Medi-Cal: Program of All-Inclusive Care for the Elderly: rates.

Plain English Breakdown

The official source material does not provide information about the resolution process for disagreements over rates or the effectiveness of direct negotiations without consultation.

Medi-Cal: Program of All-Inclusive Care for the Elderly (PACE) Rates

This law changes how Medi-Cal sets payment rates for PACE organizations by removing the requirement to consult with them and instead requiring direct negotiations on capitation rates.

What This Bill Does

• Removes the need for the State Department of Health Care Services to consult with PACE organizations when setting capitation rates.
• Requires the department to notify PACE organizations about proposed rates at least 60 days before submitting them for federal approval.
• Requires written responses from the department to any comments or questions from PACE organizations within 30 days of submission.
• Allows the department to set a reasonable deadline for PACE organizations to submit feedback on proposed rates.
• Requires the department to provide explanations and justifications for rate calculations upon request.

Who It Names or Affects

• The State Department of Health Care Services
• PACE organizations that contract with Medi-Cal

Terms To Know

Capitation rates

A fixed amount paid to a health care provider for each person enrolled in a health plan.

Medi-Cal

California's Medicaid program that provides health care services to low-income individuals, including the elderly and disabled.

Limits and Unknowns

• The bill does not specify how disagreements over rates will be resolved.
• It is unclear what constitutes a 'reasonable date' for PACE organizations to submit feedback on proposed rates.

Official Summary Text

AB 1672, as amended, Solache.
Medi-Cal: Program of All-Inclusive Care for the Elderly: rates.
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 through various delivery systems, including fee-for-service and managed care. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions.
Existing law establishes the California Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services for older individuals under the state’s Medi-Cal State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the department, and PACE organizations.
Existing law requires the
department to pay capitation rates to health plans participating in the Medi-Cal managed care program using actuarial methods. Existing law requires the department to develop and pay capitation rates to entities contracted pursuant to the PACE program, using actuarial methods consistent with those provisions, with specified exceptions. Existing law requires the department to consult with those contracted entities in developing a rate methodology.
This bill would delete the consultation-related requirement. Under the bill, and consistent with the requirements under federal law, capitation rates would be negotiated between the department and each contracting PACE organization. The bill would require the department, as part of this negotiation before submission for federal approval,
to notify the PACE organization of the proposed rates at least 60 days prior to submission and
to respond in writing to any
comments made by a contracting PACE organization concerning prospective rates,
questions or feedback on the proposed rates submitted by the PACE organization by no later than 30 days prior to submission. The bill would authorize the department to define a reasonable date by which the PACE organization must submit those questions or feedback. The bill would require the department to
provide the rationale for any assumptions or calculations concerning
rates upon
request, and
the proposed rates upon request and to
make a good faith effort to reach agreement with the contracting PACE organization on capitation rates.

Current Bill Text

Download Bill PDF