Senate Bill No. 1098

Introduced by Senator Cannella

February 17, 2016

An act to amend Section 14089 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 1098, as introduced, Cannella. Medi-Cal: geographic managed care.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law authorizes the department to provide health care services to beneficiaries through various models of managed care, including through a comprehensive program of managed health care plan services for Medi-Cal recipients residing in clearly defined geographical areas. Existing law specifies guidelines the department is required to follow in selecting and entering into contracts with managed care plans. Existing law requires the department to give an eligible beneficiary specified notices for the purpose of assisting the beneficiary in choosing a managed care plan, and imposes requirements on the beneficiary and the department regarding choice of, and enrollment in, a managed care plan.

This bill would make technical, nonsubstantive changes to those provisions.

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

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

SECTION 1.  

Section 14089 of the Welfare and Institutions
Code is amended to read:

14089.  

(a) The purpose of this article is to provide a
comprehensive program of managed health care plan services to
Medi-Cal recipients residing in clearly defined geographical areas.
It begin delete is, further, end delete begin insert is further end insert the purpose of this article to create
maximum accessibility to health care services by permitting
Medi-Cal recipients the option of choosing from among two or
more managed health care plans or fee-for-service managed case
arrangements, including, but not limited to, health maintenance
organizations, prepaid health plans, and primary care case
management plans. Independent practice associations, health
insurance carriers, private foundations, and university medical
centers systems, not-for-profit clinics, and other primary care
providers, may be offered as choices to Medi-Cal recipients under
this article if they are organized and operated as managed care
plans, for the provision of preventive managed health care plan
services.

(b) The department may seek proposals and then shall enter into
contracts based on relative costs, extent of coverage offered, quality
of health services to be provided, financial stability of the health
care plan or carrier, recipient access to services, cost-containment
strategies, peer and community participation in quality control,
emphasis on preventive and managed health care services and the
ability of the health plan to meet all requirements for both of the
following:

(1) Certification, where legally required, by the Director of the
Department of Managed Health Care and the Insurance
Commissioner.

(2) Compliance with all of the following:

(A) The health plan shall satisfy begin delete all end delete applicable state and federal
legal requirements for participation as a Medi-Cal managed care
contractor.

(B) The health plan shall meet begin delete any end delete standards established by the
department for the implementation of this article.

(C) The health plan receives the approval of the department to
participate in the pilot project under this article.

(c) (1) (A) The proposals shall be for the provision of
preventive and managed health care services to specified eligible
populations on a capitated, prepaid, or postpayment basis.

(B) Enrollment in a Medi-Cal managed health care plan under
this article shall be voluntary for beneficiaries eligible for the
federal Supplemental Security Income for the Aged, Blind, and
Disabled Program (Subchapter 16 (commencing with Section
1381) of Chapter 7 of Title 42 of the United States Code).

(2) The cost of each program established under this section shall
not exceed the total amount that the department estimates it would
pay for all services and requirements within the same geographic
area under the fee-for-service Medi-Cal program.

(d) (1) An eligible beneficiary shall be entitled to enroll in any
health care plan contracted for pursuant to this article that is in
effect for the geographic area in which he or she resides. The
department shall make available to recipients information
summarizing the benefits and limitations of each health care plan
available pursuant to this section in the geographic area in which
the recipient resides. A Medi-Cal or CalWORKs applicant or
beneficiary shall be informed of the health care options available
regarding methods of receiving Medi-Cal benefits. The county
shall ensure that each beneficiary is informed of these options and
informed that a health care options presentation is available.

(2) No later than 30 days following the date a Medi-Cal or
CalWORKs recipient is informed of the health care options
described in paragraph (1), the recipient shall indicate his or her
choice, in writing, of one of the available health care plans and his
or her choice of primary care provider or clinic contracting with
the selected health care plan. Notwithstanding the 30-day deadline
set forth in this paragraph, if a beneficiary requests a directory for
the entire service area within 30 days of the date of receiving an
enrollment form, the deadline for choosing a plan shall be extended
an additional 30 days from the date of that request.

(3) The health care options information described in this
subdivision shall include the following elements:

(A) Each beneficiary or eligible applicant shall be provided, at
a minimum, with the name, address, telephone number, and
specialty, if any, of each primary care provider, by specialty or
clinic participating in each managed health care plan option through
a personalized provider directory for that beneficiary or applicant.
This information shall be presented under the geographic area
designations by the name of the primary care provider and clinic,
and shall be updated based on information electronically provided
monthly by the health care plans to the department, setting forth
changes in the health care plan provider network. The geographic
areas shall be based on the applicant’s residence address, the minor
applicant’s school address, the applicant’s work address, or any
other factor deemed appropriate by the department, in consultation
with health plan representatives, legislative staff, and consumer
stakeholders. In addition, directories of the entire service area,
including, but not limited to, the name, address, and telephone
number of each primary care provider and hospital, of all
Geographic Managed Care health plan provider networks shall be
made available to beneficiaries or applicants who request them
from the health care options contractor. Each personalized provider
directory shall include information regarding the availability of a
directory of the entire service area, provide telephone numbers for
the beneficiary to request a directory of the entire service area, and
include a postage-paid mail card to send for a directory of the
entire service area. The personalized provider directory shall be
implemented as a pilot project in Sacramento County pursuant to
this article, and in Los Angeles County (Two-Plan Model) pursuant
to Article 2.7 (commencing with Section begin delete 14087.305). end delete begin insert 14087.3). end insert
The content, form, and geographic areas used shall be determined
by the department in consultation with a workgroup to include
health plan representatives, legislative staff, and consumer
stakeholders, with an emphasis on the inclusion of stakeholders
from Los Angeles and Sacramento Counties. The personalized
provider directories may include a section for each health plan.
Prior to implementation of the pilot project, the department, in
consultation with consumer stakeholders, legislative staff, and
health plans, shall determine the parameters, methodology, and
evaluation process of the pilot project. The pilot project shall
thereafter be in effect for a minimum of two years. Following two
years of operation as a pilot project in two counties, the department,
in consultation with consumer stakeholders, legislative staff, and
health plans, shall determine whether to implement personalized
provider directories as a permanent program statewide. If
necessary, the pilot project shall continue beyond the initial
two-year period until this determination is made. This pilot project
shall only be implemented to the extent that it is budget neutral to
the department.

(B) Each beneficiary or eligible applicant shall be informed that
he or she may choose to continue an established patient-provider
relationship in a managed care option, if his or her treating provider
is a primary care provider or clinic contracting with any of the
health plans available and has the available capacity and agrees to
continue to treat that beneficiary or eligible applicant.

(C) Each beneficiary or eligible applicant shall be informed that
if he or she fails to make a choice, he or she shall be assigned to,
and enrolled in, a health care plan.

(4) At the time the beneficiary or eligible applicant selects a
health care plan, the department shall, when applicable, encourage
the beneficiary or eligible applicant to also indicate, in writing,
his or her choice of primary care provider or clinic contracting
with the selected health care plan.

(5) Commencing with the implementation of a geographic
managed care project in a designated county, a Medi-Cal or
CalWORKs beneficiary who does not make a choice of health care
plans in accordance with paragraph (2), shall be assigned to and
enrolled in an appropriate health care plan providing service within
the area in which the beneficiary resides.

(6) If a beneficiary or eligible applicant does not choose a
primary care provider or clinic, or does not select a primary care
provider who is available, the health care plan selected by or
assigned to the beneficiary shall ensure that the beneficiary selects
a primary care provider or clinic within 30 days after enrollment
or is assigned to a primary care provider within 40 days after
enrollment.

(7) A Medi-Cal or CalWORKs beneficiary dissatisfied with the
primary care provider or health care plan shall be allowed to select
or be assigned to another primary care provider within the same
health care plan. In addition, the beneficiary shall be allowed to
select or be assigned to another health care plan contracted for
pursuant to this article that is in effect for the geographic area in
which he or she resides in accordance with Section
1903(m)(2)(F)(ii) of the Social Security Act.

(8) The department or its contractor shall notify a health care
plan when it has been selected by or assigned to a beneficiary. The
health care plan that has been selected or assigned by a beneficiary
shall notify the primary care provider that has been selected or
assigned. The health care plan shall also notify the beneficiary of
the health care plan and primary care provider selected or assigned.

(9) This section shall be implemented in a manner consistent
with any federal waiver that is required to be obtained by the
department to implement this section.

(e) A participating county may include within the plan or plans
providing coverage pursuant to this section, employees of county
government, and others who reside in the geographic area and who
depend upon county funds for all or part of their health care costs.

(f) Funds may be provided to prospective contractors to assist
in the design, development, and installation of appropriate
programs. The award of these funds shall be based on criteria
established by the department.

(g) In implementing this article, the department may enter into
contracts for the provision of essential administrative and other
services. Contracts entered into under this subdivision may be on
a noncompetitive bid basis and shall be exempt from Chapter 2
(commencing with Section 10290) of Part 2 of Division 2 of the
Public Contract Code.

(h) Notwithstanding any other begin delete provision of end delete law, on and after
the effective date of the act adding this subdivision, the department
shall have exclusive authority to set the rates, terms, and conditions
of geographic managed care contracts and contract amendments
under this article. As of that date, all references to this article to
the negotiator or to the California Medical Assistance Commission
shall be deemed to mean the department.

(i) Notwithstanding subdivision (q) of Section 6254 of the
Government Code, a contract or contract amendments executed
by both parties after the effective date of the act adding this
subdivision shall be considered a public record for purposes of the
California Public Records Act (Chapter 3.5 (commencing with
Section 6250) of Division 7 of Title 1 of the Government Code)
and shall be disclosed upon request. This subdivision includes
contracts that reveal the department’s rates of payment for health
care services, the rates themselves, and rate manuals.