BILL NUMBER: AB 1629	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Halderman

                        FEBRUARY 9, 2012

   An act to amend Section 14043.1 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 1629, as introduced, Halderman. Medi-Cal.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services and
under which low-income persons receive health care benefits. The
Medi-Cal program is, in part, governed and funded by federal Medicaid
provisions. Existing law defines an "applicant" as an individual or
other entity, as specified, that applies to enroll as a Medi-Cal
program provider, and defines a "provider" as an individual or other
entity, as specified, that is enrolled in the Medi-Cal program and
provides goods or services to a Medi-Cal beneficiary.
   This bill would make technical, nonsubstantive changes to those
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 14043.1 of the Welfare and Institutions Code is
amended to read:
   14043.1.  As used in this article:
   (a) "Abuse" means either of the following:
   (1) Practices that are inconsistent with sound fiscal or business
practices and result in unnecessary cost to the federal Medicaid and
Medicare programs, the Medi-Cal program, another state's Medicaid
program, or other health care programs operated, or financed in whole
or in part, by the federal government or a state or local agency in
this state or another state.
   (2) Practices that are inconsistent with sound medical practices
and result in reimbursement by the federal Medicaid and Medicare
programs, the Medi-Cal program or other health care programs
operated, or financed in whole or in part, by the federal government
or a state or local agency in this state or another state, for
services that are unnecessary or for substandard items or services
that fail to meet professionally recognized standards for health
care.
   (b) "Applicant" means an individual, partnership, group,
association, corporation, institution, or entity, and  the
officers, directors, owners, managing employees,   an
officer, director, owner, managing employee,  or  agents
thereof   agent of a partnership, group, association,
corporation, institution, or entity  , that  apply
  applies  to the department for enrollment as a
provider in the Medi-Cal program.
   (c) "Application or application package" means a completed and
signed application form, signed under penalty of perjury or notarized
pursuant to Section 14043.25, a disclosure statement, a provider
agreement, and all attachments or changes in the form, statement, or
agreement.
   (d) "Appropriate volume of business" means a volume that is
consistent with the information provided in the application and any
supplemental information provided by the applicant or provider, and
is of a quality and type that would reasonably be expected based upon
the size and type of business operated by the applicant or provider.

   (e) "Business address" means the location where an applicant or
provider provides services, goods, supplies, or merchandise, directly
or indirectly, to a Medi-Cal beneficiary. A post office box or
commercial box is not a business address. The business address for
the location of a vehicle or vessel owned and operated by an
applicant or provider enrolled in the Medi-Cal program and used to
provide services, goods, supplies, or merchandise, directly or
indirectly, to a Medi-Cal beneficiary shall either be the business
address location listed on the provider's application as the location
where similar services, goods, supplies, or merchandise would be
provided or the applicant's or provider's pay to address.
   (f) "Convicted" means any of the following:
   (1) A judgment of conviction has been entered against an
individual or entity by a federal, state, or local court, regardless
of whether there is a posttrial motion, an appeal pending, or the
judgment of conviction or other record relating to the criminal
conduct has been expunged or otherwise removed.
   (2) A federal, state, or local court has made a finding of guilt
against an individual or entity.
   (3) A federal, state, or local court has accepted a plea of guilty
or nolo contendere by an individual or entity.
   (4) An individual or entity has entered into participation in a
first offender, deferred adjudication, or other program or
arrangement where judgment of conviction has been withheld.
   (g) "Debt due and owing" means 60 days have passed since a notice
or demand for repayment of an overpayment or another amount resulting
from an audit or examination, for a penalty assessment, or for
another amount due to the department was sent to the provider,
regardless of whether the provider is an institutional provider or a
noninstitutional provider and regardless of whether an appeal is
pending.
   (h) "Enrolled or enrollment in the Medi-Cal program" means
authorized under any processes by the department or its agents or
contractors to receive, directly or indirectly, reimbursement for the
provision of services, goods, supplies, or merchandise to a Medi-Cal
beneficiary.
   (i) "Fraud" means an intentional deception or misrepresentation
made by a person with the knowledge that the deception could result
in some unauthorized benefit to himself or herself or some other
person. It includes any act that constitutes fraud under applicable
federal or state law.
   (j) "Location" means a street, city, or rural route address or a
site or place within a street, city, or rural route address, and the
city, county, state, and nine-digit ZIP Code.
   (k) "Not currently enrolled at the location for which the
application is submitted" means either of the following:
   (1) The provider is changing location and moving to a different
location than that for which the provider was issued a provider
number.
   (2) The provider is adding a business address.
   (l) (1) "Individual dentist practice" means a dentist licensed by
the Dental Board of California enrolled or enrolling in Medi-Cal as
an individual provider who is a sole proprietor of his or her
practice or is a corporation owned solely by the individual dentist
and the only dentist practitioner is the owner. An individual dentist
practice may include nondentist allied dental health professionals
employed and supervised by the dentist.
   (2) "Individual physician practice" means a physician and surgeon
licensed by the Medical Board of California or the Osteopathic
Medical Board of California enrolled or enrolling in Medi-Cal as an
individual provider who is sole proprietor of his or her practice or
is a corporation owned solely by the individual physician and the
only physician practitioner is the owner. An individual physician
practice may include nonphysician medical practitioners employed and
supervised by the physician.
   (m) "Preenrollment period" or "preenrollment" includes the period
of time during which an application package for enrollment, continued
enrollment, or for the addition of or change in a location is
pending.
   (n) "Professionally recognized standards of health care" means
statewide or national standards of care, whether in writing or not,
that professional peers of the individual or entity whose provision
of care is an issue recognize as applying to those peers practicing
or providing care within a state. When the United States Department
of Health and Human Services has declared a treatment modality not to
be safe and effective, practitioners that employ that treatment
modality shall be deemed not to meet professionally recognized
standards of health care. This subdivision shall not be construed to
mean that all other treatments meet professionally recognized
standards of care.
   (o) "Provider" means an individual, partnership, group,
association, corporation, institution, or entity, and  the
officers   an officer  ,  directors
  director  ,  owners   owner
 ,  managing employees   managing employee
 , or agents   agent  of a
partnership, group association, corporation, institution, or entity,
that provides services, goods, supplies, or merchandise, directly or
indirectly, to a Medi-Cal beneficiary and that has been enrolled in
the Medi-Cal program.
   (p) "Unnecessary or substandard items or services" means those
that are either of the following:
   (1) Substantially in excess of the provider's usual charges or
costs for the items or services.
   (2) Furnished, or caused to be furnished, to patients, whether or
not covered by Medicare, Medicaid, or any of the state health care
programs to which the definitions of applicant and provider apply,
and which are substantially in excess of the patient's needs, or of a
quality that fails to meet professionally recognized standards of
health care. The department's determination that the items or
services furnished were excessive or of unacceptable quality shall be
made on the basis of information, including sanction reports, from
the following sources:
   (A) The professional review organization for the area served by
the individual or entity.
   (B) State or local licensing or certification authorities.
   (C) Fiscal agents or contractors or private insurance companies.
   (D) State or local professional societies.
   (E) Any other sources deemed appropriate by the department.