SB 1315, as amended, Monning. Medi-Cal: providers.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.
Existing law permits the department to make unannounced visits to an applicant or to a provider for the purpose of determining whether enrollment, continued enrollment, or certification as a provider is warranted, or as necessary for the administration of the Medi-Cal program. Existing law further requires that a provider be subject to temporary suspension from the Medi-Cal program, which includes temporary deactivation of the provider’s number, for failure to remediate significant discrepancies in information that he or she provided to the department or for failure to remediate significant discrepancies that are discovered as a result of an announced or unannounced visit to a provider, as specified. Existing law requires the provider to be notified, in writing, of the temporary suspension and deactivation of provider numbers.
This bill would require that notice of temporary suspension to contain a list of discrepancies to be remediated and the timeframe in which the provider needs to remediate those discrepancies, which must be at least 60 days from the date the notice of temporary suspension is issued. The bill would require the department to lift a temporary suspension and notify a provider that the temporary suspension has been lifted and that he or she is eligible to receive reimbursement for Medi-Cal services provided after the date the temporary suspension was lifted if the provider has demonstrated that the identified discrepancies have been remediated within the
applicable timeframe.begin delete A provider whoend deletebegin insert The bill would require the department to send a notice to a provider whoend insert fails to remediate the identifiedbegin delete discrepancies, as specified, would be removed from enrollment as a provider in the Medi-Cal program by operation of law.end deletebegin insert discrepancies in the allotted timeframe stating that he or she will be removed from enrollment as a provider in the Medi-Cal program by operation of law based on failure to remediate the identified discrepancies.end insert
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14043.7 of the Welfare and Institutions
2Code is amended to read:
(a) The department may make unannounced visits
4to an applicant or to a provider for the purpose of determining
5whether enrollment, continued enrollment, or certification is
6warranted, or as necessary for the administration of the Medi-Cal
7program. If an unannounced site visit is conducted by the
8department for any enrolled provider, the provider shall permit
9access to any and all of their provider locations. If a provider fails
10to permit access for any site visit, the application shall be denied
11and the provider shall be subject to deactivation. At the time of
12the visit, the applicant or provider shall be required to demonstrate
13an established place of business appropriate and adequate for the
14services billed or claimed to the Medi-Cal program, as
relevant to
15his or her scope of practice, as indicated by, but not limited to, the
16following:
P3 1(1) Being open and available to the general public.
2(2) Having regularly established and posted business hours.
3(3) Having adequate supplies in stock on the premises.
4(4) Meeting all local laws and ordinances regarding business
5licensing and operations.
6(5) Having the necessary equipment and facilities to carry out
7day-to-day business for his or her practice.
8(b) An unannounced visit pursuant to subdivision (a) shall be
9prohibited with respect to
clinics licensed under Section 1204 of
10the Health and Safety Code, clinics exempt from licensure under
11Section 1206 of the Health and Safety Code, health facilities
12licensed under Chapter 2 (commencing with Section 1250) of
13Division 2 of the Health and Safety Code, and natural persons
14licensed or certified under Division 2 (commencing with Section
15500) of the Business and Professions Code, the Osteopathic
16Initiative Act, or the Chiropractic Initiative Act, unless the
17department has reason to believe that the provider will defraud or
18abuse the Medi-Cal program or lacks the organizational or
19administrative capacity to provide services under the program.
20(c) (1) Failure to remediate significant discrepancies in
21information provided to the department by the provider or
22significant discrepancies that are discovered as a result
of an
23announced or unannounced visit to a provider, for purposes of
24enrollment, continued enrollment, or certification pursuant to
25subdivision (a) shall make the provider subject to temporary
26suspension from the Medi-Cal program, which shall include
27temporary deactivation of the provider’s number, including all
28business addresses used by the provider to obtain reimbursement
29from the Medi-Cal program. The director shall notify in writing
30the provider of the temporary suspension and deactivation of
31provider numbers, which shall take effect 15 days from the date
32of the notification. Notwithstanding Section 100171 of the Health
33and Safety Code, proceedings after the imposition of sanctions in
34this subdivision shall be in accordance with Section 14043.65.
35(2) A notice of temporary suspension issued pursuant to
36paragraph (1) shall include
the following:
37(A) A list of discrepancies required to be remediated.
38(B) The timeframe in which a provider may demonstrate to the
39department that the discrepancies identified pursuant to
40subparagraph (A) have been remediated. The timeframe in which
P4 1a provider may remediate discrepancies shall not be less than 60
2days from the date the notice of the temporary suspension is issued.
3(3) If a provider who has received a notice of temporary
4suspension pursuant to paragraph (1) demonstrates to the
5department that the discrepancies identified pursuant to
6subparagraph (A) of paragraph (2) have been remediated and meets
7the standards of participation within the timeframe specified in
8subparagraph (B) of paragraph (2), the
department shall lift the
9temporary suspension and shall notify the provider that the
10temporary suspension has been lifted and that he or she is eligible
11to receive Medi-Cal reimbursement for services provided after the
12date the temporary suspension was lifted.
13(4) If a provider has received a site visit pursuant to this section
14that results in a notice of temporary suspension pursuant to
15paragraph (1), and the provider fails to remediate the discrepancies
16identified pursuant to subparagraph (A) of paragraph (2) within
17the timeframe specified in subparagraph (B) of paragraph (2)begin delete after begin insert the
18having received two written notices from the department,end delete
19department shall send the provider a notice stating that
end insert the
20providerbegin delete shallend deletebegin insert willend insert be removed from enrollment as a provider in
21the Medi-Cal program by operation of lawbegin insert based on failure to
22remediate the discrepancies identified in the notice of temporary
23suspensionend insert.
24(d) (1) This section shall become operative on the effective
25date of the state plan amendment necessary to implement this
26section, as stated in the declaration executed by the director
27pursuant to paragraph (2).
28(2) Upon approval of the state plan amendment necessary to
29implement
this section under Section 455.416 of Title 42 of the
30Code of Federal Regulations, the director shall execute a
31declaration, to be retained by the director and posted on the
32department’s Internet Web site, that states that this approval has
33been obtained and the effective date of the state plan amendment.
34The department shall transmit a copy of the declaration to the
35Legislature.
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