SB 530

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, under fee-for-service or managed care delivery systems. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law establishes, until January 1, 2026, certain time and distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified.

This bill would extend the operation of those standards to January 1, 2029. The bill would also require a managed care plan to ensure that each subcontractor network complies with certain appointment time standards unless already required to do so. The bill would require a plan to demonstrate to the department each subcontractor network's compliance with time or distance and appointment time standards, as specified.

Existing law permits the department to authorize a managed care plan to use clinically appropriate video synchronous interaction, as defined, as a means of demonstrating compliance with the time or distance standards.

Under this bill, the use of telehealth providers to meet time or distance standards would not absolve the managed care plan of responsibility to provide a beneficiary with access, including transportation, to in-person services if the beneficiary prefers. The bill would set forth other related provisions with regard to the use of telehealth.

Existing law permits the department, upon request of a managed care plan, to authorize alternative access standards for the time or distance standards under certain conditions.

This bill would, effective for contract periods commencing on or after January 1, 2027, require the department to consider the sufficiency of payment rates offered by the Medi-Cal managed care plan to the provider type or for the service type when evaluating requests for the utilization of alternative access standards.

The bill would require a Medi-Cal managed care plan that does not meet time or distance standards without the use of an alternative access standards request to submit to the department documentation demonstrating efforts to contract with providers, as specified. The bill would require a Medi-Cal managed care plan, effective no sooner than contract periods commencing on or after January 1, 2026, to inform enrollees of their option to use or not use telehealth, covered transportation services, or out-of-network providers to access covered services if the health care provider is located outside of the time or distance standards.

Existing law requires the department to annually evaluate a managed care plan's compliance with the time or distance and appointment time standards and to annually publish a report of its findings, as specified.

This bill would require, effective for contract periods commencing on or after January 1, 2029, the evaluation by the department for appointment time standards compliance to be performed using a direct testing method, as specified.

The bill would authorize the department to require enhanced time or distance standards that are more stringent than the time or distance standards described above in its contracts with Medi-Cal managed care plans. The bill would require the department to ensure that these enhanced standards are consistent across contracts for similar geographic classifications. The bill would require the department to publish all enhanced time and distance standards adopted by contract with a rationale for the enhanced standards.

Under the bill, in alignment with federal regulation that requires the department to conduct analyses when developing or adjusting network adequacy standards, the department would be required to publish on its internet website by January 1, 2027, a specified workplan. The bill would also require the department to convene a stakeholder workgroup and to provide a 30-day public comment period, as specified.

Existing law requires the department, to the extent permitted under federal law, to require a Medi-Cal managed care plan that is not licensed by the Department of Managed Health Care to comply with applicable requirements, under specified provisions relating to health equity and quality, for the purpose of serving applicable Medi-Cal beneficiaries.

Under this bill, for purposes of implementing specified federal final rules relating to Medicaid, the department would be authorized to enter into contracts, or amend existing contracts, as specified. The bill would make this provision inoperative on January 1, 2029.

The bill would authorize the department to implement the above-described provisions, relating to the health equity and quality requirements and to the Medicaid final rules, through all-county letters or similar instructions without taking any further regulatory action.