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AB-1553 Medi-Cal: managed care: exemption from plan enrollment.(2011-2012)

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AB1553:v97#DOCUMENT

Amended  IN  Assembly  May 25, 2012
Amended  IN  Assembly  April 16, 2012

CALIFORNIA LEGISLATURE— 2011–2012 REGULAR SESSION

Assembly Bill No. 1553


Introduced  by  Assembly Member Monning

January 26, 2012


An act to add Section 14103.9 to the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 1553, as amended, Monning. Medi-Cal: managed care: exemption from plan enrollment.
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. One of the methods by which these services are provided is pursuant to contracts with various types of managed care plans.
This bill would establish a process that would permit an eligible Medi-Cal beneficiary to receive fee-for-service Medi-Cal, if available, as an alternative to plan enrollment for a prescribed period of time if the beneficiary meets specified criteria. This bill would provide that these provisions shall not apply to a beneficiary who is enrolled in a county organized health system. This bill would require the department to develop a process to track a beneficiary who has been denied a request for exemption from plan enrollment and to notify the plan, if applicable, of the denial, including information identifying the provider.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

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

14103.9.
 (a) An eligible Medi-Cal beneficiary who satisfies the requirements in paragraph (1) or (2) may request fee-for-service Medi-Cal, if available, as an alternative to plan enrollment by submitting a request for exemption from plan enrollment to the Health Care Options Program as specified in subdivision (c).
(1) The eligible beneficiary is an American Indian, a member of an American Indian household, or chooses to receive health care services through an Indian Health Service facility and has written acceptance from an Indian Health Service facility for care on a fee-for-service basis.
(2) An eligible beneficiary who is receiving fee-for-service Medi-Cal treatment or services for a complex medical condition, from a physician, a certified nurse-midwife, or a licensed midwife who is participating in the Medi-Cal program but is not a contracting provider of a plan in the eligible beneficiary’s county of residence, may request a medical exemption to continue fee-for-service Medi-Cal for purposes of continuity of care.
(A) For purposes of this section, conditions meeting the criteria for a complex medical condition include, and are similar to, the following:
(i) An eligible beneficiary is pregnant.
(ii) An eligible beneficiary is under evaluation for the need for an organ transplant, has been approved for and is awaiting an organ transplant, has received a transplant and is currently either immediately postoperative or exhibiting significant medical problems related to the transplant, or has received a second or third transplant and is receiving ongoing medical supervision. Beneficiaries who are medically stable on posttransplant therapy are not eligible for exemption under this section.
(iii) An eligible beneficiary is receiving chronic renal dialysis treatment.
(iv) An eligible beneficiary has tested positive for human immunodeficiency virus (HIV) or has received a diagnosis of acquired immune deficiency syndrome (AIDS).
(v) An eligible beneficiary has been diagnosed with cancer and is currently receiving chemotherapy or radiation therapy or another course of accepted therapy for cancer that will continue for up to 12 months or more or has been approved for the therapy, or has been diagnosed with stage IV cancer and is receiving ongoing medical supervision.
(vi) An eligible beneficiary has been approved for a major surgical procedure by the Medi-Cal fee-for-service program and is awaiting surgery or is immediately postoperative.
(vii) An eligible beneficiary is receiving medical treatment, the interruption of which would put the beneficiary at risk for deleterious medical effects because of a complex neurological disorder, such as multiple sclerosis, a complex hematological disorder, such as hemophilia or a sickle cell disease, or a complex or progressive disorder not covered in clauses (i) to (vi), inclusive, such as cardiomyopathy or amyotrophic lateral sclerosis, or a disease or condition that affects more than one organ system, or requires coordinated care from more than one specialist, unless all of the specialists providing care to the beneficiary are contracting providers in one of the plans in the beneficiary’s county of residence, and the beneficiary requires ongoing medical supervision, or has been approved for or is receiving complex medical treatment for the disorder. disorder.
(viii) An eligible beneficiary is enrolled in a Medi-Cal waiver program that allows the individual to receive subacute, acute, intermediate, or skilled nursing care at home rather than in a subacute care facility, an acute care hospital, an intermediate care facility, or a skilled nursing facility, or an eligible beneficiary is under 21 years of age and is receiving nursing services in the home instead of in a subacute care facility, an acute care facility, an intermediate care facility, an intermediate care facility for the developmentally disabled, a skilled nursing facility, or any other licensed facility providing medical care or treatment at the same or a higher level of care.
(ix) An eligible beneficiary is receiving treatment services that are not available in the beneficiary’s home county.
(x) An eligible beneficiary is receiving treatment or palliative services for a disease or condition that is expected to result in death within the next 24 months.
(xi) An eligible beneficiary is participating in a pilot project organized and operated pursuant to Section 14087.3, 14094.3, or 14490.
(B) A request for exemption from plan enrollment based on a complex medical condition shall not be approved for an eligible beneficiary to whom any of the following apply:
(i) He or she has been a member of any plan on a combined basis for more than 90 calendar days and has received services for which the plan is financially responsible.
(ii) He or she has begun or is scheduled to begin treatment after the date of plan enrollment.
(b) (1) Except for pregnancy, an eligible beneficiary granted a medical exemption from plan enrollment shall remain in fee-for-service Medi-Cal only until the medical condition has stabilized to a level that would enable him or her to change physicians and begin receiving care from a plan provider without the risk of deleterious medical effects, as determined by the beneficiary’s treating physician in the Medi-Cal fee-for-service program. A
(2) A beneficiary granted a medical exemption due to pregnancy may remain with the fee-for-service Medi-Cal provider through delivery and the end of the month in which 90 days postpartum occurs.
(3) Unless otherwise requested by the provider and approved based on the supporting documentation, and except as specified in paragraph (2) for a beneficiary granted a medical exemption due to pregnancy, a medical exemption from plan enrollment shall expire at the end of 12 months from the date of approval. The Health Care Options Program shall notify the beneficiary 45 days before the expiration date of the approved medical exemption and shall inform the beneficiary of how to request an extension. An extension of the 12-month medical exemption shall be requested through the Health Care Options Program no earlier than 11 months after the starting date of the exemption in effect at that time. An extension of the medical exemption may be requested and shall be approved if the eligible beneficiary continues to meet the requirements of paragraph (2) of subdivision (a).
(c) Exemption from plan enrollment due to a complex medical condition or conditions, as specified in clauses (i) to (vii), inclusive, and clauses (ix) to (xi), inclusive, of subparagraph (A) of paragraph (2) of subdivision (a), shall be requested on a request for medical exemption from plan enrollment form approved by the department. Exemption from plan enrollment due to a beneficiary’s enrollment in a Medi-Cal waiver program, or if the beneficiary is under 21 years of age and receiving nursing services in the home, as specified in clause (viii) of subparagraph (A) of paragraph (2) of subdivision (a), or a beneficiary’s acceptance for care at an Indian Health Service facility, as specified in paragraph (1) of subdivision (a), shall be requested on a request for nonmedical exemption from plan enrollment form. The completed request for exemption shall be submitted to the Health Care Options Program by the Medi-Cal fee-for-service provider or providers or the Indian Health Service facility treating the beneficiary and shall be submitted by mail or facsimile. A request for exemption from plan enrollment shall not be submitted by the plan.
(d) The Health Care Options Program, as authorized by the department, shall approve each request for exemption from plan enrollment that meets the requirements of this section. At any time, the department may, at its discretion, verify the complexity, validity, and status of the medical condition and treatment plan and verify that the provider is not contracted or otherwise affiliated with a plan. Verification may include documentation from more than one provider if the treatment plan includes multiple specialists or other providers. The Health Care Options Program, as authorized by the department, or the department may deny a request for exemption from plan enrollment or revoke an approved request for exemption if a provider fails to fully cooperate with verification by the department. This subdivision shall not be construed as authorizing the Health Care Options Program or the department to overrule a treating physician’s determination pursuant to subdivision (b).
(e) Approval of requests for exemption from plan enrollment shall be subject to the same processing times and effective dates for the processing of enrollment and disenrollment requests.
(f) (1) The department shall provide written notice to the beneficiary and the requesting provider if a request for exemption from plan enrollment is denied. The notice shall set out with specificity the reasons for the denial or failure to unconditionally approve the request for exemption from plan enrollment. The notice shall inform the beneficiary and the provider of the right to appeal the decision, how to appeal the decision, and if the decision is not appealed, that the beneficiary shall enroll in a Medi-Cal plan and how that enrollment shall occur. The beneficiary shall also be informed of the possibility of continued access to an out-of-network provider pursuant to paragraph (13) of subdivision (b) of Section 14182. A beneficiary who has not been enrolled in a plan shall remain in fee-for-service Medi-Cal if a request for an exemption from plan enrollment or appeal is submitted, until the final resolution.
(2) The department shall develop a process to track a beneficiary who has been denied a request for exemption from plan enrollment and to notify the plan, if applicable, of the denial, including information identifying the provider.
(g) The Health Care Options Program, as authorized by the department, or the department may revoke an approved request for exemption from plan enrollment at any time if the department determines that the approval was based on false or misleading information, treatment has been completed, or the requesting provider is not or has not been providing services to the beneficiary. The department shall provide written notice to the beneficiary that the approved request for exemption from plan enrollment has been revoked and shall advise the beneficiary that he or she shall enroll in a Medi-Cal plan and how that enrollment shall occur. The revocation of an approved request for exemption from plan enrollment shall not otherwise affect an eligible beneficiary’s eligibility or ability to receive covered services as a plan member.
(h) This section shall not apply to a beneficiary who is enrolled in a county organized health system.