BILL NUMBER: AB 1759 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 21, 2014
AMENDED IN ASSEMBLY MARCH 25, 2014
INTRODUCED BY Assembly Members Pan and Skinner
(Coauthor: Assembly Member Bonta)
FEBRUARY 14, 2014
An act to add Sections 14105.196 and 14105.197 to the Welfare and
Institutions Code, relating to health care services.
LEGISLATIVE COUNSEL'S DIGEST
AB 1759, as amended, Pan. Medi-Cal: reimbursement rates.
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. The
Medi-Cal program is, in part, governed and funded by federal Medicaid
provisions. Existing federal law requires the state to provide
payment for primary care services furnished in the 2013 and 2014
calendar years by Medi-Cal providers with specified primary specialty
designations at a rate not less than 100% of the payment rate that
applies to those services and physicians under the Medicare Program.
Existing state law requires, to the extent required by federal
law, and beginning January 1, 2013, through and including December
31, 2014, that payments for primary care services provided by
specified physicians be no less than 100% of the payment rate that
applies to those services and physicians as established by the
Medicare Program, for both fee-for-service and managed care plans.
This bill would require that those payments continue indefinitely
to the extent permitted by federal law but only to the extent that
federal financial participation is available and would also require
that those payments be made to other providers identified in federal
law as eligible for the increased reimbursement. The bill would
authorize the department to implement these provisions through
provider bulletins without taking regulatory action until regulations
are adopted and would require the department to adopt those
regulations by July 1, 2017. The bill also would request the
University of California to annually conduct an independent
assessment of Medi-Cal provider reimbursement rates and would
require the department to annually review the findings and
recommendations of an independent assessment of Medi-Cal
provider reimbursement rates and to that assessment
and suggest adjustments to the reimbursement rates as necessary
to ensure that quality and access in the Medi-Cal fee-for-service
program and in Medi-Cal managed care plans are adequate to meet
applicable state and federal standards. The bill would require that
the findings and recommendations of the independent assessment and
the director's suggested adjustments to provider reimbursement rates
be submitted to the Legislature annually as part of the Governor's
Budget. The bill would also create an advisory committee
composed of 16 members appointed by the Governor and the Legislature,
as specified, to meet periodically with the University of
California and provide input on the assessment conducted pursuant to
the bill's provisions.
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 14105.196 is added to the Welfare and
Institutions Code, to read:
14105.196. (a) It is the intent of the Legislature to maintain
the increased reimbursement rates for primary care providers in the
Medi-Cal program upon expiration of the temporary increase provided
for under Chapter 23 of the Statutes of 2012, as amended by Chapter
438 of the Statutes of 2012, in order to ensure adequate access to
these providers. It is also the intent of the Legislature to provide
a mechanism to increase reimbursement rates for other Medi-Cal
providers in order to comply with federal Medicaid requirements that
care and services are available to Medi-Cal enrollees at least to the
extent that care and services are available to the general
population in the geographic area.
(b) Beginning January 1, 2015, to the extent permitted by federal
law and regulations, payments for primary care services provided by a
physician with a primary specialty designation of family medicine,
general internal medicine, or pediatric medicine shall not be less
than 100 percent of the payment rate that applies to those services
and physicians as established by the Medicare Program, for both
fee-for-service and managed care plans.
(c) (1) To the extent required by federal law or regulation,
beginning January 1, 2015, through and including the date specified
in that federal law or regulation, payments for primary care services
provided by a provider other than a physician shall not be less than
100 percent of the payment rate that applies to those services and
providers as established by the Medicare Program, for both
fee-for-service and managed care plans.
(2) To the extent permitted by federal law and regulation, the
payments to the providers identified in paragraph (1) shall continue
indefinitely.
(d) Notwithstanding any other law, to the extent permitted by
federal law and regulations, the payments for primary care services
made pursuant to this section shall be exempt from the payment
reductions under Sections 14105.191 and 14105.192.
(e) Payment increases made pursuant to this section shall not
apply to provider rates of payment described in Section 14105.18 for
services provided to individuals not eligible for Medi-Cal or the
Family Planning, Access, Care, and Treatment (Family PACT) Program.
(f) For purposes of this section, the following definitions shall
apply:
(1) "Primary care services" and "primary specialty" means the
services and primary specialties defined in Section 1202 of the
federal Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152; 42 U.S.C. Sec. 1396a(a)(13)(C)), and any amendments to
that section, and related federal regulations.
(2) "A provider other than a physician" means a health care
provider, other than a physician, who is identified in federal law or
regulation as eligible for payments for primary care services
rendered under the federal Medicaid program at a rate not less than
100 percent of the payment rate that applies to those services as
established by the Medicare Program.
(g) Notwithstanding any other law, the payment increase
implemented pursuant to this section shall apply to managed care
health plans that contract with the department pursuant to Chapter
8.75 (commencing with Section 14591) and to contracts with the Senior
Care Action Network and the AIDS Healthcare Foundation, and to the
extent that the services are provided through any of these contracts,
payments shall be increased by the actuarial equivalent amount of
the payment increases pursuant to contract amendments or change
orders effective on or after January 1, 2015.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement, clarify, make specific, and define the
provisions of this section by means of provider bulletins or similar
instructions, without taking regulatory action until the time
regulations are adopted. The department shall adopt regulations by
July 1, 2017, 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. Beginning July 1, 2015, and notwithstanding
Section 10231.5 of the Government Code, the department shall provide
a status report regarding this section to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
(i) This section shall be implemented only if and to the extent
that federal financial participation is available and any necessary
federal approvals have been obtained.
SEC. 2. Section 14105.197 is added to the Welfare and Institutions
Code, to read:
14105.197. (a) The Legislature requests the University of
California to annually conduct an independent assessment of Medi-Cal
provider reimbursement rates.
(b) (1) An advisory committee is hereby created to be composed of
16 members representing health care stakeholders, including, but not
limited to, patients, providers, public and private health delivery
systems, payers, and state officials. The Governor shall appoint
eight members, the Senate Committee on Rules shall appoint four
members, and the Speaker of the Assembly shall appoint four members.
(2) Except for the initial appointments described in paragraph
(3), members of the committee shall be appointed for a term of four
years, and each member shall hold office until the appointment and
qualification of his or her successor or until one year has elapsed
since the expiration of the term for which he or she was appointed,
whichever occurs first.
(3) (A) Of the initial members appointed by the Governor, two
shall serve a term of one year, two shall serve a term of two years,
two shall serve a term of three years, and two shall serve a term of
four years.
(B) Of the initial members appointed by the Senate Committee on
Rules, one shall serve a term of one year, one shall serve a term of
two years, one shall serve a term of three years, and one shall serve
a term of four years.
(C) Of the initial members appointed by the Speaker of the
Assembly, one shall serve a term of one year, one shall serve a term
of two years, one shall serve a term of three years, and one shall
serve a term of four years.
(4) Members of the committee shall publicly report financial and
other potential conflicts of interest.
(5) The committee shall establish an open process for the conduct
of its affairs that enables all health care stakeholders to provide
feedback on those affairs.
(6) The committee shall meet periodically with the University of
California and provide input to the University of California on the
assessment conducted pursuant to subdivision (a).
(c) The director shall annually review the
findings and recommendations of an independent assessment of
Medi-Cal provider reimbursement rates the assessment
conducted under subdivision (a) and suggest adjustments to the
reimbursement rates as necessary to ensure that quality and access in
the Medi-Cal fee-for-service program and in Medi-Cal managed care
plans are adequate to meet applicable state and federal standards.
Notwithstanding
(d) Notwithstanding Section
10231.5 of the Government Code, the findings and recommendations of
the independent assessment conducted under subdivision (a)
and the director's suggested adjustments to provider reimbursement
rates provided pursuant to subdivision (c) shall be
submitted to the Legislature annually as part of the Governor's
Budget submitted pursuant to Section 13337 of the Government Code.