Medi-Cal: managed care plan: subcontracts.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services either through a fee-for-service or managed care delivery system. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, including contracts with prepaid health plans. Existing law requires subcontracts entered into by a prepaid health plan to contain the amount of compensation or other consideration that a subcontractor will receive under the terms of the subcontract with the prepaid health plan, and to meet specified requirements, including compliance with the Knox-Keene Health Care Service Plan Act of 1975. This bill would require a Medi-Cal managed care plan to conduct, commencing January 1, 2022, specified audits of its subcontractors, including an annual medical audit of any subcontractor that performs delegated functions involving medical review and decisionmaking. The bill would authorize a Medi-Cal managed care plan to conduct additional medical audits of a subcontract, for good cause, to contract with a professional organization to perform medical audits, and to collaborate or share medical audit findings with another Medi-Cal managed care plan if 2 or more Medi-Cal managed care plans subcontract with the same subcontractor in lieu of completing separate audits. The bill would require a Medi-Cal managed care plan to report to the department the findings and certificate of completion of, and any deficiencies discovered by, the finalized annual medical audit, and to make available the finalized medical audit upon the department's request. The bill would require the department to post the annual medical report on its internet website, to develop a standardized process for Medi-Cal managed care plan audits that meets specified requirements, including requirements related to corrective action validation, and to provide this guidance to the Medi-Cal managed care plans by means of an all-plan letter.