AB 205

Bill Subjects

Abstract

(1) Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, one of the methods by which Medi-Cal services are provided is pursuant to contracts with various types of managed care plans. Existing federal regulations, published on May 6, 2016, revise regulations governing Medicaid managed care plans to, among other things, align, where feasible, those rules with those of other major sources of coverage, including coverage through qualified health plans offered through an American Health Benefit Exchange, such as the California Health Benefit Exchange, and promote quality of care and strengthen efforts to reform delivery systems that serve Medicaid and CHIP beneficiaries. These federal regulations, among other things, authorize an enrollee to request a state fair hearing only after receiving notice that the Medicaid managed care plan is upholding an adverse benefit determination, and requires the enrollee to request a state fair hearing no later than 120 calendar days from the date of the Medicaid managed care plans notice of resolution. These federal regulations require, with regards to a state fair hearing request filed by an enrollee entitled to an expedited resolution of an appeal by a managed care plan, an agency to take final administrative action as expeditiously as the enrollee's health condition requires, but not later than 3 working days after the agency receives, from the managed care plan, the case file and information for any appeal of a denial or a service that, as indicated by the managed care plan meets the criteria for expedited resolution of an appeal, but was not resolved within the timeframe for expedited resolution, or was resolved within the timeframe for expedited resolution of an appeal, but the managed care plan reached a decision wholly or partially adverse to the enrollee. Existing state law establishes hearing procedures for an applicant for or beneficiary of Medi-Cal who is dissatisfied with certain actions regarding health care services and medical assistance to request a hearing from the State Department of Social Services under specified circumstances, and requires a request for a hearing to be filed within 90 days after the order or action complained of. This bill would implement various provisions in regard to those federal regulations, as amended May 6, 2016, governing Medicaid managed care plans. The bill would authorize a person, after he or she has exhausted the Medi-Cal managed care plan's appeals process, to request a hearing involving a Medi-Cal managed care plan within 120 calendar days after he or she has either received notice from the Medi-Cal managed care plan that the adverse benefit determination, as defined, is upheld, or the person is deemed to have exhausted the Medi-Cal managed care plans appeals process, as specified, and would exclude a request from the 120-calendar day filing time if there is good cause, as defined, for filing the request beyond the 120-calendar day period. The bill would authorize the State Department of Social Services, until January 1, 2019, to implement these provisions through an all-county information letter or similar instruction. The bill would require the State Department of Social Services, by January 1, 2019, to adopt any necessary rules and regulations to implement these changes. The bill would generally require the State Department of Social Services, for a beneficiary of a Medi-Cal managed care plan who meets the criteria for an expedited resolution of an appeal, to take final administrative action as expeditiously as the individual's health condition requires, but no later than 3 working days after the State Department of Social Services receives certain information from the Medi-Cal managed care plan consistent with the federal regulation described above. The bill would require a Medi-Cal managed care plan, upon notice from the State Department of Social Services that a beneficiary has requested a state fair hearing, to provide to the department a copy of the case file and any information for any appeal of an adverse benefit determination within 3 business days of the Medi-Cal managed care plan's receipt of the department's notice of a request by a beneficiary for a state fair hearing. The bill would make conforming changes. (2) These federal regulations require a state that contracts with specified Medicaid managed care plans to develop and enforce network adequacy standards and requires each state to ensure that all services covered under the Medicaid state plan are available and accessible to enrollees of specified Medicaid managed care plans in a timely manner. This bill would establish, until January 1, 2022, certain time and distance and appointment time standards for specified services consistent with those federal regulations to ensure that all Medi-Cal managed care covered services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. The bill would authorize the State Department of Health Care Services, upon the request of a Medi-Cal managed care plan, to allow alternative access standards for the time and distance standards, if the applying Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet the time and distance standards or if the department determines that the requesting Medi-Cal managed care plan has demonstrated that its delivery structure is capable of delivering the appropriate level of care and access, and would set forth the process for submitting and reviewing a request for alternative access standards. The bill would authorize the use of clinically appropriate telecommunications technology, including telehealth, as a means of determining annual compliance with the time and distance standards established under this provision or the department's approval of a request for alternative access standards. The bill, effective for contract periods commencing on or after July 1, 2018, would require, on an annual basis and when requested by the department, a Medi-Cal managed care plan to demonstrate to the department its compliance with the time and distance and appointment time standards developed under this provision, and, effective for contract periods commencing on or after July 1, 2018, would require the department, on an annual basis, to evaluate a Medi-Cal managed care plan's compliance with the standards developed under this provision. The bill would authorize the department to implement, interpret, or make specific these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The bill would require the department to seek any federal approvals necessary to implement these provisions, and would require these provisions to be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. The bill would require, as part of the federally required external quality review organization review of Medi-Cal managed care plans in the annual detailed technical report required under federal regulations, the external quality review organization entity designated by the department to compile specified data by Medi-Cal managed care plan and by county for the purpose of informing the status of the implementation of the time and distance and appointment time standards described above. The bill would require the department to make this information publicly available, as specified. (3) These federal regulations require specified managed care plans to have a grievance and appeal system in place for enrollees, and requires managed care plans to resolve each grievance and appeal, and to provide timely and adequate notice, as expeditiously as the enrollee's health condition requires, within certain state-established timeframes that may not exceed specified timeframes. This bill would require a Medi-Cal managed care plan, as defined, to give a beneficiary timely and adequate notice of an adverse benefit determination, as defined, in writing consistent with those federal regulations. The bill would require a Medi-Cal managed care plan to establish and maintain an expedited review process for a beneficiary or the beneficiary's provider to request an expedited resolution of an appeal based on specified circumstances, including when the beneficiary's condition is such that the beneficiary faces an imminent and serious threat to his or her health, or the standard timeline would be detrimental to the beneficiary's life or health or could jeopardize the beneficiary's ability to regain maximum function. The bill would require a Medi-Cal managed care plan to resolve a standard appeal no more than 30 calendar days from the day the Medi-Cal managed care plan receives the appeal, and would require the Medi-Cal managed care plan to resolve an expedited appeal no longer than 72 hours after the Medi-Cal managed care plan receives the appeal. (4) This bill would become operative only if SB 171 of the 2017–18 Regular Session is enacted and becomes effective on or before January 1, 2018.