BILL NUMBER: SB 1516	INTRODUCED
	BILL TEXT


INTRODUCED BY   Senator Leno

                        FEBRUARY 24, 2012

   An act to amend Section 14131.07 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 1516, as introduced, Leno. Medi-Cal: physician office and
clinic visits.
   Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income individuals.
Existing law states that there is a limit on the total number of
physician office and clinic visits for physician services provided by
a physician, or under the direction of a physician, that are a
covered benefit under the Medi-Cal program of 7 visits per
beneficiary per fiscal year, except as specified.
   This bill would make a technical, nonsubstantive change 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 14131.07 of the Welfare and Institutions Code
is amended to read:
   14131.07.  (a) Notwithstanding any other provision of this chapter
or Chapter 8 (commencing with Section 14200), the total number of
physician office and clinic visits for physician services provided by
a physician, or under the direction of a physician, that are a
covered benefit under the Medi-Cal program shall be limited to seven
visits per beneficiary per fiscal year, excepting visits that meet
the conditions  set forth   described  in
subdivision (b). For purposes of this limit, a visit shall include
physician services provided at any federally qualified health center,
rural health clinic, community clinic, outpatient clinic, and
hospital outpatient department. The department may seek input from
consumer organizations and the provider community, as applicable,
prior to implementation.
   (b) (1) Visits exceeding seven per beneficiary per fiscal year
shall be required to be certified by the physician, or other medical
professional under the supervision of a physician, attesting that one
or more of the following circumstances is applicable:
   (A) The services will prevent deterioration in a beneficiary's
condition that would otherwise foreseeably result in admission to the
emergency department.
   (B) The services will prevent deterioration in the beneficiary's
condition that would otherwise result in inpatient admission.
   (C) The services will prevent disruption in ongoing medical
therapy or surgical therapy, or both, including, but not limited to,
medications, radiation, or wound management.
   (D) The services constitute diagnostic workup in progress that
would otherwise foreseeably result in inpatient or emergency
department admission.
   (E) The services are for the purpose of assessment and form
completion for Medi-Cal recipients seeking or receiving in-home
supportive services.
   (2) The certification shall consist of a written declaration by
the physician, or other medical professional under the supervision of
the physician, that the visit meets the requirements of any one or
more of the circumstances set forth in paragraph (1), and shall
include a description of the services provided.
   (3) The certification shall be maintained onsite at the physician'
s office or clinic location at which the medical records for the
beneficiary are maintained and shall be subject to audit and
inspection by the department.
   (4) This subdivision does not authorize or direct a beneficiary to
obtain services at a physician office or clinic visit for an
emergency medical condition or that should properly be provided in
the emergency department or as hospital inpatient services.
   (c) Specialty mental health services furnished or arranged for the
provision of mental health services to Medi-Cal beneficiaries
pursuant to Part 2.5 (commencing with Section 5775) of Division 5,
shall not be subject to the limit provided in subdivision (a).
   (d) Any pregnancy-related visit, or any visit for the treatment of
any other condition that might complicate a pregnancy, shall not be
subject to the limit provided in subdivision (a).
   (e) The limit on physician office and clinic visits provided in
subdivision (a) shall not apply to any of the following:
   (1) A beneficiary under the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) Program.
   (2) A beneficiary receiving long-term care in a nursing facility
that is both of the following:
   (A) A skilled nursing facility or intermediate care facility as
defined in subdivisions (c), (d), (e), (g), and (h), respectively, of
Section 1250 of the Health and Safety Code, and facilities providing
continuous skilled nursing care to persons with developmental
disabilities under the pilot project established pursuant to Section
14132.20.
   (B) Licensed pursuant to subdivision (k) of Section 1250 of the
Health and Safety Code.
   (f) For managed health care plans that contract with the
department pursuant to this chapter or Chapter 8 (commencing with
Section 14200), except for Senior Care Action Network or AIDS
Healthcare Foundation, payments shall be reduced by the actuarial
equivalent amount of the benefit reductions resulting from the
implementation of the benefit cap amounts specified in this section
pursuant to contract amendments or change orders effective on July 1,
2011, or thereafter.
   (g) This section shall be implemented only to the extent permitted
by federal law.
   (h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement this section by means of all-county letters,
provider bulletins, or similar instructions, without taking
regulatory action.
   (i) This section shall be implemented on the first day of the
first calendar month following 180 days after the effective date of
the act that added this section, or on the first day of the calendar
month following 60 days after the date the department secures all
necessary federal approvals to implement this section, whichever is
later. If the implementation date occurs after July 1, 2011, then the
benefit caps described in subdivision (a) for the first year of
implementation shall be applied from the implementation date to June
30 of the state fiscal year in which implementation begins.
Thereafter, the benefit caps shall apply on a state fiscal year
basis.