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 indefinitely. 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 set forth related reporting requirements with regard to subcontractor networks.
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 if either of the following occur: (1) the requesting plan has exhausted all other reasonable options to obtain providers to meet the applicable standard; or (2) the department determines that the requesting plan has demonstrated that its delivery structure is capable of delivering the appropriate level of care and access.
This bill would recast those provisions and would specify, under both circumstances, that there be an appropriate level of care and access that is consistent with professionally recognized standards of practice, with a departmental determination that the alternative access standards will not have a detrimental impact on the health of enrollees. The bill would make other changes to the procedure for a managed care plan to submit a previously approved alternative access standard request.
Existing law requires the department to annually evaluate a managed care plan's compliance with the time or distance and appointment time standards.
This bill would require that the evaluation be performed using a direct testing method and an examination of complaints data, as specified.
Existing law defines "specialist" for purposes of these provisions, including with regard to a managed care plan's requirement to maintain a network of providers located within the time or distance standards.
This bill would expand the scope of the definition for "specialist" to include providers of immunology, urology, and sleep medicine, among other additional areas of medicine.

Statutes affected:
SB 530: 14197 WIC
02/20/25 - Introduced: 14197 WIC