BILL NUMBER: AB 1553 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Monning
JANUARY 26, 2012
An act to add Section 14103.9 to the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 1553, as introduced, Monning. Medi-Cal: managed care: exemption
from plan enrollment.
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. One of the methods by which these
services are provided is pursuant to contracts with various types of
managed care plans.
This bill would establish a process that would permit an eligible
Medi-Cal beneficiary to receive fee-for-service Medi-Cal, if
available, as an alternative to plan enrollment if the beneficiary
meets specified criteria.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14103.9 is added to the Welfare and
Institutions Code, to read:
14103.9. (a) An eligible Medi-Cal beneficiary who satisfies the
requirements in paragraph (1) or (2) may request fee-for-service
Medi-Cal, if available, as an alternative to plan enrollment by
submitting a request for exemption from plan enrollment to the Health
Care Options Program as specified in subdivision (c).
(1) The eligible beneficiary is an American Indian, a member of an
American Indian household, or chooses to receive health care
services through an Indian Health Service facility and has written
acceptance from an Indian Health Service facility for care on a
fee-for-service basis.
(2) An eligible beneficiary who is receiving fee-for-service
Medi-Cal treatment or services for a complex medical condition, from
a physician, a certified nurse midwife, or a licensed midwife who is
participating in the Medi-Cal program but is not a contracting
provider of either plan in the eligible beneficiary's county of
residence, may request a medical exemption to continue
fee-for-service Medi-Cal for purposes of continuity of care.
(A) For purposes of this section, conditions meeting the criteria
for a complex medical condition include, and are similar to, the
following:
(i) An eligible beneficiary is pregnant.
(ii) An eligible beneficiary is under evaluation for the need for
an organ transplant, has been approved for and is awaiting an organ
transplant, or has received a transplant and is currently either
immediately postoperative or exhibiting significant medical problems
related to the transplant. Beneficiaries who are medically stable on
posttransplant therapy are not eligible for exemption under this
section.
(iii) An eligible beneficiary is receiving chronic renal dialysis
treatment.
(iv) An eligible beneficiary has tested positive for human
immunodeficiency virus (HIV) or has received a diagnosis of acquired
immune deficiency syndrome (AIDS).
(v) An eligible beneficiary has been diagnosed with cancer and is
currently receiving chemotherapy or radiation therapy or another
course of accepted therapy for cancer that will continue for up to 12
months or has been approved for the therapy.
(vi) An eligible beneficiary has been approved for a major
surgical procedure by the Medi-Cal fee-for-service program and is
awaiting surgery or is immediately postoperative.
(vii) An eligible beneficiary has a complex neurological disorder,
such as multiple sclerosis, a complex hematological disorder, such
as hemophilia or a sickle cell disease, or a complex or progressive
disorder not covered in clauses (i) through (vi), inclusive, such as
cardiomyopathy or amyotrophic lateral sclerosis, which requires
ongoing medical supervision, or has been approved for or is receiving
complex medical treatment for the disorder, the administration of
which cannot be interrupted.
(viii) An eligible beneficiary is enrolled in a Medi-Cal waiver
program that allows the individual to receive subacute, acute,
intermediate, or skilled nursing care at home rather than in a
subacute care facility, an acute care hospital, an intermediate care
facility, or a skilled nursing facility.
(ix) An eligible beneficiary is participating in a pilot project
organized and operated pursuant to Section 14087.3, 14094.3, or
14490.
(B) A request for exemption from plan enrollment based on complex
medical conditions shall not be approved for an eligible beneficiary
to whom any of the following apply:
(i) He or she has been a member of any plan on a combined basis
for more than 90 calendar days.
(ii) He or she has a current Medi-Cal provider who is contracting
with a plan.
(iii) He or she is begun or has scheduled to begin treatment after
the date of plan enrollment.
(b) Except for pregnancy, an eligible beneficiary granted a
medical exemption from plan enrollment shall remain with the
fee-for-service provider only until the medical condition has
stabilized to a level that would enable him or her to change
physicians and begin receiving care from a plan provider without
deleterious medical effects, as determined by the beneficiary's
treating physician in the Medi-Cal fee-for-service program. A
beneficiary granted a medical exemption due to pregnancy may remain
with the fee-for-service Medi-Cal provider through delivery and the
end of the month in which 90 days postpartum occurs.
(c) Exemption from plan enrollment due to a complex medical
condition, as specified in clauses (i) to (vii), inclusive, and
clause (ix) of subparagraph (A) of paragraph (2) of subdivision (a),
shall be requested on a request for medical exemption from plan
enrollment form approved by the department. Exemption from plan
enrollment due to a beneficiary's enrollment in a Medi-Cal waiver
program, as specified in clause (viii) of subparagraph (A) of
paragraph (2) of subdivision (a), or a beneficiary's acceptance for
care at an Indian Health Service facility, as specified in paragraph
(1) of subdivision (a), shall be requested on a request for
non-medical exemption from plan enrollment form. The completed
request for exemption shall be submitted to the Health Care Options
Program by the Medi-Cal fee-for-service provider or the Indian Health
Service facility treating the beneficiary and shall be submitted by
mail or facsimile. A request for exemption from plan enrollment shall
not be submitted by the plan.
(d) The Health Care Options Program, as authorized by the
department, shall approve each request for exemption from plan
enrollment that meets the requirements of this section. At any time,
the department may, at its discretion, verify the complexity,
validity, and status of the medical condition and treatment plan and
verify that the provider is not contracted or otherwise affiliated
with a plan. The Health Care Options Program, as authorized by the
department, or the department may deny a request for exemption from
plan enrollment or revoke an approved request for exemption if a
provider fails to fully cooperate with verification by the
department.
(e) Approval of requests for exemption from plan enrollment shall
be subject to the same processing times and effective dates for the
processing of enrollment and disenrollment requests.
(f) The Health Care Options Program, as authorized by the
department, or the department may revoke an approved request for
exemption from plan enrollment at any time if the department
determines that the approval was based on false or misleading
information, the medical condition was not complex, treatment has
been completed, or the requesting provider is not or has not been
providing services to the beneficiary. The department shall provide
written notice to the beneficiary that the approved request for
exemption from plan enrollment has been revoked and shall advise the
beneficiary that he or she shall enroll in a Medi-Cal plan and how
that enrollment shall occur. The revocation of an approved request
for exemption from plan enrollment shall not otherwise affect an
eligible beneficiary's eligibility or ability to receive covered
services as a plan member.