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SB-910 Population health management program.(2019-2020)

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Date Published: 03/10/2020 09:00 PM
SB910:v98#DOCUMENT

Amended  IN  Senate  March 10, 2020

CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Senate Bill
No. 910


Introduced by Senator Pan

February 03, 2020


An act to amend Section 14087.3 of add Section 14197.6 to the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


SB 910, as amended, Pan. Medi-Cal: managed care. Population health management program.
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 services pursuant to a schedule of benefits. Under existing law, health care services are provided to Medi-Cal beneficiaries through various health care delivery systems, including fee-for-service and managed care. Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, such as contracts with a Medi-Cal managed care plan, and imposes requirements on Medi-Cal managed care plan contractors, including appointment time standards and network adequacy standards.
The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law authorizes the Director of Health Care Services to contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for, or case manage the care of, Medi-Cal beneficiaries pursuant to specified provisions. Existing federal law authorizes specified managed care entities that participate in a state’s Medicaid program to cover, for enrollees, services or settings that are in-lieu-of services and settings otherwise covered under a state plan.

This bill would make technical, nonsubstantive changes to that provision.

This bill would require the department to require, by January 1, 2022, each Medi-Cal managed care plan to implement a population health management program (program) to identify, assess, and manage the needs of Medi-Cal beneficiaries who are enrolled in each plan. The bill would require a Medi-Cal managed care plan to describe case management services provided to enrollees and to report to the department on specified information, including the number of enrollees receiving in-lieu-of services. The bill would require the department to establish metrics for, and require the federally required external quality review organization (EQRO) to evaluate the effectiveness of, the enhanced care management and in-lieu-of services provided to enrollees, to establish metrics for evaluating the program, and to require the EQRO to conduct an analysis of each Medi-Cal managed care plan’s program.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NOYES   Local Program: NO  

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:

14197.6.
 (a) Commencing January 1, 2022, the department shall require each Medi-Cal managed care plan to implement a population health management program to identify, assess, and manage the needs of Medi-Cal beneficiaries who are enrolled in each plan. The population health management program shall include, at a minimum, the components specified under subdivisions (b) to (d), inclusive.
(b) (1) A Medi-Cal managed care plan shall conduct an assessment of each enrollee and risk stratify or segment the enrollee into a meaningful subpopulation.
(2) The department shall establish criteria for risk stratification and segmentation to ensure all of the following:
(A) Stratification or segmentation results are comparable and consistent between Medi-Cal managed care plans.
(B) The methodology or algorithm used by Medi-Cal managed care plans to conduct stratification and segmentation are public and mitigated for bias.
(C) Assignment of individual risk tier or segmentation is not a determination of medical necessity.
(3) The department shall report risk stratification and segmentation by Medi-Cal managed care plan and by county in the Medi-Cal managed care performance dashboard.
(c) A Medi-Cal managed care plan shall establish a model of care for addressing enrollee health needs at all points along the continuum of care, including interventions for enrollees informed by risk stratification or segmentation. The department shall establish guidelines for using risk stratification and segmentation in developing models of care and addressing the health needs of plan enrollees. The department shall ensure the model of care developed by a Medi-Cal managed care plan provides case management services, health care services, and other interventions that improve beneficiary health outcomes and reduce health disparities.
(d) A Medi-Cal managed care plan shall describe, at a minimum, case management services provided to enrollees, including any service provided under basic case management, complex case management, and enhanced care management, and report to the department on all of the following:
(1) The methodology for determining the type of case management services provided to enrollees, including the use of risk tiering or segmentation.
(2) The number of enrollees receiving each type of case management services.
(3) A description of in-lieu-of services offered to enrollees.
(4) The number of enrollees receiving in-lieu-of services.
(5) The type of in-lieu-of services enrollees are receiving.
(6) The type of covered services that the in-lieu-of services are being provided for as an alternative to those covered services.
(7) The number of enrollees receiving in-lieu-of services who are homeless.
(e) The department shall establish metrics for and require the federally required external quality review organization (EQRO) to evaluate the effectiveness of the enhanced care management and in-lieu-of services provided to enrollees.
(f) The department shall establish metrics for evaluating the population health management program and require the EQRO to conduct an analysis of each Medi-Cal managed care plan’s population health management program.
(g) The department shall require each Medi-Cal managed care plan to consult with stakeholders, including, but not limited to, county behavioral health departments, public health departments, providers, community-based organizations, consumer advocates, and Medi-Cal beneficiaries, on developing and implementing the population health management program.

SECTION 1.Section 14087.3 of the Welfare and Institutions Code is amended to read:
14087.3.

(a)The director may contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, or arrange for or case manage the care of, Medi-Cal beneficiaries. At the director’s discretion, the contract may be exclusive or nonexclusive, statewide or on a more limited geographic basis, and include provisions for the following:

(1)To perform targeted case management of selected services or beneficiary populations where it is expected that case management will reduce program expenditures.

(2)To provide for delivery of services in a manner consistent with managed care principles, techniques, and practices directed at ensuring the most cost-effective and appropriate scope, duration, and level of care.

(3)To provide for alternate methods of payment, including, but not limited to, a prospectively negotiated reimbursement rate, fee-for-service, retainer, capitation, shared savings, volume discounts, lowest bid price, negotiated price, rebates, or other basis.

(4)To secure services directed at any or all of the following:

(A)Recruiting and organizing providers to care for Medi-Cal beneficiaries.

(B)Designing and implementing fiscal or other incentives for providers to participate in the Medi-Cal program in cost-effective ways.

(C)Linking beneficiaries with cost-effective providers.

(5)To provide for:

(A)Medi-Cal managed care plans contracting under this chapter or Chapter 8 (commencing with Section 14200) to share in the efficiencies and economies realized by those contracts.

(B)Effective coordination between contractors operating under this article and Medi-Cal managed care plans in the management of health care provided to Medi-Cal beneficiaries.

(6)To permit individual physicians, groups of physicians, or other providers to participate in a manner that supports the organized system mode of operation.

(7)To encourage group practices with relationships with hospitals having low unit costs.

(b)(1)The director may require individual physicians, groups of physicians, or other providers as a condition of participation under the Medi-Cal program, to enter into capitated contracts pursuant to this section to correct or prevent irregular or abusive billing practices.

(2)Neither physician, groups of physicians, nor other providers shall be reimbursed for services rendered to Medi-Cal beneficiaries if the physician, group of physicians, or other providers have declined to enter into a contract required by the director pursuant to this section.

(c)The department shall seek federal waivers necessary to allow for federal financial participation under this section.

(d)(1)Notwithstanding this chapter, the department shall determine preliminary per capita rates of payment for services provided to Medi-Cal beneficiaries enrolled in a managed care program contracting in areas specified by the director for expansion of the Medi-Cal managed care program under this section, or Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, or 14087.96. The department shall provide to each managed care plan the preliminary contract rates and source documents at least 60 days prior to the effective date of each new rate period.

(2)On or before June 1, 1999, the department shall enter into a memorandum of understanding with the managed care plans subject to paragraph (1) on the development of capitation rates. This memorandum of understanding, which is intended to ensure that capitation rates become effective in a timely manner and remain stable throughout the rate year, shall establish all of the following:

(A)A process and timetable for the managed care plans to review and comment on any modifications in the rate development methodology.

(B)A process and timetable for the managed care plans to provide comments on the draft rates.

(C)A process and timetable for the department to respond to the managed care plan comments on the draft rates.

(D)A process and timetable to finalize managed care capitation rates.