Amended in Senate May 28, 2013

Amended in Senate April 3, 2013

Senate BillNo. 494


Introduced by Senator Monning

(Principal coauthor: Senator Hernandez)

February 21, 2013


An act to 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 Institutions Code, relating to health care providers.

LEGISLATIVE COUNSEL’S DIGEST

SB 494, as amended, Monning. Health care providers.

Existing law, the 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.

This bill wouldbegin delete 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 wouldend delete 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.

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,begin delete obstetrician/gynecologist,end deletebegin insert obstetrician-gynecologist,end insert 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.

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.

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.

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

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

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

P2    1

SECTION 1.  

Section 1375.9 is added to the Health and Safety
2Code
, to read:

3

1375.9.  

(a) begin deleteIf the assignment of plan enrollees to a primary
4care physician is authorized by this chapter, or any regulation or
P3    1contract promulgated thereunder, each full-time equivalent primary
2care physician may be assigned up to 2,000 enrollees. end delete

3Notwithstanding any other state law or regulation, if a primary
4care physician supervises one or more nonphysician medical
5practitioners, the physician may be assignedbegin delete up toend deletebegin insert an average ofend insert
6 an additional 1,750 enrollees for each full-time equivalent
7nonphysician medical practitioner supervised by thatbegin delete physician.end delete
8begin insert physician, in addition to the number of enrollees assigned to that
9physician pursuant to current law and approved by the department.end insert

10(b) This section shall not require a primary care physician to
11accept an assignment of enrollees that would be contrary to
12paragraph (2) of subdivision (b) of Section 1375.7.

begin insert

13(c) Nothing in this section shall be interpreted to modify
14subdivision (b) of Section 3516 of the Business and Professions
15Code.

end insert
16

SEC. 2.  

Section 10133.4 is added to the Insurance Code, to
17read:

18

10133.4.  

(a) If the assignment of insureds to a primary care
19physician is authorized by this part, or any regulation, contract, or
20policy promulgated thereunder, each full-time equivalent primary
21care physician may be assigned up to 2,000 insureds.
22Notwithstanding any other state law or regulation, if a primary
23care physician supervises one or more nonphysician medical
24practitioners, the physician may be assigned up to an additional
251,750 insureds for each full-time equivalent nonphysician medical
26practitioner supervised by that physician.

27(b) This section shall not require a primary care provider to
28accept the assignment of a number of insureds that would exceed
29standards of good health care as provided in Section 10133.5.

begin insert

30(c) Nothing in this section shall be interpreted to modify
31subdivision (b) of Section 3516 of the Business and Professions
32Code.

end insert
33

SEC. 3.  

Section 14087.48 of the Welfare and Institutions Code
34 is amended to read:

35

14087.48.  

(a) For purposes of this sectionbegin insert,end insert “Medi-Cal managed
36care plan” means any individual, organization, or entity that enters
37into a contract with the department pursuant to Article 2.7
38(commencing with Section 14087.3), Article 2.8 (commencing
39with Section 14087.5), Article 2.81 (commencing with Section
4014087.96), Article 2.9 (commencing with Section 14088), or
P4    1Article 2.91 (commencing with Section 14089), or pursuant to
2Article 1 (commencing with Section 14200), or Article 7
3(commencing with Section 14490) of Chapter 8.

4(b) Before a Medi-Cal managed care plan commences operations
5based upon an action of the director that expands the geographic
6area of Medi-Cal managed care, the department shall perform an
7evaluation to determine the readiness of any affected Medi-Cal
8managed care plan to commence operations. The evaluation shall
9include, at a minimum, all of the following:

10(1) The extent to which the Medi-Cal managed care plan
11demonstrates the ability to provide reliable service utilization and
12cost data, including, but not limited to, quarterly financial reports,
13audited annual reports, utilization reports of medical services, and
14encounter data.

15(2) The extent to which the Medi-Cal managed care plan has
16an adequate provider network, including, but not limited to, the
17location, office hours, and language capabilities of primary care
18practitioners, specialists, pharmacies, and hospitals, that the types
19of specialists in the provider network are based on the population
20makeup and particular geographic needs, and that whether
21requirements will be met for availability of services and travel
22distance standards, as set forth in Sections 53852 and 53885,
23respectively, of Title 22 of the California Code of Regulations.

24(3) The extent to which the Medi-Cal managed care plan has
25developed procedures for the monitoring and improvement of
26quality of care, including, but not limited to, procedures for
27retrospective reviews which include patterns of practice reviews
28and drug prescribing practice reviews, utilization management
29mechanisms to detect both under- and over-utilization of health
30care services, and procedures that specify timeframes for medical
31authorization.

32(4) The extent to which the Medi-Cal managed care plan has
33demonstrated the ability to meet accessibility standards in
34accordance with Section 1300.67.2 of Title 28 of the California
35Code of Regulations, including, but not limited to, procedures for
36appointments, waiting times, telephone procedures, after hours
37calls, urgent care, and arrangement for the provision of unusual
38specialty services.

P5    1(5) The extent to which the Medi-Cal managed care plan has
2met all standards and guidelines established by the department that
3demonstrate readiness to provide services to enrollees.

4(6) The extent to which the Medi-Cal managed care plan has
5submitted all required contract deliverables to the department,
6including, but not limited to, quality improvement systems,
7utilization management, access and availability, member services,
8member grievance systems, andbegin delete enrollmentend deletebegin insert enrollmentsend insert and
9 disenrollments.

10(7) The extent to which the Medi-Cal managed care plan’s
11Evidence of Coverage, Member Services Guide, or both, conforms
12to federal and state statutes and regulations, is accurate, and is
13easily understood.

14(8) The extent to which the Medi-Cal managed care plan’s
15primary care and facility sites have been reviewed and evaluated
16by the department.

17

SEC. 4.  

Section 14088 of the Welfare and Institutions Code is
18amended to read:

19

14088.  

(a) It is the purpose of this article to ensure that the
20Medi-Cal program shall be operated in the most cost-effective and
21efficient manner possible with the optimum number of Medi-Cal
22providers and shallbegin delete assureend deletebegin insert ensureend insert quality of care and known access
23to services.

24(b) For the purposes of this article, the following definitions
25shall apply:

26(1) “Primary care provider” means either of the following:

27(A) Any internist, general practitioner,begin delete obstetrician/gynecologist,end delete
28begin insert obstetrician-gynecologist, end insert pediatrician, family practice physician,
29nonphysician medical practitioner, or any primary care clinic, rural
30health clinic, community clinic or hospital outpatient clinic
31currently enrolled in the Medi-Cal program, which agrees to
32provide case management to Medi-Cal beneficiaries.

33(B) A county or other political subdivision that employs,
34operates, or contracts with, any of the primary care providers listed
35in subparagraph (A), and that agrees to use that primary care
36provider for the purposes of contracting under this article.

37(2) “Primary care case management” means responsibility for
38the provision of referral, consultation, ordering of therapy,
39admission to hospitals, followup care, and prepayment approval
40of referred services.

P6    1(3) “Designation form” or “form” means a form supplied by
2the department to be executed by a Medi-Cal beneficiary and a
3primary care provider or other entity eligible pursuant to this article
4who has entered into a contract with the department pursuant to
5this article, setting forth the beneficiary’s choice of contractor and
6an agreement to be limited by the case management decisions of
7that contractor and the contractor’s agreement to be responsible
8for that beneficiary’s case management and medical care, as
9specified in this article.

10(4) “Emergency services” means health care services rendered
11by an eligible Medi-Cal provider to a Medi-Cal beneficiary for
12those health services required for alleviation of severe pain or
13immediate diagnosis and treatment of unforeseen medical
14conditions which if not immediately diagnosed and treated could
15lead to disability or death.

16(5) “Modified primary care case management” means primary
17care case management wherein capitated services are limited to
18primary care practitioner office visits only.

19(6) “Service area” means an area designated by either a single
20federal Postal ZIP Code or by two or more Postal ZIP Codes that
21are contiguous.

22(c) For purposes of this part, “nonphysician medical practitioner”
23means a physician assistant performing services under physician
24supervision in compliance with Chapter 7.7 (commencing with
25Section 3500) of Division 2 of the Business and Professions Code
26or a nurse practitioner performing services in collaboration with
27a physician pursuant to Chapter 6 (commencing with Section 2700)
28of Division 2 of the Business and Professions Code.

29

SEC. 5.  

Section 14088.1 is added to the Welfare and
30Institutions Code
, to read:

31

14088.1.  

If the assignment of beneficiaries enrolled in any type
32of Medi-Cal managed care plan to a primary care physician is
33authorized or required by a provision ofbegin delete Part 3 (commencing with
34Section 11000) of Division 9end delete
begin insert this partend insert, or any regulation, contract,
35or policy promulgated thereunder, each full-time equivalent
36primary care physician may be assigned up to 2,000 beneficiaries.
37Notwithstanding any other state law or regulation, if a primary
38care physician in that plan supervises one or more nonphysician
39medical practitioners, the physician may be assigned up to an
P7    1additional 1,750 beneficiaries for each full-time equivalent
2nonphysician medical practitioner supervised by that physician.

begin insert

3Nothing in this section shall be interpreted to modify subdivision
4(b) of Section 3516 of the Business and Professions Code.

end insert
5

SEC. 6.  

Section 14254 of the Welfare and Institutions Code is
6amended to read:

7

14254.  

“Primary care practitioner” is a physician or
8nonphysician medical practitioner who has the responsibility for
9providing initial and primary care to patients, for maintaining the
10continuity of patient care, and for initiating referral for specialist
11care. A primary care physician shall be either a physician who has
12limited hisbegin insert or herend insert practice of medicine to general practice or who
13is a board-certified or board-eligible internist, pediatrician,
14obstetrician-gynecologist, or family practitioner.

15

SEC. 7.  

No reimbursement is required by this act pursuant to
16Section 6 of Article XIII B of the California Constitution because
17the only costs that may be incurred by a local agency or school
18district will be incurred because this act creates a new crime or
19infraction, eliminates a crime or infraction, or changes the penalty
20for a crime or infraction, within the meaning of Section 17556 of
21the Government Code, or changes the definition of a crime within
22the meaning of Section 6 of Article XIII B of the California
23Constitution.



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