California Welfare and Institutions Code 14197.05 – (a) As part of the federally required external quality review …
(a) As part of the federally required external quality review organization (EQRO) review of Medi-Cal managed care plans in the annual detailed technical report required by Section 438.364 of Title 42 of the Code of Federal Regulations, effective for contract periods commencing on or after July 1, 2018, the EQRO designated by the department shall compile the data described in subdivision (b), by plan and by county, for the purpose of informing the status of implementation of the requirements of Section 14197.
(b) (1) The information compiled by the EQRO shall include all of the following:
Terms Used In California Welfare and Institutions Code 14197.05
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- County: includes "city and county. See California Welfare and Institutions Code 14
- department: means the State Department of Health Services. See California Welfare and Institutions Code 14062
- Medi-Cal: means the California Medical Assistance Program. See California Welfare and Institutions Code 14063
(A) Number of requests for alternative access standards in the plan service area for time and distance, categorized by provider types, including specialists, and by adult and pediatric.
(B) Number of allowable exceptions for the appointment time standard, if known, categorized by provider types, including specialists, and by adult and pediatric.
(C) Distance and driving time between the nearest network provider and ZIP Code of the beneficiary furthest from that provider for requests for alternative access standards.
(D) Approximate number of beneficiaries impacted by alternative access standards or allowable exceptions.
(E) Percentage of providers in the plan service area, by provider and specialty type, that are under a contract with a Medi-Cal managed care plan.
(F) The number of requests for alternative access standards approved or denied by ZIP Code and provider and specialty type, and the reasons for the approval or denial of the request for alternative access standards. If an approval is authorized, the reasons for approval shall identify whether the approval was granted for either of the following reasons:
(i) A provider was not located in the requested ZIP Code.
(ii) The Medi-Cal managed care plan was unable to enter into a contract with a provider or providers in the requested ZIP Code.
(G) The process of ensuring out-of-network access.
(H) Descriptions of contracting efforts and explanation for why a contract was not executed.
(I) Timeframe for approval or denial of a request for alternative access standards by the department.
(J) Consumer complaints, if any.
(2) The information described in paragraph (1) shall be presented in a chart format to enable comparison among counties, provider types, and plans.
(c) The EQRO shall develop a methodology to assess information that will help inform the experience of individuals placed in a skilled nursing facility or intermediate care facility and the distance that they are placed from their place of residence. The EQRO shall report the results from the use of this methodology in the EQRO annual Medi-Cal managed care plan technical report.
(d) The department shall comply with the requirements of subsection (c) of Section 438.364 of Title 42 of the Code of Federal Regulations in making the information described in this section publicly available.
(Amended by Stats. 2019, Ch. 465, Sec. 5. (AB 1642) Effective January 1, 2020.)