AB 1759, as introduced, Pan. Medi-Cal: reimbursement rates.
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 persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing federal law requires the state to provide payment for primary care services furnished in the 2013 and 2014 calendar years by Medi-Cal providers with specified primary specialty designations at a rate not less than 100% of the payment rate that applies to those services and physicians under the Medicare Program.
Existing state law requires, to the extent required by federal law, and beginning January 1, 2013, through and including December 31, 2014, that payments for primary care services provided by specified physicians be no less than 100% of the payment rate that applies to those services and physicians as established by the Medicare Program, for both fee-for-service and managed care plans.
This bill would require that those payments continue indefinitely to the extent permitted by federal law but only to the extent that federal financial participation is available. The bill would authorize the department to implement those provisions through provider bulletins without taking regulatory action until regulations are adopted and would require the department to adopt those regulations by July 1, 2017. The bill also would require the department to annually review the findings and recommendations of an independent assessment of Medi-Cal provider reimbursement rates and to suggest adjustments to the reimbursement rates as necessary to ensure that quality and access in the Medi-Cal fee-for-service program and in Medi-Cal managed care plans are adequate to meet applicable state and federal standards. The bill would require that the findings and recommendations of the independent assessment and the director’s suggested adjustments to provider reimbursement rates be submitted to the Legislature annually as part of the Governor’s Budget.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14105.196 is added to the Welfare and
2Institutions Code, to read:
(a) It is the intent of the Legislature to maintain
4the increased reimbursement rates for primary care providers in
5the Medi-Cal program upon the expiration of the temporary
6increase provided for under Chapter 23 of the Statutes of 2012, as
7amended by Chapter 438 of the Statutes of 2012, in order to ensure
8adequate access to these providers. It is also the intent of the
9Legislature to provide a mechanism to increase reimbursement
10rates for other Medi-Cal providers in order to comply with federal
11Medicaid requirements that care and services are available to
12Medi-Cal enrollees at least to the extent that care and services are
13available to the general population in the geographic area.
14(b) (1) Beginning January 1, 2015, to
the extent permitted by
15federal law and regulations, payments for primary care services
16provided by a physician with a primary specialty designation of
17family medicine, general internal medicine, or pediatric medicine
18shall not be less than 100 percent of the payment rate that applies
19to those services and physicians as established by the Medicare
20Program, for both fee-for-service and managed care plans.
21(2) Notwithstanding any other law, to the extent permitted by
22federal law and regulations, the payments for primary care services
23implemented pursuant to this subdivision shall be exempt from
24the payment reductions under Sections 14105.191 and 14105.192.
P3 1(3) Payment increases made pursuant to this subdivision shall
2not apply to provider rates of payment described in Section
314105.18 for services provided to individuals not eligible for
4Medi-Cal or the Family Planning, Access,
Care, and Treatment
5(Family PACT) Program.
6(4) For purposes of this subdivision, “primary care services”
7and “primary specialty” means the services and primary specialties
8defined in Section 1202 of the federal Health Care and Education
9Reconciliation Act of 2010 (Public Law 111-152; 42 U.S.C. Sec.
101396a(a)(13)(C)) and related federal regulations.
11(5) Notwithstanding any other law, the payment increase
12implemented pursuant to this subdivision shall apply to managed
13care health plans that contract with the department pursuant to
14Chapter 8.75 (commencing with Section 14591) and to contracts
15with the Senior Care Action Network and the AIDS Healthcare
16Foundation, and to the extent that the services are provided through
17any of these contracts, payments shall be increased by the actuarial
18equivalent amount of the payment increases pursuant to contract
19amendments or change orders
effective on or after January 1, 2015.
20(6) Notwithstanding Chapter 3.5 (commencing with Section
2111340) of Part 1 of Division 3 of Title 2 of the Government Code,
22the department shall implement, clarify, make specific, and define
23the provisions of this subdivision by means of provider bulletins
24or similar instructions, without taking regulatory action until the
25time regulations are adopted. The department shall adopt
26regulations by July 1, 2017, in accordance with the requirements
27of Chapter 3.5 (commencing with Section 11340) of Part 1 of
28Division 3 of Title 2 of the Government Code. Beginning July 1,
292015, and notwithstanding Section 10231.5 of the Government
30Code, the department shall provide a status report to the Legislature
31on a semiannual basis, in compliance with Section 9795 of the
32Government Code, until regulations have been adopted.
33(7) This subdivision shall be
implemented only if and to the
34extent that federal financial participation is available and any
35necessary federal approvals have been obtained.
36(c) The director shall annually review the findings and
37recommendations of an independent assessment of Medi-Cal
38provider reimbursement rates and suggest adjustments to the
39reimbursement rates as necessary to ensure that quality and access
40in the Medi-Cal fee-for-service program and in Medi-Cal managed
P4 1care plans are adequate to meet applicable state and federal
2standards. Notwithstanding Section 10231.5 of the Government
3Code, the findings and recommendations of the independent
4assessment and the director’s suggested adjustments to provider
5reimbursement rates shall be submitted to the Legislature annually
6as part of the Governor’s Budget submitted pursuant to Section
713337 of the Government Code.
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