Amended in Assembly August 19, 2013

Amended in Assembly August 5, 2013

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 addbegin insert and repealend insert Section 1375.9begin delete toend deletebegin insert ofend insert 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 addbegin insert and repealend insert Section 14088.1begin delete to,end deletebegin insert of,end insert 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 insert, until January 1, 2019,end insert authorize the assignment of an additional 1,000 enrolleesbegin delete or insuredsend delete, as specified, to a primary care physician if that physician supervises one or more nonphysician medical practitioners, as defined. 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 wouldbegin insert additionallyend insert require that the department evaluate the location, office hours, and language capabilities of a plan’sbegin delete primary care practitioners instead of the plan’s primary care physicians.end deletebegin insert nonphysician medical practitioners.end insert 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 billbegin delete wouldend deletebegin insert would, until January 1, 2019,end insert 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 billbegin delete wouldend deletebegin insert would also, until January 1, 2019,end insert authorize the assignment of an additional 1,000 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:

P3    1

SECTION 1.  

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

3

1375.9.  

(a) begin deleteNotwithstanding any other state law or regulation, end delete
4begin deleteifend deletebegin insert Ifend insert a primary care physician supervises one or more nonphysician
5medical practitioners, the physician may be assigned an average
6of an additional 1,000 enrollees for each full-time equivalent
7nonphysician medical practitioner supervised by that physician,
8in addition to the number of enrollees assigned to that physician
9pursuant to current law and approved by the department.

10(b) This section shall not require a primary care physician to
11accept an assignment of enrollees by a health care service plan
12without his or her approval, or that would be contrary to paragraph
13(2) of subdivision (b) of Section 1375.7.

14(c) Nothing in this section shall be interpreted to modify
15begin insert subdivision (e) of Section 2836.1 of the Business and Professions
16Code or end insert
subdivision (b) of Section 3516 of the Business and
17Professions Code.

18(d) For purposes of this section, “nonphysician medical
19practitioner” means a physician assistant performing services under
20physician supervision in compliance with Chapter 7.7 (commencing
21with Section 3500) of Division 2 of the Business and Professions
22 Code or a nurse practitioner performing services in collaboration
23with a physician pursuant to Chapter 6 (commencing with Section
242700) of Division 2 of the Business and Professions Code.

begin insert

25(e) This section shall remain in effect only until January 1, 2019,
26and as of that date is repealed, unless a later enacted statute, that
27is enacted before January 1, 2019, deletes or extends that date.

end insert
28

SEC. 2.  

Section 10133.4 is added to the Insurance Code, to
29read:

30

10133.4.  

(a) For purposes of insurers who contract with
31providers for alternate rates pursuant to Section 10133,
32“nonphysician medical practitioner” means a physician assistant
33performing services under physician supervision in compliance
34with Chapter 7.7 (commencing with Section 3500) of Division 2
35of the Business and Professions Code or a nurse practitioner
36performing services in collaboration with a physician pursuant to
37Chapter 6 (commencing with Section 2700) of Division 2 of the
38Business and Professions Code. begin delete In accordance with Section 14088
P4    1of the Welfare and Institutions Code, a nonphysician medical
2practitioner shall be considered a primary care provider.end delete

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
7begin insert subdivision (e) of Section 2836.1 of the Business and Professions
8Code or end insert
subdivision (b) of Section 3516 of the Business and
9Professions Code.

10

SEC. 3.  

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

12

14087.48.  

(a) For purposes of this section, “Medi-Cal managed
13care plan” means any individual, organization, or entity that enters
14into a contract with the department pursuant to Article 2.7
15(commencing with Section 14087.3), Article 2.8 (commencing
16with Section 14087.5), Article 2.81 (commencing with Section
1714087.96), Article 2.9 (commencing with Section 14088), or
18Article 2.91 (commencing with Section 14089), or pursuant to
19Article 1 (commencing with Section 14200), or Article 7
20(commencing with Section 14490) of Chapter 8.

21(b) Before a Medi-Cal managed care plan commences operations
22based upon an action of the director that expands the geographic
23area of Medi-Cal managed care, the department shall perform an
24evaluation to determine the readiness of any affected Medi-Cal
25managed care plan to commence operations. The evaluation shall
26include, at a minimum, all of the following:

27(1) The extent to which the Medi-Cal managed care plan
28demonstrates the ability to provide reliable service utilization and
29cost data, including, but not limited to, quarterly financial reports,
30audited annual reports, utilization reports of medical services, and
31encounter data.

32(2) The extent to which the Medi-Cal managed care plan has
33an adequate provider network, including, but not limited to, the
34location, office hours, and language capabilities of primary care
35begin delete practitioners,end deletebegin insert physicians, nonphysician medical practitioners,end insert
36 specialists, pharmacies, and hospitals, that the types of specialists
37in the provider network are based on the population makeup and
38particular geographic needs, and that whether requirements will
39be met for availability of services and travel distance standards,
P5    1as set forth in Sections 53852 and 53885, respectively, of Title 22
2of the California Code of Regulations.

3(3) The extent to which the Medi-Cal managed care plan has
4developed procedures for the monitoring and improvement of
5quality of care, including, but not limited to, procedures for
6retrospective reviews which include patterns of practice reviews
7and drug prescribing practice reviews, utilization management
8mechanisms to detect both under- and over-utilization of health
9care services, and procedures that specify timeframes for medical
10authorization.

11(4) The extent to which the Medi-Cal managed care plan has
12demonstrated the ability to meet accessibility standards in
13accordance with Section 1300.67.2 of Title 28 of the California
14Code of Regulations, including, but not limited to, procedures for
15appointments, waiting times, telephone procedures, after hours
16 calls, urgent care, and arrangement for the provision of unusual
17specialty services.

18(5) The extent to which the Medi-Cal managed care plan has
19met all standards and guidelines established by the department that
20demonstrate readiness to provide services to enrollees.

21(6) The extent to which the Medi-Cal managed care plan has
22submitted all required contract deliverables to the department,
23including, but not limited to, quality improvement systems,
24utilization management, access and availability, member services,
25member grievance systems, and enrollments and disenrollments.

26(7) The extent to which the Medi-Cal managed care plan’s
27Evidence of Coverage, Member Services Guide, or both, conforms
28to federal and state statutes and regulations, is accurate, and is
29easily understood.

30(8) The extent to which the Medi-Cal managed care plan’s
31primary care and facility sites have been reviewed and evaluated
32by the department.

33

SEC. 4.  

Section 14088 of the Welfare and Institutions Code is
34amended to read:

35

14088.  

(a) It is the purpose of this article to ensure that the
36Medi-Cal program shall be operated in the most cost-effective and
37efficient manner possible with the optimum number of Medi-Cal
38providers and shall ensure quality of care and known access to
39services.

P6    1(b) For the purposes of this article, the following definitions
2shall apply:

3(1) “Primary care provider” means either of the following:

4(A) Any internist, general practitioner, obstetrician-gynecologist,
5pediatrician, family practice physician, nonphysician medical
6practitioner, or any primary care clinic, rural health clinic,
7community clinic or hospital outpatient clinic currently enrolled
8in the Medi-Cal program, which agrees to provide case
9management to Medi-Cal beneficiaries.

10(B) A county or other political subdivision that employs,
11operates, or contracts with, any of the primary care providers listed
12in subparagraph (A), and that agrees to use that primary care
13provider for the purposes of contracting under this article.

14(2) “Primary care case management” means responsibility for
15the provision of referral, consultation, ordering of therapy,
16admission to hospitals, followup care, and prepayment approval
17of referred services.

18(3) “Designation form” or “form” means a form supplied by
19the department to be executed by a Medi-Cal beneficiary and a
20primary care provider or other entity eligible pursuant to this article
21who has entered into a contract with the department pursuant to
22this article, setting forth the beneficiary’s choice of contractor and
23an agreement to be limited by the case management decisions of
24that contractor and the contractor’s agreement to be responsible
25for that beneficiary’s case management and medical care, as
26specified in this article.

27(4) “Emergency services” means health care services rendered
28by an eligible Medi-Cal provider to a Medi-Cal beneficiary for
29those health services required for alleviation of severe pain or
30immediate diagnosis and treatment of unforeseen medical
31conditions which if not immediately diagnosed and treated could
32lead to disability or death.

33(5) “Modified primary care case management” means primary
34care case management wherein capitated services are limited to
35primary care practitioner office visits only.

36(6) “Service area” means an area designated by either a single
37federal Postal ZIP Code or by two or more Postal ZIP Codes that
38are contiguous.

39(c) For purposes of Medi-Cal managed care plans, as defined
40in subdivision (m) of Section 14016.5, “nonphysician medical
P7    1practitioner” means a physician assistant performing services under
2physician supervision in compliance with Chapter 7.7 (commencing
3with Section 3500) of Division 2 of the Business and Professions
4Code, a certified nurse-midwife performing services under
5physician supervision in compliance with Article 2.5 (commencing
6with Section 2746) of Chapter 6 of Division 2 of the Business and
7Professions Code, or a nurse practitioner performing services in
8collaboration with a physician pursuant to Chapter 6 (commencing
9with Section 2700) of Division 2 of the Business and Professions
10Code.

11

SEC. 5.  

Section 14088.1 is added to the Welfare and
12Institutions Code
, to read:

13

14088.1.  

If the assignment of beneficiaries enrolled in any type
14of Medi-Cal managed care plan to a primary care physician is
15authorized or required by a provision of this part, or any regulation,
16contract, or policy promulgated thereunder, each full-time
17equivalent primary care physician may be assigned up to 2,000
18beneficiaries.begin delete Notwithstanding any other state law or regulation,
19ifend delete
begin insert Ifend insert a primary care physician in that plan supervises one or more
20nonphysician medical practitioners, the physician may be assigned
21up to an additional 1,000 beneficiaries for each full-time equivalent
22 nonphysician medical practitioner supervised by that physician.

23Nothing in this section shall be interpreted to modifybegin insert subdivision
24(e) of Section 2836.1 of the Business and Professions Code orend insert

25 subdivision (b) of Section 3516 of the Business and Professions
26Code.

begin insert

27This section shall remain in effect only until January 1, 2019,
28and as of that date is repealed, unless a later enacted statute, that
29is enacted before January 1, 2019, deletes or extends that date.

end insert
30

SEC. 6.  

Section 14254 of the Welfare and Institutions Code is
31amended to read:

32

14254.  

begin insert(a)end insertbegin insertend insert“Primary carebegin delete practitioner”end deletebegin insert physician”end insert is a
33physicianbegin delete or nonphysician medical practitionerend delete who has the
34responsibility for providing initial and primary care to patients,
35for maintaining the continuity of patient care, and for initiating
36referral for specialist care. A primary care physician shall be either
37a physician who has limited his or her practice of medicine to
38general practice or who is a board-certified or board-eligible
39internist, pediatrician, obstetrician-gynecologist, or family
40practitioner.

begin insert

P8    1(b) A nonphysician medical practitioner, as defined in
2subdivision (c) of Section 14088, who is supervised by a primary
3care physician, has the responsibility for providing initial and
4primary care to patients, for maintaining the continuity of patient
5care, and for initiating referral for specialist care.

end insert
6

SEC. 7.  

No reimbursement is required by this act pursuant to
7Section 6 of Article XIII B of the California Constitution because
8the only costs that may be incurred by a local agency or school
9district will be incurred because this act creates a new crime or
10infraction, eliminates a crime or infraction, or changes the penalty
11for a crime or infraction, within the meaning of Section 17556 of
12the Government Code, or changes the definition of a crime within
13the meaning of Section 6 of Article XIII B of the California
14Constitution.



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