SB 964, as introduced, Hernandez. Health care service plans: medical surveys.
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. Existing law establishes the California Health Benefit Exchange for the purpose of facilitating the enrollment of qualified individuals and small employers in qualified health plans.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law requires the department to periodically conduct an onsite medical survey of the health delivery system of each plan. Existing law exempts a plan that provides services solely to Medi-Cal beneficiaries from the survey upon submission to the department the medical survey audit conducted by the State Department of Health Care Services as part of the Medi-Cal contracting process.
This bill would specify that a plan that provides services solely to Medi-Cal beneficiaries is not exempt from the medical survey with respect to quality management, utilization review, timely access, network adequacy, and any other requirements related to access and availability, except as specified. The bill would require a plan that provides services to Medi-Cal beneficiaries, except for a plan that serves Medi-Cal beneficiaries exclusively, and a plan that provides services to enrollees in the California Health Benefit Exchange to be surveyed separately with respect to those products. The bill would also require a plan that provides services to Medi-Cal beneficiaries through specified programs to be surveyed annually with respect to those products until 5 years after completion of initial enrollment in those products, as specified.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 1380.3 of the Health and Safety Code is
2amended to read:
begin insert(a)end insertbegin insert end insertNotwithstanding Section 1380,begin delete anyend deletebegin insert and except as
4provided in subdivision (b), aend insert plan that provides services solely to
5Medi-Cal beneficiaries pursuant to Chapter 8 (commencing with
6Section 14200) of Part 3 of Division 9 of the Welfare and
7Institutions Code shall not be subject to the requirements of Section
81380 upon the submission to the director of the medical survey
9audit for the same period conducted by the State Department of
10Healthbegin insert
Careend insert Services as part of the Medi-Cal contracting process,
11unless the director determines that an additional medical survey
12audit is required.
13(b) A plan that provides services solely to Medi-Cal beneficiaries
14pursuant to Chapter 8 (commencing with Section 14200) of Part
153 of Division 9 of the Welfare and Institutions Code shall not be
16exempt from Section 1380 with respect to quality management,
17utilization review, timely access, network adequacy, and any other
18requirements related to access and availability unless the
19department and the State Department of Health Care Services
20jointly make a public determination that the medical survey audit
21for the same period conducted by the State Department of Health
22Care Services as part of the Medi-Cal contracting process assures
23compliance with the access and availability
requirements of this
24chapter.
Section 1380.4 is added to the Health and Safety Code,
26to read:
(a) A plan that provides services to Medi-Cal
2beneficiaries pursuant to Chapter 8 (commencing with Section
314200) of Part 3 of Division 9 of the Welfare and Institutions Code
4shall be surveyed under Section 1380 separately with respect to
5those products in order to determine whether the services received
6by Medi-Cal beneficiaries through those products comply with the
7requirements of this chapter.
8(b) If a plan provides services solely to Medi-Cal beneficiaries
9pursuant to Chapter 8 (commencing with Section 14200) of Part
103 of Division 9 of the Welfare and Institutions Code, compliance
11with Section 1380.3 shall satisfy the requirements of this section.
Section 1380.5 is added to the Health and Safety Code,
13to read:
A plan that provides services to enrollees in the
15California Health Benefit Exchange pursuant to Title 22
16(commencing with Section 100500) of the Government Code shall
17be surveyed separately under Section 1380 with respect to those
18products in order to determine whether the services received by
19those enrollees through the products comply with the requirements
20of this chapter.
Section 1380.6 is added to the Health and Safety Code,
22to read:
Notwithstanding Section 1380.3, a plan that enrolls
24Medi-Cal beneficiaries as a result of any of the following shall be
25surveyed annually under Section 1380 with respect to those
26products until five years after the completion of initial enrollment
27under those products:
28(a) The transition of Healthy Families Program enrollees to the
29Medi-Cal program pursuant to Chapter 16.2 (commencing with
30Section 12694.1) of Part 6.2 of Division 2 of the Insurance Code.
31(b) Article 2.82 (commencing with Section 14087.98) of Chapter
327 of Part 3 of Division 9 of the Welfare and Institutions Code.
33(c) Section 14182 of the Welfare and Institutions Code.
34(d) Section 14182.16 or 14232.275 of the Welfare and
35Institutions Code.
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