AB 1759, as amended, 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 availablebegin insert and would also require that those payments be made to other providers identified in federal law as eligible for the increased reimbursementend insert. The bill would authorize the department to implementbegin delete thoseend deletebegin insert theseend insert 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 uponbegin delete theend delete 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) begin delete(1)end deletebegin delete end deleteBeginning 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.
P3 1(c) (1) To the extent required by federal law or regulation,
2beginning
January 1, 2015, through and including the date
3specified in that federal law or regulation, payments for primary
4care services provided by a provider other than a physician shall
5not be less than 100 percent of the payment rate that applies to
6those services and providers as established by the Medicare
7Program, for both fee-for-service and managed care plans.
8(2) To the extent permitted by federal law and regulation, the
9payments to the providers identified in paragraph (1) shall continue
10indefinitely.
11(2)
end delete
12begin insert(d)end insert Notwithstanding any other law, to the extent permitted by
13federal law and regulations, the payments for primary care services
14begin delete implementedend deletebegin insert madeend insert pursuant to thisbegin delete subdivisionend deletebegin insert sectionend insert shall be
15exempt from the payment reductions under Sections 14105.191
16and 14105.192.
17(3)
end delete
18begin insert(e)end insert Payment increases made pursuant to thisbegin delete subdivisionend deletebegin insert
sectionend insert
19 shall not apply to provider rates of payment described in Section
2014105.18 for services provided to individuals not eligible for
21Medi-Cal or the Family Planning, Access, Care, and Treatment
22(Family PACT) Program.
23(f) For purposes of this section, the following definitions shall
24apply:
25(4) For purposes of this subdivision, “primary
end delete
26begin insert(1)end insertbegin insert end insertbegin insert“Primaryend insert
care services” and “primary specialty” means the
27services and primary specialties defined in Section 1202 of the
28federal Health Care and Education Reconciliation Act of 2010
29(Public Law 111-152; 42 U.S.C. Sec. 1396a(a)(13)(C))begin insert, and any
30amendments to that section,end insert and related federal regulations.
31(2) “A provider other than a physician” means a health care
32provider, other than a physician, who is identified in federal law
33or regulation as eligible for payments for primary care services
34rendered under the federal Medicaid program at a rate not less
35than 100 percent of the payment rate that applies to those services
36as established by the Medicare Program.
37(5)
end delete
38begin insert(g)end insert Notwithstanding any other law, the payment increase
39implemented pursuant to thisbegin delete subdivisionend deletebegin insert sectionend insert shall apply to
40managed care health plans that contract with the department
P4 1pursuant to Chapter 8.75 (commencing with Section 14591) and
2to contracts with the Senior Care Action Network and the AIDS
3Healthcare Foundation, and to the extent that the services are
4provided through any of these contracts, payments shall be
5increased by the actuarial equivalent amount of the payment
6increases pursuant to contract amendments or change orders
7effective on or after January 1, 2015.
8(6)
end delete
9begin insert(h)end insert Notwithstanding Chapter 3.5 (commencing with Section
1011340) of Part 1 of Division 3 of Title 2 of the Government Code,
11the department shall implement, clarify, make specific, and define
12the provisions of thisbegin delete subdivisionend deletebegin insert
sectionend insert
by means of provider
13bulletins or similar instructions, without taking regulatory action
14until the time regulations are adopted. The department shall adopt
15regulations by July 1, 2017, in accordance with the requirements
16of Chapter 3.5 (commencing with Section 11340) of Part 1 of
17Division 3 of Title 2 of the Government Code. Beginning July 1,
182015, and notwithstanding Section 10231.5 of the Government
19Code, the department shall provide a status reportbegin insert regarding this
20sectionend insert to the Legislature on a semiannual basis, in compliance
21with Section 9795 of the Government Code, until regulations have
22been adopted.
23(7)
end delete
24begin insert(i)end insert Thisbegin delete subdivisionend deletebegin insert sectionend insert shall be implemented only if and
25to the extent that federal financial participation is available and
26any necessary federal approvals have been obtained.
27(c) The director shall annually review the findings and
28recommendations of an independent assessment of Medi-Cal
29provider reimbursement rates and suggest adjustments to the
30reimbursement rates as necessary to ensure that quality and access
31in the Medi-Cal fee-for-service program and
in Medi-Cal managed
32care plans are adequate to meet applicable state and federal
33standards. Notwithstanding Section 10231.5 of the Government
34Code, the findings and recommendations of the independent
35assessment and the director’s suggested adjustments to provider
36reimbursement rates shall be submitted to the Legislature annually
37as part of the Governor’s Budget submitted pursuant to Section
3813337 of the Government Code.
begin insertSection 14105.197 is added to the end insertbegin insertWelfare and
40Institutions Codeend insertbegin insert, to read:end insert
The director shall annually review the findings and
2recommendations of an independent assessment of Medi-Cal
3provider reimbursement rates and suggest adjustments to the
4reimbursement rates as necessary to ensure that quality and access
5in the Medi-Cal fee-for-service program and in Medi-Cal managed
6care plans are adequate to meet applicable state and federal
7standards. Notwithstanding Section 10231.5 of the Government
8Code, the findings and recommendations of the independent
9assessment and the director’s suggested adjustments to provider
10reimbursement rates shall be submitted to the Legislature annually
11as part of the Governor’s Budget submitted pursuant to Section
1213337 of the Government Code.
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