SB 1315, as amended, Monning. Medi-Cal: providers.
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. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.
Existing law permits the department to make unannounced visits to an applicant or to a provider for the purpose of determining whether enrollment, continued enrollment, or certification as a provider is warranted, or as necessary for the administration of the Medi-Cal program. Existing law further requires that a provider be subject to temporary suspension from the Medi-Cal program, which includes temporary deactivation of the provider’s number, for failure to remediate significant discrepancies in information that he or she provided to
the department or for failure to remediate significant discrepancies that are discovered as a result of an announced or unannounced visit to a provider, as specified. Existing law requires the provider to be notified, in writing, of the temporary suspension and deactivation ofbegin delete providers number.end deletebegin insert provider numbers.end insert
This bill would require that notice of temporary suspension to contain a list of discrepancies to be remediated and the timeframe in which the provider needs to remediate thosebegin delete discrepancies.end deletebegin insert discrepancies, which would be at least 60 days from the date the notice of temporary
suspension is issued.end insert The bill would require the department to lift a temporary suspension and notify a provider that the temporary suspension has been lifted and that he or she is eligible to receive reimbursement for Medi-Cal services provided after the date the temporary suspension was lifted if the provider has demonstrated that the identified discrepancies have been remediated within the applicable timeframe. A provider who fails to remediate the identified discrepancies would be removed from enrollment as a provider in the Medi-Cal program by operation of law.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14043.7 of the Welfare and Institutions
2Code is amended to read:
(a) The department may make unannounced visits
4to an applicant or to a provider for the purpose of determining
5whether enrollment, continued enrollment, or certification is
6warranted, or as necessary for the administration of the Medi-Cal
7program. If an unannounced site visit is conducted by the
8department for any enrolled provider, the provider shall permit
9access to any and all of their provider locations. If a provider fails
10to permit access for any site visit, the application shall be denied
11and the provider shall be subject to deactivation. At the time of
12the visit, the applicant or provider shall be required to demonstrate
13an established place of business appropriate and adequate for the
14services billed or claimed to the Medi-Cal program,
as relevant to
15his or her scope of practice, as indicated by, but not limited to, the
16following:
17(1) Being open and available to the general public.
18(2) Having regularly established and posted business hours.
19(3) Having adequate supplies in stock on the premises.
20(4) Meeting all local laws and ordinances regarding business
21licensing and operations.
P3 1(5) Having the necessary equipment and facilities to carry out
2day-to-day business for his or her practice.
3(b) An unannounced visit pursuant to subdivision (a) shall be
4prohibited with respect to
clinics licensed under Section 1204 of
5the Health and Safety Code, clinics exempt from licensure under
6Section 1206 of the Health and Safety Code, health facilities
7licensed under Chapter 2 (commencing with Section 1250) of
8Division 2 of the Health and Safety Code, and natural persons
9licensed or certified under Division 2 (commencing with Section
10500) of the Business and Professions Code, the Osteopathic
11Initiative Act, or the Chiropractic Initiative Act, unless the
12department has reason to believe that the provider will defraud or
13abuse the Medi-Cal program or lacks the organizational or
14administrative capacity to provide services under the program.
15(c) (1) Failure to remediate significant discrepancies in
16information provided to the department by the provider or
17significant discrepancies that are discovered as a
result of an
18announced or unannounced visit to a provider, for purposes of
19enrollment, continued enrollment, or certification pursuant to
20subdivision (a) shall make the provider subject to temporary
21suspension from the Medi-Cal program, which shall include
22temporary deactivation of the provider’s number, including all
23business addresses used by the provider to obtain reimbursement
24from the Medi-Cal program. The director shall notify in writing
25the provider of the temporary suspension and deactivation of
26provider numbers, which shall take effect 15 days from the date
27of the notification. Notwithstanding Section 100171 of the Health
28and Safety Code, proceedings after the imposition of sanctions in
29this subdivision shall be in accordance with Section 14043.65.
30(2) A notice of temporary suspension issued pursuant to
31paragraph (1)
shall include the following:
32(A) A list of discrepancies required to be remediated.
33(B) The timeframe in which a provider may demonstrate to the
34department that the discrepancies identified pursuant to
35subparagraph (A) have been remediated.begin insert The timeframe in which
36a provider may remediate discrepancies shall not be less than 60
37days from the date the notice of the temporary suspension is issued.end insert
38(3) If a provider who has received a notice of temporary
39suspension pursuant to paragraph (1) demonstrates to the
40department that the discrepancies identified pursuant to
P4 1subparagraph (A) of paragraph (2) have been remediated and meets
2the standards of
participation within the timeframe specified in
3subparagraph (B) of paragraph (2), the department shall lift the
4temporary suspension and shall notify the provider that the
5temporary suspension has been lifted and that he or she is eligible
6to receive Medi-Cal reimbursement for services provided after the
7date the temporary suspension was lifted.
8(4) If a provider who has received a notice of temporary
9suspension pursuant to paragraph (1) fails to remediate the
10discrepancies identified pursuant to subparagraph (A) of paragraph
11(2) within the timeframe specified in subparagraph (B) of paragraph
12(2), the provider shall be removed from enrollment as a provider
13in the Medi-Cal program by operation of law.
14(d) (1) This section shall become operative on the effective
15date
of the state plan amendment necessary to implement this
16section, as stated in the declaration executed by the director
17pursuant to paragraph (2).
18(2) Upon approval of the state plan amendment necessary to
19implement this section under Section 455.416 of Title 42 of the
20Code of Federal Regulations, the director shall execute a
21declaration, to be retained by the director and posted on the
22department’s Internet Web site, that states that this approval has
23been obtained and the effective date of the state plan amendment.
24The department shall transmit a copy of the declaration to the
25Legislature.
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