text:
For purposes of this article, the following definitions apply:

(a) “Certification” means the activities related to the verification that an individual has met all of the requirements under this article and that the individual may provide peer support specialist services pursuant to this article.

(b) “Certified” means all federal and state requirements have been satisfied by an individual who is seeking designation under this article, including completion of curriculum and training requirements, testing, and agreement to uphold and abide by the code of ethics.

(c) “Code of ethics” means the standards to which a peer support specialist is required to adhere.

(d) “Core competencies” means the foundational and essential knowledge, skills, and abilities required for peer specialists.

(e) “Cultural competence” means a set of congruent behaviors, attitudes, and policies that come together in a system or agency that enables that system or agency to work effectively in cross-cultural situations. A culturally competent system of care acknowledges and incorporates, at all levels, the importance of language and culture, intersecting identities, assessment of cross-cultural relations, knowledge and acceptance of dynamics of cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs to provide services in a culturally competent manner.

(f) “Department” means the State Department of Health Care Services.

(g) “Peer support specialist” means an individual who is 18 years of age or older, who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder, or both, either as a consumer of these services or as the parent or family member of the consumer, and who has been granted certification under a county peer support specialist certification program.

(h) “Peer support specialist services” means culturally competent services that promote engagement, socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths. Peer support specialist services include, but are not limited to, prevention services, support, coaching, facilitation, or education that is individualized and is conducted by a certified peer support specialist.

(i) “Recovery” means a process of change through which an individual improves their health and wellness, lives a self-directed life, and strives to reach their full potential. This process of change recognizes cultural diversity and inclusion, and honors the different routes to resilience and recovery based on the individual and their cultural community.


kind: section

code: WIC

text:
By July 1, 2022, subject to Section 14045.19, the department shall do all of the following:

(a) Establish statewide requirements for counties, or an agency representing counties, to use in developing certification programs for the certification of peer support specialists.

(b) Define the qualifications, range of responsibilities, practice guidelines, and supervision standards for peer support specialists. The department may utilize best practice materials published by the federal Substance Abuse and Mental Health Services Administration, the United States Department of Veterans Affairs, and related notable experts in the field as a basis for development of these definitions.

(c) Determine curriculum and core competencies required for certification of an individual as a peer support specialist, including curriculum that may be offered in areas of specialization, including, but not limited to, transition-age youth, veterans, gender identity, sexual orientation, and any other areas of specialization identified by the department. Core-competencies-based curriculum shall include, at a minimum, training related to all of the following elements:

(1) The concepts of hope, recovery, and wellness.

(2) The role of advocacy.

(3) The role of consumers and family members.

(4) Psychiatric rehabilitation skills and service delivery, and addiction recovery principles, including defined practices.

(5) Cultural competence training.

(6) Trauma-informed care.

(7) Group facilitation skills.

(8) Self-awareness and self-care.

(9) Cooccurring disorders of mental health and substance use.

(10) Conflict resolution.

(11) Professional boundaries and ethics.

(12) Preparation for employment opportunities, including study and test-taking skills, application and résumé preparation, interviewing, and other potential requirements for employment.

(13) Safety and crisis planning.

(14) Navigation of, and referral to, other services.

(15) Documentation skills and standards.

(16) Confidentiality.

(d) Specify peer support specialist employment training requirements, including core-competencies-based training and specialized training necessary to become certified under this article, and require training to include people with lived experience as consumers and family members.

(e) Establish a code of ethics.

(f) Determine continuing education requirements for biennial certification renewal.

(g) Determine the process for initial certification issuance and biennial certification renewal.

(h) Determine a process for investigation of complaints and corrective action, including suspension and revocation of certification and appeals.

(i) Determine a process for an individual employed as a peer support specialist on January 1, 2022, to obtain certification under this article.

(j) Determine requirements for peer support specialist certification reciprocity between counties, and for peer support specialists from out of state.

(k) Seek any federal approvals, related to the statewide certification standards, that it deems necessary to implement this article. For any federal approvals that the department deems necessary related to the statewide certification standards, this article shall be implemented only if and to the extent that the department obtains those federal approvals.

history: (History: Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 1.4. Peer Support Specialist Certification Program


text:
(a) Subject to department approval, a county, or an agency representing the county, may develop a peer support specialist certification program in accordance with this article and any standards established by the department. That county, or an agency representing that county, shall oversee and enforce the certification requirements developed pursuant to this article. To request department approval of the county peer support specialist program, a county, or an agency representing the county, shall do all of the following:

(1) Submit to the department a peer support specialist program plan describing how the peer support specialist program will meet all of the federal and state requirements for the certification and oversight of peer support specialists.

(2) Submit to periodic reviews conducted by the department to ensure adherence to all federal and state requirements.

(3) Submit annual peer support specialist program reports to the department.

(b) If a county chooses not to develop peer support specialist certification programs in accordance with this article, the county may fund peer programs to the extent those programs meet all requirements of the applicable funding source.

(c) The Legislature finds that peer support specialist certification is conducted at the state level in other states, but this section passes this responsibility to counties. Subject to an appropriation by the Legislature, the state shall fund the startup costs to implement this section.

article: 1.4. Peer Support Specialist Certification Program


text:
(a) To receive a certification under this article, an applicant shall meet all of the following requirements:

(1) Be at least 18 years of age.

(2) Possess a high school diploma or equivalent degree.

(3) Be self-identified as having experience with the process of recovery from mental illness or substance use disorder either as a consumer of these services or as the parent or family member of the consumer.

(4) Be willing to share their experience.

(5) Have a strong dedication to recovery.

(6) Agree, in writing, to adhere to a code of ethics.

(7) Successfully complete the curriculum and training requirements for a peer support specialist.

(8) Pass a certification examination approved by the department for a peer support specialist.

(b) To maintain certification under this article, a certified peer support specialist shall meet both of the following requirements:

(1) Adhere to the code of ethics and biennially sign an affirmation.

(2) Complete any required continuing education, training, and recertification requirements.


text: This article does not authorize an individual who is certified pursuant to this article to diagnose an illness, prescribe medication, or provide clinical services.


text: The department shall solicit stakeholder input that may include input from the Office of Statewide Health Planning and Development, peer support and family organizations, mental health services and substance use disorder treatment providers and organizations, the County Behavioral Health Directors Association of California, and the California Behavioral Health Planning Council in implementing this article. Consultation shall include regular stakeholder meetings. The department may additionally conduct technical workgroups upon the request of stakeholders.


text: A participating county, or an agency representing a participating county, is authorized to establish a certification fee schedule for the purpose of supporting the activities associated with the ongoing administration of the peer support specialist certification program. Before the fee schedule may be implemented, the department shall review and either approve or disapprove the fee schedule of the participating county or an agency representing the participating county.


text:
(a) The department shall seek any federal waivers it deems necessary to establish a demonstration or pilot project for the provision of peer support services in counties that agree to participate and provide the necessary nonfederal share funding for the demonstration or pilot project. The demonstration or pilot project shall do all of the following:

(1) Include a peer support specialist certified pursuant to this article as a Medi-Cal provider type for purposes of the demonstration or pilot project.

(2) Include peer support specialist services as a distinct service type in counties that opt in to the demonstration or pilot project.

(3) Develop and implement one or more billing codes, reimbursement rates, and claiming requirements for peer support specialist services.

(b) (1) This section does not require a county to participate in a demonstration or pilot project pursuant to this section. A county that opts to participate in a demonstration or pilot project and provide the necessary nonfederal share funding shall be considered to do so voluntarily for purposes of all state and federal laws.

(2) A county that opts to participate in a demonstration or pilot project pursuant to this section agrees to fund the nonfederal share of any applicable expenditures through certified public expenditures or intergovernmental transfers in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations. Each participating county shall certify that the local funds it uses to fund the nonfederal share of expenditures pursuant to this section qualify for federal financial participation pursuant to applicable federal Medicaid laws and any terms of federal approval, in the form and manner as required by the department.

(3) Demonstration or pilot projects developed and implemented pursuant to this section shall not constitute a mandate of a new program or higher level of service that has an overall effect of increasing the costs mandated by the 2011 realignment legislation for the counties that opt in to a demonstration or pilot project.

(4) General Fund moneys shall not be used to fund the nonfederal share of any expenditures made pursuant to a demonstration or pilot project under this section.

(c) This section shall be implemented only if and to the extent that the department obtains any necessary federal approvals, and federal financial participation is available and is not otherwise jeopardized.


text: For the purpose of implementing this article, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services or the Department of Technology.


text: Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article, in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action.


text:
(a) This article shall be known as the “Medi-Cal Conflict of Interest Law.”

It is the intent of the Legislature that provisions be made for disclosure of the interests of providers of service in the services, facilities, and organizations to which they refer Medi-Cal recipients so that it is possible to determine the extent to which conflicts of interests may exist because of such referrals.

It is the further intent of the Legislature that provision be made for the regulation of employment of present and former employees of state and local agencies responsible for the expenditure of funds under Medi-Cal so as to avoid the risk of conflicts of interests.

(b) As used in this article, the term “referral” means (1) the referral of a recipient by a provider of service to any other provider of service; (2) the placement of a recipient by a provider of service in any facility; or (3) the obtaining, requesting, ordering, or prescribing of services or supplies by a provider of service on behalf of a recipient from any other provider of service.

As used in this article, the term “immediate family” includes the spouse and children of the provider of service, the parents of the provider of service and their spouses, and the spouses of the children of the provider of service.

As used in this article, the term “state or local officer or employee who is responsible for the expenditure of substantial amounts of funds under Medi-Cal” means (1) the Director of the State Department of Health Care Services, and (2) those other state officers or employees, and those local officers or employees, who are determined by the director by regulation to be responsible for the expenditure of substantial amounts of funds under the California Medical Assistance Act and California’s State Plan under Title XIX of the federal Social Security Act.

As used in this article, the term “substantial amounts of funds” shall have the meaning defined by the director by regulation. As used in this article, “judicial, quasi-judicial or other proceeding” shall have the meaning defined in Article 4 (commencing with Section 87400) of Chapter 7 of Title 9 of the Government Code.

history: (History: Added by renumbering Section 14030 by Stats. 2019, Ch. 497, Sec. 316. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)

article: 1.6. Medi-Cal Conflict of Interest Law

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 1.6. Medi-Cal Conflict of Interest Law


text: A payment under this chapter shall not be made to a provider of services or to any facility or organization in which a provider of service or the immediate family of the provider of service has a significant beneficial interest, for services rendered in connection with any referral of a recipient, unless there is on file with the director and the Advisory Health Council a statement of the nature and extent of such interest.

history: (History: Added by renumbering Section 14031 by Stats. 2019, Ch. 497, Sec. 317. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)

article: 1.6. Medi-Cal Conflict of Interest Law


text:
(a) A state or local officer or employee who is responsible for the expenditure of substantial amounts of funds under Medi-Cal, an individual who formerly was such an officer or employee, or a partner of such an officer or employee shall not commit any act, in connection with any activity concerning Medi-Cal, if the commission of such act by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee, in connection with any activity concerning the United States Government, would be prohibited by Section 207 or 208 of Title 18 of the United States Code.

(b) Upon the petition of any interested person or party, a court or state administrative agency or any officer thereof in any judicial, quasi-judicial or other proceeding may, after notice and an opportunity for hearing, exclude any person found to be in violation of this section from further participation in any judicial, quasi-judicial or other proceeding then pending before such court, agency or officer.

(c) The prohibitions of this section do not apply to any person who left government service prior to the effective date of this section except that any such person who returned to government service on or after the effective date of this section shall be covered thereby.

history: (History: Added by renumbering Section 14032 by Stats. 2019, Ch. 497, Sec. 318. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)

article: 1.6. Medi-Cal Conflict of Interest Law


text: This article shall remain in effect only until Section 1902(a)(4)(C) of the federal Social Security Act, as added by Public Law 95-559 is repealed, held invalid by a court of appeal, or otherwise made inoperative, and as of such date is repealed.

history: (History: Added by renumbering Section 14033 by Stats. 2019, Ch. 497, Sec. 319. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed by its own provisions. After repeal, see related provisions in Section 14022. Note: Repeal affects Article 1.6, commencing with Section 14047.)

article: 1.6. Medi-Cal Conflict of Interest Law


text: Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter.

history: (History: Repealed and added by Stats. 1965, 2nd Ex. Sess., Ch. 4.)

article: 2. Definitions

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2. Definitions


text: For purposes of this chapter, “categorically needy person” means a person whose coverage is mandatory under Title XIX of the Social Security Act including, but not limited to, the individuals covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the United States Code.

history: (History: Amended by Stats. 1991, Ch. 735, Sec. 3.)

article: 2. Definitions


text: For the purposes of this chapter “aid” means financial assistance provided to or in behalf of needy persons under the provisions of Chapters 2 (commencing with Section 11200), 3 (commencing with Section 12000), and 5 (commencing with Section 13000) of this part.

history: (History: Added by Stats. 1976, Ch. 126.)

article: 2. Definitions


text: “A person in long-term care” means a person who is an inpatient in a medical facility for more than the month of admission who is expected to remain for the full month after the month of admission.

article: 2. Definitions


text:
(a) “Medically needy person” means any of the following:

(1) An aged, blind, or disabled person who meets the definition of aged, blind, or disabled under the Supplemental Security Income program and whose income and resources are insufficient to provide for the costs of health care or coverage.

(2) A child in foster care for whom public agencies are assuming financial responsibility, in whole or in part, or a person receiving aid under Chapter 2.1 (commencing with Section 16115) of Part 4.

(3) A child who is eligible to receive Medi-Cal benefits pursuant to interstate agreements for adoption assistance and related services and benefits entered into under Chapter 2.6 (commencing with Section 16170) of Part 4, to the extent federal financial participation is available.

(b) “Medically needy family person” means a parent or caretaker relative of a child or a child under 21 years of age or a pregnant woman of any age with a confirmed pregnancy, exclusive of those persons specified in subdivision (a), whose income and resources are insufficient to provide for the costs of health care or coverage.

(c) This section shall become operative on January 1, 2026.

history: (History: Amended (as amended by Stats. 2023, Ch. 42, Sec. 120) by Stats. 2025, Ch. 21, Sec. 89. (AB 116) Effective June 30, 2025. Operative January 1, 2026, by its own provisions.)

article: 2. Definitions


text:
(a) “Medically needy person” means any of the following:

(1) An aged, blind, or disabled person who meets the definition of aged, blind, or disabled under the Supplemental Security Income program and whose income is insufficient to provide for the costs of health care or coverage.

(2) A child in foster care for whom public agencies are assuming financial responsibility, in whole or in part, or a person receiving aid under Chapter 2.1 (commencing with Section 16115) of Part 4.

(3) A child who is eligible to receive Medi-Cal benefits pursuant to interstate agreements for adoption assistance and related services and benefits entered into under Chapter 2.6 (commencing with Section 16170) of Part 4, to the extent federal financial participation is available.

(b) “Medically needy family person” means a parent or caretaker relative of a child or a child under 21 years of age or a pregnant woman of any age with a confirmed pregnancy, exclusive of those persons specified in subdivision (a), whose income is insufficient to provide for the costs of health care or coverage.

(c) This section shall become inoperative on January 1, 2026, and, as of January 1, 2027, is repealed.

history: (History: Amended (as added by Stats. 2023, Ch. 42, Sec. 121) by Stats. 2025, Ch. 21, Sec. 90. (AB 116) Effective June 30, 2025. Inoperative January 1, 2026, by its own provisions. Repealed as of January 1, 2027, by its own provisions. See later operative version, as amended by Sec. 89 of Stats. 2025, Ch. 21.)

article: 2. Definitions


text:
(a) “Medically needy person” also means any person who receives in-home supportive services pursuant to Section 12305.5 and whose income and resources are insufficient to provide for the costs of health care or coverage.

(b) This section shall become operative on January 1, 2026.

history: (History: Amended (as amended by Stats. 2023, Ch. 42, Sec. 122) by Stats. 2025, Ch. 21, Sec. 91. (AB 116) Effective June 30, 2025. Operative January 1, 2026, by its own provisions.)

article: 2. Definitions


text:
(a) “Medically needy person” also means any person who receives in-home supportive services pursuant to Section 12305.5 and whose income is insufficient to provide for the costs of health care or coverage.

(b) This section shall become inoperative on January 1, 2026, and, as of January 1, 2027, is repealed.

history: (History: Amended (as added by Stats. 2023, Ch. 42, Sec. 123) by Stats. 2025, Ch. 21, Sec. 92. (AB 116) Effective June 30, 2025. Inoperative January 1, 2026, by its own provisions. Repealed as of January 1, 2027, by its own provisions. See later operative version, as amended by Sec. 91 of Stats. 2025, Ch. 21.)

article: 2. Definitions


text: “Post-eligibility treatment of income” means the determination of long-term care patient liability for each month in which the patient is described in Section 14050.3 or as an institutionalized spouse described in Section 14002.5 determined in accordance with Section 435.725 of Title 42 of the Code of Federal Regulations, without regard to paragraph (1) of subsection (b) of that section, and Sections 435.832, and 435.845 of Title 42 of the Code of Federal Regulations, as appropriate.

history: (History: Added by Stats. 2023, Ch. 42, Sec. 124. (AB 118) Effective July 10, 2023.)

article: 2. Definitions


text: “Long-term care patient liability” is the term given to the result of the post-eligibility treatment of income calculation under Section 14051.7. The person in long-term care or an institutionalized spouse shall incur or expect to incur an amount of medical expenses that equal this amount pursuant to subdivision (d) of Section 14005.12.

history: (History: Added by Stats. 2023, Ch. 42, Sec. 125. (AB 118) Effective July 10, 2023.)

article: 2. Definitions


text:
“State-only Medi-Cal person” means a person who resides in a nursing facility or any category of intermediate care facility for the developmentally disabled, and who meets all of the following requirements:

(a) Could not meet the definition of a categorically needy person under Section 14050.1, a medically needy person under subdivision (a) of Section 14051 or a medically needy family person under subdivision (b) of Section 14051.

(b) Is over 21 years of age.

(c) Meets the eligibility requirements of Section 14005.4.

history: (History: Amended by Stats. 1990, Ch. 1329, Sec. 15. Effective September 26, 1990.)

article: 2. Definitions


text: “Cuban-Haitian entrant or refugee” means a person eligible under the Cuban-Haitian Entrant Program or Refugee Resettlement Program, as defined in federal regulations.

history: (History: Added by Stats. 1985, Ch. 1354, Sec. 19.)

article: 2. Definitions


text:
(a) The term “health care services” means the benefits set forth in Article 4 (commencing with Section 14131) of this chapter and in Section 14021. The term includes inpatient hospital services for any individual under 21 years of age in an institution for mental diseases. Any individual under 21 years of age receiving inpatient psychiatric hospital services immediately preceding the date on which he or she attains age 21 may continue to receive these services until he or she attains age 22. The term also includes early and periodic screening, diagnosis, and treatment for any individual under 21 years of age.

(b) The term “health care services” does not include, except to the extent permitted by federal law, any of the following:

(1) Care or services for any individual who is an inmate of an institution (except as a patient in a medical institution).

(2) Care or services for any individual who has not attained 65 years of age and who is a patient in an institution for tuberculosis.

(3) Care or services for any individual who is 21 years of age or over, except as provided in the first paragraph of this section, and has not attained 65 years of age and who is a patient in an institution for mental disease.

(4) Inpatient services provided to individuals 21 to 64 years of age, inclusive, in an institution for mental diseases operating under a consolidated license with a general acute care hospital pursuant to Section 1250.8 of the Health and Safety Code, unless federal financial participation is available for such inpatient services.

history: (History: Amended by Stats. 2000, Ch. 93, Sec. 64. Effective July 7, 2000.)

article: 2. Definitions


text: Notwithstanding Section 14053, ancillary outpatient services, pursuant to Section 14132, for any eligible individual who is 21 years of age or over, and has not attained 65 years of age and who is a patient in an institution for mental diseases shall be covered regardless of the availability of federal financial participation.

history: (History: Amended by Stats. 2001, Ch. 171, Sec. 38. Effective August 10, 2001. Note: Because the previously existing Section 14053.1 was repealed on July 1, 2001, Ch. 171, this section may have been added.)

article: 2. Definitions


text:
(a) Except as provided under federal law, federal financial participation reimbursement is not allowed for ancillary services provided to persons residing in facilities that have been found to be institutions for mental disease (IMD), and since, consistent with Part 2 (commencing with Section 5600) of Division 5 and Chapter 6 (commencing with Section 17600) of Part 5, counties are financially responsible for specialty mental health services and related ancillary services provided to persons through county mental health programs when Medi-Cal reimbursement is not available, when it is determined that Medi-Cal reimbursement has been paid for ancillary services for residents of IMDs, both the federal financial participation reimbursement and any state funds paid for the ancillary services provided to residents of IMDs shall be recovered from counties by the department in accordance with applicable state and federal statutes and regulations.

(b) Mental health plans shall report to the department admission and discharge dates for Medi-Cal beneficiaries in institutions for mental diseases on a quarterly basis in a format provided by the department.

history: (History: Amended by Stats. 2012, Ch. 34, Sec. 225. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

article: 2. Definitions


text:
For the purposes of the Medi-Cal Act, the terms “prescribed drug” and “prescription drug” shall not include any drug which, because of differing prices charged by the manufacturer on a discriminatory basis or discriminatory refusal to sell by the manufacturer, or both, is not available on the same terms and conditions to all providers of prescription services, or any drug which is found to be overpriced in comparison to another drug which has an equivalent therapeutic effect, unless the director determines that the drug is vital to the program and no acceptable substitute is available.

Before the director determines that any drug has an equivalent therapeutic effect in comparison to another drug, or is vital to the program and no acceptable substitute is available, he must have received a report to that effect from the Medi-Cal Contract Drug Advisory Committee.

Nothing in this section shall be construed to apply to quantity or other nondiscriminatory discounts available on the same terms and conditions to all providers of prescription services, to sales by competitive bidding to federal, state or local governmental agencies, or to sales to wholesalers so long as the manufacturer does not require or induce the wholesalers to make the drug available other than on the same terms and conditions to all providers of prescription services.

This section shall not be construed to deny reimbursement to hospitals for prescribed drugs furnished to inpatients or, unless the regulations provide to the contrary, to registered outpatients.

history: (History: Amended by Stats. 1990, Ch. 456, Sec. 11. Effective July 31, 1990.)

article: 2. Definitions


text: Prior to including or excluding any drug from the program, the director shall give adequate notice to those California associations of health professionals and those recognized national associations of pharmaceutical manufacturers that are affected by such action and shall seek and consider the advice of those associations.

history: (History: Amended by Stats. 1969, Ch. 21.)

article: 2. Definitions


text:
(a) Notwithstanding any other provision of law, and only to the extent that federal financial participation is available, the department may provide Medi-Cal eligibility and reimbursement for acute inpatient hospital services available under this chapter in accordance with Section 5072 of the Penal Code.

(b) The department may disenroll inmates made eligible for services under this section or in accordance with Section 5072 of the Penal Code from Medi-Cal managed care health plans, and may exempt inmates from enrollment into new or existing plans.

(c) Except as provided for in paragraph (2) of subdivision (e), the Department of Corrections and Rehabilitation shall be responsible for the nonfederal share of any reimbursement made for the provision of acute inpatient hospital services rendered to inmates who are eligible for and enrolled in a LIHP and receive services pursuant to this section and Section 5072 of the Penal Code.

(d) (1) Notwithstanding any other provision of law, including Section 11050, the department, as the single state agency, may make eligibility determinations and redeterminations for inmates in accord with this section and Section 5072 of the Penal Code.

(2) The department may enroll and disenroll inmates eligible for acute inpatient hospital services under this section or in accord with Section 5072 of the Penal Code in Medi-Cal or in the LIHP in which the inmate’s county of last legal residence participates.

(e) (1) In accordance with the requirements and conditions set forth under this section and Section 5072 of the Penal Code, the county may seek from the Medi-Cal program or from the responsible LIHP in which the county participates, reimbursement for the provision of inpatient hospital services to adults involuntarily detained or incarcerated in county facilities.

(2) (A) To the extent that a county seeks reimbursement for the provision of acute inpatient hospital services to adults who are involuntarily detained or incarcerated in county facilities and who are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, the county shall be responsible for the nonfederal share of the reimbursement.

(B) To the extent that a county seeks reimbursement for the provision of acute inpatient hospital services to adults who are involuntarily detained or incarcerated in county facilities and who are otherwise eligible for and enrolled in the LIHP in which the county participates, the LIHP shall be responsible for the nonfederal share of the reimbursement.

(f) Reimbursement pursuant to this section shall be limited to only those services for which federal financial participation pursuant to Title XIX of the federal Social Security Act is allowed.

(g) This section shall be implemented only if and to the extent that existing levels of federal financial participation are not otherwise jeopardized. To the extent that the department determines that existing levels of federal financial participation are jeopardized, this section shall no longer be implemented.

(h) The department shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only if and to the extent that any necessary federal approvals are obtained.

(i) This section shall have no force or effect if there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services, that disallows, defers, or alters the implementation of this section or in accord with Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the hospitals used to provide acute inpatient hospital services to inmates.

(j) It is the intent of the Legislature that the implementation of this section will result in state General Fund savings for the funding of acute inpatient hospital services provided to inmates and any related administrative costs.

(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions.

(l) For purposes of this section, the following terms have the following meanings:

(1) The term “county of last legal residence” means the county in which the inmate resided at the time of arrest that resulted in conviction and incarceration in a state prison facility.

(2) The term “inmate” means an adult who is involuntarily residing in a state prison facility operated, administered or regulated, directly or indirectly, by the Department of Corrections and Rehabilitation.

history: (History: Amended by Stats. 2011, Ch. 36, Sec. 82. (SB 92) Effective June 30, 2011.)

article: 2. Definitions


text:
(a) Notwithstanding any other law, the department shall develop a process to allow counties to receive any available federal financial participation for acute inpatient hospital services and inpatient psychiatric services provided to juvenile inmates who are admitted as inpatients in a medical institution off the grounds of the correctional facility, and who, but for their institutional status as inmates, are otherwise eligible for Medi-Cal benefits pursuant to this chapter. This process shall be coordinated, to the extent possible, with the processes and procedures established pursuant to Section 14053.7 of this code and Section 5072 of the Penal Code. This section shall not be construed to alter or abrogate any obligation of the state pursuant to an administrative action or a court order that is final and no longer subject to appeal to reimburse counties for any acute inpatient hospital services or inpatient psychiatric services provided to a juvenile inmate.

(b) A juvenile inmate who is an inpatient in a medical institution off the grounds of the correctional facility shall not be denied eligibility for Medi-Cal benefits under this section because of his or her institutional status as an inmate of a public institution.

(c) The department shall consult with counties in the development of the process pursuant to this section.

(d) This section shall not be construed to limit the department’s authority to suspend or terminate Medi-Cal eligibility pursuant to Section 14011.10, except during such times that the juvenile inmate is receiving acute inpatient hospital services or inpatient psychiatric services pursuant to subdivision (b).

(e) This section shall be implemented only if and to the extent that existing levels of federal financial participation are not otherwise jeopardized. To the extent that the department determines that existing levels of federal financial participation are jeopardized, this section shall no longer be implemented.

(f) The department shall seek any federal approvals necessary to implement the process developed pursuant to this section. This section shall be implemented only if and to the extent that any necessary federal approvals have been obtained, and only to the extent that federal financial participation is available.

(g) Notwithstanding any other law, as part of the process developed pursuant to this section, the department may exempt juvenile inmates from enrollment into new or existing managed care health plans.

(h) The process developed pursuant to this section shall be implemented in only those counties that elect to provide the county’s pro rata portion of the nonfederal share of the state’s administrative costs associated with implementation of this section and the nonfederal share of expenditures for acute inpatient hospital services and inpatient psychiatric services provided to eligible juvenile inmates described in subdivision (a).

(i) (1) The federal financial participation received pursuant to the process implemented under this section shall be paid to the participating counties for services rendered to the juvenile inmates. If a federal audit disallowance and interest results from claims made under the process created pursuant to this section, the department shall recoup from the county that received the disallowed funds the amount of the disallowance and any applicable interest.

(2) It is the intent of the Legislature that implementation of this section will result in no increased cost to the state General Fund.

(j) (1) If there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services (CMS), that disallows, defers, or alters the implementation of this section or, to the extent applicable, Section 14053.7 of this code or Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the facilities used to provide acute inpatient hospital services and inpatient psychiatric services to juvenile inmates, then any provision of this section that is inconsistent with the final judicial or CMS determination shall have no force or effect.

(2) In addition, the department may, at its discretion, cease to implement any other part of this section that is implicated by the final judicial or CMS determination.

(k) For the purposes of Medi-Cal eligibility pursuant to this section, “juvenile inmate” means an individual under 21 years of age who is involuntarily residing in a public institution, including state and local institutions.

(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions.

history: (History: Amended by Stats. 2014, Ch. 836, Sec. 1. (SB 1089) Effective January 1, 2015.)

article: 2. Definitions


text:
(a) Notwithstanding any other provision of law, the department shall develop a process to allow the Department of Corrections and Rehabilitation, Division of Juvenile Facilities, or any successor, to receive any available federal financial participation for acute inpatient hospital services and inpatient psychiatric services provided to any juvenile inmates in the Division of Juvenile Facilities who are admitted as inpatients in a medical institution off the grounds of the correctional facility, and who, but for their institutional status as juvenile inmates, are otherwise eligible for Medi-Cal benefits pursuant to this chapter. This process shall be coordinated, to the extent possible, with the processes and procedures established pursuant to Section 14053.7 of this code and Section 5072 of the Penal Code.

(b) Any juvenile inmate in the Division of Juvenile Facilities who is an inpatient in a medical institution off the grounds of the correctional facility shall not be denied eligibility for Medi-Cal benefits under this section because of his or her institutional status as an inmate in the Division of Juvenile Facilities.

(c) The department shall consult with the Division of Juvenile Facilities in the development of the process pursuant to this section.

(d) The department shall seek any federal approvals necessary to implement the process developed pursuant to this section. This section shall be implemented only if and to the extent that any necessary federal approvals have been obtained, and only to the extent that federal financial participation is available.

(e) Notwithstanding any other provision of law, as part of the process developed pursuant to this section, the department may exempt any juvenile inmate in a facility operated by the Division of Juvenile Facilities from enrollment into new or existing managed care health plans.

(f) The process developed pursuant to this section shall be implemented only to the extent that the Division of Juvenile Facilities agrees voluntarily to provide the nonfederal share of any costs to the department associated with the administration of this section and the nonfederal share of expenditures for acute inpatient hospital services and inpatient psychiatric services provided off the grounds of the correctional facility to any juvenile inmate of the Division of Juvenile Facilities who is eligible for Medi-Cal benefits pursuant to this section.

(g) The federal financial participation received pursuant to this section shall be paid to the Department of Corrections and Rehabilitation for services rendered to any juvenile inmate in the Division of Juvenile Facilities.

(h) Reimbursement pursuant to this section shall be limited to only those services for which federal financial participation is available.

(i) (1) If there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services (CMS), that disallows, defers, or alters the implementation of this section or, to the extent applicable, Section 14053.7 of this code or Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the facilities used to provide acute inpatient hospital services and inpatient psychiatric services to juvenile inmates in the Division of Juvenile Facilities, then any provision of this section that is inconsistent with the final judicial or CMS determination shall have no force or effect.

(2) In addition, the department may, at its discretion, cease to implement any other part of this section that is implicated by the final judicial or CMS determination.

(j) For the purposes of Medi-Cal eligibility pursuant to this section, “juvenile inmate” means an individual under 21 years of age who is involuntarily residing in a public institution, including state and local institutions.

(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions.

history: (History: Amended by Stats. 2012, Ch. 162, Sec. 212. (SB 1171) Effective January 1, 2013.)

article: 2. Definitions


text:
(a) “Share of cost” or “spend down of excess income” means the amount of the costs of health care that a person or family eligible under Section 14005.4 or 14005.7 shall incur prior to being certified by the department as specified in Section 14018.

(b) Upon the effective date of the act that added this subdivision, any reference to “share of cost” in this chapter or elsewhere in this code that relates to an individual Medi-Cal beneficiary’s or applicant’s eligibility under the medically needy persons or medically needy family persons categories shall be read as “spend down of excess income” and the definition in subdivision (a) shall apply.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 126. (AB 118) Effective July 10, 2023.)

article: 2. Definitions


text: “Elective services” means any treatment service which generally can be postponed without seriously affecting the health of the person requiring the service.

history: (History: Added by Stats. 1968, Ch. 1242.)

article: 2. Definitions


text:
(a) For the purposes of this chapter, “caretaker relative” means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following:

(1) The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, great grandparent, uncle, aunt, nephew, niece, great-great grandparent, great uncle or aunt, first cousin, great-great-great grandparent, great-great uncle or aunt, or first cousin once removed.

(2) The spouse or registered domestic partner of one of the relatives identified in paragraph (1), even after the marriage is terminated by death or divorce or the domestic partnership has been legally terminated.

(b) This section shall become operative on January 1, 2014.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 3, Sec. 23. (AB 1 1x) Effective September 30, 2013. Section operative January 1, 2014, by its own provisions.)

article: 2. Definitions


text: “Minimum coverage” means prescribed drugs for public assistance recipients as established by the director, and care or coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of Section 14053, except that it shall not include elective services.

history: (History: Amended by Stats. 1972, Ch. 1101.)

article: 2. Definitions


text:
(a) For the purposes of this chapter, “insurance affordability program” means a program that is one of the following:

(1) The state’s Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).

(2) The state’s children’s health insurance program (CHIP) under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.).

(3) A program that makes available to qualified applicants coverage in a qualified health plan through the California Health Benefit Exchange, established pursuant to Title 22 (commencing with Section 100500) of the Government Code, with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code.

(4) A program that makes available coverage in a qualified health plan through the California Health Benefit Exchange, established pursuant to Title 22 (commencing with Section 100500) of the Government Code, with cost-sharing reductions established under Section 1402 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), and any subsequent amendments to that act.

(b) This section shall become operative on October 1, 2013.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 24. (SB 1 1x) Effective September 30, 2013. Section operative October 1, 2013, by its own provisions.)

article: 2. Definitions


text: “Contract hospital” means a nonprofit medical facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, with which the board of supervisors of a county which does not maintain a county hospital has executed a contract, currently in effect, to care for medically indigent individuals.

history: (History: Amended by Stats. 1973, Ch. 142.)

article: 2. Definitions


text:
Health care provided under this chapter may include diagnostic, preventive, corrective, and curative services and supplies essential thereto, provided by qualified medical and related personnel for conditions that cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity including employment, or for conditions which may develop into some significant handicap.

Medical care shall include, but is not limited to, other remedial care, not necessarily medical. Other remedial care shall include, without being limited to, treatment by prayer or healing by spiritual means in the practice of the religion of any church or religious denomination.

article: 2. Definitions


text:
(a) For individuals 21 years of age or older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

(b) (1) For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if the service meets the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code.

(2) The department and its contractors shall update any model evidence of coverage documents, beneficiary handbooks, and related material to ensure the medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials.

(3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, and make specific this subdivision by means of all-county letters, plan letters, plan provider bulletins, manuals, plan contract amendments, or similar instructions until regulations are revised or adopted.

(4) By July 1, 2022, the department shall revise or adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. This paragraph shall not apply to a Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101.

(c) This section shall not be construed to limit the application of subdivisions (a) and (b) of Section 51184 of Title 22 of the California Code of Regulations.

(d) Medical necessity for covered benefits provided in a Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101, shall also be governed in accordance with Section 14184.402.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 371. (AB 133) Effective July 27, 2021.)

article: 2. Definitions


text: Every recipient who is entitled to visual care under this chapter, which may be rendered either by an optometrist or a physician, may select a duly licensed member of either profession to render the service.

history: (History: Added by Stats. 1965, 2nd Ex. Sess., Ch. 4.)

article: 2. Definitions


text: As used in this chapter, “director” means the State Director of Health Services.

history: (History: Amended by Stats. 1977, Ch. 1252.)

article: 2. Definitions


text: As used in this chapter, “department” means the State Department of Health Services.

article: 2. Definitions


text: As used in this chapter, “Medi-Cal” means the California Medical Assistance Program.

history: (History: Added by Stats. 1971, Ch. 577.)

article: 2. Definitions


text:
(a) Inpatient intensive rehabilitation hospital services shall consist of programs for:

(1) Strengthening and training of selected muscle groups.

(2) Preservation and restoration of joint mobility (prevention and correction of contractures).

(3) Training in application and use of equipment.

(4) Training in activities of daily living, self-care, locomotion and homemaking skills.

(5) Cognitive reorganization and communication skills.

(6) Resolution of psychological and social problems which are impeding rehabilitation.

(b) These programs shall use a multidiscipline approach carried out under the general or direct supervision of a physician with special training or experience in the field of rehabilitation. When medically indicated, a program of this scope includes but is not limited to:

(1) Skilled rehabilitation nursing care.

(2) Physical therapy.

(3) Occupational therapy.

(4) Speech therapy.

(5) Prosthetic or orthotic services.

(6) Psychologist services.

(7) Medical social worker services.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 127. (AB 118) Effective July 10, 2023.)

article: 2. Definitions


text: As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Director of Health” and “Director of Benefit Payments” shall be construed to refer to and mean the State Director of Health Services.

history: (History: Amended by Stats. 1978, Ch. 429.)

article: 2. Definitions


text: As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Department of Health,” “State Department of Health,” “Department of Benefit Payments,” and “State Department of Benefit Payments” shall be construed to refer to and mean the State Department of Health Services.

history: (History: Added by renumbering Section 14064 (as added by Stats. 1977, Ch. 1252) by Stats. 1978, Ch. 429.)

article: 2. Definitions


text:
(a) The department, in conjunction with the Managed Risk Medical Insurance Board, may develop and conduct a community outreach and education campaign to help families learn about, and apply for, Medi-Cal and the Healthy Families Program of the Managed Risk Medical Insurance Board, subject to the requirements of federal law. In conducting this campaign, the department may seek input from, and contract with, various entities and programs that serve children, including, but not limited to, the State Department of Education, counties, Women, Infants, and Children program agencies, Head Start and Healthy Start programs, and community-based organizations that deal with potentially eligible families and children to assist in the outreach, education, and application completion process. The department shall implement the campaign if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute.

(b) In implementing this section, the department may amend any existing or future media outreach campaign contract that it has entered into pursuant to Section 14148.5. Notwithstanding any other provision of law, any such contract entered into, or amended, as required to implement this section, shall be exempt from the approval of the Director of General Services and from the provisions of the Public Contract Code.

(c) (1) The department, in conjunction with the Managed Risk Medical Insurance Board, may award contracts to community-based organizations to help families learn about, and enroll in, the Medi-Cal program and Healthy Families Program, and other health care programs for low-income children. The department shall implement this subdivision if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute.

(2) Contracts for these outreach and enrollment projects shall be awarded based on, but not limited to, all of the following criteria:

(A) Capacity to reach populations or geographic areas with disproportionately low enrollment rates. If it is not possible to estimate the number of uninsured children in a geographic area who are eligible for the Medi-Cal program or the Healthy Families Program, proxy measures for rates of eligible children may be used. These measures may include, but are not limited to, the number of children in families with gross annual household incomes at or below the federal poverty levels pertinent to the programs.

(B) Organizational capacity and experience, including, but not limited to, any of the following:

(i) Organizational experience in serving low-income families.

(ii) Ability to work effectively with populations that have disproportionately low enrollment rates.

(iii) Organizational experiences in helping families learn about, and enroll in, the Medi-Cal program and Healthy Families Program. Organizations that do not have experience helping families learn about, and enroll in, the Medi-Cal program and Healthy Families Program shall be eligible only to the extent that they support and collaborate with the outreach and enrollment activities of entities with that experience.

(C) Effectiveness of the outreach and education plan, including, but not limited to, all of the following:

(i) Culturally and linguistically appropriate outreach and education strategies.

(ii) Strategies to identify and address barriers to enrollment, such as transportation limitations and community perceptions regarding the Medi-Cal program and Healthy Families Program.

(iii) Coordination with other outreach efforts in the community, including the statewide Healthy Families Program and Medi-Cal program outreach campaign, the state and federally funded county Medi-Cal outreach program, and any other Medi-Cal program and Healthy Families Program outreach projects in the target community.

(iv) Collaboration with other local organizations that serve families of eligible children.

(v) Strategies to ensure that children and families retain coverage and are informed of options for health coverage and services when they lose eligibility for a particular program.

(vi) Plans to inform families about all available health care programs and services.

history: (History: Amended by Stats. 2012, Ch. 728, Sec. 199. (SB 71) Effective January 1, 2013.)

article: 2. Definitions


text:
(a) (1) The department may maintain an allocation program for the management and funding of county outreach and enrollment plans to enroll and retain eligible children in the Medi-Cal program and the Healthy Families Program.

(2) Notwithstanding any other provision of law, and in a manner that the director shall provide, the department may allocate an amount to fund county outreach and enrollment plans identified in this section.

(b) (1) The sum of three million dollars ($3,000,000) in the 2006–07 fiscal year, and thereafter adjusted proportionately on a pro rata basis contingent upon the annual appropriation, but not less than two million dollars ($2,000,000), shall be set aside, from the annual allocation for purposes of this section, for counties identified in subdivision (d).

(2) Notwithstanding paragraph (1), the total of all county allocations made pursuant to this section shall not exceed the annual appropriation for the implementation of this section.

(c) The director shall make allocations to not more than 20 counties that have the highest number of children who appear to be eligible for the Medi-Cal program or the Healthy Families Program, as determined by the director, but who are not currently enrolled in either program, and the highest number of Medi-Cal program and Healthy Families Program cases for children. This number shall be weighted to emphasize those who appear eligible, but are not currently enrolled in the programs.

(d) With funds set aside under paragraph (1) of subdivision (b), the director shall make allocations to those counties that have an existing infrastructure for outreach, enrollment, retention, and utilization, and that can demonstrate they have well established and documented county coalitions for children’s coverage with organizations such as community-based organizations, schools, clinics, labor organizations, and other safety net providers in place for at least 12 months.

(e) (1) To obtain an allocation authorized under this section, a county shall submit an allocation plan, which shall include an outreach and enrollment plan, as outlined in paragraph (2). The director shall establish the procedures and format for submission to the department of all county allocation plans.

(2) The following shall constitute the minimum components required of a county outreach and enrollment plan:

(A) An active collaboration with a wide range of organizations, such as community-based organizations, schools, clinics, labor organizations, and other safety net providers.

(B) A streamlined application assistance process.

(C) Establishment of an oversight, performance management, and review program to ensure that the outreach and enrollment plan submitted by the county is properly implemented and administered.

(D) A description of each of the following:

(i) The amount of the current funding and funding source for application, enrollment, retention, and utilization activities.

(ii) The current application, enrollment, retention, and utilization activities.

(iii) How the allocation funds awarded under this section will be used to supplement and not supplant existing application, enrollment, retention, and utilization activities.

(E) A detailed proposed budget of all expenditures for the relevant fiscal year or years for the county’s outreach and enrollment plan activities, expenses, services, materials, and support.

(f) Counties receiving an allocation under this section shall provide reports to the department, as determined by the department, on the progress made in achieving the objectives of the allocation plan.

(g) (1) The funds allocated under this section shall be used only for outreach, enrollment, retention, and utilization. The funds allocated under this section may supplement, but shall not supplant, existing local, state, and foundation funding of county outreach, enrollment, retention, and utilization activities. Notwithstanding Section 10744, the department may recoup or withhold all or part of a county’s allocation for failure to comply with the standards set forth in the county’s outreach and enrollment plan upon which the allocation was based.

(2) Notwithstanding any other provision in this section, any acquisitions made with funds allocated under this section shall be made in compliance with federal law.

(h) Reimbursements for costs incurred under the allocation plan authorized under this section shall be made in arrears and in a manner as provided by the director. The allocations may be used only to fund activities provided in each of the designated fiscal years and in accordance with the county’s approved outreach and enrollment plan and budget for the fiscal year.

(i) As authorized by the director, on a case by case basis, funds allocated pursuant to this section may be used to support automated enrollment of children in the Medi-Cal program or the Healthy Families Program. Funds under this subdivision shall further the goal of increasing the enrollment of uninsured children, as well as increasing the retention of children, in the Medi-Cal program and Healthy Families Program in the same fiscal year for which the funds are allocated.

(j) The department and the Managed Risk Medical Insurance Board shall seek approval of any amendments to the state plan necessary to implement this section for purposes of funding under Titles XIX and XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq. and 1397aa et seq., respectively). This section shall be implemented only when federal approvals have been obtained and only to the extent federal financial participation is available.

(k) The department shall reimburse a county pursuant to this section in lieu of commencing a cooperative agreement or contract with a county for the operation of an outreach program.

(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all county letters, provider bulletins, or similar instructions.

(m) For the purposes of this section, “county outreach and enrollment plan” means a county outreach program designed to identify and enroll children who are eligible either for the Healthy Families Program or the Medi-Cal program, but are not currently enrolled in either program, and to facilitate the retention of eligible children currently enrolled in these programs.

history: (History: Added by Stats. 2006, Ch. 74, Sec. 63. Effective July 12, 2006.)

article: 2. Definitions


text: The department shall encourage counties to outstation additional Medi-Cal eligibility workers in nontraditional sites, such as schools, private hospitals, clinics, mental health centers, sites providing services under California Supplemental Food Program for Women, Infants, and Children sites, and community-based organizations. The department shall permit counties to redirect a portion of existing funding for Medi-Cal eligibility administration for this purpose. The department shall require counties that redirect funds to provide an annual report on the cost of the additional outstationed workers and their effectiveness in increasing or facilitating Medi-Cal enrollment. Expenditures under this section shall be subject to the availability of federal financial participation, and shall not cause an increase in the allocation of funds for the administration of the Medi-Cal program.

history: (History: Added by Stats. 2000, Ch. 93, Sec. 66. Effective July 7, 2000.)

article: 2. Definitions


text: In conducting outreach activities for the enrollment of special needs populations into a Medi-Cal managed care program, the department and its contractors, as deemed applicable by the department, shall work with state, local, and regional organizations with the ability to target low-income seniors and individuals with disabilities in the communities where they live. This shall include, but not be limited to, all applicable state departments that serve these individuals, regional centers, seniors’ organizations, local health consumer centers, and other consumer-focused organizations that are engaging in providing assistance to this population.

history: (History: Added by Stats. 2006, Ch. 74, Sec. 64. Effective July 12, 2006.)

article: 2. Definitions


text: The Legislature intends that Medi-Cal recipients have reasonable access to medical care services and especially to primary and maternity care services. In order to obtain such access, the Legislature intends that, to the extent feasible and permitted by federal law, physicians be reimbursed equally statewide for comparable services, at a rate sufficient to provide Medi-Cal recipients with such reasonable access, and also intends that higher rates be paid, relatively, for providing primary and maternity care services.

history: (History: Added by Stats. 1976, Ch. 1207.)

article: 2.5. Physicians Costs

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.5. Physicians Costs


text:
As used in this article:

(a) “Medically underserved area” means a county, standard metropolitan statistical area, or other area within the state in which the director determines that Medi-Cal recipients do not have access to an adequate number of physicians.

(b) “Primary care services” means those general medical services, as determined by the director, which are not performed on an emergency, referral, or consulting basis.

(c) “Maternity care services” are prenatal, postnatal, perinatal, and neonatal services.

article: 2.5. Physicians Costs


text: Notwithstanding any other provisions of this chapter the director shall establish, within 15 days of the effective date of this act a statewide, uniform schedule for reimbursing physician services to Medi-Cal patients provided on or after July 1, 1976; except that, the director may establish physician reimbursement rates higher than the statewide rates for; (a) areas which the director determines to be medically underserved: and (b) other problems of equity in payment levels which adversely affect the accessibility of physician services to Medi-Cal recipients. Nothing in this section shall be construed to prevent the director from adopting physician reimbursement rates for primary care services and maternity care services which are relatively higher than the rates paid for other types of physician services.

article: 2.5. Physicians Costs


text: The director shall establish, at the time he or she establishes the statewide rate for physician services required by Section 14077, a level of reimbursement for physician services which represents at least an average increase over the statewide average amounts paid under the Medi-Cal program for the three-month period ending February 29, 1976, of 9.5 percent for all physician services except primary care services and maternity care services; of 20 percent for primary care services; and of 30 percent for maternity care services.

article: 2.5. Physicians Costs


text:
(a) The director shall periodically review the reimbursement levels for physician and dental services in the Medi-Cal fee-for-service delivery system, and shall periodically revise the rates of reimbursement to physicians and dentists to the extent the director deems necessary to comply with applicable federal Medicaid program requirements, including provisions on reasonable access to physician and dental services for Medi-Cal beneficiaries.

(b) To the extent consistent with the department’s federally approved access monitoring plan, or any successor methodology for monitoring reasonable access to Medi-Cal covered services, as described in Section 1396a(a)(30)(A) of Title 42 of the United States Code, this periodic review, as it relates to rates for physician services, shall take into account at least the following factors:

(1) Annual cost increases for physicians as reflected by the Consumer Price Index.

(2) Physician reimbursement levels under the Medicare Program.

(3) Prevailing customary physician charges within the state and in various geographical areas.

(4) Characteristics of the current population of Medi-Cal beneficiaries and the medical services needed.

history: (History: Amended by Stats. 2020, Ch. 12, Sec. 56. (AB 80) Effective June 29, 2020.)

article: 2.5. Physicians Costs


text: Rates of reimbursement established pursuant to this chapter shall make no distinction based on whether a particular service is provided by a physician or a dentist. The director shall not reduce any rate of reimbursement for physician services in order to comply with this section.

history: (History: Added by Stats. 1981, Ch. 995, Sec. 1.)

article: 2.5. Physicians Costs


text:
(a) Notwithstanding any other provision of this chapter, reimbursement to providers for dental services provided to individuals 21 years of age or older at the time of services shall be limited to not more than one thousand eight hundred dollars ($1,800) per beneficiary in any calendar year, commencing January 1, 2006. This limitation shall not apply to any of the following:

(1) Emergency dental services within the scope of covered dental benefits defined as a dental condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(2) Services that are federally mandated under Part 440 (commencing with Section 440.1) of Title 42 of the Code of Federal Regulations, including pregnancy-related services and services for other conditions that might complicate the pregnancy.

(3) Dentures.

(4) Maxillofacial and complex oral surgery.

(5) Maxillofacial services, including dental implants and implant-retained prostheses.

(6) Services provided in long-term care facilities.

(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions. No later than January 1, 2008, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.

(c) The department shall pursue any state plan amendment or other federal approval necessary in order to effectuate this section. This section shall be implemented only to the extent that federal financial participation is available.

history: (History: Amended by Stats. 2008, Ch. 758, Sec. 35. Effective September 30, 2008.)

article: 2.5. Physicians Costs


text: Notwithstanding any other provision of this article, no increase in the reimbursement levels for physician and dental services under Medi-Cal shall be made for the period from July 1, 1982, to September 30, 1982, inclusive, except to the extent funds may be provided therefor by the Budget Act of 1982.

history: (History: Added by Stats. 1982, Ch. 115, Sec. 51. Effective March 13, 1982.)

article: 2.5. Physicians Costs


text:
It is the purpose of this article to ensure that the Medi-Cal program shall be operated in the most cost-effective and efficient manner possible with the optimum number of inpatient hospital service providers. In order to carry out this purpose it is the specific intent of the Legislature that the special negotiator have maximum discretion and flexibility in order to select among various methods of arranging for the provision of health services while achieving significant cost savings. This article shall be the exclusive means of providing inpatient hospital services to recipients qualifying for such care under this chapter.

All previously eligible hospitals may continue to participate in the Medi-Cal program and receive reimbursement for the provision of inpatient hospital services under this article until the special negotiator has negotiated contracts with a sufficient number of hospitals to assure bed capacity to meet the needs of Medi-Cal beneficiaries in an area and notifies the hospital that it is no longer eligible to serve Medi-Cal inpatients except as provided for in Section 14087. A determination by the negotiator under this section shall not require a hearing under Section 14123 or any other section.

history: (History: Amended by Stats. 1982, Ch. 1594, Sec. 35. Effective September 30, 1982.)

article: 2.6. Selective Provider Contracts

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.6. Selective Provider Contracts


text:
(a) The Legislature finds and declares the need to improve the reporting relationship between the state and hospitals eligible to contract with the state for the provision of inpatient services to Medi-Cal eligible persons as provided for in the Medi-Cal reform legislation enacted during the 1981–82 Legislative Session.

(b) Existing statutes require hospitals to file a multiplicity of reports with various state agencies for a variety of purposes, including, but not limited to, the development of Medi-Cal reimbursement rates for inpatient services. The Medi-Cal reform legislation enacted during the 1981–82 Legislative Session significantly altered the manner in which hospitals are reimbursed under the program for these services, thereby establishing the opportunity to redefine and restructure the existing hospital reporting requirements.

(c) It is the Legislature’s intent, therefore, that the existing reporting requirements be reviewed and revised for efficiency, wherever possible, with consideration given to the development of a consolidated, single, multipurpose report for use by all state agencies.

(d) It is the Legislature’s further intent that, in determining these efficiencies, the purposes for which the reports are required be preserved.

history: (History: Added by Stats. 1983, Ch. 1120, Sec. 1.)

article: 2.6. Selective Provider Contracts


text: Hospitals that are not selected for contracting under this article and that have negotiated in good faith to obtain a contract need not fulfill preexisting obligations relating to the provision of inpatient services to Medi-Cal beneficiaries arising under Section 15459 of the Government Code, and subdivision (j) of Section 129050 of, paragraph (4) of subdivision (b) of Section 127175 of, the Health and Safety Code, so long as this article remains in effect.

history: (History: Amended by Stats. 1996, Ch. 1023, Sec. 470. Effective September 29, 1996.)

article: 2.6. Selective Provider Contracts


text:
Notwithstanding any other provision of law, the Governor shall designate a person in his office to act as a special negotiator to negotiate rates, terms, and conditions for contracts with hospitals for inpatient services to be rendered to Medi-Cal program beneficiaries. The negotiator may also, if he or she deems it expedient, call for bids, in lieu of negotiations. The special negotiator shall consider, when contracting, the total funds appropriated for inpatient hospital services.

The department and every other state agency concerned with health care or public social services shall provide such assistance as the negotiator may require. The department shall enter into contracts with hospitals and shall be bound by the rates, terms, and conditions negotiated by the negotiator.

The negotiator shall have the powers of a head of a department pursuant to Chapter 2 (commencing with Section 11150) of Part 1 of Division 3 of Title 2 of the Government Code, except, that he or she shall adopt only such rules and regulations pursuant to Section 11152 of the Government Code as are necessary to carry out those duties specifically conferred upon the negotiator by Articles 2.6 (commencing with Section 14081), 2.8 (commencing with Section 14087.5), 2.91 (commencing with Section 14089), and 2.92 (commencing with Section 14090) of this chapter.

The negotiator shall adopt such regulations as emergency regulations in accordance with the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. For the purposes of the Administrative Procedure Act, the adoption of the regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare.

Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted in accordance with this section shall not be subject to the review and approval of the Office of Administrative Law. These regulations shall become effective immediately upon filing with the Secretary of State.

In addition to the powers specified in this section, the negotiator has the authority to negotiate contracts under Article 2.8 (commencing with Section 14087.5), Article 2.91 (commencing with Section 14089), and Article 2.92 (commencing with Section 14090) of this chapter. Also, the California Medical Assistance Commission shall have the authority to enter into contracts for the provision of acute inpatient hospital services for the care of County Medical Services Program beneficiaries pursuant to Section 16809 of the Welfare and Institutions Code.

Nothing in this article or the Budget Act of 1984 prohibits the negotiator from adjusting rates paid to hospitals to reflect inflation, provided that such adjustments are determined during the negotiating process.

The amendment of this section made at the 1983–84 Regular Session of the Legislature does not constitute a change in, but is declaratory of, the existing law.

history: (History: Amended by Stats. 1992, Ch. 722, Sec. 68.5. Effective September 15, 1992.)

article: 2.6. Selective Provider Contracts


text:
The negotiator provided for in Section 14082 shall serve in such capacity for the 1982–83 fiscal year, after which his or her functions shall be assumed by the California Medical Assistance Commission. Commencing on July 1, 1983, any reference in this article or in Article 2.8 (commencing with Section 14087.5), and Article 2.91 (commencing with Section 14089) of this chapter to the negotiator shall be deemed to be references to the California Medical Assistance Commission.

As of July 1, 1983, the negotiator shall serve as the executive director of the commission.

history: (History: Added by Stats. 1982, Ch. 328, Sec. 17. Effective June 30, 1982.)

article: 2.6. Selective Provider Contracts


text:
The factors to be considered by the negotiator in negotiating contracts under this article, or in drawing specifications for competitive bidding, include, but are not limited to, all of the following:

(a) Beneficiary access.

(b) Utilization controls.

(c) Ability to render quality services efficiently and economically.

(d) Demonstrated ability to provide or arrange needed specialized services.

(e) Protection against fraud and abuse.

(f) Any other factor which would reduce costs, promote access, or enhance the quality of care.

(g) The capacity to provide a given tertiary service, such as specialized children’s services, on a regional basis.

(h) Recognition of the variations in severity of illness and complexity of care.

(i) Existing labor-management collective bargaining agreements.

(j) The situation of county hospitals and university medical centers contracting with counties for provision of health care to indigent persons entitled to care under Section 17000, which are burdened to a greater extent than private hospitals with bad debts, indirect costs, medical education programs, and capital needs.

(k) The special circumstances of hospitals serving a disproportionate number of Medi-Cal beneficiaries and patients who are not covered by other third-party payers, including the costs associated with assuring an adequate supply of registered nurses.

(l) The costs of providing complex emergency services, including the costs of meeting and maintaining state and local requirements for trauma center designation.

(m) The hospital does any of the following:

(1) Provides additional obstetrical beds.

(2) Contracts with one or more comprehensive perinatal providers.

(3) Permits certified nurse midwives, subject to hospital rules, and consistent with existing laws and regulations, to admit patients to the health facility.

(4) Expands overall obstetrical services in the hospital.

(n) The special circumstances of hospitals whose Medi-Cal inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate by at least one-half of one standard deviation.

(o) The ability and capacity of the contracting hospital in a closed health facility planning area to provide health care services to beneficiaries who are in life-threatening or emergency situations, but have been sufficiently stabilized at another noncontracting facility in order to facilitate transportation to the contracting hospital.

(p) The ability of the contracting hospital to provide a secure environment for the provision of health care services. In this regard, the negotiator shall consider additional security measures that the contracting hospital may have taken to provide a secure environment, including, but not limited to, the use of detection equipment or procedures to detect lethal weapons, the appropriate use of surveillance cameras, limiting access of unauthorized personnel to the emergency department, installation of bullet proof glass as appropriate in designated areas, the use of emergency “panic” buttons to alert local law enforcement agencies, and assigning full-time security personnel to the emergency department.

history: (History: Amended by Stats. 2010, Ch. 328, Sec. 244. (SB 1330) Effective January 1, 2011.)

article: 2.6. Selective Provider Contracts


text: In addition to considering factors specified in Section 14083, the negotiator, in negotiating contracts under this article, or in drawing specifications for competitive bidding, shall give special consideration to the reimbursement issues faced by hospitals caring for Medi-Cal beneficiaries who are receiving treatment for acquired immune deficiency syndrome (AIDS).

history: (History: Added by Stats. 1987, Ch. 1470, Sec. 1. Effective September 30, 1987.)

article: 2.6. Selective Provider Contracts


text:
(a) Payments to the contractor may be either on a capitation or prepayment basis, or on a combination of both methods of payment, or such other methods as the negotiator determines to be feasible. Hospitals may assume all or part of the risk of utilization of services, or costs of services, or both.

(b) The department shall insure that the system for reimbursing contracting hospitals is capable of making contract payments in the manner determined pursuant to subdivision (a). At a minimum, the department shall insure that the reimbursement system is capable of making contract payments on a per diem and a per case basis.

history: (History: Amended by Stats. 1983, Ch. 1315, Sec. 2.)

article: 2.6. Selective Provider Contracts


text: All utilization controls applied to inpatient hospital services by the director in accordance with Section 14133.1 shall continue to be applied to inpatient hospital services rendered under this article, except that the director may waive utilization controls which are no longer necessary in the case of hospitals entering into negotiated, capitated, at-risk contracts under this article.

article: 2.6. Selective Provider Contracts