BILL NUMBER: SB 1170	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Florez

                        FEBRUARY 18, 2010

   An act to amend Section 14087.329 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1170, as introduced, Florez. Medi-Cal: managed care.
   Existing law provides for the Medi-Cal program, administered by
the State Department of Health Services, under which qualified
low-income persons are provided with health care services.
   Existing law allows the Director of Health Care Services to
contract with any qualified individual, organization, or entity,
including counties, to provide services to, or arrange for or case
manage the care of, Medi-Cal beneficiaries.
   Existing law authorizes the department to establish pilot
programs, as prescribed, for the establishment of reimbursement
methodologies for local initiative and commercial plans providing
services under the above-mentioned contracts.
   This bill would make technical, nonsubsantive changes to these
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 14087.329 of the Welfare and Institutions Code
is amended to read:
   14087.329.  (a) The department may establish, for local initiative
and  for  commercial plans  , 
that are providing services to Medi-Cal beneficiaries under a
two-plan model contract with the department, not more than two pilot
programs for the establishment of reimbursement methodologies. The
reimbursement methodologies shall not be limited to those provided in
Section 14087.325. The pilot programs may be implemented by
amendment to the contract between the department and the local
initiative or commercial plan. The department may select the pilot
program county or counties on a nonbid basis. The selected counties
shall include one county with a sizable number of entities defined in
Section 1396d(  l  )(2)(B) of Title 42 of the United States
Code. The department shall review each pilot program annually.
Following the review, and notwithstanding any determination made
pursuant to subdivision (d), the department shall terminate a pilot
program established under this section and shall delete amendments
made to the contract implementing the pilot program if the department
determines that the pilot program creates any additional cost to the
General Fund. The department may also terminate a pilot program
based upon criteria specified in the department's contract
establishing the pilot program. The department shall provide the
local initiative and commercial plan with notice of the department's
decision to terminate the pilot program for this reason at least 90
days prior to the termination date of the pilot program and deletion
of the contract amendments.
   (b) Each local initiative and commercial plan participating in a
pilot program under this section shall make available to the
department any and all financial, membership, utilization, and other
information reasonably required by the department to conduct the
annual review described in subdivision (a). The information may
include, but is not limited to, the financial or other records of
participating providers. The amendment to the contract between the
local initiative or commercial plan and the department establishing
the pilot program shall specify a reasonable timeframe in which the
commercial plan or local initiative shall furnish records to the
department pursuant to the request of the department.
   (c) In assessing whether the pilot program creates any additional
cost to the General Fund, as described in subdivision (a), the
department shall specifically consider all of the following factors,
and may consider additional factors:
   (1) Increases in the number of Medi-Cal beneficiaries assigned by
the plan to cost-based primary care providers. To enable the
department to evaluate these factors, the department may include in
the contract amendments establishing the pilot program a requirement
that contractors shall periodically report data regarding the number
of plan members assigned to each cost-based primary care provider in
the plan's network.
   (2) Expansions in the services provided by providers entitled to
cost-based reimbursement under the Medi-Cal program.
   (3) Medi-Cal caseload or plan membership growth.
   (4) Inflation or other reasonable costs of provider operations.
   (5) The necessity for a plan to assign plan members to specific
primary care providers to meet all of the following requirements:
   (A) Medi-Cal contract requirements for access to care.
   (B) Unique Medi-Cal member cultural and linguistic needs.
   (C) Unique member needs for age-appropriate, gender-appropriate,
or pregnancy care requirements.
   (d) The pilot program shall be deemed to be successful if the
alternative reimbursement methodologies tested result in no
additional cost to the General Fund as described in subdivision (c),
and the local initiatives, commercial plans, and federally qualified
health centers participating in the pilot program agree to accept
full financial risk for the scope of services provided by the
federally qualified health centers during the final year of the pilot
program.