SB530 - Medi-Cal: time and distance standards.

Senate Bill No. 530 CHAPTER 418 An act to amend Sections 14197 and 14197.9 of the Welfare and Institutions Code, relating to Medi-Cal. [ Approved by Governor October 06, 2025. Filed with Secretary of State October 06, 2025. ] LEGISLATIVE COUNSEL'S DIGEST SB 530, Richardson. Medi-Cal: time and distance standards. 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. Existing law establishes, until January 1, 2026, certain time and distance and appointment time standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as specified. This bill would extend the operation of those standards to January 1, 2029. The bill would also require a managed care plan to ensure that each subcontractor network complies with certain appointment time standards unless already required to do so. The bill would require a plan to demonstrate to the department each subcontractor network’s compliance with time or distance and appointment time standards, as specified. Existing law permits the department to authorize a managed care plan to use clinically appropriate video synchronous interaction, as defined, as a means of demonstrating compliance with the time or distance standards. Under this bill, the use of telehealth providers to meet time or distance standards would not absolve the managed care plan of responsibility to provide a beneficiary with access, including transportation, to in-person services if the beneficiary prefers. The bill would set forth other related provisions with regard to the use of telehealth. Existing law permits the department, upon request of a managed care plan, to authorize alternative access standards for the time or distance standards under certain conditions. This bill would, effective for contract periods commencing on or after January 1, 2027, require the department to consider the sufficiency of payment rates offered by the Medi-Cal managed care plan to the provider type or for the service type when evaluating requests for the utilization of alternative access standards. The bill would require a Medi-Cal managed care plan that does not meet time or distance standards without the use of an alternative access standards request to submit to the department documentation demonstrating efforts to contract with providers, as specified. The bill would require a Medi-Cal managed care plan, effective no sooner than contract periods commencing on or after January 1, 2026, to inform enrollees of their option to use or not use telehealth, covered transportation services, or out-of-network providers to access covered services if the health care provider is located outside of the time or distance standards. Existing law requires the department to annually evaluate a managed care plan’s compliance with the time or distance and appointment time standards and to annually publish a report of its findings, as specified. This bill would require, effective for contract periods commencing on or after January 1, 2029, the evaluation by the department for appointment time standards compliance to be performed using a direct testing method, as specified. The bill would authorize the department to require enhanced time or distance standards that are more stringent than the time or distance standards described above in its contracts with Medi-Cal managed care plans. The bill would require the department to ensure that these enhanced standards are consistent across contracts for similar geographic classifications. The bill would require the department to publish all enhanced time and distance standards adopted by contract with a rationale for the enhanced standards. Under the bill, in alignment with federal regulation that requires the department to conduct analyses when developing or adjusting network adequacy standards, the department would be required to publish on its internet website by January 1, 2027, a specified workplan. The bill would also require the department to convene a stakeholder workgroup and to provide a 30-day public comment period, as specified. Existing law requires the department, to the extent permitted under federal law, to require a Medi-Cal managed care plan that is not licensed by the Department of Managed Health Care to comply with applicable requirements, under specified provisions relating to health equity and quality, for the purpose of serving applicable Medi-Cal beneficiaries. Under this bill, for purposes of implementing specified federal final rules relating to Medicaid, the department would be authorized to enter into contracts, or amend existing contracts, as specified. The bill would make this provision inoperative on January 1, 2029. The bill would authorize the department to implement the above-described provisions, relating to the health equity and quality requirements and to the Medicaid final rules, through all-county letters or similar instructions without taking any further regulatory action. Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill Text The people of the State of California do enact as follows: SECTION 1. Section 14197 of the Welfare and Institutions Code is amended to read: 14197. (a) It is the intent of the Legislature that the department implement and monitor compliance with the time or distance requirements set forth in Sections 438.68, 438.206, and 438.207 of Title 42 of the Code of Federal Regulations and this section, to ensure that all Medi-Cal managed care covered services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as those standards were enacted in May 2016. (b) Commencing January 1, 2018, for covered benefits under its contract, as applicable, a Medi-Cal managed care plan shall maintain a network of providers that are located within the following time or distance standards for the following services: (1) For primary care, both adult and pediatric, 10 miles or 30 minutes from the beneficiary’s place of residence. (2) For hospitals, 15 miles or 30 minutes from the beneficiary’s place of residence. (3) For dental services provided by a Medi-Cal managed care plan, 10 miles or 30 minutes from the beneficiary’s place of residence. (4) For obstetrics and gynecology primary care, 10 miles or 30 minutes from the beneficiary’s place of residence. (c) Commencing July 1, 2018, for the covered benefits under its contracts, as applicable, a Medi-Cal managed care plan shall maintain a network of providers that are located within the following time or distance standards for the following services: (1) For specialists, as defined in subdivision (i), adult and pediatric, including obstetric and gynecology specialty care, as follows: (A) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (2) For pharmacy services, 10 miles or 30 minutes from the beneficiary’s place of residence. (3) For outpatient mental health services, as follows: (A) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (4) (A) For outpatient substance use disorder services other than opioid treatment programs, as follows: (i) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (ii) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (iii) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Madera, Mariposa, Mendocino, Merced, Modoc, Monterey, Mono, Napa, Nevada, Plumas, San Benito, San Bernardino, San Luis Obispo, Santa Barbara, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tulare, Tuolumne, Yolo, and Yuba. (B) For opioid treatment programs, as follows: (i) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (ii) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (iii) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (iv) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (d) (1) (A) A Medi-Cal managed care plan shall comply with the appointment time standards developed pursuant to Section 1367.03 of the Health and Safety Code, Section 1300.67.2.2 of Title 28 of the California Code of Regulations, subject to any authorized exceptions in Section 1300.67.2.2 of Title 28 of the California Code of Regulations, and the standards set forth in contracts entered into between the department and Medi-Cal managed care plans. (B) Commencing July 1, 2018, subparagraph (A) applies to Medi-Cal managed care plans that are not, as of January 1, 2018, subject to the appointment time standards described in subparagraph (A). (C) A Medi-Cal managed care plan shall ensure that each subcontractor network complies with the appointment time standards described in subparagraph (A), unless already required to ensure compliance. (2) A Medi-Cal managed care plan shall comply with the following availability standards for skilled nursing facility services and intermediate care facility services, as follows: (A) Within five business days of the request for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Within seven business days of the request for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Within 14 calendar days of the request for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Within 14 calendar days of the request for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (3) A county Drug Medi-Cal organized delivery system shall provide an appointment within three business days to an opioid treatment program. (4) A dental managed care plan shall provide an appointment within four weeks of a request for routine pediatric dental services and within 30 calendar days of a request for specialist pediatric dental services. (e) The department may authorize a Medi-Cal managed care plan to use clinically appropriate video synchronous interaction, as defined in paragraph (5) of subdivision (a) of Section 2290.5 of the Business and Professions Code, as a means of demonstrating compliance with the time or distance standards established pursuant to this section, as defined by the department. The use of telehealth providers to meet time or distance standards does not absolve the Medi-Cal managed care plan of responsibility to provide a beneficiary with access, including transportation, to in-person services if the beneficiary prefers. (f) (1) The department may develop policies for granting credit in the determination of compliance with time or distance standards established pursuant to this section when Medi-Cal managed care plans contract with specified providers to use clinically appropriate video synchronous interaction, as defined in paragraph (5) of subdivision (a) of Section 2290.5 of the Business and Professions Code, and only for Medi-Cal managed care plans that cover at least 85 percent of the population points in the ZIP Code. (2) The department, upon request of a Medi-Cal managed care plan, may authorize alternative access standards for the time or distance standards established under this section if either of the following occurs: (A) The requesting Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet the applicable standard. (B) The [Text truncated for display. Full text available on Congress.gov.]