AB 1225

This bill prohibits the Department of Health Services from entering into or renewing a contract with managed care organizations for the provision of Medical Assistance, prohibits DHS from entering into or renewing a contract to shift the risk for Medical Assistance costs to health care providers or other entities, requires DHS to maintain a statewide network of Medical Assistance providers, and directs DHS to pay providers directly, on a fee-for-service basis, for services provided to Medical Assistance recipients. The prohibitions on managed care and risk-shifting contracts do not apply to contracts between DHS and counties that operate managed care organizations for the Family Care, Family Care Partnership, and Program for All-Inclusive Care for the Elderly (PACE) programs, and the requirement for direct payments does not apply to services provided under those programs.

The bill authorizes DHS to contract with administrative services organizations for the administration of the Medical Assistance program. Under the bill, administrative service organizations are noninsurance entities that do not assume financial risk for the cost of Medical Assistance.

In addition, the bill requires DHS to maintain a call center and website to assist Medical Assistance recipients in locating health care providers; provide a nurse consultation helpline for Medical Assistance recipients; assist Medical Assistance recipients who have not had preventive visits in selecting a primary care provider; ensure provider reimbursement rates are reasonable and fair and conform to the requirements of the federal Centers for Medicare and Medicaid services; increase the reimbursement rate for services for which there is a a severe shortage of health care providers due to inadequate reimbursement rates; reimburse Medical Assistance providers on a timely basis; collaborate with Medical Assistance providers to improve health care quality and reduce costs; track data related to the Medical Assistance program; and maintain a publicly accessible dashboard containing the data.

The bill also requires DHS to provide a flat fee payment to primary care providers for care coordination services provided to Medical Assistance recipients. The bill requires DHS to request any necessary waiver of federal law or amendment to the state Medical Assistance plan for federal financial participation in the payments, but requires DHS to provide the payments even if no waiver or amendment is granted. The bill also allows DHS to contract with counties, federally qualified health centers, and community-based programs to provide care coordination services to Medical Assistance recipients.

In addition, the bill requires DHS to award grants as follows:

1. To community health centers and managed care organizations operated by counties for the Family Care, Family Care Partnership, and PACE programs to hire community health workers, nurses, or social workers to perform community outreach and deliver medical care and coordination services to patients who are unlikely to obtain needed care and treatment and assist patients in enrolling in the Medical Assistance program.

2. To community health workers to visit patients in their homes to chart their health status and coordinate the delivery of health care.

The bill provides funding to DHS for the grants, for increasing Medical Assistance provider reimbursement rates, for the cost of administering the Medical Assistance program through direct, fee-for-service payments, and for improving Medical Assistance technology systems and outreach and enrollment efforts.