Amended in Assembly August 5, 2013

Amended in Senate May 28, 2013

Amended in Senate April 3, 2013

Senate Bill No. 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 would authorize the assignment of an additional begin delete 1,750 end delete begin insert 1,000 end insert enrollees or insureds, as specified, to a primary care physician if that physician supervises one or more nonphysician medical begin delete practitioners. end delete begin insert practitioners, as defined. end insert 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 1,750 end delete begin insert 1,000 end insert 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) Notwithstanding any other state law or regulation,
if a primary care physician supervises one or more nonphysician
medical practitioners, the physician may be assigned an average
of an additional begin delete 1,750 end delete begin insert 1,000 end insert enrollees for each full-time equivalent
nonphysician medical practitioner supervised by that 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 begin insert by a health care service plan
without his or her approval, or end insert 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.

begin insert

(d) For purposes of this section, “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.

end insert

SEC. 2.  

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

begin delete

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.

end delete

begin insert

begin insert 10133.4. end insert   

end insert begin insert

(a) For purposes of insurers who contract with
providers for alternate rates pursuant to Section 10133,
“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. In accordance with Section 14088
of the Welfare and Institutions Code, a nonphysician medical
practitioner shall be considered a primary care provider.

end insert

(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 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 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,
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 begin delete this part, end delete begin insert Medi-Cal managed care plans, as
defined in subdivision (m) of Section 14016.5, end insert “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 begin delete Code end delete begin insert Code, a certified nurse-midwife performing
services under physician supervision in compliance with Article
2.5 (commencing with Section 2746) of Chapter 6 of Division 2 of
the Business and Professions Code, end insert 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 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 begin delete 1,750 end delete begin insert 1,000 end insert 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.