AB 2466

Bill Subjects

Abstract

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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. Existing law authorizes the Director of Health Care Services to terminate a contract or impose sanctions if the director finds that a Medi-Cal managed care plan fails to comply with contract requirements, state or federal law or regulations, or the state plan or approved waivers, or for other good cause. Existing law establishes, until January 1, 2026, certain time and distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. Under this bill, a Medi-Cal managed care plan would be deemed to be not in compliance with the appointment time standards if either (1) fewer than 85% of the network providers had an appointment available within the standards or (2) the department receives information establishing that the plan was unable to deliver timely, available, or accessible health care services to enrollees, as specified. Under the bill, failure to comply with the appointment time standard may result in contract termination or the issuance of sanctions as described above. Existing law requires a Medi-Cal managed care plan to submit a request for alternative access standards if the plan cannot meet the time or distance standards. Under existing law, a plan is not required to submit a previously approved request on an annual basis, unless the plan requires modifications to its request. Existing law requires the plan to submit this previously approved request at least every 3 years for review and approval when the plan is required to demonstrate compliance with time or distance standards. This bill would instead require a plan that has a previously approved alternative access standard to submit a renewal request on an annual basis, explaining which efforts the plan has made in the previous 12 months to mitigate or eliminate circumstances that justify the use of an alternative access standard, as specified. The bill would require the department to consider the reasonableness and effectiveness of the mitigating efforts as part of the renewal decision. Existing law requires a Medi-Cal managed care plan to demonstrate, annually and upon request by the department, how the plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, with a report measuring compliance, as specified. Existing law requires the department to annually evaluate a plan's compliance with the standards and to annually publish a report. This bill would, effective for contract periods commencing on or after July 1, 2025, require the plan's and department's reports to include certain information and require the department's evaluation to be performed using a direct testing method, as specified. Under the bill, failure to comply with these provisions may result in contract termination or the issuance of sanctions. Existing law, as part of the federally required external quality review organization (EQRO) review of Medi-Cal managed care plans, requires the EQRO designated by the department to compile certain data, by plan and by county, for the purpose of informing the status of implementation of the above-described standards. This bill would require that the data include, effective for contract periods commencing on or after July 1, 2025, the number of requests for alternative access standards, categorized by new and returning patients, and the number of allowable exceptions for the appointment time standards, categorized by urgent and nonurgent appointment types and by new and returning patients. Under existing law, in lieu of contract termination, the director has the power and authority to require or impose a plan of correction and issue one or more of specified sanctions against a contractor for findings of noncompliance or good cause. This bill would require the department to monitor any plan of correction imposed by the director, with progress reported publicly no less than annually for the duration of the plan of correction. Existing law authorizes the director to impose monetary sanctions based on any of specified circumstances, including, among others, failure to submit timely and accurate network provider data. This bill would, for purposes of the particular circumstance described above, set forth definitions for the terms of "timely" and "accurate network provider data."