BILL NUMBER: SB 494 AMENDED
BILL TEXT
AMENDED IN SENATE MAY 28, 2013
AMENDED IN SENATE APRIL 3, 2013
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 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.
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, 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.
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:
SECTION 1. Section 1375.9 is added to the Health and Safety Code,
to read:
1375.9. (a) If the assignment of plan enrollees to a
primary care physician is authorized by this chapter, or any
regulation or contract promulgated thereunder, each full-time
equivalent primary care physician may be assigned up to 2,000
enrollees. Notwithstanding any other state law or
regulation, if a primary care physician supervises one or more
nonphysician medical practitioners, the physician may be assigned
up to an average of an additional 1,750
enrollees for each full-time equivalent nonphysician medical
practitioner supervised by that physician.
physician, in addition to the number of enrollees assigned to that
physician pursuant to current law and approved by the department.
(b) This section shall not require a primary care physician to
accept an assignment of enrollees that would be contrary to paragraph
(2) of subdivision (b) of Section 1375.7.
(c) Nothing in this section shall be interpreted to modify
subdivision (b) of Section 3516 of the Business and Professions Code.
SEC. 2. Section 10133.4 is added to the Insurance Code, to read:
10133.4. (a) If the assignment of insureds to a primary care
physician is authorized by this part, or any regulation, contract, or
policy promulgated thereunder, each full-time equivalent primary
care physician may be assigned up to 2,000 insureds. Notwithstanding
any other state law or regulation, if a primary care physician
supervises one or more nonphysician medical practitioners, the
physician may be assigned up to an additional 1,750 insureds for each
full-time equivalent nonphysician medical practitioner supervised by
that physician.
(b) This section shall not require a primary care provider to
accept the assignment of a number of insureds that would exceed
standards of good health care as provided in Section 10133.5.
(c) Nothing in this section shall be interpreted to modify
subdivision (b) of Section 3516 of the Business and Professions Code.
SEC. 3. Section 14087.48 of the Welfare and Institutions Code is
amended to read:
14087.48. (a) For purposes of this section , "Medi-Cal
managed care plan" means any individual, organization, or entity
that enters into a contract with the department pursuant to Article
2.7 (commencing with Section 14087.3), Article 2.8 (commencing with
Section 14087.5), Article 2.81 (commencing with Section 14087.96),
Article 2.9 (commencing with Section 14088), or Article 2.91
(commencing with Section 14089), or pursuant to Article 1 (commencing
with Section 14200), or Article 7 (commencing with Section 14490) of
Chapter 8.
(b) Before a Medi-Cal managed care plan commences operations based
upon an action of the director that expands the geographic area of
Medi-Cal managed care, the department shall perform an evaluation to
determine the readiness of any affected Medi-Cal managed care plan to
commence operations. The evaluation shall include, at a minimum, all
of the following:
(1) The extent to which the Medi-Cal managed care plan
demonstrates the ability to provide reliable service utilization and
cost data, including, but not limited to, quarterly financial
reports, audited annual reports, utilization reports of medical
services, and encounter data.
(2) The extent to which the Medi-Cal managed care plan has an
adequate provider network, including, but not limited to, the
location, office hours, and language capabilities of primary care
practitioners, specialists, pharmacies, and hospitals, that the types
of specialists in the provider network are based on the population
makeup and particular geographic needs, and that whether requirements
will be met for availability of services and travel distance
standards, as set forth in Sections 53852 and 53885, respectively, of
Title 22 of the California Code of Regulations.
(3) The extent to which the Medi-Cal managed care plan has
developed procedures for the monitoring and improvement of quality of
care, including, but not limited to, procedures for retrospective
reviews which include patterns of practice reviews and drug
prescribing practice reviews, utilization management mechanisms to
detect both under- and over-utilization of health care services, and
procedures that specify timeframes for medical authorization.
(4) The extent to which the Medi-Cal managed care plan has
demonstrated the ability to meet accessibility standards in
accordance with Section 1300.67.2 of Title 28 of the California Code
of Regulations, including, but not limited to, procedures for
appointments, waiting times, telephone procedures, after hours calls,
urgent care, and arrangement for the provision of unusual specialty
services.
(5) The extent to which the Medi-Cal managed care plan has met all
standards and guidelines established by the department that
demonstrate readiness to provide services to enrollees.
(6) The extent to which the Medi-Cal managed care plan has
submitted all required contract deliverables to the department,
including, but not limited to, quality improvement systems,
utilization management, access and availability, member services,
member grievance systems, and enrollment
enrollments and disenrollments.
(7) The extent to which the Medi-Cal managed care plan's Evidence
of Coverage, Member Services Guide, or both, conforms to federal and
state statutes and regulations, is accurate, and is easily
understood.
(8) The extent to which the Medi-Cal managed care plan's primary
care and facility sites have been reviewed and evaluated by the
department.
SEC. 4. Section 14088 of the Welfare and Institutions Code is
amended to read:
14088. (a) It is the purpose of this article to ensure that the
Medi-Cal program shall be operated in the most cost-effective and
efficient manner possible with the optimum number of Medi-Cal
providers and shall assure ensure
quality of care and known access to services.
(b) For the purposes of this article, the following definitions
shall apply:
(1) "Primary care provider" means either of the following:
(A) Any internist, general practitioner,
obstetrician/gynecologist, obstetrician-gynecologist,
pediatrician, family practice physician, nonphysician medical
practitioner, or any primary care clinic, rural health clinic,
community clinic or hospital outpatient clinic currently enrolled in
the Medi-Cal program, which agrees to provide case management to
Medi-Cal beneficiaries.
(B) A county or other political subdivision that employs,
operates, or contracts with, any of the primary care providers listed
in subparagraph (A), and that agrees to use that primary care
provider for the purposes of contracting under this article.
(2) "Primary care case management" means responsibility for the
provision of referral, consultation, ordering of therapy, admission
to hospitals, followup care, and prepayment approval of referred
services.
(3) "Designation form" or "form" means a form supplied by the
department to be executed by a Medi-Cal beneficiary and a primary
care provider or other entity eligible pursuant to this article who
has entered into a contract with the department pursuant to this
article, setting forth the beneficiary's choice of contractor and an
agreement to be limited by the case management decisions of that
contractor and the contractor's agreement to be responsible for that
beneficiary's case management and medical care, as specified in this
article.
(4) "Emergency services" means health care services rendered by an
eligible Medi-Cal provider to a Medi-Cal beneficiary for those
health services required for alleviation of severe pain or immediate
diagnosis and treatment of unforeseen medical conditions which if not
immediately diagnosed and treated could lead to disability or death.
(5) "Modified primary care case management" means primary care
case management wherein capitated services are limited to primary
care practitioner office visits only.
(6) "Service area" means an area designated by either a single
federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
(c) For purposes of this part, "nonphysician medical practitioner"
means a physician assistant performing services under physician
supervision in compliance with Chapter 7.7 (commencing with Section
3500) of Division 2 of the Business and Professions Code or a nurse
practitioner performing services in collaboration with a physician
pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of
the Business and Professions Code.
SEC. 5. Section 14088.1 is added to the Welfare and Institutions
Code, to read:
14088.1. If the assignment of beneficiaries enrolled in any type
of Medi-Cal managed care plan to a primary care physician is
authorized or required by a provision of Part 3 (commencing
with Section 11000) of Division 9 this part , or
any regulation, contract, or policy promulgated thereunder, each
full-time equivalent primary care physician may be assigned up to
2,000 beneficiaries. Notwithstanding any other state law or
regulation, if a primary care physician in that plan supervises one
or more nonphysician medical practitioners, the physician may be
assigned up to an additional 1,750 beneficiaries for each full-time
equivalent nonphysician medical practitioner supervised by that
physician.
Nothing in this section shall be interpreted to modify subdivision
(b) of Section 3516 of the Business and Professions Code.
SEC. 6. Section 14254 of the Welfare and Institutions Code is
amended to read:
14254. "Primary care practitioner" is a physician or nonphysician
medical practitioner who has the responsibility for providing
initial and primary care to patients, for maintaining the continuity
of patient care, and for initiating referral for specialist care. A
primary care physician shall be either a physician who has limited
his or her practice of medicine to general practice or who
is a board-certified or board-eligible internist, pediatrician,
obstetrician-gynecologist, or family practitioner.
SEC. 7. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.