California Children's Services: reimbursement rates.

Existing law establishes the California Children's Services (CCS) Program, administered by the State Department of Health Care Services and a designated agency of each county, to provide medically necessary services for persons under 21 years of age who have any of specified medical conditions and who meet certain financial eligibility requirements. Existing law establishes the Medi-Cal program, which is administered by the department and under which qualified low-income individuals receive health care services. Existing law requires that provider rates of payment for services rendered in the CCS Program be identical to the rates of payment for the same service performed by the same provider type pursuant to the Medi-Cal program. Notwithstanding that requirement, existing law authorizes the reimbursement of services provided under the CCS Program at rates greater than the Medi-Cal rate that would otherwise be applicable if those rates are adopted by the Director of Health Care Services in regulations. Existing law establishes a Whole Child Model program for Medi-Cal eligible CCS children and youth enrolled in a Medi-Cal managed care plan served by a county organized health system or Regional Health Authority in specified counties. Existing law requires the department to pay a participating managed care plan a certain rate, and requires the plan to pay physician and surgeon provider services at rates that are equal to or exceed the applicable CCS fee-for-service rates, except as specified. Physician services provided under the CCS Program are currently reimbursed at rates that are 39.7% greater than the applicable Medi-Cal rates. This bill would make legislative findings relating to the need for an increase in the reimbursement rates for physician services provided under the CCS Program. Under the bill, subject to an appropriation, and commencing January 1, 2023, those reimbursement rates would be increased by adding at least 25% to the above-described augmentation percentage relative to the applicable Medi-Cal rates. The bill would make the rate increase applicable only if the services are provided by a physician in a practice in which at least 30% of the practice's pediatric patients are Medi-Cal beneficiaries. The bill would, no later than January 1, 2026, and every 3 years thereafter, require the department to complete a review of those reimbursement rates, including whether the department recommends an increase in the rates, as specified. The bill would require that the reviews contain data disaggregated by rural or urban area, ZIP Code, and satellite clinic providing CCS services. The bill would require the department to submit reports of the reviews and any recommendations to the legislative health committees.