Senate BillNo. 1457


Introduced by Senator Evans

February 21, 2014


An act to amend Section 123929 of, and to add Section 125185 to, the Health and Safety Code, and to amend Section 14133.01 of the Welfare and Institutions Code, relating to medical care.

LEGISLATIVE COUNSEL’S DIGEST

SB 1457, as introduced, Evans. Medical care: electronic treatment authorization requests.

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 benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law also requires the department to administer various health programs, including the California Children’s Services Program and the Genetically Handicapped Person’s Program.

This bill would, by July 1, 2015, or a subsequent date determined by the department, require requests for authorization for treatment or services to be submitted in an electronic format determined by the department via the department’s Internet Web site or other electronic means. The bill would authorize the department to implement these provisions in phases and by means of all-county letters, plan letters, provider bulletins, or similar instructions, but would require the department to adopt regulations by July 1, 2017.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

P2    1

SECTION 1.  

Section 123929 of the Health and Safety Code
2 is amended to read:

3

123929.  

(a) Except as otherwise provided in this section and
4Section 14133.05 of the Welfare and Institutions Code, California
5Children’s Services Program services provided pursuant to this
6article require prior authorization by the department or its designee.
7Prior authorization is contingent on determination by the
8department or its designee of all of the following:

9(1) The child receiving the services is confirmed to be medically
10eligible for the CCS program.

11(2) The provider of the services is approved in accordance with
12the standards of the CCS program.

13(3) The services authorized are medically necessary to treat the
14child’s CCS-eligible medical condition.

15(b) The department or its designee may approve a request for a
16treatment authorization that is otherwise in conformance with
17subdivision (a) for services for a child participating in the Healthy
18Families Program or the AIM-Linked Infants Program pursuant
19to clause (ii) of subparagraph (A) of paragraph (6) of subdivision
20(a) of Section 12693.70 of the Insurance Code or Chapter 2
21(commencing with Sectionbegin delete 15850)end deletebegin insert 15810)end insert of Part 3.3 of Division
229 of the Welfare and Institutions Code, received by the department
23or its designee after the requested treatment has been provided to
24the child.

25(c) If a provider of services who meets the requirements of
26paragraph (2) of subdivision (a) incurs costs for services described
27in paragraph (3) of subdivision (a) to treat a child described in
28subdivision (b) who is subsequently determined to be medically
29eligible for the CCS program as determined by the department or
30its designee, the department may reimburse the provider for those
31costs. Reimbursement under this section shall conform to the
32requirements of Section 14105.18 of the Welfare and Institutions
33Code.

begin insert

34(d) (1) Notwithstanding any other provision of law, by July 1,
352015, or a subsequent date determined by the department, requests
36for authorization of services shall be submitted in an electronic
37format determined by the department and shall be submitted via
38the department’s Internet Web site or other electronic means
P3    1designated by the department. The department may implement this
2requirement in phases.

end insert
begin insert

3(2) The department may designate an alternate format for
4submitting requests for authorization of services when the
5department’s Internet Web site or other electronic means
6designated in paragraph (1) are unavailable due to an unplanned
7disruption.

end insert
begin insert

8(3) Notwithstanding Chapter 3.5 (commencing with Section
911340) of Part 1 of Division 3 of Title 2 of the Government Code,
10the department may, without taking regulatory action, implement,
11interpret, or make specific this subdivision and any applicable
12waivers and state plan amendments by means of all-county letters,
13plan letters, plan or provider bulletins, or similar instructions.
14Thereafter, the department shall adopt regulations by July 1, 2017,
15in accordance with the requirements of Chapter 3.5 (commencing
16with Section 11340) of Part 1 of Division 3 of Title 2 of the
17Government Code. The department shall consult with interested
18parties and appropriate stakeholders in implementing this
19subdivision.

end insert
20

SEC. 2.  

Section 125185 is added to the Health and Safety Code,
21to read:

22

125185.  

(a) (1) Notwithstanding any other provision of law,
23by July 1, 2015, or a subsequent date determined by the department,
24Genetically Handicapped Persons Program (GHPP) requests for
25authorization of services shall be submitted in an electronic format
26determined by the department and shall be submitted via the
27department’s Internet Web site or other electronic means designated
28by the department. The department may implement this
29requirement in phases.

30(2) The department may designate an alternate format for
31submitting requests for authorization of services when the
32department’s Internet Web site or other electronic means designated
33in paragraph (1) are unavailable due to an unplanned disruption.

34(b) Notwithstanding Chapter 3.5 (commencing with Section
3511340) of Part 1 of Division 3 of Title 2 of the Government Code,
36the department may, without taking regulatory action, implement,
37interpret, or make specific this section and any applicable waivers
38and state plan amendments by means of all-county letters, plan
39letters, plan or provider bulletins, or similar instructions. Thereafter,
40the department shall adopt regulations by July 1, 2017, in
P4    1accordance with the requirements of Chapter 3.5 (commencing
2with Section 11340) of Part 1 of Division 3 of Title 2 of the
3Government Code. The department shall consult with interested
4parties and appropriate stakeholders in implementing this section.

5

SEC. 3.  

Section 14133.01 of the Welfare and Institutions Code
6 is amended to read:

7

14133.01.  

(a) Notwithstanding any other provision of law, the
8director or his or her designee may apply prior authorization by
9designing a sampling methodology that will result in a generally
10acceptable audit standard for approval of a treatment authorization
11request (TAR), or a class of TARs. The director or his or her
12designee shall determine the applicable sampling methodology
13based upon health care industry standards and discussions with
14applicable Medi-Cal providers or their representatives. This
15sampling methodology shall be implemented by no later than July
161, 2005, and an outline of it shall be provided to the fiscal and
17policy committees of both houses of the Legislature. It is the intent
18of the Legislature for the department to review the sampling
19methodology on an ongoing basis and update it as applicable on
20a periodic basis in order to keep abreast of health care industry
21trends and the need to manage an efficient and effective Medi-Cal
22program.

23(b) The department shall pursue additional means to improve
24and streamline the treatment authorization request process
25including, where applicable, those identified by independent
26analyses such as the July 2003 report by the California Healthcare
27Foundation entitled Medi-Cal Treatment Authorizations and Claims
28Processing: Improving Efficiency and Access to Care, and those
29identified by Medi-Cal providers. It is the Legislature’s intent that
30any identified improvements be cost-beneficial to the state and to
31the Medi-Cal program as a whole.

begin insert

32(c) (1) Notwithstanding any other law, by July 1, 2015, or a
33subsequent date determined by the department, treatment
34authorization requests shall be submitted in an electronic format
35determined by the department and shall be submitted via the
36department’s Internet Web site or other electronic means
37designated by the department. The department may implement this
38requirement in phases.

end insert
begin insert

39(2) The department may designate an alternate format for
40submitting requests for authorization of services when the
P5    1department’s Internet Web site or other electronic means
2designated in paragraph (1) are unavailable due to an unplanned
3disruption.

end insert
begin delete

4(c)

end delete

5begin insert(d)end insert Notwithstanding Chapter 3.5 (commencing with Section
611340) of Part 1 of Division 3 of Title 2 of the Government Code,
7the department maybegin insert, without taking regulatory action,end insert implement,
8interpret, or make specific, this sectionbegin insert and any applicable waivers
9and state plan amendmentsend insert
by means of all-county letters,begin insert plan
10latters, plan orend insert
provider bulletins, or similar instructions.
11Thereafter, the departmentbegin delete mayend deletebegin insert shallend insert adopt regulationsbegin insert by July 1,
122017,end insert
in accordance with the requirements of Chapter 3.5
13(commencing with Section 11340) of Part 1 of Division 3 of Title
142 of the Government Code.



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