BILL NUMBER: AB 1037	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 15, 2009

INTRODUCED BY   Assembly Member Bonnie Lowenthal
   (Coauthor: Assembly Member Torres)
   (Coauthor: Senator Negrete McLeod)

                        FEBRUARY 27, 2009

   An act to add and repeal Article 2.75 (commencing with Section
14087.481) of Chapter 7 of Part 3 of Division 9 of the Welfare and
Institutions Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 1037, as amended, Bonnie Lowenthal. Medi-Cal: managed care.
   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 allows the department to contract with one or more
prepaid health plans in order to provide Medi-Cal benefits.
   Existing law allows the Director of Health Care Services to
contract with any qualified individual, organization, or entity,
including counties, to provide services to, or arrange for or case
manage the care of, Medi-Cal beneficiaries.
   This bill would establish the Medi-Cal Managed Care Pilot Program.
Under this program, until July 31,  2015   2016
 , and subject to the receipt of any necessary federal waivers,
the department would be required to provide all seniors and persons
with disabilities in the Counties of Riverside and San Bernardino who
are not expressly excluded from enrollment with the ability to
enroll in a Medi-Cal managed care health plan. The bill would require
the department, by July 1, 2010, to complete an implementation plan
containing specified elements and prepared in consultation with a
health care stakeholder advisory committee, which this bill would
require the department to convene in accordance with specified
criteria, and to take certain other actions relating to the
development of the pilot program. The bill would impose various
requirements on managed care plans participating in the program. The
bill would require the department to seek federal approval for the
program, and to conduct, and, by March 1, 2014, report to the
Legislature the results of, an evaluation of the program.
   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.  Article 2.75 (commencing with Section 14087.481) is
added to Chapter 7 of Part 3 of Division 9 of the Welfare and
Institutions Code, to read:

      Article 2.75.  Medi-Cal Managed Care Pilot Program


   14087.481.  (a) It is the intent of the Legislature in enacting
this article to improve the quality of health care for seniors and
persons with disabilities by testing standards for timely access to
care, enrollee assistance, appropriate accommodations, and other
measures through the pilot program authorized by this article, and to
provide for an evaluation of the results.
   (b) It is further the intent of the Legislature that the pilot
program be conducted in the Counties of Riverside and San Bernardino
in a manner that does all of the following:
   (1) Recognizes the multiple and complex needs of low-income
seniors and persons with disabilities, including the need for
specialized care and out-of-network services.
   (2) Provides  exemptions for   individuals
with a choice between managed care and fee-for-service so that 
individuals with  a   complex  medical
 condition that would not be adequately served by the pilot
program.   conditions can select the system that best
meets their needs. 
   (3) Respects and maintains enrollees' existing, longstanding
provider relationships whenever possible.
   (4) Focuses on prevention and wellness programs to improve health
outcomes for seniors and persons with disabilities.
   (5) Tests performance standards for Medi-Cal managed care plans
that address the specific needs of seniors and persons with
disabilities.
   (6) Tests clinical and service measures to ensure that Medi-Cal
beneficiaries receive appropriate care and are provided assistance in
obtaining access to care.
   (7) Identifies best practices for providing health care services
to low-income seniors and persons with disabilities.
   (8) Involves stakeholders in planning, implementation, and
evaluation.
   (9) Provides sufficient compensation for coordination of care
among multiple providers and care management by providers.
   (10) Provides sufficient payment rates to attract and retain
providers, particularly those with specialized expertise in providing
care to seniors and persons with disabilities.
   (11) Promotes accessibility, including physical and communications
access  and compliance with the federal Americans with
Disabilities Act of 1990 (42 U.S.C. Sec. 12101 et seq.)  , for
all seniors and persons with disabilities.
   14087.482.  (a) For purposes of this article, the following
definitions shall apply:
   (1) "Medi-Cal managed care plan contracts" means those contracts
entered into with the department by any individual, organization, or
entity pursuant to Article 2.7 (commencing with Section 14087.3),
Article 2.8 (commencing with Section 14087.5), or Article 2.91
(commencing with Section 14089)  of this chapter  ,
or Article 1 (commencing with Section 14200) or Article 7 (commencing
with Section 14490) of Chapter 8.
   (2) "Medi-Cal managed care health plan" or "health plan" means an
individual, organization, or entity operating under a Medi-Cal
managed care plan contract with the department under this chapter or
Chapter 8 (commencing with Section 14200), which is licensed as a
full service health care service plan in compliance with the
Knox-Keene Health Care Service Plan Act of 1975.
   (3) "Seniors and persons with disabilities" means Medi-Cal
beneficiaries eligible for benefits through age, blindness, or
disability, as defined in Title XVI of the Social Security Act (42
U.S.C. Sec. 1381 et seq.) who are not excluded persons, as defined in
paragraph (4).
   (4) "Excluded persons" means persons who are simultaneously
qualified for full benefits under Title XIX of the Social Security
Act (42 U.S.C. Sec. 1396 et seq.) and Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395 et seq.), persons who are eligible
for Medi-Cal with a share of cost, except to the extent that these
persons are made mandatory enrollees in a Medi-Cal managed care
health plan under Article 2.8 (commencing with Section 14087.5),
persons enrolled in the California Children's Services Program under
Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of
Division 106 of the Health and Safety Code, and persons who, at the
time they are enrolled in the pilot program described in this
article, are either on a major organ, except kidney, transplant list
or in one of the following home- and community-based waivers under
Section 1396n of Title 42 of the United States Code:
   (A) In-Home Medical Care Waiver.
   (B) Nursing Facility Subacute Waiver.
   (C) Nursing Facility Level A/B Waiver.
   (b) (1) Notwithstanding subparagraph (B) of paragraph (1) of
subdivision (c) of Section 14089, and paragraph (3) of subdivision
(b) of Section 53845 of, subparagraph (A) of paragraph (3) of
subdivision (b) of Section 53906 of, and subdivision (a) of Section
53921 of, Title 22 of the California Code of Regulations, and subject
to subdivision (c), the department shall provide all seniors and
persons with disabilities who reside in the Counties of Riverside and
San Bernardino, and who are not excluded persons, with the ability
to enroll in a Medi-Cal managed care health plan in accordance with
the requirements set forth in this article and consistent with
applicable state and federal laws. The choice to enroll in a health
plan shall be provided to seniors and persons with disabilities who
reside in the Counties of Riverside and San Bernardino upon
enrollment, or, if the individual is an existing Medi-Cal
beneficiary,  upon the commencement of enrollment in the pilot
program, upon the individual's   annual redetermination, or,
if not subject to annual redetermination,  through notice. 
Individuals who select a managed care plan pursuant to this article
shall be enrolled in the chosen plan pursuant to the department's
existing process for enrollment.  
   (2) Individuals who select Medi-Cal managed care pursuant to this
section shall remain enrolled in a managed care plan until the
individual's next annual redetermination, unless the enrollee is
exempted pursuant to the continuity of care provisions or medical
exemption provisions of Section 14087.487. At the time of the annual
redetermination, the enrollee shall have a choice to return to
fee-for-service Medi-Cal. Individuals not subject to annual
redetermination shall be given the option to return to
fee-for-service on an annual basis.  
   (3) 
    (2)  Individuals who fail to select fee-for-service or a
managed care plan pursuant to this section  upon their initial
enrollment  shall be enrolled in  a  managed care 
plan  , and shall be assigned to a managed care plan pursuant to
 Section 14087.491. Individuals subject to assignment to
Medi-Cal managed care pursuant to this paragraph shall be permitted
to opt out of managed care, without cause, within the first 60 days
of enrollment in a managed care plan. Nothing in this paragraph
precludes an enrollee from seeking an exemption from managed care
pursuant to Section 14087.487 after the 60-day period expires.
  Section 14087.491. An individual who is an existing
Medi-Cal beneficiary in the fee-for-service program upon the
commencement of the pilot program, who is given a choice of
fee-for-service or managed care by notice or during annual
redetermination, and who does not make any selection within 60 days
of the notice shall be assigned to a managed care plan pursuant to
Section 14087.491. Individuals who select fee-for-service shall
remain in the fee-for-service program. Individuals subject to
assignment to Medi-Cal managed care pursuant to this paragraph shall
be permitted to opt out of managed care at any time. Disenrollment
shall be effective at the end of the month during which the
disenrollment is requested.  
   (4) 
    (3)  Nothing in this section shall preclude an enrollee
who is in one managed care plan from selecting a different managed
care plan  in accordance with existing policy  .
   (c)  This article shall not be implemented in a county without the
official endorsement of that county's county-operated public
hospital.
   (d) Nothing in this section shall be construed to imply changes to
existing services being provided by Medi-Cal managed care health
plans in the pilot counties pursuant to this article.
   (e) Services provided through the California Children's Services
Program shall not be included in the pilot programs authorized under
this article.
   (f) Notwithstanding Section 14087.491, individuals meeting
participation requirements for the Program for All-Inclusive Care for
the Elderly (PACE) may select a PACE plan if one is available in
that county.
   (g)  Nothing in this section is intended to limit existing
authority provided by Article 2.8 (commencing with Section 14087.5).
   (h) The department shall seek all necessary federal waivers to
implement this article. The department shall submit to the
Legislature all proposed state plan amendments, waiver amendments,
and waiver applications, including amendments to the Medicaid state
plan specifically outlining the reimbursement methodology developed
pursuant to this article.
   14087.483.  No later than July 1, 2010, the department shall
develop an implementation plan for compliance with this article. The
implementation plan shall be developed in consultation with the
stakeholder advisory committee established pursuant to Section
14087.484. The implementation plan shall specifically address the
multiple and complex needs of seniors and persons with disabilities,
and the specific strategies the department will use to ensure the
provision of quality, accessible health care services under the pilot
program, including at least all of the following elements:
   (a) (1) Criteria, performance standards, and indicators to ensure
compliance with this article. Health plans shall comply with existing
statutory and regulatory requirements and protections applicable to
two-plan model and geographic managed care plans, as well as those
protections available under the Knox-Keene Health Care Service Plan
Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2
of the Health and Safety Code; the Knox-Keene Act) . Performance
standards developed pursuant to this article shall include specific
standards in all of the following areas:
   (A) Plan readiness.
   (B) Availability and accessibility of services, including physical
access and communication access.
   (C) Care coordination and care management.
   (D) Beneficiary participation.
   (E) Measurement and improvement of health outcomes.
   (F) Network capacity, including travel time and distance and
specialty care access.
   (G) Performance measurement and improvement.
   (H) Quality care.
   (I) Timely contact and screening of new enrollees to identify
clinical and access needs.
   (2) Any standards developed in addition to those described in
paragraph (1) shall be guided by the Performance Standards for
Medi-Cal Managed Care Organizations Serving People with Disabilities
and Chronic Conditions, published by the California Health Care
Foundation, November 2005.
   (b) (1) A process and timeline for enrollment and beneficiary
selection of a health plan. The department shall assess and revise
the health care options and enrollment process established pursuant
to Section 14016.5 as necessary to ensure that they effectively meet
the diverse and specific needs of seniors and persons with
disabilities. The department shall explore the feasibility of
developing a broker or enrollment support system to provide
assistance to seniors and persons with disabilities who need
enrollment assistance.
   (2) The enrollment process developed pursuant to this subdivision
shall include both of the following:
   (A) Provisions to ensure that Medi-Cal beneficiaries receive
information and assistance related to their rights, including, but
not limited to, the right to  request any medical exemption
from the pilot program when necessary, in accordance with Section
14087.487.   accessible facilities. 
   (B) Identification of categories of seniors and persons with
disabilities who may need special assistance in the enrollment
process and those with special health care needs or other conditions
that warrant immediate contact by a plan at initial enrollment.
   (c)  Requirements for the coordination of services under managed
care plans for beneficiaries receiving services from other state or
local government programs or institutions.
   (d) An appropriate awareness and sensitivity training program
regarding the multiple and complex needs of seniors and persons with
disabilities for all staff in the department's Medi-Cal Managed Care
Office of the Ombudsman, in consultation with the stakeholder
committee established under this article.
   (e) (1) A system for responding to and resolving complaints or
requests for assistance in a timely manner. The system shall be
available 24 hours a day, seven days a week, and shall include a
statewide, toll-free "800" telephone hotline  for the pilot
area  .
   (2)  The department shall develop and coordinate the response
system and hotline in consultation with the Department of Managed
Health Care's HMO Help Center and the Health Insurance Counseling and
Advocacy Program administered by the California Department of Aging.

   (3)  Public complaint information shall be available to the
stakeholder committee established under this article.
   (f) An outreach and education program for seniors and persons with
disabilities in the pilot program regarding enrollment options,
rights and responsibilities under the pilot program, and  the
criteria for a medical exemption under this article  
benefits and services provided  . The outreach and education
program shall be developed in consultation with the local stakeholder
committee, established pursuant to Section 14087.484, and shall
include strategies to inform and coordinate with community
organizations providing services to seniors and persons with
disabilities.
   (g)  The system for assessing ongoing compliance of managed care
plans consistent with the requirements of this article. The
department shall cease new enrollments in a health plan if it finds
that the health plan is not in substantial compliance with this
article, and may cease enrollment in a health plan that fails to meet
any provision of this article if the department determines that the
failure to comply jeopardizes the health, safety, or access to
quality care for beneficiaries.
   (h) The specific methodology for developing capitation rates for
Medi-Cal managed care plans enrolling seniors and persons with
disabilities in the pilot program. The methodology shall comply with
Section 14087.486.
   (i) Budgetary projections of the effect of managed care expansion
pursuant to this article on the total Medi-Cal budget for the 2009-10
to 2013-14, inclusive, fiscal years, including an evaluation of the
cost-effectiveness of the expansion compared to providing Medi-Cal
coverage to the same beneficiaries in fee-for-service Medi-Cal.
   (j) The process and timeline for outreach, education, enrollment,
and beneficiary selection of health plans and providers, including
the health care options process and policies for assigning
beneficiaries who do not choose a fee-for-service health plan within
30 days. The department shall develop assignment distribution
policies consistent with Section 14087.491. 
   (k) Outline any specific changes needed to the existing two-plan
model's medical exemption process to accommodate seniors and persons
with a disability consistent with Section 14087.487. 

   (l) 
    (k)  The process, timelines, and criteria for evaluating
the pilot program required by Section 14087.493. 
   (m) 
    (l)  Review of the current overlap in regulations and
authority and recommendations for clear assignment of
responsibilities to the department and the Department of Managed
Health Care for ensuring compliance with all state and federal laws
relevant to Medi-Cal managed care plans. The Department of Managed
Health Care shall retain its responsibility for ensuring consumer
protections, adequacy of network, and financial solvency of the
participating health plans. The  Department of Health Care
Services   department  shall be responsible for
ensuring compliance with additional standards appropriate for seniors
and persons with disabilities within Medi-Cal. 
   (n) 
    (m)  Identify any additional state or federal
legislation and authority needed to implement this article.
   14087.484.  (a) In preparing the implementation plan required by
Section 14087.483, the department shall convene a health care
stakeholder advisory committee  of 21 members  to
advise the department and the participating health plans on the
implementation of this article. Committee members may serve for the
entire duration of the pilot program.
   (b) The health care stakeholder advisory committee shall remain in
place to advise the department regarding the implementation,
continued operation, and evaluation of the pilot program and to
advise health plans about the provision of services to seniors and
persons with disabilities in the pilot program. The health care
stakeholder advisory committee shall also solicit input from seniors
and persons with disabilities in the community regarding the
performance and operation of the pilot program, and shall review
publicly available data on grievances, complaints, and requests for
disenrollment.
   (c) The committee shall include the following participants:
   (1)  Six   A maximum of six  Medi-Cal
beneficiaries who are persons with disabilities in the Counties of
Riverside and San Bernardino.  Beneficiaries shall represent a
broad spectrum of disabilities. 
   (2) Two Medi-Cal beneficiaries who are seniors living in the
Counties of Riverside and San Bernardino.
   (3) One representative of a community-based organization serving
persons with disabilities in the Counties of Riverside and San
Bernardino.
   (4) Two representatives from statewide advocacy organizations
serving persons with disabilities.
   (5) One representative from a statewide organization or local
community-based organization serving seniors in the Counties of
Riverside and San Bernardino.
   (6) One representative from a statewide advocacy organization
serving low-income communities.
   (7) One representative from a local or statewide advocacy
organization serving communities of color or multilingual
communities.
   (8) One representative from each participating health plan.
   (9) Two physicians participating in the health plans. 
   (10) Two representatives of public hospitals contracting with

    (10)     One representative from each of
the two public hospitals in the Counties of Riverside and San
Bernardino and two individuals who represent other hospitals
contracting with  one or both of the participating health plans.

   (11) One representative of the exclusive collective bargaining
agents for hospital workers of affected hospitals.
   (d) Members of the committee selected pursuant to paragraphs (3),
(5), and (7) of subdivision (c) shall be nominated by local
community-based organizations and disability organizations.
   (e) The department may seek grants or other private funding
sources for the operational and other costs necessary for the
implementation of this section.
   14087.485.  Prior to initiating the pilot program authorized by
this article, the department shall provide Medi-Cal managed care
plans with both of the following:
   (a) (1) Identification of seniors and persons with disabilities
who may need special assistance in the enrollment process and those
with special health care needs or other conditions that warrant
immediate contact by a plan at initial enrollment.
   (2)  The department shall provide the list described in paragraph
(1) to those entities administering the enrollment process and to the
health plans to ensure that beneficiaries receive necessary
assistance.
   (b) A list of fee-for-service Medi-Cal providers who are actively
providing services to beneficiaries within the pilot area to allow
the health plans to actively recruit these providers to participate
in plan networks and maintain existing patient-provider
relationships.
   14087.486.  (a) The department shall develop capitation rates in a
manner that ensures that rates are actuarially sound and comply with
Section 438.6(c) of Title 42 of the Code of Federal Regulations. The
department shall ensure that the development of rates is based on
data specific to seniors and persons with disabilities.
   (b) In determining and evaluating capitation rates, the department
shall take into account the full range of reimbursements for all
covered medical procedures and services.
   (c) The director may require Medi-Cal managed care health plans to
submit financial and utilization data, as deemed necessary. The
department shall ensure that the submission of financial and
utilization data does not place an undue burden on the health plans'
ability to provide comprehensive, patient-centered care to all
enrollees regardless of disability.
   (d) The department shall develop a process for initial
ratesetting, and for adjusting the capitation rates during the pilot
program to meet the restorative and health maintenance needs of
seniors and persons with disabilities.
   (e) At least 90 days prior to enrollment of beneficiaries pursuant
to this article, and annually thereafter, the department shall do
all of the following:
   (1) Provide the managed care plan with the opportunity to review
and comment on the rate development methodology prior to the contract
year for which the rates will be paid.
   (2) Provide the managed care plan with the opportunity to provide
comment on the draft rates and the rate manual providing the basis
for those rates.
   (3) Respond to managed care plan comments on the draft rates.
   (f) Capitation rates shall be finalized prior to the contract year
for which the rates will be paid, and shall be reviewed and updated
at least annually to reflect changes in cost and utilization.
   14087.487.  (a) The department shall develop and implement
policies and procedures to ensure continuity of care that provide for
all of the following: 
   (1) Adherence to the existing standards for medical exemptions
contained in subparagraph (A) of paragraph (2) of subdivision (a) of
Section 53887 of Title 22 of the California Code of Regulations.
 
   (2) Any additional conditions that would permit a beneficiary to
be eligible for a permanent medical exemption from the pilot program
based on the unique needs of seniors and persons with disabilities,
or because certain needs cannot be met within the pilot program.
 
   (3) Expedited timelines for reviewing and processing requests for
medical exemptions pursuant to this article. No enrollee who has
requested an exemption shall be required to enroll in a managed care
plan until the exemption has been processed.  
   (4) Provisions that permit an enrollee, at his or her discretion,
to disenroll from mandatory managed care and return to
fee-for-service Medi-Cal if the enrollee's complaint is not resolved
within the appropriate timelines pursuant to paragraph (1) of
subdivision (e) of Section 14087.483 or is not resolved in compliance
with Section 1368 of the Health and Safety Code, consistent with
subdivision (d) of Section 14087.490, and the department finds that
this failure poses a threat to the health of the enrollee. Nothing in
this paragraph precludes an enrollee from selecting another managed
care plan in the pilot program. Enrollees shall be informed of this
right at the time the complaint is made.  
   (5) 
    (1)  A requirement that participating health plans
comply at all times with Section 1373.96 of the Health and Safety
Code regarding continuity of care with terminated providers and with
 nonparticipating providers. If the provider actively
treating the enrollee is not a participating provider and is not
subject to Section 1373.96 of the Health and Safety Code, the
beneficiary may request a medical exemption pursuant to Section 53887
of Title 22 of the California Code of Regulations. This provision
applies with respect   nonparticipating providers. This
provision applies with respect  to all providers, including, but
not limited to, physicians, specialists, and certified or licensed
nurse midwives who are actively treating the enrollee  for a
medical condition that qualifies for an exemption under this article
 . 
   (6) 
    (2)  A description of the conditions warranting
continuity of care through fee-for-service Medi-Cal on a permanent or
extended basis because of a medical condition that may not be easily
stabilized. 
   (7) 
    (3)  A requirement that participating plans permit
enrollees in the pilot program to continue an established
patient-provider relationship if the treating provider contracts with
the plan in the service area, has available capacity, and agrees to
continue to treat the beneficiary. 
   (4) Adequate notice to beneficiaries of their right to continuity
of care pursuant to this section and of their ability to select
another managed care plan or opt out of managed care. 
   (b) The policies and procedures developed pursuant to this section
shall be developed in consultation with the participating plans and
the health care stakeholder committee created pursuant to Section
14087.484. The policies and procedures shall meet all of the
following criteria:
   (1) Address the specialized care and treatment needs of seniors
and all persons with a disability.
   (2) Extend all existing continuity of care rights to those
entering Medi-Cal managed care from the fee-for-service Medi-Cal
program.
   (3) Extend all existing continuity of care rights to cover all
providers, including, but not limited to, physicians, specialists,
and certified or licensed nurse midwives, who are actively treating
                                          the enrollee for a medical
condition that qualifies under this article. For purposes of this
paragraph, "actively treating" means providing treatment within the
last 90 days before enrollment into the pilot program created
pursuant to this article. 
   (c) Unless permanently exempted, any beneficiary granted a medical
exemption from health plan enrollment pursuant to this section shall
remain with the fee-for-service program until the medical condition
has stabilized so that the individual may safely transition to the
new provider and begin receiving care from a plan provider without
deleterious medical effects, as determined by the treating physician
or specialist in the fee-for-service Medi-Cal program. If the medical
condition is not sufficiently stable to permit safe transfer, the
beneficiary may choose to remain in the fee-for-service Medi-Cal
program until the medical condition is stable. 
   14087.488.  The department shall, at all times, ensure that it
complies with all provisions of this article, all applicable state
and federal laws and regulations, and all applicable contracts. On an
ongoing basis, the department shall do all of the following:
   (a) Track, monitor, and report to the Legislature on the pilot
program in the annual budget process and to the policy and fiscal
committees of both houses of the Legislature.
   (b) Ensure ongoing compliance of participating health plans and
providers with this article and all applicable state and federal laws
and regulations pertaining to the program.
   (c) Develop the pilot program in a manner that accomplishes all of
the following:
   (1) Protects the safety net providers in the community.
   (2) Recognizes the multiple and complex needs of seniors and
persons with disabilities, including the need for specialized care
and out-of-network services.
   (3) Provides sufficient compensation for coordination of care
among multiple providers and care management by providers.
   (4) Reflects the need to attract and retain providers,
particularly those with specialized expertise in the care of seniors
and persons with disabilities.
   (d) Make all relevant notices accessible to seniors or persons
with disabilities through methods that may include, but need not be
limited to, assistive listening devices, sign language interpreters,
and translation in appropriate languages.
   (e) Require that Medi-Cal managed care beneficiaries retain and
are informed of all rights to grievances and appeals processes
available under state and federal laws and regulations.
   14087.489.  (a) (1) Enrollment in the pilot program authorized by
this article shall commence no later than January 1, 2011. Prior to
implementing enrollment in the pilot program, the department shall
conduct a readiness review to ensure the readiness and the ability of
the health plans to serve the special needs of seniors and persons
with disabilities, and to comply with all requirements of this
article, applicable state and federal laws, and relevant performance
standards and contract requirements. To accomplish the readiness
review, the department may contract with an independent contractor to
review each participating health plan, which may include a review of
a health plan's site.
   (2) In determining readiness, each participating health plan shall
demonstrate all of the following:
   (A) The existence of an appropriate provider network within the
two counties, which shall include a sufficient number of all of the
provider types necessary to furnish comprehensive services to seniors
and persons with disabilities.
   (B) (i) Evidence that the plan has specific policies, procedures,
and protocols to ensure timely access to the specialists,
subspecialists, specialty care centers, ancillary therapists, and
providers of specialized equipment and supplies, including durable
medical equipment, either through health plan providers or through
referrals to specialists outside the plan, including those providers
outside of the plan network or geographic service area. For purposes
of this subparagraph, "access" shall include physical access for
individuals with disabilities, consistent with subparagraph (J).
   (ii) Evidence that the plan has written policies and procedures in
place that apply when contracting providers are unable to provide
timely access to services to enrolled Medi-Cal beneficiaries,
including provision for referrals for out-of-network care.
   (C) Evidence that the plan has adequate policies and procedures in
place to ensure that persons enrolled pursuant to this article
secure standing referrals, consistent with the requirements of the
Knox-Keene Act, to the appropriate specialists, subspecialists, and
specialty care centers necessary to ensure continuity of care and to
meet their ongoing care and treatment needs.
   (D)  Evidence that the plan provides an opportunity for members to
select a specialist as a primary care provider, as defined in
subdivision (gg) of Section 53810 of Title 22 of the California Code
of Regulations.
   (E) Evidence that the plan provides access to all of the following
services:
   (i) Inpatient and outpatient rehabilitation services through
providers accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF) or other similar accreditation
organization.
   (ii) Applied rehabilitative technology.
   (iii) Speech pathologists, including those experienced in working
with significant speech impairment, persons with developmental
disabilities, and persons who require augmentative communication
devices.
   (iv) Occupational therapy and orthotic providers.
   (v) Physical therapy.
   (vi) Low-vision centers.
   (F) Evidence that the Medi-Cal managed care health plans involved
in the pilot program provide access to assessments and evaluations
for wheelchairs that are independent of durable medical equipment
providers and include, when necessary, a home assessment.
   (G) Evidence that Medi-Cal managed care health plans involved in
the pilot program are able to provide communication access to
seniors, persons with disabilities, and those who are limited English
proficient. This communication must be provided in a manner that is
understandable and usable to people with reduced or no ability to
speak, see or hear, or who have limitations in learning,
comprehension, or ability to communicate in English. Materials must
be provided in alternative formats or through other methods necessary
to ensure effective communication, including assistive listening
systems, sign language interpreters, captioning, or written
translations and oral interpreters. These alternative communication
methods shall be provided in accordance with the preferences of the
enrollee.
   (H) Evidence that the plan will have a process in place to do the
following:
   (i) Contact, within 30 days of enrollment, each enrollee
identified in advance for the plan by the department as having any
special health care needs, access requirements, or a need for
assistance in securing necessary health care services.
   (ii) Identify any accommodation needs such as interpreters,
language spoken, and alternative format requirements, and identify
any urgent medical needs.
   (iii) For those identified by the plan as being high risk, provide
referral to a care coordinator and develop a care plan within 60
days of the initial contact. The care plan shall be both of the
following:
   (I) Developed, in consultation with, and with the consent of, the
enrollee or his or her designated representative.
   (II) Updated at the request of the enrollee or his or her
designated representative, when there is a significant change in the
health or services needs of the enrollee, and at least annually.
   (I) Evidence that the plan has the staff and systems in place to
coordinate care for enrolled seniors and persons with disabilities
across all settings, including coordination of discharge to
appropriate services within and outside of the plan's provider
network when necessary.
   (J) Evidence that the plan assesses its participating primary care
providers and high utilization specialists to determine whether they
are accessible and usable by persons with disabilities in compliance
with Titles II and III of the Americans with Disabilities Act of
1990 (42 U.S.C. Sec. 12131 et seq., and 42 U.S.C. Sec. 12181 et seq.,
respectively), and all relevant state and federal laws and
regulations. Each participating plan shall demonstrate the ability to
identify and communicate to potential enrollees the level and type
of service accessibility offered by providers in the network.
   (K) Evidence that the plan contracts with a sufficient number of
traditional and safety net providers to ensure access to care and
services, and to preserve the local community's capacity to provide
care and services, for uninsured and other safety net populations.
   (L) Evidence that the plan has developed specific strategies and
policies to inform seniors and persons with disabilities of
procedures for obtaining nonemergency transportation services to
service sites that are offered by the plan or are available through
the Medi-Cal program, and that the plan ensures that the
transportation is provided, consistent with the current Medi-Cal
managed care benefit provisions in the pilot area.
   (M) Evidence that the plan has specific strategies in place to
communicate and coordinate services with relevant community agencies
and programs serving seniors and persons with disabilities,
including, but not limited to, regional centers, independent living
centers, county health, mental health, and social service agencies,
area agencies on aging, and relevant nonprofit community-based
organizations.
   (N) Evidence that the plan has executed, at a minimum, memoranda
of understanding with the county mental health managed care plan in
the county, regional centers in the service area, and the local
California Children's Services (CCS) office.
   (b) The department shall coordinate with the Department of Managed
Health Care in conducting facility site reviews of the plan to
assess plan and provider readiness in a manner that eliminates
duplication and burdens on plans and their providers.
   14087.490.  The department shall ensure that health plans
contracting to provide services pursuant to this article shall meet
the following requirements at all times:
   (a) Ensure timely access to specialists and specialty care within
or outside of the plan's network, including specialists,
subspecialists, specialty care centers, ancillary therapists, and
specialized equipment and supplies, including durable medical
equipment.
   (b) Ensure that persons with disabilities at all times have access
to accessible, appropriate care, as required by this article.
   (c) The cultural and linguistic requirements set forth in
subdivision (c) of Section 53853 and Section 53876 of Title 22 of the
California Code of Regulations.
   (d)  Maintain a grievance system pursuant to the requirements of
Section 1368 of the Health and Safety Code, and establish a procedure
for the expedited review of grievances pursuant to the requirements
of Section 1368.01 of the Health and Safety Code. Urgent complaints
or grievances shall be resolved within 72 hours, and nonurgent
complaints or grievances shall be resolved within 30 days. At any
time during the complaint process, the enrollee may request a change
of health plan. If a complaint or grievance is not resolved within
the periods set forth in this subdivision and Section 1368 of the
Health and Safety Code, the enrollee may petition the department to
disenroll from the plan and enroll in fee-for-service Medi-Cal ,
pursuant to Section 14087.487.
   (e) Maintain a toll-free "800" nurse advice telephone service
available and accessible to seniors and persons with disabilities,
including those with hearing or other communication disabilities, to
respond to urgent clinical needs.
   (f) Demonstrate to the department and the Department of Managed
Health Care compliance with applicable state and federal laws and
regulations, all readiness criteria and performance standards
developed by the department, effective implementation of the plan's
proposed policies and procedures by the plan and its providers,
contract deliverables, and other submissions.
   (g) (1)  By September 30, 2010, and annually thereafter, each
health plan shall produce, publish, and file with the department an
accessibility plan, which shall do both of the following:
   (A) Set goals, list priority activities, and commit resources for
increasing accessibility to network provider  services
  services, particularly increasing the number of
providers with facilities that are fully compliant with the federal
Americans with Disabilities Act of 1990 (42 U.S.C. Sec. 12101 et
seq.)  .
   (B) Include goals related to disability, literacy, and competency
training for health plan staff and health care providers; ongoing
identification of existing physical, equipment, communication,
transportation, and policy barriers encountered by enrollees;
strategies for removing the identified barriers; and collection and
incorporation of feedback from consumers with disabilities and
chronic conditions.
   (2)  Participating health plans shall, when feasible, partner with
academic and research institutions to identify and test new clinical
and service performance measures specific to the unique needs of
seniors and persons with a disability.
   (3) The department shall require contracting health plans to
establish internal patient advocate programs specifically for persons
with disabilities enrolled in managed care. 
   14087.491.  (a)  Beneficiaries who select Medi-Cal managed care
pursuant to this article and who do not select a Medi-Cal managed
care plan within 30 days shall be assigned to a health plan by the
enrollment contractor. The contractor shall assign a beneficiary to a
health plan that includes one or more of his or her existing
providers of record, including, but not limited to, his or her
primary care provider, specialist, or clinic. The department shall
establish the Medi-Cal providers of record based on a review of
Medi-Cal paid claims history.
   (b) If a beneficiary chooses to not enroll in a health plan, the

    14087.491.    (a)     If a new
beneficiary fails to make any selection upon initial enrollment, or
an existing beneficiary selects managed care but fails to select a
specific plan, pursuant to paragraph (2) of subdivision (b) of
Section 14087.482 the  contractor shall assign the beneficiary
to a health plan as follows:
   (1) If the beneficiary's primary physician or specialist has a
current contract with the publicly sponsored local initiative and the
commercial plan, or, if the beneficiary's primary physician or
specialist does not have a contract with either plan, the beneficiary
shall be assigned to either plan based on the Medi-Cal member
default assignment procedures set by the Medi-Cal performance-based
auto-assignment algorithm.
   (2) If a beneficiary's primary physician or specialist has a
current contract with only one of the plans, the beneficiary shall be
assigned to that plan.
   (3) Nothing in this section shall preclude the beneficiary from
choosing to enroll in a specific plan or from requesting a medical
exemption. 
   (b) For purposes of this section, the department shall establish
the Medi-Cal providers of record based on a review of Medi-Cal paid
claims history. 
   14087.492.  The department shall adopt regulations in accordance
with the requirements of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code for the
implementation of this article.
   14087.493.  (a) The department shall contract with an independent
third-party organization to conduct an evaluation of the pilot
program, the results of which shall be reported to the Legislature by
March 1, 2014. The evaluation shall be based on data collected
during the  three-year   four-year 
duration of the pilot program, and shall include, but not be limited
to, all of the following:
   (1) The impact of enrollment on seniors and persons with
disabilities, including access to care, outcome measures, enrollee
satisfaction, continuity of care, and health plan compliance with all
applicable standards and guidelines, including the performance
standards developed pursuant to this article.
   (2) An analysis of the impact upon access to care for managed care
compared to fee-for-service Medi-Cal beneficiaries, including, but
not limited to, access to a medical home, primary care physician,
specialty care, disease management programs.
   (3) An analysis of quality of care provided in the managed care
versus fee-for-service delivery models, including access to
preventive services and preventable hospitalizations.
   (4) Enrollee satisfaction.
   (5) The effectiveness of the implementation plan and the readiness
program.
   (6) The effectiveness of the standards tested.
   (b) The department may seek funding from foundations, nonprofit
organizations, and the federal government to implement this section.
   (c)  Prior to the completion of the evaluation required pursuant
to this section, the health care stakeholder committee and other
interested stakeholders shall be provided an opportunity to review
and comment on the report. The department may collaborate with the
health care stakeholder advisory committee established pursuant to
Section 14087.484 for this purpose.
   (d) The department shall make the results of the evaluation
available to the public, which shall include, at a minimum,
publishing the evaluation on the department's Internet Web site.
   (e) The department shall make recommendations for the
continuation, expansion, or termination of the pilot program in the
affected counties based in part on the evaluation results.
   14087.494.  This article shall become inoperative on July 31,
 2015   2016  , and, as of January 1,
 2016   2017  , is repealed, unless a later
enacted statute, that becomes operative on or before January 1,
 2016   2017  , deletes or extends the
dates on which it becomes inoperative and is repealed.