Medi-Cal: managed care plans.

(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 through various health care delivery systems, including managed care pursuant to Medi-Cal managed care plan contracts. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing federal regulations require a state that contracts with specified Medicaid managed care plans to develop and enforce network adequacy standards, to ensure that services covered under the Medicaid state plan are available and accessible to enrollees of specified Medicaid managed care plans in a timely manner, and to contract with a qualified external quality review organization (EQRO) to produce annually an external quality review technical report that summarizes findings on access and quality of care. Existing state law establishes, until January 1, 2022, certain time and distance and appointment time standards for specified services consistent with those federal regulations to ensure that Medi-Cal managed care covered services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, and authorizes a Medi-Cal managed care plan to request approval from the department to use alternative access standards for the time and distance standards if specified conditions are met, including that the Medi-Cal managed care plan has exhausted all reasonable options to obtain providers to meet the applicable standard. Existing state law requires a Medi-Cal managed care plan to provide annually to the department, or upon the department's request, a report that demonstrates the Medi-Cal managed care plan's compliance with time and distance standards, and requires the EQRO to compile various data, by plan and by county, related to time and distance standards, including the number of requests for alternative access standards in the plan service area for time and distance. This bill would require a Medi-Cal managed care plan to provide to the department additional information in its request for the alternative access standards, including a description of the reasons justifying the alternative access standards, and to demonstrate to the department how the Medi-Cal managed care plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, such as through the use of Medi-Cal covered transportation. The bill would require the department to evaluate, as part of its review and approval of an alternative access standard, if the resulting time and distance is reasonable to expect a beneficiary to travel to receive care. The bill would require a Medi-Cal managed care plan that has received approval from the department to utilize an alternative access standard to assist an enrollee who would travel farther than the established time and distance standards in obtaining an appointment with an appropriate provider within established appointment time and distance standards, to arrange for Medi-Cal covered transportation for the enrollee, as determined by the department, and to inform affected members of the approved alternative access standards. This bill would require the information compiled by the EQRO to include the extent to which each Medi-Cal managed care plan uses clinically appropriate telecommunications technology to meet established time and distance standards. (2) Existing law requires the Director of Health Care Services, in accordance with specified procedures, to either terminate a contract with or impose one or more specified sanctions, including civil penalties pursuant to federal law, on a prepaid health plan or Medi-Cal managed care plan if the department makes a finding of noncompliance or for other good cause. This bill would modify criteria for a finding of noncompliance or for other good cause under those provisions. The bill would expand the types of authorized sanctions and bases for sanctions, would raise the maximum limits of certain sanctions based on the number of violations, and would modify the terms of notice. The bill would require the department to use nonfederal moneys collected by the department under these provisions to be deposited into the General Fund for use, and, upon appropriation by the Legislature, would require these moneys to be used to address workforce issues in the Medi-Cal program and to improve access to care in the Medi-Cal program. The bill would condition the implementation of these requirements on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would make technical and conforming changes related to these requirements. (3) Existing law requires the department to implement managed mental health care for Medi-Cal beneficiaries through contracts with county mental health plans. Under existing law, the county mental health plans are responsible for providing specialty mental health services to beneficiaries, and Medi-Cal managed care health plans are responsible for delivering nonspecialty mental health services to beneficiaries. Existing law requires the department to notify the mental health plan of the department's determination that a mental health plan has failed to comply with certain provisions, and authorizes the department to impose sanctions. Existing law authorizes the department, if the department imposes fines or penalties, to offset the fines from certain accounts, including the Mental Health Subaccount. This bill would instead extend the provisions described under paragraph (2) to mental health plans, and would apply those provisions to additional contractors. The bill would authorize the department to temporarily withhold payments of federal financial participation and payments from the above-described accounts until the department determines the contractor has come into compliance.