Amended in Assembly September 6, 2013

Amended in Assembly September 3, 2013

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 add and repeal Section 1375.9 of the Health and Safety Code, to add Section 10133.4 to the Insurance Code, and to amend Sections 14087.48, 14088, and 14254begin delete of, and to add and repeal Section 14088.1 of,end deletebegin insert ofend 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 would, until January 1, 2019,begin insert require a health care service plan to ensure that there is at least one full-time equivalent primary care physician for every 2,000 enrollees. This bill would, until January 1, 2019,end insert authorize the assignment ofbegin insert up toend insert an additional 1,000 enrollees, as specified, to a primary care physicianbegin delete if that physician supervises one or moreend deletebegin insert for each full-time equivalentend insert nonphysician medicalbegin delete practitioners,end deletebegin insert practitionerend insertbegin insert,end insert asbegin delete defined.end deletebegin insert defined, supervised by that physician.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 physicians and, if applicable, nonphysician medical practitioners. 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.begin delete The bill would, until January 1, 2019, 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 in a Medi-Cal managed care plan.end delete 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:

begin delete
3

1375.9.  

(a) If a primary care physician supervises one or more
4nonphysician medical practitioners, the physician may be assigned
5an average of an additional 1,000 enrollees for each full-time
6equivalent nonphysician medical practitioner supervised by that
7physician, in addition to the number of enrollees assigned to that
8physician pursuant to current law.

end delete
9begin insert

begin insert1375.9.end insert  

end insert
begin insert

(a) A health care service plan shall ensure there is at
10least one full-time equivalent primary care physician for every
112,000 enrollees of the plan. The number of enrollees per primary
12care physician may be increased by up to 1,000 additional
13enrollees for each full-time equivalent nonphysician medical
14practitioner supervised by that primary care physician.

end insert

15(b) This section shall not require a primary care physician to
16accept an assignment of enrollees by a health care service plan
17without his or her approval, or that would be contrary to paragraph
18(2) of subdivision (b) of Section 1375.7.

19(c) Nothing in this section shall be interpreted to modify
20subdivision (e) of Section 2836.1 of the Business and Professions
21Code or subdivision (b) of Section 3516 of the Business and
22Professions Code.

23(d) For purposes of this section,begin insert a primary care provider
24includes aend insert
“nonphysician medicalbegin delete practitioner” meansend delete
25begin insert practitioner,” which is defined asend insert a physician assistant performing
26services underbegin insert the supervision of a primary care end insert physician
27begin delete supervisionend delete in compliance with Chapter 7.7 (commencing with
28Section 3500) of Division 2 of the Business and Professions Code
29or a nurse practitioner performing services in collaboration with
30a physician pursuant to Chapter 6 (commencing with Section 2700)
31of Division 2 of the Business and Professions Code.

32(e) This section shall remain in effect only until January 1, 2019,
33and as of that date is repealed, unless a later enacted statute, that
34is enacted before January 1, 2019, deletes or extends that date.

35

SEC. 2.  

Section 10133.4 is added to the Insurance Code, to
36read:

37

10133.4.  

(a) For purposes of insurers who contract with
38providers for alternate rates pursuant to Section 10133,begin insert a primary
P4    1care provider includes a end insert
“nonphysician medicalbegin delete practitioner”
2meansend delete
begin insert practitioner,end insertbegin insert” which is defined asend insert a physician assistant
3performing services underbegin insert the supervision of a primary careend insert
4 physicianbegin delete supervisionend delete in compliance with Chapter 7.7 (commencing
5with Section 3500) of Division 2 of the Business and Professions
6Code or a nurse practitioner performing services in collaboration
7with a physician pursuant to Chapter 6 (commencing with Section
82700) of Division 2 of the Business and Professions Code.

9(b) This section shall not require a primary care provider to
10accept the assignment of a number of insureds that would exceed
11standards of good health care as provided in Section 10133.5.

12(c) Nothing in this section shall be interpreted to modify
13subdivision (e) of Section 2836.1 of the Business and Professions
14Code or subdivision (b) of Section 3516 of the Business and
15Professions Code.

16

SEC. 3.  

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

18

14087.48.  

(a) For purposes of this section, “Medi-Cal managed
19care plan” means any individual, organization, or entity that enters
20into a contract with the department pursuant to Article 2.7
21(commencing with Section 14087.3), Article 2.8 (commencing
22with Section 14087.5), Article 2.81 (commencing with Section
2314087.96), Article 2.9 (commencing with Section 14088), or
24Article 2.91 (commencing with Section 14089), or pursuant to
25Article 1 (commencing with Section 14200), or Article 7
26(commencing with Section 14490) of Chapter 8.

27(b) Before a Medi-Cal managed care plan commences operations
28based upon an action of the director that expands the geographic
29area of Medi-Cal managed care, the department shall perform an
30evaluation to determine the readiness of any affected Medi-Cal
31managed care plan to commence operations. The evaluation shall
32include, at a minimum, all of the following:

33(1) The extent to which the Medi-Cal managed care plan
34demonstrates the ability to provide reliable service utilization and
35cost data, including, but not limited to, quarterly financial reports,
36audited annual reports, utilization reports of medical services, and
37encounter data.

38(2) The extent to which the Medi-Cal managed care plan has
39an adequate provider network, including, but not limited to, the
40location, office hours, and language capabilities of primary care
P5    1 physicians and, if applicable, nonphysician medical practitioners,
2specialists, pharmacies, and hospitals, that the types of specialists
3in the provider network are based on the population makeup and
4particular geographic needs, and that whether requirements will
5be met for availability of services and travel distance standards,
6as set forth in Sections 53852 and 53885, respectively, of Title 22
7of the California Code of Regulations.

8(3) The extent to which the Medi-Cal managed care plan has
9developed procedures for the monitoring and improvement of
10quality of care, including, but not limited to, procedures for
11retrospective reviews which include patterns of practice reviews
12and drug prescribing practice reviews, utilization management
13mechanisms to detect both under- and over-utilization of health
14care services, and procedures that specify timeframes for medical
15authorization.

16(4) The extent to which the Medi-Cal managed care plan has
17demonstrated the ability to meet accessibility standards in
18accordance with Section 1300.67.2 of Title 28 of the California
19Code of Regulations, including, but not limited to, procedures for
20appointments, waiting times, telephone procedures, after hours
21 calls, urgent care, and arrangement for the provision of unusual
22specialty services.

23(5) The extent to which the Medi-Cal managed care plan has
24met all standards and guidelines established by the department that
25demonstrate readiness to provide services to enrollees.

26(6) The extent to which the Medi-Cal managed care plan has
27submitted all required contract deliverables to the department,
28including, but not limited to, quality improvement systems,
29utilization management, access and availability, member services,
30member grievance systems, and enrollments and disenrollments.

31(7) The extent to which the Medi-Cal managed care plan’s
32Evidence of Coverage, Member Services Guide, or both, conforms
33to federal and state statutes and regulations, is accurate, and is
34easily understood.

35(8) The extent to which the Medi-Cal managed care plan’s
36primary care and facility sites have been reviewed and evaluated
37by the department.

38

SEC. 4.  

Section 14088 of the Welfare and Institutions Code is
39amended to read:

P6    1

14088.  

(a) It is the purpose of this article to ensure that the
2Medi-Cal program shall be operated in the most cost-effective and
3efficient manner possible with the optimum number of Medi-Cal
4providers and shall ensure quality of care and known access to
5services.

6(b) For the purposes of this article, the following definitions
7shall apply:

8(1) “Primary care provider” means either of the following:

9(A) Any internist, general practitioner, obstetrician-gynecologist,
10pediatrician, family practice physician, nonphysician medical
11practitioner, or any primary care clinic, rural health clinic,
12community clinic or hospital outpatient clinic currently enrolled
13in the Medi-Cal program, which agrees to provide case
14management to Medi-Cal beneficiaries.

15(B) A county or other political subdivision that employs,
16operates, or contracts with, any of the primary care providers listed
17in subparagraph (A), and that agrees to use that primary care
18provider for the purposes of contracting under this article.

19(2) “Primary care case management” means responsibility for
20the provision of referral, consultation, ordering of therapy,
21admission to hospitals, followup care, and prepayment approval
22of referred services.

23(3) “Designation form” or “form” means a form supplied by
24the department to be executed by a Medi-Cal beneficiary and a
25primary care provider or other entity eligible pursuant to this article
26who has entered into a contract with the department pursuant to
27this article, setting forth the beneficiary’s choice of contractor and
28an agreement to be limited by the case management decisions of
29that contractor and the contractor’s agreement to be responsible
30for that beneficiary’s case management and medical care, as
31specified in this article.

32(4) “Emergency services” means health care services rendered
33by an eligible Medi-Cal provider to a Medi-Cal beneficiary for
34those health services required for alleviation of severe pain or
35immediate diagnosis and treatment of unforeseen medical
36conditions which if not immediately diagnosed and treated could
37lead to disability or death.

38(5) “Modified primary care case management” means primary
39care case management wherein capitated services are limited to
40primary care practitioner office visits only.

P7    1(6) “Service area” means an area designated by either a single
2federal Postal ZIP Code or by two or more Postal ZIP Codes that
3are contiguous.

4(c) For purposes of Medi-Cal managed care plans, as defined
5in subdivision (m) of Section 14016.5, “nonphysician medical
6practitioner” means a physician assistant performing services under
7physician supervision in compliance with Chapter 7.7 (commencing
8with Section 3500) of Division 2 of the Business and Professions
9Code, a certified nurse-midwife performing services under
10physician supervision in compliance with Article 2.5 (commencing
11with Section 2746) of Chapter 6 of Division 2 of the Business and
12Professions Code, or a nurse practitioner performing services in
13collaboration with a physician pursuant to Chapter 6 (commencing
14with Section 2700) of Division 2 of the Business and Professions
15Code.

begin delete
16

SEC. 5.  

Section 14088.1 is added to the Welfare and
17Institutions Code
, to read:

18

14088.1.  

If a primary care physician in a Medi-Cal managed
19care plan supervises one or more nonphysician medical
20practitioners, the physician may be assigned up to an additional
211,000 beneficiaries for each full-time equivalent nonphysician
22medical practitioner supervised by that physician, in addition to
23the number of beneficiaries assigned to that physician pursuant to
24current law.

25Nothing in this section shall be interpreted to modify subdivision
26(e) of Section 2836.1 of the Business and Professions Code or
27subdivision (b) of Section 3516 of the Business and Professions
28Code.

29This section shall remain in effect only until January 1, 2019,
30and as of that date is repealed, unless a later enacted statute, that
31is enacted before January 1, 2019, deletes or extends that date.

end delete
32

begin deleteSEC. 6.end delete
33begin insertSEC. 5.end insert  

Section 14254 of the Welfare and Institutions Code is
34amended to read:

35

14254.  

(a) “Primary care physician” is a physician who has
36the responsibility for providing initial and primary care to patients,
37for maintaining the continuity of patient care, and for initiating
38referral for specialist care. A primary care physician shall be either
39a physician who has limited his or her practice of medicine to
40general practice or who is a board-certified or board-eligible
P8    1internist, pediatrician, obstetrician-gynecologist, or family
2practitioner.

3(b) A nonphysician medical practitioner, as defined in
4subdivision (c) of Section 14088, who is supervised by a primary
5care physician, has the responsibility for providing initial and
6primary care to patients, for maintaining the continuity of patient
7care, and for initiating referral for specialist care.

8

begin deleteSEC. 7.end delete
9begin insertSEC. 6.end insert  

No reimbursement is required by this act pursuant to
10Section 6 of Article XIII B of the California Constitution because
11the only costs that may be incurred by a local agency or school
12district will be incurred because this act creates a new crime or
13infraction, eliminates a crime or infraction, or changes the penalty
14for a crime or infraction, within the meaning of Section 17556 of
15the Government Code, or changes the definition of a crime within
16the meaning of Section 6 of Article XIII B of the California
17Constitution.



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