Amended in Senate April 10, 2014

Senate Bill No. 986

Introduced by Senator Hernandez

February 11, 2014

An act to begin delete amend Section 14182 of end delete begin insert add Section 14103.9 end insert begin insert to end insert the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 986, as amended, Hernandez. Medi-Cal: managed care: begin delete seniors and persons with disabilities. end delete begin insert exemption from plan enrollment. end insert

Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. begin delete Existing law authorizes the department, in furtherance of a specified waiver or demonstration project, to require seniors and persons with disabilities who do not have other health coverage to be assigned as mandatory enrollees into new or existing managed care health plans. Existing law requires the department, in exercising its authority pursuant to these provisions, to, among other things, ensure that managed care health plans participating in the demonstration project provide access to out-of-network providers for new individual members and comply with continuity of care requirements, as specified. end delete

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This bill would instead require the department to ensure that the managed care health plans participating in the demonstration project provide timely access to out-of-network providers for new individual members and fully comply with the continuity of care requirements.

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This bill would require that a Medi-Cal beneficiary who has received a medical exemption from enrollment in a Medi-Cal managed care plan and who is to receive or has received specified transplantations, including allogeneic bone marrow transplantation, receive an extension of the medical exemption for up to 12 months if the treating physician who provided or oversaw the transplantation or who is providing the followup care determines that it is medically necessary for the beneficiary to remain under the care of the treating physician. The bill would require, at the end of the extension, the treating physician to assess the beneficiary’s condition to determine whether the beneficiary’s condition has stabilized to a level that would enable the beneficiary to be safely transferred to a physician within a Medi-Cal managed care health plan without any deleterious effects to the beneficiary’s health. If the condition is not stable enough to transfer, the medical exemption would be extended up to an additional 12 months. The bill would prohibit a beneficiary meeting the criteria of these provisions from being transitioned into a Medi-Cal managed care health plan until appeals and other specified means of redress have been exhausted. The bill would make related findings and declarations.

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Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

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begin insert SECTION 1. end insert   

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The Legislature finds and declares all of the
following:

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(a) Medi-Cal beneficiaries with severe conditions have
difficulties finding specialists and centers of excellence to treat
them. Even when they do find this care, Medi-Cal beneficiaries
often lose continuity of care with these providers due to regulations
pertaining to the medical exemption from enrollment in a Medi-Cal
managed care plan process, which leads to delays in obtaining
care, inability to maintain continuity with specialists with the
knowledge required to treat their conditions, and a painful and
costly worsening or relapse of their medical conditions.

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(b) It is important that Medi-Cal beneficiaries maintain
continuity of care with their specialty care providers when the
beneficiary has been diagnosed with cancer or other
life-threatening blood disorders or undergone bone marrow, blood
stem cell, cord blood, or haploidentical transplantation.

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(c) Bone marrow, blood stem cell, cord blood, and
haploidentical transplantation, particularly allogeneic transplants
in which the marrow or stem cells of an unrelated donor are used,
can create significant complications for the patient long after the
initial hospital stay. Medi-Cal beneficiaries on immunosuppressive
medications, if not properly monitored, can suffer significant
adverse reactions, including relapses of their original cancer or
blood disorder, graft versus host disease, and rare infections that
can be severe, disabling, and fatal. When these complications
occur, they are not only significantly painful and distressing to
the beneficiary and his or her loved ones, but add tremendous,
preventable costs to the Medi-Cal system.

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(d) Therefore, the Legislature finds that it is in the best interests
of Medi-Cal beneficiaries who have undergone allogeneic bone
marrow, blood stem cell, cord blood, or haploidentical
transplantations to maintain continuity of care with these specialty
care providers when those providers certify the need for continuity
and can appropriately monitor and treat their conditions and
comorbidities. The Legislature also finds that it in the best interests
of the beneficiaries, the Medi-Cal system, and the taxpayers of this
state that this more cost-effective continuity of care is maintained,
thereby preventing costly, disabling, and even fatal adverse
reactions, relapses, and infection.

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begin insert SEC. 2. end insert   

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begin insert Section 14103.9 is added to the end insert begin insert Welfare and Institutions
Code end insert begin insert , to read: end insert

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begin insert 14103.9. end insert   

(a) A Medi-Cal beneficiary who has received a
medical exemption from enrollment in a Medi-Cal managed care
plan pursuant to the medical exemption request process, as
provided for in Section 53887 of Title 22 of the California Code
of Regulations, and who is to receive or has received an allogeneic
bone marrow transplantation, allogeneic blood stem cell
transplantation, cord blood transplantation, or haploidentical
transplantation shall receive an extension of the medical exemption
beyond the initial 12-month exemption period if the treating
physician who provided or oversaw the transplantation or who is
providing the followup care to the beneficiary determines that it
is medically necessary for the beneficiary to remain under the care
of the treating physician. The extension shall be provided for up
to 12 months, after which the treating physician who provided or
oversaw the transplant, or who is providing the followup care,
shall assess the beneficiary’s condition to determine whether the
beneficiary’s medical condition has stabilized to a level that would
enable the beneficiary to be safely transferred to a physician within
a managed care health plan without any deleterious effects to the
beneficiary’s health.

(b) If, at the end of the extension pursuant to subdivision (a),
the treating physician determines that the beneficiary’s condition
is not sufficiently stable to enable a transfer without deleterious
effects to the beneficiary, the medical exemption shall be extended
for up to an additional 12 months, after which another assessment
shall be conducted pursuant to the process described in subdivision
(a). A beneficiary meeting the criteria of subdivision (a) who
requests an extension of a medical exemption shall not be
transitioned into a Medi-Cal managed care plan until all appeals,
fair hearings processes, litigation, and other means of redress
have been exhausted.

(c) The existence of a contract between the provider or
provider’s medical group and a Medi-Cal managed care plan, or
a contract between the hospital that provided the transplantation
or followup care and a Medi-Cal managed care plan, or the
beneficiary’s prior enrollment in a managed care plan shall not
be considered as a factor in determining the extension of a medical
exemption request pursuant to this section for beneficiaries who
have received the procedures specified in subdivision (a). The
contracts shall not be used as a reason or basis for returning a
beneficiary who has received one or more of these procedures to
a Medi-Cal managed care plan.

(d) For the purposes of this section, the following definitions
shall apply:

(1) “Allogeneic bone marrow transplantation” means the
transplantation of bone marrow from an immunologically matched
sibling or an unrelated donor following treatment with one or
more of the following therapies: chemotherapy, radiation therapy,
or immunotherapy.

(2) “Allogeneic blood stem cell transplantation” means
transplantation of growth factor mobilized blood stem cells from
an immunologically matched sibling or unrelated donor following
treatment with one or more of the following therapies:
chemotherapy, radiation therapy, or immunotherapy.

(3) “Cord blood transplantation” means transplantation of
umbilical cord blood cells from partially or fully immunologically
matched and previously collected cord blood following treatment
with one or more of the following therapies: chemotherapy,
radiation therapy, or immunotherapy.

(4) “Haploidentical transplantation” means transplantation of
bone marrow or growth factor mobilized blood stem cells from a
partially matched familial donor following treatment with one or
more of the following therapies: chemotherapy, radiation therapy,
or immunotherapy.

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All matter omitted in this version of the bill appears in the bill as introduced in the Senate, February 11, 2014. (JR11)