BILL NUMBER: AB 839 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MARCH 26, 2009
INTRODUCED BY Assembly Member Emmerson
FEBRUARY 26, 2009
An act to amend Section Sections 14043.28
and 14104.5 of the Welfare and Institutions Code, relating to
Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 839, as amended, Emmerson. Medi-Cal service providers:
judicial : providers: remedies.
Existing
(1) 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.
Existing law requires that health care providers apply to, and be
certified by, the department prior to their participation in the
Medi-Cal program.
Existing law allows the department, if specified conditions are
met, to grant provisional provider status or preferred provisional
provider status to an applicant or provider, and requires the
department to terminate that status if any of specified grounds
exist.
Existing law provides that, if an application for provisional
provider status or preferred provisional provider status is denied
under specified provisions, or that status is terminated under the
provisions described above, the applicant or provider is prohibited
from reapplying for enrollment or continued enrollment in the
Medi-Cal program or for participation in any health care program
administered by the department for a period of 3 years from the date
the application package is denied or the provisional provider status
is terminated, or from the date of the final decision following an
appeal from that denial or termination, except as specified.
Existing law provides that, if an application for provisional
provider status or preferred provisional provider status is denied
based upon a conviction for specified offenses or acts, the applicant
or provider is prohibited from reapplying for enrollment or
continued enrollment in the Medi-Cal program or for participation in
any health care program administered by the department for a period
of 10 years from the date the application package is denied or the
provisional provider status or preferred provisional provider status
is terminated, or from the date of the final decision following an
appeal from that denial or termination.
This bill would delete the provisions that provide that the 3-year
and 10-year prohibitions may begin from the date of the final
decision following an appeal from that denial or termination.
Existing
(2) Existing law requires the
Director of Health Care Services to adopt procedures for the review
of grievances or complaints filed by Medi-Cal service providers
concerning the processing or payment of money that the provider
alleges is payable under the Medi-Cal program. A provider
that who complies with these procedures and is
not satisfied with the director's decision regarding that claim may
seek appropriate judicial remedies within a specified time period.
This bill would, instead, specify that the provider who has
complied with these procedures may, within the time period prescribed
in existing law, seek either a writ of mandate
or, if the claim meets the jurisdictional requirements, file
a claim in small claims court .
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14043.28 of the
Welfare and Institutions Code is amended to read:
14043.28. (a) (1) If an application package is denied under
Section 14043.26 or provisional provider status or preferred
provisional provider status is terminated under Section 14043.27, the
applicant or provider may not reapply shall
be prohibited from reapplying for enrollment or continued
enrollment in the Medi-Cal program or for participation in any health
care program administered by the department or its agents or
contractors for a period of three years from the date the application
package is denied or the provisional provider status is terminated,
or from the date of the final decision following an appeal
from that denial or termination, except as provided
otherwise in paragraph (2) of subdivision (e), or paragraph (2) of
subdivision (f), of Section 14043.26 and as set forth in this
section.
(2) If the application is denied under paragraph (2) of
subdivision (e) of Section 14043.26 because the applicant failed to
resubmit an incomplete application package or is denied under
paragraph (2) of subdivision (f) of Section 14043.26 because the
applicant failed to remediate discrepancies, the applicant may
resubmit an application in accordance with paragraph (2) of
subdivision (d) or paragraph (2) of subdivision (f), respectively.
(3) If the denial of the application package is based upon a
conviction for any offense or for any act included in Section
14043.36 or termination of the provisional provider status or
preferred provisional provider status is based upon a conviction for
any offense or for any act included in paragraph (1) of subdivision
(c) of Section 14043.27, the applicant or provider may not
reapply shall be prohibited from reapplying for
enrollment or continued enrollment in the Medi-Cal program or for
participation in any health care program administered by the
department or its agents or contractors for a period of 10 years from
the date the application package is denied or the provisional
provider status or preferred provisional provider status is
terminated or from the date of the final decision following
an appeal from that denial or termination .
(4) If the denial of the application package is based upon two or
more convictions for any offense or for any two or more acts included
in Section 14043.36 or termination of the provisional provider
status or preferred provisional provider status is based upon two or
more convictions for any offense or for any two acts included in
paragraph (1) of subdivision (c) of Section 14043.27, the applicant
or provider shall be permanently barred from enrollment or continued
enrollment in the Medi-Cal program or for participation in any health
care program administered by the department or its agents or
contractors.
(5) The prohibition in paragraph (1) against reapplying for three
years shall not apply if the denial of the application or termination
of provisional provider status or preferred provisional provider
status is based upon any of the following:
(A) The grounds provided for in paragraph (4), or subparagraph (B)
of paragraph (7), of subdivision (c) of Section 14043.27.
(B) The grounds provided for in subdivision (d) of Section
14043.27, if the investigation is closed without any adverse action
being taken.
(C) The grounds provided for in paragraph (6) of subdivision (c)
of Section 14043.27. However, the department may deny reimbursement
for claims submitted while the provider was noncompliant with CLIA.
(b) (1) If an application package is denied under subparagraph
(A), (B), or (D) of paragraph (4) of subdivision (d) of Section
14043.26, or with respect to a provider described in subparagraph (B)
of paragraph (2) of subdivision (e), or subparagraph (B) of
paragraph (2) of subdivision (f), of Section 14043.26, or provisional
provider status or preferred provisional provider status is
terminated based upon any of the grounds stated in subparagraph (A)
of paragraph (7), or paragraphs (1), (2), (3), (5), and (8) to (12),
inclusive, of subdivision (c) of Section 14043.27, all business
addresses of the applicant or provider shall be deactivated and the
applicant or provider shall be removed from enrollment in the
Medi-Cal program by operation of law.
(2) If the termination of provisional provider status is based
upon the grounds stated in subdivision (d) of Section 14043.27 and
the investigation is closed without any adverse action being taken,
or is based upon the grounds in subparagraph (B) of paragraph (7) of
subdivision (c) of Section 14043.27 and the applicant or provider
obtains the appropriate license, permits, or approvals covering the
period of provisional provider status, the termination taken pursuant
to subdivision (c) of Section 14043.27 shall be rescinded, the
previously deactivated provider numbers shall be reactivated, and the
provider shall be reenrolled in the Medi-Cal program, unless there
are other grounds for taking these actions.
(c) Claims that are submitted or caused to be submitted by an
applicant or provider who has been suspended from the Medi-Cal
program for any reason or who has had its provisional provider status
terminated or had its application package for enrollment or
continued enrollment denied and all business addresses deactivated
may not be paid for services, goods, merchandise, or supplies
rendered to Medi-Cal beneficiaries during the period of suspension or
termination or after the date all business addresses are
deactivated.
SECTION 1. SEC. 2. Section 14104.5
of the Welfare and Institutions Code is amended to read:
14104.5. Notwithstanding any other provision of law, the director
shall by regulation adopt such procedures as are necessary for the
review of a grievance or complaint concerning the processing or
payment of money alleged by a provider of services to be payable by
reason of any of the provisions of this chapter. After complying with
these procedures, if the provider is not satisfied with the director'
s decision on his or her claim, he or she may not later than one year
after receiving notice of the decision, file a petition for writ of
mandate pursuant to Section 1085 of the Code of Civil Procedure in
the superior court or file a claim in small claims court if
the claim meets the jurisdictional requirements . This
section shall be the exclusive remedy available to the provider of
services for moneys alleged to be payable by reason of this chapter.
This section shall not apply to those grievances or complaints
arising from the findings of an audit or examination made by or on
behalf of the director pursuant to Sections 10722 and 14170. Article
5.3 (commencing with Section 14170) shall govern the grievances or
complaints.