Medi-Cal: Independent Medical Review System.
(1) Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to qualified low-income persons pursuant to a schedule of benefits, which includes pharmacy benefits, through various health care delivery systems, including fee-for-service and managed care. 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 a managed care plan. Existing law generally requires Medi-Cal managed care plan contractors to be licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975. The Knox-Keene Health Care Service Plan Act provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Under this act, a health care service plan is required to provide an external, independent review process, which meets prescribed standards, to examine the plan’s coverage decisions for an enrollee who meets specified criteria, including that the enrollee’s provider has recommended a health care service as medically necessary. Existing law requires the Department of Managed Health Care to establish the Independent Medical Review System, which generally serves to address grievances involving disputed health care services.
This bill would require the department to establish the Independent Medical Review System (IMRS) for the Medi-Cal program, commencing on January 1, 2022, which generally models the above-described requirements of the Knox-Keene Health Care Service Plan Act. The bill would provide that any Medi-Cal beneficiary grievance involving a disputed health care service is eligible for review under the IMRS, and would define “disputed health care service” as any service covered under the Medi-Cal program that has been denied, modified, or delayed by a decision of the department, or by one of its contractors that makes a final decision, in whole or in part, due to a finding that the service is not medically necessary. The bill would require information on the IMRS to be included in specified material, including the “myMedi-Cal: How to Get the Health Care You Need” publication and on the department’s internet website. The bill would authorize a beneficiary to apply to the department for an Independent Medical Review (IMR) of a decision involving a disputed health care service within 6 months of receipt of the notice of adverse action, and would prohibit a beneficiary from paying any application or processing fee. The bill would require the department to provide a beneficiary with an application form and an addressed envelope, which the beneficiary may return to initiate an IMR, as part of the department’s notification to the beneficiary on a disposition of the beneficiary’s grievance involving a disputed health care service, and would require the form to include specified information, such as a statement indicating the beneficiary’s consent to obtain necessary medical records from the Medi-Cal managed care plan and the beneficiary’s providers. Upon notice from the department that the beneficiary has applied for an IMR, the bill would require the department and its contractors to provide to the IMR organization designated by the department specified information, including a copy of the beneficiary’s medical records with specified information, for purposes of the IMR organization’s evaluation of the request.
This bill would require the department to contract with one or more IMR organizations to conduct IMRs, and would require those organizations to be independent of any Medi-Cal managed care plan. The bill would also authorize the department to enter into an intra-agency agreement with the Department of Managed Health Care to perform some or all of the department’s duties. The bill would impose various requirements on the IMR organization, including that the organization submit to the department specified information, such as the name of any stockholder and owner of more than 5% of any stock or options, if a publicly held organization. The bill would require the medical professional reviewer or reviewers selected to conduct the IMR by the organization to perform specified duties, including reviewing pertinent medical records of the beneficiary. The bill would require the IMR organization to complete its review and make a written determination within 30 days of receipt of the application for review and supporting documentation, or less time as prescribed by the director, and to provide specified information, such as the analyses and determinations of the medical professionals reviewing the case, to identified individuals, including the director and the beneficiary. The bill would require the director to immediately adopt the determination of the IMR organization, promptly issue a written decision to the parties, and implement that decision. The bill would provide that the director’s decision adopting a determination of an IMR organization be made publicly available, as prescribed, including in a searchable database on the department’s internet website. The bill would require the director to perform an annual audit of IMR cases for education and determination of whether any denials, modifications, or delays in the coverage of service necessitate an evaluation of the department’s coverage policies, and would require the department to establish a reasonable, per-case reimbursement schedule to pay the costs of IMR organization review.
(2) Existing state law establishes hearing procedures for an applicant for, or beneficiary of, the Medi-Cal program who is dissatisfied with certain actions regarding health care services and medical assistance to request a hearing from the State Department of Social Services under specified circumstances, and provides that a person is not entitled to a hearing unless they file their request within 90 days after the order or action complained of.
This bill would instead provide that a person is entitled to a hearing if they file their request within 90 days of the issuance of the order or action complained of or the unfavorable independent medical review decision, except as specified.
(3) After an administrative law judge has held a hearing and issued a proposed decision, existing law authorizes the director to take specified action under prescribed timeframes. These actions include deciding the matter themselves on the record, including the transcript, with or without taking additional evidence, or ordering a further hearing to be conducted by the director or another administrative law judge on their behalf. Existing law provides that failure of the director to take certain action, including adopting the proposed decision, shall be deemed an affirmation of the proposed decision.
This bill would instead require the director to decide the matter on the record after reviewing the transcript or recording of the hearing without taking additional evidence or order a further hearing to be conducted by the director or another administrative law judge on their behalf that affords the parties the opportunity to present and respond to additional evidence. The bill would clarify that a proposed decision shall be deemed affirmed and adopted if the director fails to take prescribed action, and would require the director’s alternated decision to contain a statement of the facts and evidence, including references to the applicable provisions of law and regulations, and the analysis that supports their decision.
(4) Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest.
This bill would make legislative findings to that effect.