BILL NUMBER: AB 1553 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 16, 2012
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 amended, 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. This bill would provide that these
provisions shall not apply to a beneficiary who is enrolled in a
county organized health system. This bill would require
the department to develop a process to track a beneficiary who has
been denied a request for exemption from plan enrollment and to
notify the plan, if applicable, of the denial, including information
identifying the provider.
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
nurse-midwife , or a licensed midwife who is participating in
the Medi-Cal program but is not a contracting provider of
either a 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 , or has received a
second or third transplant and is receiving ongoing medical
supervision . 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 more or has been approved for the therapy
, or has been diagnosed with stage IV cancer and is receiving
ongoing medical supervision .
(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 is
receiving medical treatment, the interruption of which would put the
beneficiary at risk for deleterious medical effects because of
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 to (vi), inclusive, such as
cardiomyopathy or amyotrophic lateral sclerosis, which
or a disease or condition that affects more than one
organ system, or requires coordinated care from more than one
specialist, unless all of the specialists providing care to the
beneficiary are contracting providers in one of the plans in the
beneficiary's county of residence, and the beneficiary 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 , or an eligible
beneficiary is under 21 years of age and is receiving nursing
services in the home instead of in a subacute care facility, an acute
care facility, an intermediate care facility, an intermediate care
facility for the developmentally disabled, a skilled nursing
facility, or any other licensed facility providing medical care or
treatment at the same or a higher level of care .
(ix) An eligible beneficiary is receiving treatment services that
are not available in the beneficiary's home county.
(x) An eligible beneficiary is receiving treatment or palliative
services for a disease or condition that is expected to result in
death within the next 24 months.
(ix)
(xi) 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 a
complex medical conditions condition
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 and has received services for
which the plan is financially responsible .
(ii) He or she has a current Medi-Cal provider who is contracting
with a plan.
(iii)
(ii) He or she is has
begun or has is 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
in fee-for-service provider
Medi-Cal 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 the risk of
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 or conditions , as specified in clauses (i) to
(vii), inclusive, and clause clauses
(ix) to (xi), inclusive, 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 , or if the beneficiary is under 21
years of age and receiving nursing services in the home , 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
nonmedical 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
providers 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. Verification may include documentation from more
than one provider if the treatment plan includes multiple specialists
or other providers. 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. This subdivision shall not be construed as
authorizing the Health Care Options Program or the department to
overrule a treating physician's determination pursuant to subdivision
(b).
(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) (1) The department shall provide written notice to the
beneficiary and the requesting provider if a request for exemption
from plan enrollment is denied. The notice shall set out with
specificity the reasons for the denial or failure to unconditionally
approve the request for exemption from plan enrollment. The notice
shall inform the beneficiary and the provider of the right to appeal
the decision, how to appeal the decision, and if the decision is not
appealed, that the beneficiary shall enroll in a Medi-Cal plan and
how that enrollment shall occur. The beneficiary shall also be
informed of the possibility of continued access to an out-of-network
provider pursuant to paragraph (13) of subdivision (b) of Section
14182. A beneficiary who has not been enrolled in a plan shall remain
in fee-for-service Medi-Cal if a request for an exemption from plan
enrollment or appeal is submitted, until the final resolution.
(2) The department shall develop a process to track a beneficiary
who has been denied a request for exemption from plan enrollment and
to notify the plan, if applicable, of the denial, including
information identifying the provider.
(f)
(g) 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.
(h) This section shall not apply to a beneficiary who is enrolled
in a county organized health system.