Medi-Cal managed care plans: enrollees with other health care coverage.

Plain English Breakdown

The bill includes provisions for CalHHS to form a workgroup on functional, hormonal, integrative, and metabolic health practices, which was not mentioned in the candidate explanation.

Medi-Cal Managed Care Plans: Enrollees with Other Health Coverage

This law aims to simplify billing processes for doctors treating patients who have both Medi-Cal managed care plans and other health insurance, ensuring that providers are not burdened with excessive administrative requirements.

What This Bill Does

• Requires the State Department of Health Care Services to ensure that non-contracted providers can bill Medi-Cal managed care plans without facing overly burdensome administrative requirements if another health coverage does not pay for a service.
• Allows Medi-Cal managed care plans to request letters or agreements from providers under certain conditions, such as when services need prior authorization or are covered by Medi-Cal but not other insurance.
• Requires the department to provide clear instructions and guidance on how doctors can bill for services if a patient has both Medi-Cal and another health coverage.
• Encourages the department to offer educational resources to help people understand their healthcare options when they have both Medi-Cal and other health coverage.

Who It Names or Affects

• People enrolled in Medi-Cal managed care plans who also have other health insurance.
• Doctors and healthcare providers serving patients with both types of coverage.
• The State Department of Health Care Services and CalHHS.

Terms To Know

Medi-Cal

A government program that helps low-income people get health care services in California.

Managed care plan

An insurance plan where doctors and hospitals are part of a network, and patients usually need to use these providers for their healthcare needs.

Limits and Unknowns

• The bill's requirements depend on getting federal approval and having enough money from the government.
• It is not clear how many people will be helped by this law or what specific changes it will bring about in practice.

Official Summary Text

AB 1126, as amended, Patterson.
California Workgroup on Functional, Hormonal, Integrative, and Metabolic Health.
Medi-Cal managed care plans: enrollees with other health care coverage.
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. Under existing federal law, in accordance with third-party liability rules, Medicaid is generally the payer of last resort if a beneficiary has another source of health care coverage in addition to Medicaid coverage.
This bill would require the department, in the case of a Medi-Cal managed care plan enrollee who also has other health care coverage and for whom the Medi-Cal program is a payer of last resort, to ensure that
a provider that is not contracted with the plan and that is billing the plan for Medi-Cal allowable costs not paid by the other health care coverage does not face administrative requirements significantly in excess of the administrative requirements for billing those same costs to the Medi-Cal fee-for-service delivery system. Under the bill, in the case of an enrollee who meets those coverage criteria, except as specified, a Medi-Cal fee-for-service provider would not be required to contract as an in-network provider with the Medi-Cal managed care plan in order to bill the plan for Medi-Cal allowable costs for covered health care services.
The bill would authorize a Medi-Cal managed care plan to require a letter of agreement, or a similar agreement, under specified circumstances, including if a covered service requires prior authorization, or if a service is not covered by the other health care coverage but is a covered service under the plan, as specified.
The bill would require the department to take the actions that it deems necessary to provide clarification regarding the conditions for billing plans to providers that render services to enrollees who also have other health care coverage. The bill would specify the intent of the Legislature that the department offer educational resources to an enrollee who needs assistance with understanding continuity of care and coordinating Medi-Cal and their other health care coverage when requested by the enrollee.
The bill would require the department, annually from 2027 through 2030, to update the legislative health committees on the effectiveness of implementing these provisions. The bill would authorize the department to implement these provisions through plan letters or similar instructions. The bill would condition implementation of these provisions on receipt of any necessary federal approvals and the availability of federal
financial participation.
Existing law establishes the California Health and Human Services Agency, also known as CalHHS, which includes the State Department of Public Health, the State Department of Health Care Services, and the State Department of Social Services, among other state departments and offices. Under existing law, CalHHS is charged with the administration of health, social, and other human services.
This bill would require CalHHS to convene a workgroup to explore the use and effectiveness of functional, hormonal, integrative, and metabolic health and medicine. The bill would require the workgroup to meet at least four times a year and report any findings to the
Senate Health and Human Services Committee and the Assembly Health Committee.

Current Bill Text

Download Bill PDF