BILL NUMBER: AB 1553	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MAY 25, 2012
	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  for a prescribed
period of time  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, or a licensed midwife who is
participating in the Medi-Cal program but is not a contracting
provider of 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, 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 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) to (vi),
inclusive, such as cardiomyopathy or amyotrophic lateral sclerosis,
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.   disorder. 
   (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.
   (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 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 begun or is scheduled to begin treatment after
the date of plan enrollment.
   (b)  (1)    Except for pregnancy, an eligible
beneficiary granted a medical exemption from plan enrollment shall
remain in fee-for-service 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 
    (2)     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. 
   (3) Unless otherwise requested by the provider and approved based
on the supporting documentation, and except as specified in paragraph
(2) for a beneficiary granted a medical exemption due to pregnancy,
a medical exemption from plan enrollment shall expire at the end of
12 months from the date of approval. The Health Care Options Program
shall notify the beneficiary 45 days before the expiration date of
the approved medical exemption and shall inform the beneficiary of
how to request an extension. An extension of the 12-month medical
exemption shall be requested through the Health Care Options Program
no earlier than 11 months after the starting date of the exemption in
effect at that time. An extension of the medical exemption may be
requested and shall be approved if the eligible beneficiary continues
to meet the requirements of paragraph (2) of subdivision (a). 
   (c) Exemption from plan enrollment due to a complex medical
condition or conditions, as specified in clauses (i) to (vii),
inclusive, and 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 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.
   (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, 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.