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 the assignment of an additional
begin delete 1,750end delete enrollees or insureds, as specified, to a primary care physician if that physician supervises one or more nonphysician medical begin delete practitioners.end delete 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, 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
begin delete 1,750end delete 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 1375.9 is added to the Health and Safety
2Code, to read:
(a) Notwithstanding any other state law or regulation,
4if a primary care physician supervises one or more nonphysician
5medical practitioners, the physician may be assigned an average
P3 1of an additional
begin delete 1,750end delete enrollees for each full-time equivalent
2nonphysician medical practitioner supervised by that physician,
3in addition to the number of enrollees assigned to that physician
4pursuant to current law and approved by the department.
5(b) This section shall not require a primary care physician to
6accept an assignment of enrollees that would be contrary to paragraph
8(2) of subdivision (b) of Section 1375.7.
9(c) Nothing in this section shall be interpreted to modify
10subdivision (b) of Section 3516 of the Business and Professions
Section 10133.4 is added to the Insurance Code, to
(a) If the assignment of insureds to a primary care
23physician is authorized by this part, or any regulation, contract, or
24policy promulgated thereunder, each full-time equivalent primary
25care physician may be assigned up to 2,000 insureds.
26Notwithstanding any other state law or regulation, if a primary
27care physician supervises one or more nonphysician medical
28practitioners, the physician may be assigned up to an additional
291,750 insureds for each full-time equivalent nonphysician medical
30practitioner supervised by that physician.
3(b) This section shall not require a primary care provider to
4accept the assignment of a number of insureds that would exceed
5standards of good health care as provided in Section 10133.5.
6(c) Nothing in this section shall be interpreted to modify
7subdivision (b) of Section 3516 of the Business and Professions
Section 14087.48 of the Welfare and Institutions Code
10 is amended to read:
(a) For purposes of this section, “Medi-Cal managed
12care plan” means any individual, organization, or entity that enters
13into a contract with the department pursuant to Article 2.7
14(commencing with Section 14087.3), Article 2.8 (commencing
15with Section 14087.5), Article 2.81 (commencing with Section
1614087.96), Article 2.9 (commencing with Section 14088), or
17Article 2.91 (commencing with Section 14089), or pursuant to
18Article 1 (commencing with Section 14200), or Article 7
19(commencing with Section 14490) of Chapter 8.
20(b) Before a Medi-Cal managed care plan commences operations
21based upon an action of the director that expands the geographic
22area of Medi-Cal managed care, the department shall perform an
23evaluation to determine the readiness of any affected Medi-Cal
24managed care plan to commence operations. The evaluation shall
25include, at a minimum, all of the following:
26(1) The extent to which the Medi-Cal managed care plan
27demonstrates the ability to provide reliable service utilization and
28cost data, including, but not limited to, quarterly financial reports,
29audited annual reports, utilization reports of medical services, and
31(2) The extent to which the Medi-Cal managed care plan has
32an adequate provider network, including, but not limited to, the
33location, office hours, and language capabilities of primary care
34practitioners, specialists, pharmacies, and hospitals, that the types
35of specialists in the provider network are based on the population
36makeup and particular geographic needs, and that whether
37requirements will be met for availability of services and travel
38 distance standards, as set forth in Sections 53852 and 53885,
39respectively, of Title 22 of the California Code of Regulations.
P5 1(3) The extent to which the Medi-Cal managed care plan has
2developed procedures for the monitoring and improvement of
3quality of care, including, but not limited to, procedures for
4retrospective reviews which include patterns of practice reviews
5and drug prescribing practice reviews, utilization management
6mechanisms to detect both under- and over-utilization of health
7care services, and procedures that specify timeframes for medical
9(4) The extent to which the Medi-Cal managed care plan has
10demonstrated the ability to meet accessibility standards in
11accordance with Section 1300.67.2 of Title 28 of the California
12Code of Regulations, including, but not limited to, procedures for
13appointments, waiting times, telephone procedures, after hours
14 calls, urgent care, and arrangement for the provision of unusual
16(5) The extent to which the Medi-Cal managed care plan has
17met all standards and guidelines established by the department that
18demonstrate readiness to provide services to enrollees.
19(6) The extent to which the Medi-Cal managed care plan has
20submitted all required contract deliverables to the department,
21including, but not limited to, quality improvement systems,
22utilization management, access and availability, member services,
23member grievance systems, and enrollments and disenrollments.
24(7) The extent to which the Medi-Cal managed care plan’s
25Evidence of Coverage, Member Services Guide, or both, conforms
26to federal and state statutes and regulations, is accurate, and is
28(8) The extent to which the Medi-Cal managed care plan’s
29primary care and facility sites have been reviewed and evaluated
30by the department.
Section 14088 of the Welfare and Institutions Code is
32amended to read:
(a) It is the purpose of this article to ensure that the
34Medi-Cal program shall be operated in the most cost-effective and
35efficient manner possible with the optimum number of Medi-Cal
36providers and shall ensure quality of care and known access to
38(b) For the purposes of this article, the following definitions
40(1) “Primary care provider” means either of the following:
P6 1(A) Any internist, general practitioner, obstetrician-gynecologist,
2pediatrician, family practice physician, nonphysician medical
3practitioner, or any primary care clinic, rural health clinic,
4community clinic or hospital outpatient clinic currently enrolled
5in the Medi-Cal program, which agrees to provide case
6management to Medi-Cal beneficiaries.
7(B) A county or other political subdivision that employs,
8operates, or contracts with, any of the primary care providers listed
9in subparagraph (A), and that agrees to use that primary care
10provider for the purposes of contracting under this article.
11(2) “Primary care case management” means responsibility for
12the provision of referral, consultation, ordering of therapy,
13admission to hospitals, followup care, and prepayment approval
14of referred services.
15(3) “Designation form” or “form” means a form supplied by
16the department to be executed by a Medi-Cal beneficiary and a
17primary care provider or other entity eligible pursuant to this article
18who has entered into a contract with the department pursuant to
19this article, setting forth the beneficiary’s choice of contractor and
20an agreement to be limited by the case management decisions of
21that contractor and the contractor’s agreement to be responsible
22for that beneficiary’s case management and medical care, as
23specified in this article.
24(4) “Emergency services” means health care services rendered
25by an eligible Medi-Cal provider to a Medi-Cal beneficiary for
26those health services required for alleviation of severe pain or
27immediate diagnosis and treatment of unforeseen medical
28conditions which if not immediately diagnosed and treated could
29lead to disability or death.
30(5) “Modified primary care case management” means primary
31care case management wherein capitated services are limited to
32primary care practitioner office visits only.
33(6) “Service area” means an area designated by either a single
34federal Postal ZIP Code or by two or more Postal ZIP Codes that
36(c) For purposes of
begin delete this part,end delete “nonphysician
38medical practitioner” means a physician assistant performing
39services under physician supervision in compliance with Chapter
407.7 (commencing with Section 3500) of Division 2 of the Business
P7 1and Professions
begin delete Codeend delete or a nurse practitioner
5performing services in collaboration with a physician pursuant to
6Chapter 6 (commencing with Section 2700) of Division 2 of the
7Business and Professions Code.
Section 14088.1 is added to the Welfare and
9Institutions Code, to read:
If the assignment of beneficiaries enrolled in any type
11of Medi-Cal managed care plan to a primary care physician is
12authorized or required by a provision of this part, or any regulation,
13contract, or policy promulgated thereunder, each full-time
14equivalent primary care physician may be assigned up to 2,000
15beneficiaries. Notwithstanding any other state law or regulation,
16if a primary care physician in that plan supervises one or more
17nonphysician medical practitioners, the physician may be assigned
18up to an additional
begin delete 1,750end delete beneficiaries for each full-time
19equivalent nonphysician medical practitioner supervised by that
21Nothing in this section shall be interpreted to modify subdivision
22(b) of Section 3516 of the Business and Professions Code.
Section 14254 of the Welfare and Institutions Code is
24amended to read:
“Primary care practitioner” is a physician or
26nonphysician medical practitioner who has the responsibility for
27providing initial and primary care to patients, for maintaining the
28continuity of patient care, and for initiating referral for specialist
29care. A primary care physician shall be either a physician who has
30limited his or her practice of medicine to general practice or who
31is a board-certified or board-eligible internist, pediatrician,
32obstetrician-gynecologist, or family practitioner.
No reimbursement is required by this act pursuant to
34Section 6 of Article XIII B of the California Constitution because
35the only costs that may be incurred by a local agency or school
36district will be incurred because this act creates a new crime or
37infraction, eliminates a crime or infraction, or changes the penalty
38for a crime or infraction, within the meaning of Section 17556 of
39the Government Code, or changes the definition of a crime within
P8 1the meaning of Section 6 of Article XIII B of the California