Medi-Cal: covered benefits. Existing law establishes 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. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Under existing law, health care services are provided under the Medi-Cal program pursuant to a schedule of benefits, and those benefits are provided to 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, including contracts with a Medi-Cal managed care plan. Existing law requires the department to pay capitations rates to health plans participating in the Medi-Cal managed care program using actuarial methods, and authorizes the department to establish health-plan- and county-specific rates, as specified. Existing law requires the department to utilize health-plan- and county-specific rates for specified Medi-Cal managed care plan contracts, and requires those developed rates to include identified specified information, such as health-plan-specific encounter and claims data.
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 those mandatorily developed health-plan- and county-specific rates for specified Medi-Cal managed care plan contracts to include in lieu of services and settings provided by the Medi-Cal managed care plan. The bill would require each Medi-Cal managed care plan to disclose the availability of in lieu of services on its internet website and its beneficiary handbook, and to disclose to the department specified information on in lieu of services that are plan specific, including the number of people receiving those services. The bill would require the department to publish that information on its internet website.
This bill would, to the extent that federal financial participation is available and any necessary federal approvals have been obtained, expand the schedule of benefits under the Medi-Cal program to include enhanced care management if the service is provided in person to a beneficiary and, at a minimum, the service includes coordinating primary, acute, behavioral, oral, and long-term services and supports for that person. The bill would authorize the department to implement these provisions by various means, including all-county letters or provider bulletins, without taking regulatory action. The bill would require the department to adopt, by July 1, 2023, regulations on these provisions, and, commencing January 1, 2022, to provide a status report to the Legislature on a semiannual basis until regulations are promulgated. The bill would make technical, nonsubstantive changes to these provisions. provisions on the Medi-Cal schedule of benefits.