as amended, Monning. Health care
begin delete providers: California Health Benefit Exchange.end delete
Existing law, the
begin delete federal Patient Protection and Affordable Care Act, requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that makes available qualified health plans to qualified individuals and qualified employers, as specified, and meets certain other requirements. Existing law establishes the California Health Benefit Exchange (the Exchange) within state government for that purpose.end delete
This bill would state the intent of the Legislature to ensure that qualified health plans participating in the California Health Benefit Exchange provide an adequate network of primary care providers, including non-physician providers.end delete
begin deleteno end delete.
State-mandated local program: begin deleteno end delete.
The people of the State of California do enact as follows:
(a) For purposes of this section “Medi-Cal managed
2care plan” means any individual, organization, or entity that enters
3into a contract with the department pursuant to Article 2.7
4(commencing with Section 14087.3), Article 2.8 (commencing
5with Section 14087.5), Article 2.81 (commencing with Section
614087.96), Article 2.9 (commencing with Section 14088), or
7Article 2.91 (commencing with Section 14089), or pursuant to
8Article 1 (commencing with Section 14200), or Article 7
9(commencing with Section 14490) of Chapter 8.
10(b) Before a Medi-Cal managed care plan commences operations
11based upon an action of the director that expands the geographic
12area of Medi-Cal managed care, the department shall perform an
13evaluation to determine the readiness of any affected Medi-Cal
14managed care plan to commence operations. The evaluation shall
15include, at a minimum, all of the following:
16(1) The extent to which the Medi-Cal managed care plan
17demonstrates the ability to provide reliable service utilization and
18cost data, including, but not limited to, quarterly financial reports,
19audited annual reports, utilization reports of medical services, and
21(2) The extent to which the Medi-Cal managed care plan has
22an adequate provider network, including, but not limited to, the
23location, office hours, and language capabilities of primary care
begin delete physicians,end delete specialists, pharmacies, and hospitals,
25 that the types of specialists in the provider network are based on
26the population makeup and particular geographic needs, and that
27whether requirements will be met for availability of services and
28travel distance standards, as set forth in Sections 53852 and 53885,
29respectively, of Title 22 of the California Code of Regulations.
30(3) The extent to which the Medi-Cal managed care plan has
31developed procedures for the monitoring and improvement of
32quality of care, including, but not limited to, procedures for
33retrospective reviews which include patterns of practice reviews
34and drug prescribing practice reviews, utilization management
35mechanisms to detect both under- and over-utilization of health
36care services, and procedures that specify timeframes for medical
38(4) The extent to which the Medi-Cal managed care plan has
39demonstrated the ability to meet accessibility standards in
40accordance with Section 1300.67.2 of Title 28 of the California
P5 1Code of Regulations, including, but not limited to, procedures for
2appointments, waiting times, telephone procedures, after hours
3calls, urgent care, and arrangement for the provision of unusual
5(5) The extent to which the Medi-Cal managed care plan has
6met all standards and guidelines established by the department that
7demonstrate readiness to provide services to enrollees.
8(6) The extent to which the Medi-Cal managed care plan has
9submitted all required contract deliverables to the department,
10including, but not limited to, quality improvement systems,
11utilization management, access and availability, member services,
12member grievance systems, and enrollment and disenrollments.
13(7) The extent to which the Medi-Cal
managed care plan’s
14Evidence of Coverage, Member Services Guide, or both, conforms
15to federal and state statutes and regulations, is accurate, and is
17(8) The extent to which the Medi-Cal managed care plan’s
18primary care and facility sites have been reviewed and evaluated
19by the department.
(a) It is the purpose of this article to ensure that the
23Medi-Cal program shall be operated in the most cost-effective and
24efficient manner possible with the optimum number of Medi-Cal
25providers and shall assure quality of care and known access to
27(b) For the purposes of this article, the following definitions
29(1) “Primary care provider” means either of the following:
30(A) Any internist, general practitioner, obstetrician/gynecologist,
begin delete pediatrician orend delete family practice begin delete physicianend delete or any primary care clinic,
33rural health clinic, community clinic or hospital outpatient clinic
34currently enrolled in the Medi-Cal program, which agrees to
35provide case management to Medi-Cal beneficiaries.
36(B) A county or other political subdivision that employs,
37operates, or contracts with, any of the primary care providers listed
38in subparagraph (A), and that agrees to use that primary care
39provider for the purposes of contracting under this article.
P6 1(2) “Primary care case management” means responsibility for
2the provision of referral, consultation, ordering of therapy,
3admission to hospitals, follow up care, and prepayment approval
4of referred services.
5(3) “Designation form” or “form” means a form supplied by
6the department to be executed by a Medi-Cal beneficiary and a
7primary care provider or other entity eligible pursuant to this article
8who has entered into a contract with the department pursuant to
9this article, setting forth the beneficiary’s choice of contractor and
10an agreement to be limited by the case management decisions of
11that contractor and the contractor’s agreement to be responsible
12for that beneficiary’s case management and medical care, as
13specified in this article.
14(4) “Emergency services” means health care services rendered
15by an eligible Medi-Cal provider to a Medi-Cal beneficiary for
16those health services required for alleviation of severe pain or
17immediate diagnosis and treatment of unforeseen medical
18conditions which if not immediately diagnosed and treated could
19lead to disability or death.
20(5) “Modified primary care case management” means primary
21care case management wherein capitated services are limited to
begin delete physicianend delete office visits only.
23(6) “Service area” means an area designated by either a single
24federal Postal ZIP Code or by two or more Postal ZIP Codes that
begin delete physician”end delete is a physician
10 who has the responsibility
11for providing initial and primary care to patients, for maintaining
12the continuity of patient care, and for initiating referral for
13specialist care. A primary care physician shall be either a physician
14who has limited his practice of medicine to general practice or
15who is a board-certified or board-eligible internist, pediatrician,
16obstetrician-gynecologist, or family practitioner.
Section 3500 of the Business and Professions
27Code is amended to read:
In its concern with the growing shortage and geographic
29maldistribution of health care services in California, the Legislature
30intends to establish in this chapter a framework for development
31of a new category of health manpower--the physician assistant.
32It is the intent of the legislature to ensure that qualified health
33plans participating in the California Health Benefit Exchange,
34created by Section 100500 of the Government Code, provide an
35adequate network of primary care providers, including
37The purpose of this chapter is to encourage the more effective
38utilization of the skills of physicians, and physicians and podiatrists
39practicing in the same medical group practice, by enabling them
40to delegate health care tasks to qualified physician assistants where
P8 1this delegation is consistent with the patient’s health and welfare
2and with the laws and regulations relating to physician assistants.
3This chapter is established to encourage the utilization of
4physician assistants by physicians, and by physicians and
5podiatrists practicing in the same medical group, and to provide
6that existing legal constraints should not be an unnecessary
7hindrance to the more effective provision of health care services.
8It is also the purpose of this chapter to allow for innovative
9development of programs for the education, training, and utilization
10of physician assistants.