CA Welf & Inst Code Section 14087.98

(a)

The purpose of this article is to provide a comprehensive program of managed health care plan services to Medi-Cal recipients residing in the following counties that currently receive Medi-Cal services on a fee-for-service basis: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Imperial, Inyo, Lake, Lassen, Mariposa, Modoc, Nevada, Mono, Placer, Plumas, San Benito, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba.

(b)

The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis with one or more managed health care plans to provide a comprehensive program of managed health care plan services to Medi-Cal recipients residing in the counties described in subdivision (a). The director shall give special consideration to managed health care plans that meet all of the following:

(1)

Have demonstrated experience in effectively serving Medi-Cal beneficiaries, including diverse populations.

(2)

Have demonstrated experience in effectively partnering with public and traditional safety net health care providers.

(3)

Have demonstrated experience in working with local stakeholders, including consumers, providers, advocates, and county officials, in plan oversight and in delivery of care.

(4)

Have the lowest administrative costs.

(5)

Show support from local county officials as demonstrated by an action of the county board of supervisors.

(6)

Show recent successful experience with expansion of managed care to a rural area.

(7)

Offer a quality improvement program for primary care providers.

(c)

Contracts entered into or amended pursuant to this section shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code.

(d)

The managed health care plans that the department contracts with under this article shall comply with the requirements of Section 14087.48 and meet all of the following:

(1)

Have Medi-Cal managed health care plan contract experience, or evidence of the ability to meet these contracting requirements.

(2)

Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), if applicable.

(3)

Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department and the federal Centers for Medicare and Medicaid Services.

(e)

The managed health care plans that the department contracts with under this article shall provide Medi-Cal beneficiaries with information about enrollment rights and options, plan benefits and rules, and care plan elements so that beneficiaries have the ability to make informed choices. This information shall be delivered in a format and language accessible to beneficiaries. The managed health care plans shall provide access to providers in compliance with applicable state and federal laws, including, but not limited to, physical accessibility and the provision of health plan information in alternative formats.

(f)

The department shall conduct a stakeholder process including relevant stakeholders to ensure that beneficiaries, health care providers, and managed health care plans have an opportunity to provide input into the delivery model for these counties and to help ensure smooth care transitions for beneficiaries.

(g)

Enrollment in a Medi-Cal managed health care plan or plans under this article shall be mandatory in order to receive services under Medi-Cal, except as otherwise provided by law.

(h)

Each beneficiary or eligible applicant shall be informed that he or she may choose to continue an established patient-provider relationship if his or her treating provider is a primary care provider or clinic contracting with the managed health care plan, has the available capacity, and agrees to continue to treat that beneficiary or eligible applicant. The managed health care plans shall comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code.

(i)

(1)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and amend regulations and orders adopted by the department by means of plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until the time regulations are adopted. It is the intent of the Legislature that the department have temporary authority as necessary to implement program changes until completion of the regulatory process.

(2)

The department shall adopt emergency regulations no later than July 1, 2014. The department may readopt any emergency regulation authorized by this section that is the same as or substantially equivalent to an emergency regulation previously adopted pursuant to this section. The initial adoption of emergency regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. Initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law.

(3)

The initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.

(j)

The cost of any program established under this section shall not exceed the total amount that the department estimates it would pay for all services and requirements within the same geographic area under the fee-for-service Medi-Cal program.

(k)

The department shall have exclusive authority to set the rates, terms, and conditions of managed health care plan contracts and contract amendments under this article. The director may include in the contract a provision for quality assurance withholding from the plan payment, to be paid only if quality measures identified in the plan contract are met.

(l)

The department shall provide the fiscal and appropriate policy committees of the Legislature with quarterly updates, commencing January 1, 2014, and ending January 1, 2016, regarding the expansion of Medi-Cal managed care into the new counties authorized pursuant to this section. These updates shall include, but not be limited to, continuity of care requests, grievance and appeal rates, and utilization reports for the new counties.

(m)

The department shall seek all necessary federal approvals to allow for federal financial participation in expenditures under this article. This article shall not be implemented until all necessary federal approvals have been obtained.

(n)

This section shall be implemented only to the extent federal financial participation or funding is available.

(o)

Notwithstanding subdivision (q) of Section 6254 of the Government Code, a contract or contract amendments executed by both parties after the effective date of the act adding this subdivision shall be considered a public record for purposes of the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code) and shall be disclosed upon request. This subdivision applies to contracts that reveal the department’s rates of payment for health care services, the rates themselves, and rate manuals.

(p)

To implement this section, the department may contract with public or private entities. Contracts or amendments entered into under this section may be on an exclusive or nonexclusive basis and a noncompetitive bid basis and shall be exempt from the following:

(1)

Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and any policies, procedures, or regulations authorized by that part.

(2)

Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code.

(3)

Review or approval of contracts by the Department of General Services.