Bill Text: CA SB171 | 2017-2018 | Regular Session | Amended
Bill Title: Medi-Cal: Medi-Cal managed care plans.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2017-10-13 - Chaptered by Secretary of State. Chapter 768, Statutes of 2017. [SB171 Detail]
Download: California-2017-SB171-Amended.html
Amended
IN
Assembly
September 07, 2017 |
Amended
IN
Assembly
July 05, 2017 |
Amended
IN
Senate
May 02, 2017 |
Amended
IN
Senate
April 19, 2017 |
Senate Bill | No. 171 |
Introduced by Senator Hernandez (Coauthor: Assembly Member Wood) |
January 23, 2017 |
LEGISLATIVE COUNSEL'S DIGEST
Existing state law establishes hearing procedures for an applicant for or beneficiary of Medi-Cal who is dissatisfied with certain actions regarding health care services and medical assistance to request a hearing from the State Department of Social Services under specified circumstances, and requires a request for a hearing to be filed within 90 days after the order or action complained of.
This bill would implement various provisions in regard to those federal regulations, as amended May 6, 2016, governing Medicaid managed care plans. The bill would authorize a person, after he or she has exhausted the Medi-Cal managed care plan’s appeals process, to request a hearing involving a Medi-Cal managed care plan
within 120 calendar days after he or she has either received verbal or written notice from the Medi-Cal managed care plan that the adverse benefit determination, as defined, is upheld or the appeal or expedited appeal is denied, or the person is deemed to have exhausted the Medi-Cal managed care plans appeals process, as specified, and would exclude a request from the 120-calendar day filing time if there is good cause, as defined, for filing the request beyond the 120-calendar day period. The bill would require the State Department of Social Services to adopt any necessary rules and regulations to implement these changes, and, until July 1, 2018, would authorize the State Department of Social Services to adopt any necessary rules and regulations as emergency regulations.
The bill would require the State Department of Social Services, for a beneficiary of a Medi-Cal managed care plan who meets the criteria for an expedited resolution of an
appeal, to take final administrative action as expeditiously as the individual’s health condition requires, but no later than 3 working days after the State Department of Social Services receives certain information from the Medi-Cal managed care plan consistent with the federal regulation described above. The bill would require a Medi-Cal managed care plan, upon notice from the State Department of Social Services that a beneficiary has requested a state fair hearing, to provide to the department a copy of the case file and any information for any appeal of a denial of a service within 3 business days of the Medi-Cal managed care plan’s receipt of the department’s notice of a request by a beneficiary for a state fair hearing.
(2)These federal regulations require a state that contracts with specified Medicaid managed care plans to develop and enforce network adequacy standards and requires each state to ensure that all
services covered under the Medicaid state plan are available and accessible to enrollees of specified Medicaid managed care plans in a timely manner. These regulations also require specified Medicaid managed care plans to calculate and report a medical loss ratio (MLR) for the rating period that begins in 2017. If a state elects to mandate a minimum MLR for its Medicaid managed care plans, these regulations require that minimum MLR to be equal to or higher than 85% and authorizes the state to impose a remittance requirement consistent with the minimum standards established in these federal regulations for the failure to meet the minimum ratio standard imposed by the state.
The bill would require the State Department of Health Care Services, in consultation with the Department of Managed Health Care, to develop time and distance standards for specified provider types to ensure that covered and medically necessary services are accessible to enrollees of Medi-Cal
managed care plans, as defined, to develop, for those Medi-Cal managed care plans that cover long-term services and supports (LTSS), time and distance standards for LTSS providers and network adequacy standards other than time and distance standards, and to develop timeliness standards to ensure that all covered and medically necessary services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. The bill would require these standards to meet specified existing standards for timeliness of access to care established by the Department of Managed Health Care or those set forth in existing Medi-Cal managed care plan contracts, and would require the department, in developing these standards, to take into consideration requirements under a specified federal regulation. The bill would authorize the State Department of Health Care Services, upon the request of a Medi-Cal managed care plan, to allow alternative access standards, including the use of
telecommunications technology, if the applying Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet either the time and distance or timely access standards. The bill would require, on an annual basis and when requested by the State Department of Health Care Services, a Medi-Cal managed care plan, as defined, to demonstrate to the State Department of Health Care Services and, for Medi-Cal managed care plans licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), the Department of Managed Health Care its compliance with the standards developed under this provision. The bill would also require a health care service plan licensed under the Knox-Keene Act that provides services to Medi-Cal beneficiaries to provide to the Department of Managed Health Care, in a manner specified by the department, data regarding the standards developed under this provision. Because a willful violation of the Knox-Keene Act by a health care service plan is a
crime, this bill would impose a state-mandated local program.
The bill would require a Medi-Cal managed care plan, as defined, to comply with the MLR calculation and reporting requirements imposed under those federal regulations, and would require a Medi-Cal managed care plan to comply with a minimum 85% MLR and to
The bill would require the department to adopt regulations by July 1, 2019, and, commencing July 1, 2018, would require the department to provide a status report to the Legislature on a semiannual basis until regulations are adopted.
(3)These federal regulations require specified managed care plans to have a grievance and appeal system in place for enrollees, and requires managed care plans to resolve each grievance and appeal, and to provide timely and adequate notice, as expeditiously as the enrollee’s health condition requires, within certain state-established timeframes that may not exceed specified timeframes.
This bill would require a Medi-Cal managed care plan, as defined, to give a beneficiary timely and adequate notice of an adverse benefit determination, as defined, in writing consistent with those federal regulations. The bill
would require a Medi-Cal managed care plan to establish and maintain an expedited review process for a beneficiary or the beneficiary’s provider to request an expedited resolution of an appeal based on specified circumstances, including when the beneficiary’s condition is such that the beneficiary faces an imminent and serious threat to his or her health, or the standard timeline would be detrimental to the beneficiary’s life or health or could jeopardize the beneficiary’s ability to regain maximum function. The bill would require a Medi-Cal managed care plan to resolve a standard appeal no more than 30 calendar days from the day the Medi-Cal managed care plan receives the appeal, and would require the Medi-Cal managed care plan to resolve an expedited appeal no longer than 72 hours after the Medi-Cal managed care plan receives the appeal.
(4)
(5)
(6)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Digest Key
Vote: MAJORITY Appropriation: YES Fiscal Committee: YES Local Program:Bill Text
The people of the State of California do enact as follows:
SECTION 1.
It is the intent of the Legislature to implement the revisions to federal regulations governing Medicaid managed care plans at Parts 431, 433, 438, 440, 457, and 495 of Title 42 of the Code of Federal Regulations, as amended May 6, 2016, as published in the Federal Register (81 Fed. Reg. 27498).(a)As part of the reports submitted to the department pursuant to subdivision (f) of Section 1367.03 and regulations adopted pursuant to that section, a health care service plan shall submit to the department, in a manner specified by the department, data regarding network adequacy, including, but not limited to, the following:
(1)Provider office location.
(2)Area of specialty.
(3)Hospitals where providers have admitting privileges, if any.
(4)Providers with open practices.
(5)The number of patients assigned to a primary care provider or, for providers who do not have assigned enrollees, information that demonstrates the capacity of primary care providers to be accessible and available to enrollees.
(6)Grievances regarding network adequacy and timely access that the health care service plan received during the preceding calendar year.
(b)A health care service plan that uses a network for its Medi-Cal managed care product line that is different from the network used for its other product lines shall submit the data required under subdivision (a) for its Medi-Cal managed care product line separately from the data submitted for its other product lines.
(c)A health care service plan that uses a network for its individual market product line that is different from the network used for its small group market product line shall submit the data required under subdivision (a) for its individual market product line separate from the data submitted for its small group market product line.
(d)The department shall review the data submitted pursuant to this section for compliance with this chapter.
(e)(1)In submitting data under this section, a health care service plan that provides services to Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare
and Institutions Code shall provide the same data to the State Department of Health Care Services pursuant to Section 14456.3 of the Welfare and Institutions Code.
(2)A health care service plan that provides services to Medi-Cal beneficiaries also shall provide to the department, in a manner specified by the department, data regarding the standards set forth in Section 14197 of the Welfare and Institutions Code.
(f)In developing the format and requirements for reports, data, or other information provided by plans pursuant to subdivision (a), the department shall not create duplicate reporting requirements, but, instead, shall take into consideration all existing relevant reports, data, or other information provided by plans to the department. This subdivision does not limit the
authority of the department to request additional information from the plan as deemed necessary to carry out and complete any enforcement action initiated under this chapter.
(g)If the department requests additional information or data to be reported pursuant to subdivision (a), which is different or in addition to the information required to be reported in paragraphs (1) to (6), inclusive, of subdivision (a), the department shall provide health care service plans notice of that change by November 1 of the year prior to the change.
(h)A health care service plan may include in the provider contract provisions requiring compliance with the reporting requirements of Section 1367.03 and this section.
(a)If any applicant for or recipient of public social services is dissatisfied with any action of the county department relating to his or her application for or receipt of public social services, if his or her application is not acted upon with reasonable promptness, or if any person who desires to apply for public social services is refused the opportunity to submit a signed application therefor, and is dissatisfied with that refusal, he or she shall, in person or through an authorized representative, without the necessity of filing a claim with the board of supervisors, upon filing a request with the State Department of Social Services or the State Department of Health Care Services, whichever department administers the public social
service, be accorded an opportunity for a state hearing.
(b)(1)The requirements of Sections 100506.2 and 100506.4 of the Government Code apply to state hearings regarding eligibility for or enrollment in an insurance affordability program administered by the State Department of Health Care Services to the extent that those sections conflict with the state hearing requirements under this chapter.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time
regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning July 1, 2015, the department shall provide a semiannual status report to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(3)This subdivision shall be implemented only to the extent it does not conflict with federal law.
(c)Priority in setting and deciding cases shall be given in those cases in which aid is not being provided pending the outcome of the hearing. This priority shall not be construed to permit or excuse the failure to render
decisions within the time allowed under federal and state law.
(d)Notwithstanding any other provision of this code, there is no right to a state hearing when either (1) state or federal law requires automatic grant adjustments for classes of recipients unless the reason for an individual request is incorrect grant computation, or (2) the sole issue is a federal or state law requiring an automatic change in services or medical assistance which adversely affects some or all recipients.
(e)For the purposes of administering health care services and medical assistance, the Director of Health Care Services shall have those powers and duties conferred on the Director of Social Services by this chapter to conduct state hearings in order to secure approval of a state plan under
applicable federal law.
(f)The Director of Health Care Services may contract with the State Department of Social Services for the provisions of state hearings in accordance with this chapter.
(g)As used in this chapter, the following terms have the following meanings:
(1)“Adverse benefit determination” means, in the case of a Medi-Cal managed care plan, any of the following:
(A)The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
(B)The reduction, suspension, or termination of a previously authorized service.
(C)The denial, in whole or in part, of payment for a service.
(D)The failure to provide services in a timely manner, as defined by the State Department of Health Care Services.
(E)The failure of a Medi-Cal managed care plan to act within the timeframes provided in Section 438.408(b)(1) of Title 42 of the Code of Federal Regulations regarding the standard resolution of grievances and appeals.
(F)For a resident of a rural area with only one Medi-Cal managed care plan, the denial of an enrollee's request to exercise his or her right under Section 438.52(b)(2)(i) of Title 42 of the Code of Federal Regulations to obtain services outside the network.
(G)The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
(2)“Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the
following:
(A)Article 2.7 (commencing with Section 14087.3) of Chapter 7 of Part 3, including dental managed care programs developed pursuant to Section 14087.46.
(B)Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3.
(C)Article 2.81 (commencing with Section 14087.96) of Chapter 7 of Part 3.
(D)Article 2.9 (commencing with Section 14088) of Chapter 7 of Part 3.
(E)Article 2.91 (commencing with Section 14089) of Chapter 7 of Part 3.
(F)Chapter 8 (commencing with Section 14200) of Part 3, including
dental managed care plans.
(G)Chapter 8.9 (commencing with Section 14700) of Part 3.
(H)A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
(3)“Recipient” means an applicant for or recipient of public social services except aid exclusively financed by county funds or aid under Article 1 (commencing with Section 12000) to Article 6 (commencing with Section 12250), inclusive, of
Chapter 3 of Part 3, and under Article 8 (commencing with Section 12350) of Chapter 3 of Part 3, or those activities conducted under Chapter 6 (commencing with Section 18350) of Part 6, and shall include any individual who is an approved adoptive parent, as described in
subdivision (C) of Section 8708 of the Family Code, and who alleges that he or she has been denied or has experienced delay in the placement of a child for adoption solely because he or she lives outside the jurisdiction of the department.
(a)(1)A person is not entitled to a hearing pursuant to this chapter unless he or she files his or her request for the same within 90 days after the order or action complained of.
(2)Notwithstanding paragraph (1), a person shall be entitled to a hearing pursuant to this chapter if he or she files the request more than 90 days after the order or action complained of and there is good cause for filing the request beyond the 90-day period. The director may determine whether good cause exists. The department shall not grant a request for a hearing for good cause if the request is filed more than 180 days after the order or action complained of.
(b)(1)Notwithstanding subdivision (a), a person who is enrolled in a Medi-Cal managed care plan and who has received an adverse benefit determination from the Medi-Cal managed care plan shall, to the extent required by federal law or regulation, appeal the adverse benefit determination to the Medi-Cal managed care plan before requesting a state fair hearing pursuant to this chapter. After appealing to the Medi-Cal managed care plan, the enrollee may request a hearing pursuant to this chapter involving a Medi-Cal managed care plan within 120 calendar days after
either of the following:
(A)Receiving verbal or written notice from the Medi-Cal managed care plan that the adverse benefit determination is upheld or the appeal or expedited appeal is denied.
(B)When the enrollee’s appeal is deemed exhausted because the Medi-Cal managed care plan failed to comply with state or federal requirements for notice and timeliness related to the disputed action or the appeal, including when a Medi-Cal managed care plan fails to respond to an appeal within 30 days as required pursuant to subdivision (b) of Section 14197.2 or asks the enrollee or
his or her treating provider for more information to resolve the appeal solely for purposes of delaying a decision.
(2)Notwithstanding paragraph (1), a person shall be entitled to a hearing pursuant to this chapter if he or she files the request more than 120 calendar days after receiving notice from the Medi-Cal managed care plan that the adverse benefit determination is upheld and there is good cause for filing the request beyond the 120-calendar day period. The director may determine whether good cause exists. The department shall not grant a request for a hearing for good cause if the request is filed more than 180 days after receipt of the notice from the Medi-Cal managed care plan that the adverse benefit determination is upheld.
(c)For purposes of this section, “good cause” means a substantial and compelling reason beyond the party’s control, considering the length of the delay, the diligence of the party making the request, and the potential prejudice to the other party. The inability of a person to understand an adequate and language-compliant notice, in and of itself, shall not constitute good cause.
(d)This section shall not preclude the application of the principles of equity jurisdiction as otherwise provided by law.
(e)Notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), the department shall implement this section through an all-county information notice. The department may also
provide further instructions through training notes.
(f)Notwithstanding subdivision (e), the department shall implement the amendments made to this section by the act that added this subdivision by adopting any necessary rules and regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). Until July 1, 2018, any rules and regulations necessary to implement the amendments made to this section by the act that added this subdivision may be adopted as emergency regulations in accordance with the Administrative Procedure Act. The adoption of emergency regulations pursuant to this subdivision shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare.
(a)Notwithstanding Sections 10952 and 10959, for a beneficiary of a Medi-Cal managed care plan who meets the criteria for an expedited resolution of an appeal as set forth in subdivision (c) of Section 14197.2, the department shall take final administrative action as expeditiously as the individual’s health condition requires, but no later than three working days after the department receives, from the Medi-Cal managed care plan, the case file and information for any appeal of a denial of a service that, as indicated by the Medi-Cal managed care
plan, meets either of the following criteria:
(1)Meets the criteria for expedited resolution as set forth in Section 438.410 (a) of Title 42 of the Code of Federal Regulations, but was not resolved within the timeframe for expedited resolution.
(2)Was resolved within the timeframe for expedited resolution, but reached a decision wholly or partially adverse to the beneficiary.
(b)Upon notice from the department that a Medi-Cal managed care plan’s beneficiary has requested a state fair hearing, the Medi-Cal managed care plan shall provide
to the department a copy of the following information within three business days of the Medi-Cal managed care plan’s receipt of the department’s notice of a request by a beneficiary for a state fair hearing:
(1)The case file.
(2)Any information for any appeal of a denial of a service that, as indicated by the Medi-Cal managed care plan, meets either of the criteria described in paragraph (1) or (2) of subdivision (a).
(a)It is the intent of the Legislature that the department implement the time and distance requirements set forth in Sections 438.68, 438.206, and 438.207 of Title 42 of the Code of Federal Regulations, to ensure that all Medi-Cal covered services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as those standards were enacted in May 2016.
(b)The department, in consultation with the Department of Managed Health Care, shall develop all of the following:
(1)Time and distance standards for the following provider types, as specified in Section 438.68(b)(1) of
Title 42 of the Code of Federal Regulations, to ensure that covered and medically necessary services are accessible to enrollees of Medi-Cal managed care plans.
(A)Primary care, adult and pediatric.
(B)Obstetrics and gynecology.
(C)Behavioral health, including mental health and substance use disorder, adult and pediatric.
(D)Specialist, adult and pediatric.
(E)Hospital.
(F)Pharmacy.
(G)Pediatric dental.
(H)Additional provider types when it promotes the objectives of the Medicaid program, as determined by the federal Centers for Medicare and Medicaid Services, for the provider type to be subject to time and distance access standards.
(2)For those Medi-Cal managed care plans that cover long-term services and supports (LTSS), both of the following:
(A)Time and distance standards for LTSS provider types in which an enrollee must travel to the provider to receive services.
(B)Network adequacy standards other than time and distance standards for LTSS provider types that travel to the enrollee to deliver services.
(3)Standards to ensure that all
covered and medically necessary services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner.
(c)The standards developed by the department pursuant to this section shall, at a minimum, do all of the following:
(1)Meet existing time and distance standards
set forth in Section 1300.51 of Title 28 of the California Code of Regulations and the standards set forth in Medi-Cal managed care contracts entered into with the department as of January 1, 2016. In the event of a conflict between the time and distance standards set forth in Section 1300.51 of Title 28 of the California Code of Regulations and the Medi-Cal managed care contracts entered into within the department as of January 1, 2016, the standard that requires a shorter travel time or less distance shall prevail.
(2)Meet the appointment time standards developed pursuant to Section 1367.03 of the Health and Safety Code, Section 1300.67.2.2 of Title 28 of the California Code of Regulations, and the standards set forth in contracts entered into between the department and Medi-Cal managed care
plans.
(3)Take into consideration the requirements of subdivision (c) of Section 438.68 of Title 42 of the Code of Federal Regulations.
(d)In developing the time and distance standards, if the department elects a county standard for time and distance, the department shall categorize counties into at least five or more county categories, one of which is a rural county category.
(e)The department may have varying standards for the same provider type based on geographic areas, subject to the requirements of this section.
(f)(1)The department, upon request of a Medi-Cal managed care plan, may allow alternative access
standards if the requesting Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet either time and distance or timely access standards, and, if the Medi-Cal managed care plan is licensed as a health care service plan under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), has obtained approval from the Department of Managed Health Care. The department shall post any approved alternative access standards on its Internet Web site.
(2)The department may allow for the use of telecommunications technology as a means of alternative access to care, including telehealth consistent with the requirements of Section 2290.5 of the Business and Professions Code, e-visits, or other evolving and innovative
technological solutions that are used to provide care from a distance.
(g)The department may permit standards other than time and distance if the health care provider travels to the beneficiary or to a community-based setting to deliver services.
(h)(1)A Medi-Cal managed care plan shall, on an annual basis and when requested by the department, demonstrate to the department its compliance with the time and distance and appointment wait time standards developed pursuant to this section. The report shall measure compliance separately for adult and pediatric services for primary care, behavioral health, and core specialist services. A Medi-Cal managed care plan licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code) shall also, on an annual basis, demonstrate to the Department of Managed Health Care its compliance with the time and distance and appointment wait time standards developed pursuant to this section.
(2)The department shall annually publish on its Internet Web site a report for each Medi-Cal managed care plan that specifies any areas where the Medi-Cal managed care plan was found to be out of compliance and the Medi-Cal managed care plan’s corrective action plan.
(i)The department shall consult with Medi-Cal managed care plans, including mental health plans, health care providers, consumers, providers and consumers of LTSS, and organizations representing Medi-Cal
beneficiaries in the implementation of the requirements of this section.
(j)For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:
(1)Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46.
(2)Article 2.8 (commencing with Section 14087.5).
(3)Article 2.81 (commencing with Section 14087.96).
(4)Article 2.9 (commencing
with Section 14088).
(5)Article 2.91 (commencing with Section 14089).
(6)Chapter 8 (commencing with Section 14200), including dental managed care plans.
(7)Chapter 8.9 (commencing with Section 14700).
(8)A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
(k)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2019, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2018, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations are adopted.
SEC. 2.
Section 128555 of the Health and Safety Code is amended to read:128555.
(a) The Medically Underserved Account for Physicians is hereby established within the Health Professions Education Fund. The primary purpose of this account is to provide funding for the ongoing operations of the Steven M. Thompson Physician Corps Loan Repayment Program provided for under this article. This account also may be used to provide funding for the Physician Volunteer Program provided for under this article.SEC. 3.
Section 14197.1 is added to the Welfare and Institutions Code, immediately following Section 14197.05, to read:14197.1.
(a) The department shall ensure that all covered mental health benefits and substance use disorder(c)A Medi-Cal managed care plan, on an annual basis and when requested by the department, shall demonstrate compliance with this section. The department shall make an annual compliance report available on its Internet Web site.
(4)
(5)
(6)
(7)
SEC. 4.
Section 14197.2 is added to the Welfare and Institutions Code, to read:14197.2.
(a) This section implements the state option in subdivision (j) of Section 438.8 of Title 42 of the Code of Federal Regulations.(iv)
(v)
(vi)
(g)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time any regulations are adopted. The department shall adopt regulations by July 1, 2019, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2018, the
department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations are adopted.
(a)A Medi-Cal managed care plan shall give a beneficiary timely and adequate notice of an adverse benefit determination in writing consistent with the requirements in Sections 438.404, 438.408, and 438.10 of Title 42 of the Code of Federal Regulations. For purposes of this subdivision, “adverse benefit determination” means either of the following:
(1)Any action described in Section 10950.
(2)Any health care service eligible for coverage and payment under a Medi-Cal managed care plan contract that has been denied, modified, or delayed by a decision of the Medi-Cal managed care plan, or by one of its
contracting providers.
(b)Except as provided in subdivision (c), a Medi-Cal managed care plan shall resolve an appeal no more than 30 calendar days from the day the Medi-Cal managed care plan receives the appeal.
(c)A Medi-Cal managed care plan shall resolve an expedited appeal no longer than 72 hours after the Medi-Cal managed care plan receives the appeal. A Medi-Cal managed care plan shall establish and maintain an expedited review process for a beneficiary or the beneficiary’s provider to request an expedited resolution of an appeal based on either of the following circumstances:
(1)If the Medi-Cal managed care plan determines, for a request from the beneficiary, or the provider indicates, in making the request
on the beneficiary’s behalf or supporting the beneficiary’s request, that taking the time for a standard resolution under the timeframe described in subdivision (b) could seriously jeopardize the beneficiary’s life, physical or mental health, or ability to attain, or regain, maximum function.
(2)When the beneficiary’s condition is such that the beneficiary faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the timeframe described in subdivision (b) would be detrimental to the beneficiary’s life or health or could jeopardize the beneficiary’s ability to regain maximum function.
(d)For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or
entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:
(1)Article 2.7 (commencing with Section 14087.3), including
dental managed care programs developed pursuant to Section 14087.46.
(2)Article 2.8 (commencing with Section 14087.5).
(3)Article 2.81 (commencing with Section 14087.96).
(4)Article 2.9 (commencing with Section 14088).
(5)Article 2.91 (commencing with Section 14089).
(6)Chapter 8 (commencing with Section 14200), including dental managed care plans.
(7)Chapter 8.9 (commencing with Section 14700).
(8)A county Drug Medi-Cal organized delivery system authorized
under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
SEC. 5.
Section 14197.4 is added to the Welfare and Institutions Code, immediately following Section 14197.3, to read:14197.4.
(a) The Legislature finds and declares all of the following:(A)Designated public hospital systems owned and operated by the University of California.
(B)Designated public hospital systems that hold a risk-based per member per month capitated contract with one or more Medi-Cal managed
care plans that includes capitation for the provision of inpatient hospital services.
(C)Designated public hospital systems not identified in subparagraph (A) or (B) that include a designated public hospital with a level 1 or level 2 trauma designation.
(D)Designated public hospital systems not identified in subparagraph (A), (B), or (C).
(3)A Medi-Cal managed care plan’s obligation to pay the directed payments and quality incentive payments required under subdivisions (b) and (c) to a designated public hospital shall be contingent upon receipt of notice from the department that the department is in receipt of the necessary
federal approvals pursuant to paragraph (1) of subdivision (g).
(l)
(iv)
(v)
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.