BILL NUMBER: SB 1098 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 11, 2016
INTRODUCED BY Senator Cannella
FEBRUARY 17, 2016
An act to amend Section 14089 of add
Section 14005.273 to the Welfare and Institutions Code,
relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 1098, as amended, Cannella. Medi-Cal: geographic
managed care. dental services: advisory group.
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.
provides coverage for certain dental services, as
specified, to Medi-Cal beneficiaries 17 years of age and under
through the Denti-Cal program.
This bill would make technical, nonsubstantive changes to
those provisions. establish the Denti-Cal Advisory
Group in the department, as specified, for the purpose of studying
and overseeing the policies and priorities of Denti-Cal with the goal
of raising the Denti-Cal utilization rate among children and
providing assistance a nd advice to the department, the
Governor, and the Legislature to ensure that proposed decisions
relating to the Denti-Cal program are based on the best
available evidence. The bill would make related legislative findings
and declarations.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. (a) The
Legislature finds and declares all of the following:
(1) Denti-Cal is the Medi-Cal dental health care component program
that was established soon after the 1966 creation of the Medi-Cal
program.
(2) According to an audit conducted by the State Auditor in 2014,
only 43.9 percent of children enrolled in the Denti-Cal program had
seen a dentist in the previous year--a utilization rate that was the
12th worst among states that submitted data to the federal Centers
for Medicare and Medicaid Services. Eleven California counties had no
Denti-Cal providers or no providers willing to accept new child
patients covered by Denti-Cal.
(3) Denti-Cal's 13 million or more beneficiaries need the State
Department of Health Care Services and dental care providers to
improve their relationships.
(4) In any sector, public or private, good relationships are built
on a foundation of good customer service.
(b) Therefore, the Legislature establishes pursuant to this act an
evidence-based advisory group to guide Denti-Cal priorities, to
oversee policy decisions, and to increase annual Denti-Cal
utilization rates among children in the state to 60 percent or
greater, as is the case in approximately 20 percent of states.
SEC. 2. Section 14005.273 is added to the
Welfare and Institutions Code , to read:
14005.273. (a) There is hereby established in the department the
Denti-Cal Advisory Group. The duties of the advisory group shall
include, but not be limited to, all of the following:
(1) Studying and overseeing the policies and priorities of
Denti-Cal, the state Medi-Cal dental services program, with the goal
of raising the Denti-Cal utilization rate among eligible child
beneficiaries to 60 percent or greater.
(2) Providing assistance and advice to the department, the
Legislature, and the Governor regarding proposed decisions relating
to the Denti-Cal program to ensure that those decisions are based on
the best available evidence.
(b) The advisory group shall consist of the following members:
(1) The state dental director, who shall serve as its chair.
(2) Eight members appointed by the Governor that shall include the
following:
(A) A representative from the California Dental Association.
(B) A representative from the California Dental Hygienists'
Association.
(C) A licensed social worker.
(D) A representative of a health care foundation.
(E) A licensed pediatrician who is qualified to assess impacts on
the overall health of children.
(F) An expert on practices in the dental insurance or health
insurance markets.
(G) Two university professors who are experts in dental practice
or the dental services field.
(3) Two members appointed by the Senate Committee on Rules that
shall include the following:
(A) A licensed dentist.
(B) A licensed dental hygienist.
(4) Two members appointed by the Speaker of the Assembly that
shall include the following:
(A) A licensed dentist.
(B) A licensed dental hygienist.
(c) Before entering upon the discharge of his or her official
duties, each member of the advisory group appointed pursuant to this
section shall take and file an oath pursuant to Sections 1360 and
1363 of the Government Code.
(d) A member of the commission shall serve for a term of three
years. There shall be no limit on the number of terms a member may
serve. The terms of members may be staggered so that the terms of all
members will not expire at the same time.
(e) A member of the advisory group shall not be compensated for
his or her services, except that he or she shall be paid reasonable
per diem and reimbursement of reasonable expenses for attending
meetings and discharging other official responsibilities as
authorized by the department and this section.
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 is further 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 applicable state and federal
legal requirements for participation as a Medi-Cal managed care
contractor.
(B) The health plan shall meet 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 14087.3). 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 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.