level that would enable the beneficiary to be safely
transferred to a physician within a managed care health plan without
any deleterious effects to the beneficiary's health.
   (b) If, at the end of the extension pursuant to subdivision (a),
the treating physician determines that the beneficiary's condition is
not sufficiently stable to enable a transfer without deleterious
effects to the beneficiary, the medical exemption shall be extended
for up to an additional 12 months, after which another assessment
shall be conducted pursuant to the process described in subdivision
(a). A beneficiary meeting the criteria of subdivision (a) who
requests an extension of a medical exemption shall not be
transitioned into a Medi-Cal managed care plan until all appeals,
fair hearings processes, litigation, and other means of redress have
been exhausted.
   (c) The existence of a contract between the provider or provider's
medical group and a Medi-Cal managed care plan, or a contract
between the hospital that provided the transplantation or followup
care and a Medi-Cal managed care plan, or the beneficiary's prior
enrollment in a managed care plan shall not be considered as a factor
in determining the extension of a medical exemption request pursuant
to this section for beneficiaries who have received the procedures
specified in subdivision (a). The contracts shall not be used as a
reason or basis for returning a beneficiary who has received one or
more of these procedures to a Medi-Cal managed care plan.
   (d) For the purposes of this section, the following definitions
shall apply:
   (1) "Allogeneic bone marrow transplantation" means the
transplantation of bone marrow from an immunologically matched
sibling or an unrelated donor following treatment with one or more of
the following therapies: chemotherapy, radiation therapy, or
immunotherapy.
   (2) "Allogeneic blood stem cell transplantation" means
transplantation of growth factor mobilized blood stem cells from an
immunologically matched sibling or unrelated donor following
treatment with one or more of the following therapies: chemotherapy,
radiation therapy, or immunotherapy.
   (3) "Cord blood transplantation" means transplantation of
umbilical cord blood cells from partially or fully immunologically
matched and previously collected cord blood following treatment with
one or more of the following therapies: chemotherapy, radiation
therapy, or immunotherapy.
   (4) "Haploidentical transplantation" means transplantation of bone
marrow or growth factor mobilized blood stem cells from a partially
matched familial donor following treatment with one or more of the
following therapies: chemotherapy, radiation therapy, or
immunotherapy.  All matter omitted in this version of the bill
appears in the bill as introduced in the Senate, February 11, 2014.
(JR11)