Amended in Senate April 3, 2013

Senate BillNo. 494


Introduced by Senator Monning

(Principal coauthor: Senator Hernandez)

February 21, 2013


An act tobegin delete amend Section 3500 of the Business and Professionsend deletebegin insert add Section 1375.9 to the Health and Safety Code, to add Section 10133.4 to the Insurance Code, and to amend Sections 14087.48, 14088, and 14254 of, and to add Section 14088.1 to, the Welfare and Institutionsend insert Code, relating to health care providers.

LEGISLATIVE COUNSEL’S DIGEST

SB 494, as amended, Monning. Health carebegin delete providers: California Health Benefit Exchange.end deletebegin insert providers.end insert

Existing law, thebegin 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 deletebegin insert Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance.end insert

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This bill would authorize, if the assignment of plan enrollees or insureds to a primary care physician is authorized by certain provisions of law or contract, the assignment of up to 2,000 enrollees or insureds to each full-time equivalent primary care physician and would authorize the assignment of an additional 1,750 enrollees or insureds, as specified, to a primary care physician if that physician supervises one or more nonphysician medical practitioners. By imposing new requirements on health care service plans, the willful violation of which would be a crime, this bill would impose a state-mandated local program.

end insert
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Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services. Prior to a Medi-Cal managed care plan commencing operations, existing law requires the department to evaluate, among other things, the extent to which the plan has an adequate provider network, including the location, office hours, and language capabilities of the plan’s primary care physicians. Existing law defines primary care provider for these purposes as an internist, general practitioner, obstetrician/gynecologist, pediatrician, family practice physician, or, as specified, types of clinics and defines primary care physician as a physician who has the responsibility, among other duties, for providing initial and primary care to patients.

end insert
begin insert

This bill would require that the department evaluate the location, office hours, and language capabilities of a plan’s primary care practitioners instead of the plan’s primary care physicians. The bill would add nonphysician medical practitioners to the definition of a primary care provider. The bill would define nonphysician medical practitioner as a physician assistant performing services under physician supervision, as specified, or as a nurse practitioner performing services in collaboration with a physician, as specified. The bill would authorize, if the assignment of beneficiaries enrolled in any type of Medi-Cal managed care plan to a primary care physician is authorized by specified provisions of law or contract, the assignment of up to 2,000 beneficiaries to each full-time equivalent primary care physician. The bill would authorize the assignment of an additional 1,750 beneficiaries, as specified, to a primary care physician when that physician supervises one or more nonphysician medical practitioners. The bill would make conforming changes.

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begin insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end insert
begin insert

This bill would provide that no reimbursement is required by this act for a specified reason.

end insert
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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.

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Vote: majority. Appropriation: no. Fiscal committee: begin deleteno end deletebegin insertyesend insert. State-mandated local program: begin deleteno end deletebegin insertyesend insert.

The people of the State of California do enact as follows:

P3    1begin insert

begin insertSECTION 1.end insert  

end insert

begin insertSection 1375.9 is added to the end insertbegin insertHealth and Safety
2Code
end insert
begin insert, to read:end insert

begin insert
3

begin insert1375.9.end insert  

(a) If the assignment of plan enrollees to a primary
4care physician is authorized by this chapter, or any regulation or
5contract promulgated thereunder, each full-time equivalent primary
6care physician may be assigned up to 2,000 enrollees.
7Notwithstanding any other state law or regulation, if a primary
8care physician supervises one or more nonphysician medical
9practitioners, the physician may be assigned up to an additional
101,750 enrollees for each full-time equivalent nonphysician medical
11practitioner supervised by that physician.

12(b) This section shall not require a primary care physician to
13accept an assignment of enrollees that would be contrary to
14paragraph (2) of subdivision (b) of Section 1375.7.

end insert
15begin insert

begin insertSEC. 2.end insert  

end insert

begin insertSection 10133.4 is added to the end insertbegin insertInsurance Codeend insertbegin insert, to
16read:end insert

begin insert
17

begin insert10133.4.end insert  

(a) If the assignment of insureds to a primary care
18physician is authorized by this part, or any regulation, contract,
19or policy promulgated thereunder, each full-time equivalent
20primary care physician may be assigned up to 2,000 insureds.
21Notwithstanding any other state law or regulation, if a primary
22care physician supervises one or more nonphysician medical
23practitioners, the physician may be assigned up to an additional
241,750 insureds for each full-time equivalent nonphysician medical
25practitioner supervised by that physician.

26(b) This section shall not require a primary care provider to
27accept the assignment of a number of insureds that would exceed
28standards of good health care as provided in Section 10133.5.

end insert
29begin insert

begin insertSEC. 3.end insert  

end insert

begin insertSection 14087.48 of the end insertbegin insertWelfare and Institutions Codeend insert
30begin insert is amended to read:end insert

P4    1

14087.48.  

(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
20encounter data.

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
24begin delete physicians,end deletebegin insert practitioners,end insert 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
37authorization.

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
4specialty services.

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
16easily understood.

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.

20begin insert

begin insertSEC. 4.end insert  

end insert

begin insertSection 14088 of the end insertbegin insertWelfare and Institutions Codeend insertbegin insert is
21amended to read:end insert

22

14088.  

(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
26services.

27(b) For the purposes of this article, the following definitions
28shall apply:

29(1) “Primary care provider” means either of the following:

30(A) Any internist, general practitioner, obstetrician/gynecologist,
31begin delete pediatrician orend deletebegin insert pediatrician,end insert family practicebegin delete physicianend deletebegin insert physician,
32nonphysician medical practitioner,end insert
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
22primary carebegin delete physicianend deletebegin insert practitionerend insert 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
25are contiguous.

begin insert

26(c) For purposes of this part, “nonphysician medical
27practitioner” means a physician assistant performing services
28under physician supervision in compliance with Chapter 7.7
29(commencing with Section 3500) of Division 2 of the Business and
30Professions Code or a nurse practitioner performing services in
31collaboration with a physician pursuant to Chapter 6 (commencing
32with Section 2700) of Division 2 of the Business and Professions
33Code.

end insert
34begin insert

begin insertSEC. 5.end insert  

end insert

begin insertSection 14088.1 is added to the end insertbegin insertWelfare and Institutions
35Code
end insert
begin insert, to read:end insert

begin insert
36

begin insert14088.1.end insert  

If the assignment of beneficiaries enrolled in any type
37of Medi-Cal managed care plan to a primary care physician is
38authorized or required by a provision of Part 3 (commencing with
39Section 11000) of Division 9, or any regulation, contract, or policy
40promulgated thereunder, each full-time equivalent primary care
P7    1physician may be assigned up to 2,000 beneficiaries.
2Notwithstanding any other state law or regulation, if a primary
3care physician in that plan supervises one or more nonphysician
4medical practitioners, the physician may be assigned up to an
5additional 1,750 beneficiaries for each full-time equivalent
6nonphysician medical practitioner supervised by that physician.

end insert
7begin insert

begin insertSEC. 6.end insert  

end insert

begin insertSection 14254 of the end insertbegin insertWelfare and Institutions Codeend insertbegin insert is
8amended to read:end insert

9

14254.  

“Primary carebegin delete physician”end deletebegin insert practitionerend insertbegin insertend insert is a physician
10begin insert or nonphysician medical practitionerend insert 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.

17begin insert

begin insertSEC. 7.end insert  

end insert
begin insert

No reimbursement is required by this act pursuant to
18Section 6 of Article XIII B of the California Constitution because
19the only costs that may be incurred by a local agency or school
20district will be incurred because this act creates a new crime or
21infraction, eliminates a crime or infraction, or changes the penalty
22for a crime or infraction, within the meaning of Section 17556 of
23the Government Code, or changes the definition of a crime within
24the meaning of Section 6 of Article XIII B of the California
25Constitution.

end insert
begin delete
26

SECTION 1.  

Section 3500 of the Business and Professions
27Code
is amended to read:

28

3500.  

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
36non-physician providers.

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.

end delete


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