Medi-Cal: utilization controls.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law establishes a program in Alameda County in which utilization controls shall not be required when, pursuant to federal law under the Medicare Program, a county hospital based utilization review committee has been established to determine the level of authorization for payment under Medi-Cal and a utilization plan has been filed with, and approved by, the department. This bill would establish a program, whereby state utilization controls shall not be required for inpatient hospital services provided by designated public hospitals, as defined, with participation being optional for each hospital. The bill would require the department to consult with designated public hospitals in the development of the program. This bill would require the department, as part of the above-described program, to seek any necessary federal approvals, including waivers and state plan amendments, for an alternative utilization control system, as specified. The bill would provide that an alternative utilization control system established for inpatient hospital services shall apply only to the extent that the nonfederal share of expenditures for the services is incurred by the designated public hospital or governmental entity with which it is affiliated, or is otherwise funded with public funds that are transferred to the state from the hospital or governmental entity. This bill would provide that the above-described provisions shall become inoperative on the date the Director of Health Care Services executes a declaration specifying that either the nonfederal share of expenditures for inpatient hospitalization at designated public hospitals used for purposes of claiming federal financial participation is not comprised of funds that are paid and certified by designated public hospitals in accordance with applicable state and federal requirements or the above-described program will result in increased costs to the General Fund. Under existing law, one of the utilization controls to which services are subject under the Medi-Cal program is the treatment authorization request (TAR) process, which is approval by a department consultant of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Existing law requires the department to pursue additional means to improve and streamline the TAR process. In addition to the above-described program providing designated public hospitals with the option of not using state utilization controls, the bill would authorize the department to utilize any process or program, including any pilot project, that is established or authorized pursuant to the above-described provisions authorizing the department to pursue additional means to improve and streamline the TAR process, that is modified or developed to meet the needs of the particular designated public hospital.