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SB-936 Medi-Cal managed care plans: contracts.(2019-2020)

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Date Published: 04/03/2020 09:00 PM
SB936:v97#DOCUMENT

Amended  IN  Senate  April 03, 2020
Amended  IN  Senate  March 20, 2020

CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Senate Bill
No. 936


Introduced by Senator Pan

February 06, 2020


An act to add Sections 14087.302 and 14197.25 to the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


SB 936, as amended, Pan. Medi-Cal managed care plans: contract procurement. contracts.
Existing law establishes 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 either through a fee-for-service or managed care delivery system. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, including contracts with managed care plans, and imposes requirements upon those contracted managed care plans, such as network adequacy standards.
This bill would require the Director of Health Care Services to conduct a contract procurement at least once every 5 years if the director contracts with a commercial Medi-Cal managed care plan for the provision of care of Medi-Cal beneficiaries on a state-wide or limited geographic basis, and would authorize the director to extend an existing contract for one year if the director takes specified action, including providing notice to the Legislature, at least one year before exercising that extension. The bill would require the department to perform specified duties, including establishing a stakeholder process in the planning and development of each commercial Medi-Cal managed care contract procurement process, and receiving public comment on the model contract, procurement qualifications, and evaluation criteria. The bill would authorize a county to submit to the department its preferences for any commercial Medi-Cal managed care plan to provide services in that county, and to request and receive from the department any report on specified matters, such as beneficiary health outcomes. The bill would authorize the department to contract with any commercial Medi-Cal managed care plan only if the plan can demonstrate its ability to meet specified evaluation criteria set forth by the department, including the ability of a commercial Medi-Cal managed care plan to comply with time and distance requirements, appointment time standards, and performance targets, as established by the department.
With respect to Medi-Cal managed care plan contracts generally, this bill would require those contractors to collaborate with identified stakeholders, including consumer advocates and public health experts in their respective Medi-Cal managed care plans’ service area, on identifying and achieving health priorities in that service area.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

 Section 14087.302 is added to the Welfare and Institutions Code, immediately following Section 14087.301, to read:

14087.302.
 (a) (1) If the director contracts with a commercial Medi-Cal managed care plan for the provision of care of Medi-Cal beneficiaries on a state-wide or limited geographic basis, as authorized in Section 14087.3, the director shall conduct a contract procurement for that geographic region at least once every five years.
(2) The director may extend an existing contract for one year. At least one year before extending an existing contract, the director shall provide notice to the Legislature and post on the department’s internet website the director’s intent to extend that contract.
(b) (1) The department shall do all of the following:
(A) Establish a stakeholder process in the planning and development of each commercial Medi-Cal managed care contract procurement process. The process shall include working with counties that are interested in modifying or changing their Medi-Cal managed care model. The stakeholders shall include, but are not limited to, representatives from any county that a commercial Medi-Cal managed care plan contract procurement is planned, Medi-Cal beneficiaries or their representatives, health care providers, consumer advocates, and public health experts.
(B) Post on the department’s internet website, at a minimum, the procurement schedule and model contract.
(C) Receive public comment on the model contract, procurement qualifications, and evaluation criteria.
(2) (A) A county may submit to the department, in writing, its preferences for any commercial Medi-Cal managed care plan to provide services in that county. If a county elects to submit its preferences to the department, the county shall consult with stakeholders, including Medi-Cal beneficiaries, health care providers, consumer advocates, and public health experts, in developing its preferences. The department shall review the county’s submitted request, and only use that information as a consideration for the contract procurement.
(B) A county may request, in writing, and receive from the department any report on access to providers, beneficiary health outcomes, network adequacy, and managed care plan performance related to the provision of Medi-Cal services in the county.
(c) The department may contract with a commercial Medi-Cal managed care plan only if the plan can demonstrate its ability to meet evaluation criteria established by the department. The evaluation criteria shall include, at a minimum, all of the following factors:
(1) The ability of a commercial Medi-Cal managed care plan to comply with the time and distance requirements and appointment time standards, as specified in subdivisions (c) and (d) of Section 14197, respectively. If a commercial Medi-Cal managed care plan contracts, or previously contracted, with the department, the ability of a commercial Medi-Cal managed care plan to meet the criteria of this subdivision evaluation criteria shall be evaluated on all of the following:
(A) The number of approved requests for alternative access standards and approved allowable exceptions for the appointment time standard in the plan service area, by provider types, including specialists, and by adult and pediatric specialists, in comparison to any Medi-Cal managed care plan in a similar service area.
(B) The approximate number of Medi-Cal beneficiaries impacted by a commercial Medi-Cal managed care plan’s alternative access standards or allowable exceptions in comparison to any Medi-Cal managed care plan in a similar service area.
(C) The ability of a commercial Medi-Cal managed care plan that has received approval to utilize an alternative access standard to assist an enrollee in obtaining an appointment with an appropriate specialist provider within the time and distance standards and the appointment time standards.
(D) The ability of a commercial Medi-Cal managed plan to reduce the number of requests for alternative access standards and allowable exceptions for the appointment time standards.

(E)

(2) The ability of a commercial Medi-Cal managed care plan to comply with provider directory requirements as specified in Section 1367.27 of the Health and Safety Code.

(2)

(3) The percentage of providers in the service area, by provider and specialty type, that are under contract, or proposed to be under contract, with the commercial Medi-Cal managed care plan in comparison to any Medi-Cal managed care plan in a similar service area.

(3)

(4) The ability of a commercial Medi-Cal managed care plan to comply with performance targets established by the department, including a commercial Medi-Cal managed care plan’s current or previous ability to comply with achieving at least the 50th percentile level on quality measures for a managed care plan under the Medicaid program in the United States or alternative benchmarks as established by the department.

(4)

(5) The number and severity of any corrective action plan and sanction the director has imposed against the commercial Medi-Cal managed care plan, pursuant to Section 14197.7, and the ability of the commercial Medi-Cal managed care plan to resolve the issues that led to a corrective action plan or sanction.

(5)

(6) The number, type, and severity of consumer complaints, grievances, and appeals, and the ability of the commercial Medi-Cal managed care plan to resolve the issues that led to the consumer complaint, grievance, or appeal.

(6)

(7) The ability of a commercial Medi-Cal managed care plan to provide language assistance services to limited English-proficient Medi-Cal enrollees, including oral interpretation services and translation services, pursuant to Section 14029.91 of the Welfare and Institutions Code. 14029.91.

(7)

(8) The ability of a commercial Medi-Cal managed care plan to collect, report, and utilize demographic data, and to increase collection of meaningful data. Demographic data shall include race, ethnicity, language, and sex, and, to the extent data is available, sexual orientation and gender identity.

(8)

(9) The ability of a commercial Medi-Cal managed care plan to collect and report accurate encounter data and to produce annual public summaries of encounter data, as determined by the department.

(9)

(10) The ability of a commercial Medi-Cal managed care plan to coordinate care and services between various settings and Medi-Cal delivery systems, programs, and providers, including the fee-for-service Medi-Cal program, the Medi-Cal Specialty Mental Health Services Program, the Drug Medi-Cal Treatment Program, the Drug Medi-Cal organized delivery system, dental managed care, and, for purposes of the nonmedical transportation benefit, transportation providers.

SEC. 2.

 Section 14197.25 is added to the Welfare and Institutions Code, immediately following Section 14197.2, to read:

14197.25.
 A Medi-Cal managed care plan contract shall require a Medi-Cal managed care plan to collaborate with stakeholders on identifying and achieving health priorities, including the reduction of health disparities, in the service area. The stakeholders shall include, but are not limited to, representatives of counties, Medi-Cal beneficiaries or their representatives, health care providers, consumer advocates, and public health experts in the Medi-Cal managed care plan’s service area.