Population health management program.

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 pursuant to a schedule of benefits. Under existing law, health care services are provided to Medi-Cal beneficiaries through various health care delivery systems, including fee-for-service and managed care. Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, such as contracts with a Medi-Cal managed care plan, and imposes requirements on Medi-Cal managed care plan contractors, including appointment time standards and network adequacy standards. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing federal law authorizes specified managed care entities that participate in a state's Medicaid program to cover, for enrollees, services or settings that are in-lieu-of services and settings otherwise covered under a state plan. This bill would require the department to require, by January 1, 2022, each Medi-Cal managed care plan to implement a population health management program (program) to identify, assess, and manage the needs of Medi-Cal beneficiaries who are enrolled in each plan. The bill would require a Medi-Cal managed care plan to describe case management services provided to enrollees and to report to the department on specified information, including the number of enrollees receiving in-lieu-of services. The bill would require the department to establish metrics for, and require the federally required external quality review organization (EQRO) to evaluate the effectiveness of, the enhanced care management and in-lieu-of services provided to enrollees, to establish metrics for evaluating the program, and to require the EQRO to conduct an analysis of each Medi-Cal managed care plan's program.