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AB-301 Medi-Cal: managed care.(2011-2012)

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AB301:v94#DOCUMENT

Assembly Bill No. 301
CHAPTER 460

An act to amend Sections 14094.3 and 14105.18 of the Welfare and Institutions Code, relating to Medi-Cal.

[ Approved by Governor  October 04, 2011. Filed with Secretary of State  October 04, 2011. ]

LEGISLATIVE COUNSEL'S DIGEST


AB 301, Pan. Medi-Cal: managed care.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, pursuant to which medical benefits are provided to public assistance recipients and other low-income persons. Existing law provides for the department to enter into contracts with managed care systems, hospitals, and prepaid health plans for the provision of various Medi-Cal benefits. Existing law prohibits services covered by the California Children’s Services program (CCS) from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2012, except with respect to contracts entered into for county organized health systems in specified counties.
This bill would extend to January 1, 2016, the termination of the prohibition against CCS covered services being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994.
Existing law requires the provider rates of payment for services rendered for the Healthy Families Program to be identical to the rates of payment for the same service performed by the same provider type pursuant to the Medi-Cal program if the services are provided by a Medi-Cal provider.
This bill would require identical rates only if the service was provided by a Medi-Cal provider pursuant to specified contracts.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

 The Legislature finds and declares all of the following:
(a) The State Department of Health Care Services is currently pursuing pilot projects to examine organized health care delivery models for children eligible for the California Children’s Services program (CCS). These delivery models may include an enhanced primary care case management program, a provider-based accountable care organization, a specialty health care plan, and a Medi-Cal managed care plan. The services provided under these models will be comprehensive and coordinated through a medical home. These models must establish clear standards and criteria, provide care coordination, establish appropriate networks, as defined, coordinate out-of-network access, ensure children enrolled in the model receive care for their CCS-eligible medical conditions from CCS-approved providers consistent with the CCS standards of care, and establish and support medical homes, incorporating specified principles.
(b) The department is required to conduct an evaluation to assess the effectiveness of each model in improving the delivery of health care services for children who are eligible for the CCS program simultaneously with the development and implementation of the model delivery systems, to compare the care provided to, and outcomes of, children enrolled in the models with those not enrolled in the models. The department plans to have the evaluation and outcomes of the tested models by September 2015 in conjunction with California’s Section 1115 Medi-Cal Demonstration Project Waiver established pursuant to Section 14180 of the Welfare and Institutions Code.
(c) Therefore, it is the intent of the Legislature to continue the prohibition of services covered by the CCS program from being incorporated solely into Medi-Cal managed care until the department is able to consider the pilot evaluations, along with stakeholder input, and demonstrate the most appropriate organized health care delivery models for children eligible for CCS program services, which may include continuation of the current system of care.

SEC. 2.

 Section 14094.3 of the Welfare and Institutions Code is amended to read:

14094.3.
 (a) Notwithstanding this article or Section 14093.05 or 14094.1, CCS covered services shall not be incorporated into any Medi-Cal managed care contract entered into after August 1, 1994, pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.9 (commencing with Section 14088), Article 2.91 (commencing with Section 14089), Article 2.95 (commencing with Section 14092); or either Article 2 (commencing with Section 14200), or Article 7 (commencing with Section 14490) of Chapter 8, until January 1, 2016, except for contracts entered into for county organized health systems or Regional Health Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa.
(b) Notwithstanding any other provision of this chapter, providers serving children under the CCS program who are enrolled with a Medi-Cal managed care contractor but who are not enrolled in a pilot project pursuant to subdivision (c) shall continue to submit billing for CCS covered services on a fee-for-service basis until CCS covered services are incorporated into the Medi-Cal managed care contracts described in subdivision (a).
(c) (1) The department may authorize a pilot project in Solano County in which reimbursement for conditions eligible under the CCS program may be reimbursed on a capitated basis pursuant to Section 14093.05, and provided all CCS program’s guidelines, standards, and regulations are adhered to, and CCS program’s case management is utilized.
(2) During the time period described in subdivision (a), the department may approve, implement, and evaluate limited pilot projects under the CCS program to test alternative managed care models tailored to the special health care needs of children under the CCS program. The pilot projects may include, but need not be limited to, coverage of different geographic areas, focusing on certain subpopulations, and the employment of different payment and incentive models. Pilot project proposals from CCS program-approved providers shall be given preference. All pilot projects shall utilize CCS program-approved standards and providers pursuant to Section 14094.1.
(d) (1) The department shall submit to the appropriate committees of the Legislature an evaluation of pilot projects established pursuant to subdivision (c) based on at least one full year of operation.
(2) The evaluation required by paragraph (1) shall address the impact of the pilot projects on outcomes as set forth in paragraph (4) and, in addition, shall do both of the following:
(A) Examine the barriers, if any, to incorporating CCS covered services into the Medi-Cal managed care contracts described in subdivision (a).
(B) Compare different pilot project models with the fee-for-service system. The evaluation shall identify, to the extent possible, those factors that make pilot projects most effective in meeting the special needs of children with CCS eligible conditions.
(3) CCS covered services shall not be incorporated into the Medi-Cal managed care contracts described in subdivision (a) before the evaluation process has been completed.
(4) The pilot projects shall be evaluated to determine whether:
(A) All children enrolled with a Medi-Cal managed care contractor described in subdivision (a) identified as having a CCS eligible condition are referred in a timely fashion for appropriate health care.
(B) All children in the CCS program have access to coordinated care that includes primary care services in their own community.
(C) CCS program standards are adhered to.
(e) For purposes of this section, CCS covered services include all program benefits administered by the program specified in Section 123840 of the Health and Safety Code regardless of the funding source.
(f) Nothing in this section shall be construed to exclude or restrict CCS eligible children from enrollment with a managed care contractor, or from receiving from the managed care contractor with which they are enrolled primary and other health care unrelated to the treatment of the CCS eligible condition.

SEC. 3.

 Section 14105.18 of the Welfare and Institutions Code is amended to read:

14105.18.
 (a) Notwithstanding any other provision of law, provider rates of payment for services rendered in all of the following programs shall be identical to the rates of payment for the same service performed by the same provider type pursuant to the Medi-Cal program.
(1) The California Children’s Services Program established pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
(2) The Genetically Handicapped Person’s Program established pursuant to Article 1 (commencing with Section 125125) of Chapter 2 of Part 5 of Division 106 of the Health and Safety Code.
(3) The Breast and Cervical Cancer Early Detection Program established pursuant to Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103 of the Health and Safety Code and the breast cancer programs specified in Section 30461.6 of the Revenue and Taxation Code.
(4) The State-Only Family Planning Program established pursuant to Division 24 (commencing with Section 24000).
(5) The Family Planning, Access, Care, and Treatment (Family PACT) Program established pursuant to subdivision (aa) of Section 14132.
(6) The Healthy Families Program established pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code if the health care services are provided by a Medi-Cal provider pursuant to subdivision (b) of Section 12693.26 of the Insurance Code.
(7) The Access for Infants and Mothers Program established pursuant to Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code if the health care services are provided by a Medi-Cal provider.
(b) The director may identify in regulations other programs not listed in subdivision (a) in which providers shall be paid rates of payment that are identical to the rates of payments in the Medi-Cal program pursuant to subdivision (a).
(c) Notwithstanding subdivision (a), services provided under any of the programs described in subdivisions (a) and (b) may be reimbursed at rates greater than the Medi-Cal rate that would otherwise be applicable if those rates are adopted by the director in regulations.
(d) This section shall become operative on January 1, 2011.