Amended in Senate September 3, 2013

Amended in Senate July 2, 2013

Amended in Senate June 6, 2013

Amended in Assembly April 18, 2013

Amended in Assembly April 9, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 411

Introduced by Assembly Member Pan

February 15, 2013

An act to add Section 14029.92 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 411, as amended, Pan. Medi-Cal: performance measures.

Existing law provides for the Medi-Cal program, which is 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. Under existing law, one of the methods by which Medi-Cal services are provided is pursuant to contracts with managed care plans. begin insert Existing federal law generally requires that a state that contracts with certain managed care plans ensure that an external quality review is performed by an External Quality Review Organization (EQRO). end insert

This bill would begin delete require end delete begin insert require, when the department enters into a new contract end insert begin insert end insert begin insert with an EQRO, end insert all Medi-Cal managed care plans to link individual level data collected as a part of analyzing their Healthcare Effectiveness Data and Information Set (HEDIS) measures, or their External Accountability Set (EAS) performance measure equivalent, to patient identifiers in a manner that allows for an analysis of disparities in medical treatment by certain begin delete characteristics end delete begin insert characteristics, including geographic region and primary language, end insert and to submit that data to the department annually. The department would be required to make that individual level data available for research purposes, as specified. The bill would begin delete further require the department to stratify, in the aggregate, that data end delete begin insert also require, when the department enters into a new contract with an EQRO, that the department either include in the terms of the new contract a requirement that, upon approval of the contract, the EQRO stratify all patient-specific HEDIS measures, or their EAS performance measure equivalent, in the aggregate, end insert by certain begin delete characteristics and to develop a report, which would be published end delete begin insert characteristics, including geographic region and primary language, or that the department, upon approval of the contract, stratify those same measures, in the aggregate, by those same characteristics. The bill would require the department to publicly report this analysis end insert on the department’s Internet Web site. begin delete The bill would also require the department to identify, based upon that data, any disparities in care provided to all Medi-Cal managed care enrollees on the basis of those characteristics, and notify Medi-Cal managed care plans of any disparities identified. If disparities in care are identified, the bill would require each Medi-Cal managed care plan to analyze its internal data to determine if that disparity in care is present among Medi-Cal managed care enrolled in its plan, and require the Medi-Cal managed care plan to develop and implement a quality improvement plan, as specified. end delete

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.  

Section 14029.92 is added to the Welfare and
Institutions Code, to read:

14029.92.  

(a)  begin delete The end delete begin insert When the department enters into a new
contract end insert begin insert with an External Quality Review Organization (EQRO),
the end insert department shall require all Medi-Cal managed care plans,
including county organized health systems and plans contracting
with the department to provide services pursuant to two-plan and
geographic managed care models, to link all individual level data
collected as a part of analyzing their Healthcare Effectiveness Data
and Information Set (HEDIS) measures, or their External
Accountability Set (EAS) performance measure equivalent, to
patient identifiers in a manner that allows for an analysis of
disparities in medical treatment by geographic region, primary
language, race, ethnicity, gender, and, to the extent data is
available, by sexual orientation and gender identity, and to provide
that information to the department annually. The department shall
make this data available, in a format that complies with the Health
Insurance Portability and Accountability Act of 1996, for research
purposes through a data use or business associate agreement.

(b)  begin delete The department shall stratify, in the aggregate, end delete begin insert (1) end insert begin insert   end insert begin insert When
the department enters into a new contract with an EQRO, the
department shall do either of the following: end insert

begin insert (A) end insert begin insert   end insert begin insert Include in the terms of the new contract a requirement that,
upon approval of the contract, the EQRO end insert begin insert stratify end insert begin insert end insert all
begin insert patient-specific end insert HEDIS measures, or their EAS performance
measure equivalent, begin delete from the plans described in subdivision (a) end delete begin insert in
the aggregate, end insert by geographic region, primary language, race,
ethnicity, gender, and, to the extent data is available, by sexual
orientation and gender begin delete identity, in end delete begin insert identity. end insert

begin insert

(B) Stratify, upon approval of the contract, all patient-specific
HEDIS measures, or their EAS performance measure equivalent,
in the aggregate, by geographic region, primary language, race,
ethnicity, gender, and, to the extent data is available, by sexual
orientation and gender identity.

end insert

begin insert (2) end insert begin insert   end insert begin insert The stratification required pursuant to paragraph (1) shall
be completed in end insert order to identify disparities in the quality of care
provided to Medi-Cal managed care enrollees based on begin delete those
factors. The end delete begin insert the factors identified in paragraph (1). end insert

begin insert (3) end insert begin insert   end insert begin insert The end insert department shall begin delete develop a report with this data and
publish the end delete begin insert publicly end insert report begin insert the analysis identified in paragraph (1) end insert
on the department’s Internet Web site.

begin delete

(c) (1) The department shall, based upon the data described in
subdivision (b), identify disparities in care provided to all Medi-Cal
managed care enrollees based upon the factors described in
subdivision (b), and notify the plans described in subdivision (a)
of any disparities identified.

(2) If the department identifies any disparities, a plan described
in subdivision (a) shall review its administrative data, including,
but not limited to, encounter and claims data, to assess whether
the disparities identified by the department exist among the
Medi-Cal managed care enrollees enrolled in its plan.

(3) If, upon review of its administrative data, a plan described
in subdivision (a) identifies the same disparities identified by the
department among the Medi-Cal managed care enrollees enrolled
in its plan, the plan shall develop and implement a quality
improvement plan to address those disparities. The quality
improvement plan may be used to meet existing contractual
requirements to develop and implement a quality improvement
plan. A quality improvement plan developed and implemented
pursuant to this paragraph shall be provided to the department and
the department shall publish that plan on the department’s Internet
Web site.

end delete