Bill Text: CA SB382 | 2019-2020 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: managed care health plan.

Spectrum: Bipartisan Bill

Status: (Vetoed) 2020-01-13 - Veto sustained. [SB382 Detail]

Download: California-2019-SB382-Amended.html

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Amended  IN  Assembly  June 27, 2019

Amended  IN  Senate  April 29, 2019

Amended  IN  Senate  March 26, 2019

CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Senate Bill

No. 382

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Introduced by Senators Nielsen and Stern

February 20, 2019

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An act to amend Section 1371.36 of the Health and Safety Code, and to amend Section 796.04 of the Insurance Code, relating to health care coverage. add Section 14197.6 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

SB 382, as amended, Nielsen. Health care coverage: state of emergency. Medi-Cal: managed care health plan.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services that are medically necessary are provided to qualified, low-income persons through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law generally requires Medi-Cal managed care plan contractors to be licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975. Under the act, a health care service plan is required to provide access to medically necessary health care services to its enrollees who have been displaced by a state of emergency, and existing law enumerates actions that a plan may be required to take to meet the needs of its enrollees during the state of emergency.

This bill would require a Medi-Cal managed care health plan to ensure that an enrollee who remains in a general acute care hospital continues to receive medically necessary postacute care services at the general acute care hospital if specified requirements are met, including that the Medi-Cal managed care health plan is unable to locate a postacute care facility within the plan’s network, as a result of a state of emergency, for purposes of transferring the enrollee to the postacute care facility.

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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer to provide access to medically necessary health care services to its enrollees who have been displaced by a state of emergency. Existing law enumerates actions that a plan or insurer may be required to take to meet the needs of its enrollees or insureds during the state of emergency.

This bill would prohibit a health care service plan or health insurer from denying payment of a claim for care provided to an enrollee or insured who remains in an acute care hospital due to a lack of access to postacute care services during a state of emergency if the enrollee or insured is displaced because of the emergency. The bill would require daily reimbursement of that claim to be at least the administrative day rate established by the State Department of Health Care Services, unless the plan or insurer has otherwise contracted for reimbursement. Because a willful violation of the bill’s requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program.

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: NO   Fiscal Committee: YES   Local Program: YESNO  

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Bill Text

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

SECTION 1.

 Section 14197.6 is added to the Welfare and Institutions Code, to read:

(4) (A) The Medi-Cal managed care health plan has not otherwise addressed payment for an extended stay at a general acute care hospital in its contract with the general acute care hospital.

(B) For purposes of this paragraph, “extended stay” means the days of care provided in the general acute care hospital following the period that the patient no longer meets the medical necessity criteria to receive care from the general acute care hospital.

(b) The daily reimbursement for health care provided by the general acute care hospital until the transfer occurs shall be, at a minimum, the acute administrative day rate established by the department.

(c) This section does not alter, reduce, or modify in any manner the responsibilities and duties of a Medi-Cal managed care health plan relating to benefits, services, or reimbursement standards.

(d) For purposes of this section, “Medi-Cal managed care health plan” means any individual, organization, or entity that enters into a contract with the department to provide services, excluding dental and mental health services, to enrolled Medi-Cal beneficiaries, pursuant to any of the following:

(1) Article 2.7 (commencing with Section 14087.3).

(2) Article 2.8 (commencing with Section 14087.5).

(3) Article 2.81 (commencing with Section 14087.96).

(4) Article 2.82 (commencing with Section 14087.98).

(5) Article 2.91 (commencing with Section 14089).

(6) Chapter 8 (commencing with Section 14200).

(7) Chapter 3 (commencing with Section 101675) of Part 4 of Division 101 of the Health and Safety Code.

SECTION 1.Section 1371.36 of the Health and Safety Code is amended to read:

1371.36.

(a) A health care service plan shall not deny payment of a claim on the basis that the plan, medical group, independent practice association, or other contracting entity did not provide authorization for health care services that were provided in a licensed acute care hospital and that were related to services that were previously authorized, if all of the following conditions are met:

(1) It was medically necessary to provide the services at the time.

(2) The services were provided after the plan’s normal business hours.

(3) The plan does not maintain a system that provides for the availability of a plan representative or an alternative means of contact through an electronic system, including voicemail or electronic mail, whereby the plan can respond to a request for authorization within 30 minutes of the time that a request was made.

(b)A health care service plan shall not deny payment of a claim for care provided to an enrollee who remains in an acute care hospital due to a lack of access to postacute care services during a state of emergency if the enrollee is displaced because of the emergency. The daily reimbursement for that care provided shall be no lower than the administrative day rate established by the State Department of Health Care Services, unless the plan has otherwise addressed extended stays in a contract.

(c) This section shall not apply to investigational or experimental therapies, or other noncovered services.

SEC. 2.Section 796.04 of the Insurance Code is amended to read:

796.04.

(a)A health insurer that provides coverage for hospital, medical, or surgical expenses that authorizes a specific type of treatment for services covered under a policyholder’s contract or plan by a provider shall not rescind or modify this authorization after the provider renders the health care service in good faith and pursuant to the authorization for any reason, including, but not limited to, the insurer’s subsequent rescission, cancellation, or modification of the insured’s or policyholder’s contract or the insurer’s subsequent determination that it did not make an accurate determination of the insured’s eligibility. This section shall not be construed to expand or alter the benefits available or the terms and conditions of the contract as may be agreed upon between a policyholder, certificate holder, or trust, and the insurer. The Legislature finds and declares that by adopting the amendments made to this section by Assembly Bill 1324 of the 2007–08 Regular Session it does not intend to instruct a court as to whether or not the amendments are existing law.

(b)A health insurer shall not deny payment of a claim for care provided to an insured who remains in an acute care hospital due to a lack of access to postacute care services during a state of emergency if the insured is displaced because of the emergency. The daily reimbursement for that care provided shall be no lower than the administrative day rate established by the State Department of Health Care Services, unless the insurer has otherwise addressed extended stays in a contract.

SEC. 3.

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.