text:
Subject to Section 14188, the department shall develop all of the following VBP programs:

(a) A VBP program that is aimed at improving behavioral health integration in Medi-Cal managed care.

(1) Designated Medi-Cal managed care plans may earn incentive payments for achieving milestones and measures through partnerships with qualified network providers that adopt a team-based care approach for individuals with serious mental health conditions or other chronic health conditions.

(2) Different levels of incentive payments may be available depending on the level of integration, using either a coordination or collocation approach. Partial incentive payments may be available for meeting above-minimum standards.

(3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article.

(b) A VBP program that is aimed at improving prenatal and postpartum care in Medi-Cal managed care.

(1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network primary care or appropriate specialist providers that meet achievement levels on selected prenatal and postpartum care measures, as determined by the department.

(2) Qualified network primary care or appropriate specialist providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards.

(3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article.

(c) A VBP program that is aimed at improving chronic disease management in Medi-Cal managed care.

(1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network providers that meet achievement levels on selected chronic disease care measures, as determined by the department. The measures shall be in chronic disease care areas, including, but not limited to, diabetes care and control of hypertension, using measures currently recognized for those areas in the Healthcare Effectiveness Data and Information Set (HEDIS) or other nationally recognized measures that the department deems appropriate.

(2) Qualified network providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards.

(3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article.

(d) A VBP program that is aimed at improving quality and outcomes for children in Medi-Cal managed care.

(1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network providers that meet achievement levels on selected childhood health care quality measures, as determined by the department. The measures shall be developed using measures currently recognized for those areas in HEDIS or other nationally recognized measures that the department deems appropriate.

(2) Qualified network providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards.

(3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 408. (AB 133) Effective July 27, 2021. Section inoperative on July 1, 2021, pursuant to Section 14188.4.)

article: 5.8. Value-Based Incentives in Medi-Cal Managed Care


kind: section

code: WIC

text:
(a) The VBP programs described in Section 14188.1 shall be funded using moneys appropriated to the department for purposes of those programs in the Budget Act of 2019, or a Budget Act in a subsequent fiscal year, from the Healthcare Treatment Fund established pursuant to subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.

(b) The Legislature finds and declares that the expenditures authorized by this article are all of the following:

(1) Made in accordance with the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Article 2.5 (commencing with Section 30130.50) of Chapter 2 of Part 13 of Division 2 of the Revenue and Taxation Code).

(2) Based on criteria developed and periodically updated as part of the annual state budget process, in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.

(3) Consistent with the purposes and conditions of expenditures described in subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.

history: (History: Added by Stats. 2019, Ch. 38, Sec. 50. (SB 78) Effective June 27, 2019.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 5.8. Value-Based Incentives in Medi-Cal Managed Care


text:
(a) To implement this article, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision 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, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services.

(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 article, in whole or in part, by means of plan letters or other similar instructions, without taking regulatory action.


text:
(a) Notwithstanding any other law, the department shall only implement the payments described under Section 14188.1 for a service period during a state fiscal year subject to appropriation by the Legislature for that state fiscal year.

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

(c) Notwithstanding any other law, this section shall supersede any law suspending authority for any program described in Section 14188.1. The law on suspending authority includes, but is not limited to, provisions under the Budget Act of 2019, the Budget Act of 2020, and enacted legislation providing for appropriations related to those acts.

(d) The Legislature finds and declares that this section complies with all of the following:

(1) Made in accordance with the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Article 2.5 (commencing with Section 30130.50) of Chapter 2 of Part 13 of Division 2 of the Revenue and Taxation Code).

(2) Based on criteria developed and periodically updated as part of the annual state budget process, in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.

(3) Consistent with the purposes and conditions of expenditures described in subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.

history: (History: Repealed and added by Stats. 2021, Ch. 143, Sec. 410. (AB 133) Effective July 27, 2021.)


text: Medi-Cal managed care plans shall provide mental health benefits covered in the state plan excluding those benefits provided by county mental health plans under the Specialty Mental Health Services Waiver. The department may require the managed care plans to cover mental health pharmacy benefits to the extent provided in the contracts between the department and the Medi-Cal managed care plans.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. (SB 1 1x) Effective September 30, 2013.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 5.9. Medi-Cal Managed Care Plan Mental Health Benefits


text:
(a) The department shall convene an advisory group to receive feedback on the changes, modifications, and operational timeframes regarding the implementation of pharmacy benefits offered in the Medi-Cal program. This advisory group shall be composed of organizations and entities such as hospitals, clinics, health plans, and consumer advocates.

(b) The department, through this advisory group as well as through other existing stakeholder meetings, shall provide regular updates on the pharmacy transition that include the following:

(1) A description of the changes in the division of responsibilities between the department and managed care plans as a result of a transition of the outpatient pharmacy benefit to fee-for-service.

(2) A description of anticipated changes, if any, to beneficiary access to prescription medications.

(c) The department shall include in the Governor’s proposed budget the fiscal assumptions for the transition of the outpatient pharmacy benefit to a fee-for-service benefit.

history: (History: Added by Stats. 2019, Ch. 38, Sec. 51. (SB 78) Effective June 27, 2019.)

article: 5.9. Medi-Cal Managed Care Plan Mental Health Benefits


text:
(a) Subject to subdivision (b), and no later than January 1, 2025, a Medi-Cal managed care plan shall conduct annual outreach and education for its enrollees, based on a plan that the Medi-Cal managed care plan develops and submits to the department upon the department’s approval of the Medi-Cal managed care plan’s Population Needs Assessment, regarding the mental health benefits that are covered by the Medi-Cal managed care plan pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402.

(1) The outreach and education plan shall be informed by the Medi-Cal managed care plan’s stakeholder engagement, including the community advisory committee established by the Medi-Cal managed care plan, and by local stakeholders representing diverse racial and ethnic communities.

(2) The outreach and education plan shall be informed by the Medi-Cal managed care plan’s Population Needs Assessment and an assessment of utilization of covered mental health benefits by race, ethnicity, language, age, sexual orientation, gender identity, and disability, and shall ensure that materials and messaging are appropriate for the diversity of the plan enrollee membership. The Medi-Cal managed care plan shall submit the utilization assessment to the department.

(3) The outreach and education plan shall meet cultural and linguistic appropriateness standards, in alignment with the National Standards for Culturally and Linguistically Appropriate Services, shall incorporate best practices in stigma reduction, and shall provide multiple points of contact for enrollees to access mental health benefits.

(b) (1) The department shall review the new or updated outreach and education plan submitted by each Medi-Cal managed care plan as described in this section and shall approve or modify the plan within 180 calendar days since submission, to ensure appropriate local stakeholder engagement, alignment with the Population Needs Assessment, and cultural and linguistic appropriateness.

(2) Implementation of a Medi-Cal managed care plan’s outreach and education plan described in this section shall be subject to approval by the department pursuant to paragraph (1).

(3) Each Medi-Cal managed care plan shall publicly post, on its internet website and in an accessible manner, its approved outreach and education plan and its utilization assessment described in paragraph (2) of subdivision (a), excluding any personally identifiable information.

(c) The department shall consult with stakeholders representative of diverse racial and ethnic communities, including, but not limited to, consumer advocates, mental health stigma reduction experts, community-based organizations, and Medi-Cal managed care plan stakeholders, to develop the standards by which outreach and education plans will be reviewed and approved.

(d) Approval standards may include, but are not limited to, any of the following:

(1) Outreach and education methods that include, but are not limited to, online outreach, mail, telephone, partnerships with community-based organizations, partnerships with primary care providers, and use of navigators, community health workers, and other providers trained to conduct outreach and education.

(2) Alignment of the culturally and linguistically tailored outreach and education strategies with the National Standards for Culturally and Linguistically Appropriate Services, utilization assessment and Population Needs Assessment.

(3) Inclusion of consumer-friendly information in existing member-facing communication channels, including the Medi-Cal managed care plan’s internet website.

(4) An independent evaluation plan to assess and improve outreach to enrollees related to nonspecialty mental health services upon the department’s approval of a Medi-Cal managed care plan’s Population Needs Assessment.

(e) A Medi-Cal managed care plan shall also conduct annual outreach and education, based on a plan that the Medi-Cal managed care plan develops, to inform primary care providers regarding the mental health benefits covered by the Medi-Cal managed care plan pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402.

(f) 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, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar guidance, until any necessary regulations are adopted.

(g) For purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. 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, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services.

history: (History: Added by Stats. 2022, Ch. 879, Sec. 1. (SB 1019) Effective January 1, 2023.)


text:
(a) Once every three years, the department shall assess enrollee experience with mental health benefits covered by Medi-Cal managed care plans pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402.

(b) No later than January 1, 2025, the department shall adopt survey tools and methodologies that shall meet all of the following conditions:

(1) Assess experience with the full range of mental health benefits covered by Medi-Cal managed care plans pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402.

(2) Assess consumer experience in various domains, including, but not limited to, receipt of treatment quickly, how well clinicians communicate, cultural competency of providers, communication with the plan and provider, receipt of treatment and information from the plan, including information related to patients’ rights, the treatment plan and options, and the sides effects of medication, perceived improvement, overall rating of counseling and other treatment, and overall rating of the plan.

(3) Assess consumer experience in a manner that utilizes survey best practice methods for data collection and reporting, including, but not limited to, staff training on data collection, the legality and use of data collection, how to work with patients to improve comfort levels in sharing the data, oversampling and collection of self-reported demographic data at the individual encounter level, and the use of data through existing enrollment and renewal processes.

(c) The department shall consider, and may utilize, existing tools in order to ensure alignment with national standards and state health care programs.

(d) (1) The department shall publish reports, commencing with a report in April 2026 and once every three years thereafter, on its internet website on consumer experience with mental health benefits covered by Medi-Cal managed care plans.

(2) The reports shall include plan-by-plan data, provide granularity for subpopulations, and address inequities based on key demographic factors, including, but not limited to, language, race, ethnicity, disability status, sexual orientation, and gender identity, to the extent that survey response rates produce statistically valid results. The reports shall exclude any personally identifiable information.

(3) The reports shall provide recommendations for improving access to mental health benefits covered by Medi-Cal managed care plans.

(e) 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, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar guidance, until any necessary regulations are adopted.

(f) For purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. 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, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services.

history: (History: Added by Stats. 2022, Ch. 879, Sec. 2. (SB 1019) Effective January 1, 2023.)


text:
Notwithstanding any other provision of law, no payment for care or services shall be made under Medi-Cal to the attending physician under this chapter for the costs of any voluntary nonemergency sterilization unless the treatment authorization request is accompanied by the documents evidencing informed consent required by regulations of the department. In the event that the department does not require a treatment authorization request, such documents evidencing informed consent shall accompany the billing of the attending physician. The department shall promulgate regulations under this article and shall adopt a standard informed consent form in English and Spanish which is readily understandable to Medi-Cal beneficiaries for use by health providers performing voluntary nonemergency sterilizations.

The failure of the attending physician performing the sterilization to fulfill his obligations under this section shall not be construed as requiring the department to deny or withhold reimbursement under Medi-Cal to other providers participating in the sterilization.

history: (History: Added by Stats. 1975, Ch. 220.)

article: 6. Sterilizations

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 6. Sterilizations


text: Willful failure on the part of a health facility to comply with the provisions of the regulations of the department under this article shall constitute cause for suspension as a provider of services under Medi-Cal.

article: 6. Sterilizations


text: The department shall transmit any data acquired by it regarding willful failure of a physician and surgeon to comply with the regulations of the department under this article to the Medical Board of California.

history: (History: Amended by Stats. 1989, Ch. 886, Sec. 107.)

article: 6. Sterilizations


text: The department shall submit reports to the Legislature as to compliance by health facilities with the requirements of this article, 6, 12, and 24 months after its operative date.

article: 6. Sterilizations


text: It is the intent of the Legislature to provide medical assistance, including prescribed drugs, to the state’s eligible poor in a manner consistent with the provisions of the federal Medicaid Act, provided for under Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.). It is the further intent of the Legislature to test the effectiveness of an open formulary drug therapy program. In order to help achieve this goal, the Legislature hereby establishes an open drug formulary under the Medi-Cal program wherein a beneficiary may receive the most appropriate, most effective, and most cost-efficient drug available for the treatment of his or her illness. It is also the intent of the Legislature in enacting this article to establish a drug utilization review system which will evaluate and enhance the therapeutic outcome of drugs prescribed for persons eligible for Medi-Cal pursuant to this chapter.

history: (History: Amended by Stats. 1987, Ch. 1340, Sec. 1.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 6.1. Medi-Cal Therapeutic Drug Utilization Review


text: The open drug formulary, as established pursuant to this article, shall be implemented in one pilot project site. The site shall be located in a northern California test area, comprised of Sacramento and Placer Counties which includes urban, suburban, and rural settings. This pilot project shall not be implemented until federal approval is secured and full federal financial participation is assured.

history: (History: Amended by Stats. 1987, Ch. 1340, Sec. 3.)

article: 6.1. Medi-Cal Therapeutic Drug Utilization Review


text:
(a) For purposes of the open drug formulary pilot project as established by this article, a provider may be reimbursed for any drug prescribed to a beneficiary if the drug is prescribed by a licensed provider within the scope of his or her practice, as defined by law, and if the drug is approved for use by the federal Food and Drug Administration.

(b) Controlled substances shall be prescribed pursuant to the requirements of federal laws and regulations and the requirements set forth in Chapter 4 (commencing with Section 11150) of Division 10 of the Health and Safety Code.

(c) For purposes of the open drug formulary pilot project as established by this article, there shall be no requirement that prior authorization be obtained by a provider before prescribing any drug to a beneficiary if the provider determines the drug to be a medical necessity in the treatment of the beneficiary.

(d) For purposes of the open drug formulary pilot project as established by this article, a drug determined to be a medical necessity shall be one whose use in the treatment is reasonable and consistent with the objectives of the federal Medicaid Act as set forth in Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.).

history: (History: Added by Stats. 1985, Ch. 135, Sec. 7. Effective July 1, 1985.)


text:
A Medi-Cal Therapeutic Drug Utilization and Review Committee is hereby established. The committee shall be composed of 17 members who shall serve at the pleasure of the appointing powers as follows:

(a) The Governor shall appoint two representatives from the State Department of Health Services, one representative from the Health and Welfare Agency, and two representatives from schools of pharmacy.

(b) The Governor, the Speaker of the Assembly, and the Senate Rules Committee shall each appoint one representative from the following groups:

(1) Licensed pharmacists.

(2) Licensed physicians.

(3) Drug manufacturers.

(4) Medi-Cal beneficiaries.

history: (History: Added by renumbering Section 14195.1 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 4. Effective July 1, 1985.)


text:
The Medi-Cal Therapeutic Drug Utilization and Review Committee shall set standards for evaluation of the therapeutic outcomes of prescribed drugs to be applied by an expert contractor to the department. The committee shall have the following responsibilities:

(a) Developing policy for monitoring and controlling therapeutically inappropriate drug utilization.

(b) Overseeing the establishment of a computer-based information system using the State Medicaid MMIS System, which shall provide timely information on drug prescription and consumption and shall be capable of tracking prescriptions by drug, by illness, by beneficiary, and by provider.

The committee shall consult with expert contractors experienced in therapeutically oriented drug utilization review in the discharge of this responsibility.

(c) Establishing standards, in consultation with an expert contractor experienced in the therapeutically oriented drug utilization review, for dosage, duration, and effectiveness of medications with respect to a particular diagnosis.

(d) Setting standards to serve as guidelines on misprescribing, overprescribing, and contraindicated drug use, and protocols for informing prescribers of inappropriate prescribing.

history: (History: Added by renumbering Section 14195.2 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 5. Effective July 1, 1985.)


text:
The department shall develop a request for a proposal, and may award a contract to an expert contractor to implement the standards and practices established by the Medi-Cal Therapeutic Drug Utilization Review System through use of a therapeutically oriented drug utilization review system by July 1, 1989. The contract shall include a requirement to analyze the therapeutic outcomes of the Medi-Cal Drug Program using the California MMIS for the period of July 1, 1987, through the date the standards established by this article are implemented. Thereafter, the contractor shall submit quarterly reports to the department and the Legislature analyzing therapeutic outcomes in a manner that will allow comparisons with the experience analyzed for the period of July 1, 1987, until implementation of the standards established by this article. The analysis shall include reports on at least the following items:

(a) Compatibility of medication to diagnosis.

(b) Overprescribing of drugs.

(c) Prescription of contraindicated or incompatible drugs.

(d) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or all categories of intermediate care for the developmentally disabled occurring because of the factors specified in subdivisions (a) to (c), inclusive.

(e) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or any category of intermediate care facility for the developmentally disabled avoided due to changes in drug regimes which result from compliance by prescribers and beneficiaries with the standards established pursuant to this article.

The department is authorized to require the contractor to phase in implementation of the prescriber notification, as established by protocols for informing prescribers of inappropriate prescribing.

history: (History: Amended by Stats. 1990, Ch. 1329, Sec. 33. Effective September 26, 1990.)


text: This article shall not apply to any service rendered by a provider in conjunction with any capitated rate or primary care case contract negotiated pursuant to this chapter or Chapter 8 (commencing with Section 14200) by either the department or the California Medical Assistance Commission unless both parties to the contract mutually agree that application of the standards established by this article would be beneficial to the Medi-Cal eligibles enrolled in plans operating pursuant to capitated rate contracts.

history: (History: Added by Stats. 1984, Ch. 1636, Sec. 5.)


text: In no case shall the director’s discretion under Section 14120 be exercised to reduce reimbursement to providers of pharmaceutical services because of increased costs in the drug component of the Medi-Cal program arising from the implementation of the open formulary concept.


text:
(a) The department shall adopt any regulations necessary to implement this article. These regulations shall be adopted as emergency regulations in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and, for the purposes of the Administrative Procedure Act, shall be deemed an emergency, and necessary for the immediate preservation of the public peace, health and safety, or general welfare.

(b) Any provision of this article which is in conflict with any federal statute or regulation shall be inapplicable to the extent of that conflict but the remainder of the provisions shall be in effect to the extent no conflict exists.

The department shall seek all federal waivers necessary to implement this article. The provisions for which federal waivers cannot be obtained shall not be implemented, but provisions for which waivers are either obtained or found to be unnecessary shall be unaffected by the inability to obtain federal waivers for the other provisions.

(c) The department shall seek maximum federal reimbursement for the MMIS-based Drug Establishment Review System established by this article.


text:
(a) (1) The Legislature finds and declares that in order to reduce the risk of transmission of COVID-19 during the current pandemic and to further the objectives of the Money Follows the Person Rebalancing Demonstration, a temporary program is hereby established to facilitate the transition of individuals from an inpatient facility who have resided in that setting for fewer than 60 days.

(2) The department shall provide services consistent with the Money Follows the Person Rebalancing Demonstration program, pursuant to Section 6071 of Public Law 109-171, and subsequent amendments, for transitioning eligible individuals out of inpatient 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 article by means of letters, provider bulletins, or similar instructions, without taking regulatory action.

(c) Commencing January 1, 2026, the department shall cease to enroll beneficiaries pursuant to this article and commencing January 1, 2027, the department shall cease to provide services pursuant to this article.

history: (History: Amended by Stats. 2022, Ch. 898, Sec. 2. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)

article: 6.2. Short-Term Community Transitions

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 6.2. Short-Term Community Transitions


text:
The following definitions apply for purposes of this article:

(a) “Eligible individual” means a Medi-Cal beneficiary who meets both of the following requirements:

(1) The individual meets the definition of an “eligible individual” under Section 6071(b)(2) of Public Law 109-171, and subsequent amendments, except that the individual is not required to have resided for at least 60 consecutive days in an inpatient facility.

(2) The individual is targeted to receive assistance in transitioning from an inpatient facility to a qualified residence, identified in the agreement between the department and the federal Centers for Medicare and Medicaid Services for the Money Follows the Person Rebalancing Demonstration, except the individual shall not be required to have resided for at least 60 consecutive days in an inpatient facility.

(b) “Inpatient facility” has the same meaning as that term is defined in Section 6071(b)(3) of Public Law 109-171, and subsequent amendments.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 412. (AB 133) Effective July 27, 2021. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)

article: 6.2. Short-Term Community Transitions


text:
(a) A Medi-Cal beneficiary who has resided for at least 60 consecutive days in an inpatient facility, as required by the Money Follows the Person Rebalancing Demonstration, is ineligible for services under this article unless the department determines that any necessary federal approvals have been obtained and federal financial participation is available for this purpose.

(b) Services shall not be provided pursuant to this article during any period that the department has obtained any necessary federal approvals under the Money Follows the Person Rebalancing Demonstration to not apply the eligibility requirement that the beneficiary has resided for at least 60 consecutive days in an inpatient facility.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 413. (AB 133) Effective July 27, 2021. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)

article: 6.2. Short-Term Community Transitions


text: This article shall remain in effect only until January 1, 2028, and as of that date is repealed.

history: (History: Repealed and added by Stats. 2022, Ch. 898, Sec. 4. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, by its own provisions. Note: Repeal affects Art. 6.2, commencing with Section 14196.2.)

article: 6.2. Short-Term Community Transitions


text:
(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 department determines that the requesting Medi-Cal managed care plan has demonstrated that its delivery structure is capable of delivering the appropriate level of care and access.

(3) (A) If a Medi-Cal managed care plan cannot meet the time or distance standards set forth in this section, the Medi-Cal managed care plan shall submit a request for alternative access standards to the department, in the form and manner specified by the department.

(B) An alternative access standard request may be submitted at the same time as the Medi-Cal managed care plan submits its annual demonstration of compliance with time or distance standards, if known at that time and at any time the Medi-Cal managed care plan is unable to meet time or distance standards.

(C) A Medi-Cal managed care plan is not required to submit a previously approved alternative access standard request to the department for review and approval on an annual basis, unless the Medi-Cal managed care plan requires modifications to its previously approved request. However, the Medi-Cal managed care plan shall submit this previously approved alternative access standard request to the department at least every three years for review and approval when the plan is required to demonstrate compliance with time or distance standards.

(i) Medi-Cal managed care plans that do not meet time or distance standards without the use of an alternative access standards request shall submit to the department documentation demonstrating efforts to contract with providers in those areas, based on guidance by the department.

(ii) Effective no sooner than contract periods commencing on or after January 1, 2026, the Medi-Cal managed care plan shall 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 specified in subdivision (c) in a manner specified by the department.

(D) A Medi-Cal managed care plan shall close out any corrective action plan deficiencies in a timely manner to ensure that beneficiary access is adequate and shall continually work to improve access in its provider network.

(4) A request for alternative access standards shall be approved or denied on a ZIP Code and provider type, including specialty type, basis by the department within 90 days of submission of the request. The Medi-Cal managed care plan shall also include a description of the reasons justifying the alternative access standards based on those facts and circumstances. Effective no sooner than contract periods commencing on or after July 1, 2020, the Medi-Cal managed care plan shall include a description on how the Medi-Cal managed care plan intends to arrange for enrollees to access covered services if the health care provider is located outside of the time or distance standards specified in subdivision (c). The department may stop the 90-day timeframe, on one or more occasions as necessary, in the event of an incomplete submission or to obtain additional information from the Medi-Cal managed care plan requesting the alternative access standards. Upon submission of sufficient additional information to the department, the 90-day timeframe shall resume at the same point in time it was previously stopped, except if there is less than 30 days remaining in which case the department shall approve or deny the request within 30 days of submission of sufficient additional information. If the department rejects the Medi-Cal managed care plan’s proposal, the department shall inform the Medi-Cal managed care plan of the department’s reason for rejecting the proposal. The department shall post any approved alternative access standards on its internet website.

(5) (A) As part of the department’s evaluation of a request submitted by a Medi-Cal managed care plan to utilize an alternative access standard pursuant to this subdivision, the department shall evaluate and determine whether the resulting time or distance is reasonable to expect a beneficiary to travel to receive care.

(B) Effective for contract periods commencing on or after January 1, 2027, as part of the department’s evaluation of a request pursuant to this subdivision, the department shall also consider the sufficiency of payment rates offered by the Medi-Cal managed care plan to the provider type or for the service type for which an alternative access standard is being requested.

(6) 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 part of an alternative access standard request.

(g) (1) (A) Effective for contract periods commencing on or after July 1, 2018, a Medi-Cal managed care plan shall, on an annual basis and when requested by the department, demonstrate to the department the Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards developed pursuant to this section. The report shall measure compliance separately for adult and pediatric services for primary care, behavioral health, and core specialist services.

(B) (i) Effective for contract periods commencing on or after January 1, 2026, a Medi-Cal managed care plan shall, on an annual basis and when requested by the department, demonstrate to the department each subcontractor network’s compliance with the time or distance and appointment time standards developed pursuant to this section, including how the Medi-Cal managed care plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, such as through the use of either Medi-Cal covered transportation or clinically appropriate video synchronous interaction, as specified in paragraph (6) of subdivision (f), if the enrollees of a Medi-Cal managed care plan needed to obtain health care services from a health care provider or a facility located outside of the time or distance standards, as specified in subdivision (c), in accordance with the CalAIM 1915(b) Waiver Special Terms and Conditions A4.

(ii) This subparagraph shall not apply to dental managed care plans, or to Medi-Cal behavioral health delivery systems as defined in subdivision (i) of Section 14184.101.

(2) Effective for contract periods commencing on or after July 1, 2020, the Medi-Cal managed care plan shall demonstrate, on an annual basis, and when requested by the department, to the department how the Medi-Cal managed care plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, such as through the use of either Medi-Cal covered transportation or clinically appropriate video synchronous interaction, as specified in paragraph (6) of subdivision (f), if the enrollees of a Medi-Cal managed care plan needed to obtain health care services from a health care provider or a facility located outside of the time or distance standards, as specified in subdivision (c).

The report shall measure compliance separately for adult and pediatric services for primary care, behavioral health, and core specialist services.

(3) (A) Effective for contract periods commencing on or after July 1, 2018, the department shall evaluate on an annual basis a Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards implemented pursuant to this section. This evaluation may include, but need not be limited to, annual and random surveys, investigation of complaints, grievances, or other indicia of noncompliance. Nothing in this subdivision shall be construed to limit the appeal rights of a Medi-Cal managed care plan under its contracts with the department.

(B) Effective for contract periods commencing on or after January 1, 2029, the evaluation by the department for appointment time standards compliance as described in this paragraph shall be performed using a direct testing method, which shall include, but need not be limited to, a “secret shopper” method. The direct testing shall be used to evaluate compliance with the appointment time standards set forth in subdivision (d) for appointments. To determine compliance with the urgent care standard, the evaluation shall measure the network’s ability to provide urgent care within 48 hours pursuant to Section 1367.03 of the Health and Safety Code and Section 1300.67.2.2(c)(5)(A) of Title 28 of the California Code of Regulations. The evaluation shall also utilize a method for accounting for and reporting the number of providers who are unavailable or unreachable for purposes of the evaluation.

(C) Failure to comply with the evaluations required by this paragraph may result in contract termination or the issuance of sanctions pursuant to Section 14197.7.

(4) The department shall publish annually on its internet website a report that details the department’s findings in evaluating a Medi-Cal managed care plan’s compliance under paragraph (2). At a minimum, the department shall specify in this report those Medi-Cal managed care plans, if any, that were subject to a corrective action plan due to noncompliance with the time or distance and appointment time standards implemented pursuant to this section during the applicable year and the basis for the department’s finding of noncompliance. The report shall include a Medi-Cal managed care plan’s response to the corrective plan, if available.

(h) The department shall consult with Medi-Cal managed care plans, including dental managed care plans, mental health plans, and Drug Medi-Cal Organized Delivery System programs, health care providers, consumers, providers and consumers of long-term services and supports, and organizations representing Medi-Cal beneficiaries in the implementation of the requirements of this section.

(i) For purposes of this section, the following definitions apply:

(1) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(A) Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46.

(B) Article 2.8 (commencing with Section 14087.5).

(C) Article 2.81 (commencing with Section 14087.96).

(D) Article 2.82 (commencing with Section 14087.98).

(E) Article 2.9 (commencing with Section 14088).

(F) Article 2.91 (commencing with Section 14089).

(G) Chapter 8 (commencing with Section 14200), including dental managed care plans.

(H) Chapter 8.9 (commencing with Section 14700).

(I) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver, as applicable.

(2) “Specialist” means any of the following:

(A) Cardiology/interventional cardiology.

(B) Nephrology.

(C) Dermatology.

(D) Neurology.

(E) Endocrinology.

(F) Ophthalmology.

(G) Ear, nose, and throat/otolaryngology.

(H) Orthopedic surgery.

(I) Gastroenterology.

(J) Physical medicine and rehabilitation.

(K) General surgery.

(L) Psychiatry.

(M) Hematology.

(N) Oncology.

(O) Pulmonology.

(P) HIV/AIDS specialists/infectious diseases.

(3) “Subcontractor network” means a provider network of a subcontractor or downstream subcontractor, wherein the subcontractor or downstream subcontractor is delegated risk and is responsible for arranging for the provision of, and paying for, covered services as stated in their subcontractor or downstream subcontractor agreement.

(j) (1) The department may require enhanced time or distance standards that are more stringent than those set forth in this section in its contracts with Medi-Cal managed care plans. However, the other requirements of this section shall otherwise apply.

(2) The department shall ensure that enhanced time or distance standards contracted for with Medi-Cal managed care plans are consistent across contracts for similar geographic classifications.

(3) The department shall publish all enhanced time and distance standards adopted by contract with a rationale for the enhanced standards.

(k) 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, may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.

(l) The department shall seek any federal approvals it deems necessary to implement this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.

(m) (1) In alignment with federal regulation that requires the department to conduct analyses when developing or adjusting network adequacy standards, the department shall publish on the department’s internet website by January 1, 2027, a workplan that includes an explanation of the department’s approach to updating network adequacy standards, a description of the data, and a summary of the analyses that will inform the department’s approach.

(2) By January 1, 2027, the department shall convene a stakeholder workgroup to assist in the development of evidence-based network adequacy standards informed by the analyses described in paragraph (1).

(3) The department shall provide a 30-day public comment period before implementing any changes to network adequacy standards.

(n) This section shall remain in effect only until January 1, 2029, and as of that date is repealed, unless a later enacted statute that is enacted before January 1, 2029, deletes or extends that date.

history: (History: Amended by Stats. 2025, Ch. 418, Sec. 1. (SB 530) Effective January 1, 2026. Repealed as of January 1, 2029, by its own provisions.)

article: 6.3. Medi-Cal Managed Care Plans

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 6.3. Medi-Cal Managed Care Plans


text:
(a) The department shall ensure that all covered mental health benefits and substance use disorder benefits, as those terms are defined in Section 438.900 of Title 42 of the Code of Federal Regulations, are provided in compliance with Parts 438, 440, 456, and 457 of Title 42 of the Code of Federal Regulations, as amended March 30, 2016, as published in the Federal Register (81 Fed. Reg. 18390), and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services.

(b) 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, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. In doing so, the director shall consult with managed care plans and consumer advocates. By July 1, 2022, the department shall adopt regulations, where appropriate, 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 make any findings of noncompliance and corrective action plans available on its Internet Web site.

(d) For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(1) Article 2.7 (commencing with Section 14087.3), excluding dental managed care programs developed pursuant to Section 14087.46.

(2) Article 2.8 (commencing with Section 14087.5).

(3) Article 2.81 (commencing with Section 14087.96).

(4) Article 2.82 (commencing with Section 14087.98).

(5) Article 2.91 (commencing with Section 14089).

(6) Chapter 8 (commencing with Section 14200), excluding dental managed care plans.

(7) Chapter 8.9 (commencing with Section 14700).

(8) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.

history: (History: Added by Stats. 2017, Ch. 768, Sec. 3. (SB 171) Effective January 1, 2018.)

article: 6.3. Medi-Cal Managed Care Plans


text:
(a) This section implements the state option in subsection (j) of Section 438.8 of Title 42 of the Code of Federal Regulations.

(b) Commencing July 1, 2019, a Medi-Cal managed care plan shall comply with a minimum 85 percent medical loss ratio (MLR) consistent with Section 438.8 of Title 42 of the Code of Federal Regulations. The ratio shall be calculated and reported for each MLR reporting year by the Medi-Cal managed care plan consistent with Section 438.8 of Title 42 of the Code of Federal Regulations.

(c) (1) Effective for contract rating periods commencing on or after July 1, 2023, a Medi-Cal managed care plan shall provide a remittance for an MLR reporting year if the ratio for that MLR reporting year does not meet the minimum MLR standard of 85 percent. The department shall determine the remittance amount on a plan-specific basis for each rating region of the plan and shall calculate the federal and nonfederal share amounts associated with each remittance.

(2) After the department returns the requisite federal share amounts associated with any remittance funds collected in any applicable fiscal year to the federal Centers for Medicare and Medicaid Services, the remaining amounts remitted by a Medi-Cal managed care plan pursuant to this section shall be deposited in the General Fund.

(d) Except as otherwise required under this section, and until June 30, 2022, the requirements under this section do not apply to a health care service plan under a subcontract with a Medi-Cal managed care plan to provide covered health care services to Medi-Cal beneficiaries enrolled in the Medi-Cal managed care plan. This subdivision shall be inoperative on July 1, 2022.

(e) The department shall post on its internet website all of the following information:

(1) The aggregate MLR of all Medi-Cal managed care plans.

(2) The MLR of each Medi-Cal managed care plan, and, as applicable, the MLR of each subcontractor plan or other delegated entity, under contract with the Medi-Cal managed care plan, that is required to report an MLR pursuant to the CalAIM Terms and Conditions.

(3) Any required remittances owed by each Medi-Cal managed care plan, and, as applicable, any required remittances owed by each subcontractor plan or other delegated entity to that Medi-Cal managed care plan pursuant to the CalAIM Terms and Conditions.

(f) For purposes of this section, the following definitions apply:

(1) “Medical loss ratio (MLR) reporting year” shall have the same meaning as that term is defined in Section 438.8 of Title 42 of the Code of Federal Regulations.

(2) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(A) Article 2.7 (commencing with Section 14087.3).

(B) Article 2.8 (commencing with Section 14087.5).

(C) Article 2.81 (commencing with Section 14087.96).

(D) Article 2.82 (commencing with Section 14087.98).

(E) Article 2.91 (commencing with Section 14089).

(F) Article 1 (commencing with Section 14200) of Chapter 8.

(G) Article 7 (commencing with Section 14490) of Chapter 8.

(3) “CalAIM Terms and Conditions” shall have the same meaning as that term is defined in subdivision (c) of Section 14184.101.

(g) The department shall seek any federal approvals it deems necessary to implement this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.

(h) 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, in whole or in part, by means of plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.

history: (History: Amended by Stats. 2026, Ch. 27, Sec. 93. (SB 164) Effective June 29, 2026.)

article: 6.3. Medi-Cal Managed Care Plans


text:
(a) A Medi-Cal managed care plan shall give a beneficiary timely and adequate notice of an adverse benefit determination in writing consistent with the requirements in Sections 438.404, 438.408, and 438.10 of Title 42 of the Code of Federal Regulations. For purposes of this subdivision, “adverse benefit determination” means either of the following:

(1) Any action described in Section 10950.

(2) Any health care service eligible for coverage and payment under a Medi-Cal managed care plan contract that has been denied, modified, or delayed by a decision of the Medi-Cal managed care plan, or by one of its contracting providers.

(b) Except as provided in subdivision (c), a Medi-Cal managed care plan shall resolve an appeal no more than 30 calendar days from the day the Medi-Cal managed care plan receives the appeal.

(c) A Medi-Cal managed care plan shall resolve an expedited appeal no longer than 72 hours after the Medi-Cal managed care plan receives the appeal. A Medi-Cal managed care plan shall establish and maintain an expedited review process for a beneficiary or the beneficiary’s provider to request an expedited resolution of an appeal based on either of the following circumstances:

(1) If the Medi-Cal managed care plan determines, for a request from the beneficiary, or the provider indicates, in making the request on the beneficiary’s behalf or supporting the beneficiary’s request, that taking the time for a standard resolution under the timeframe described in subdivision (b) could seriously jeopardize the beneficiary’s life, physical or mental health, or ability to attain, or regain, maximum function.

(2) When the beneficiary’s condition is such that the beneficiary faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the timeframe described in subdivision (b) would be detrimental to the beneficiary’s life or health or could jeopardize the beneficiary’s ability to regain maximum function.

(d) For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(1) Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46.

(2) Article 2.8 (commencing with Section 14087.5).

(3) Article 2.81 (commencing with Section 14087.96).

(4) Article 2.82 (commencing with Section 14087.98).

(5) Article 2.9 (commencing with Section 14088).

(6) Article 2.91 (commencing with Section 14089).

(7) Chapter 8 (commencing with Section 14200), including dental managed care plans.

(8) Chapter 8.9 (commencing with Section 14700).

(9) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.

history: (History: Added by Stats. 2017, Ch. 738, Sec. 7. (AB 205) Effective January 1, 2018.)

article: 6.3. Medi-Cal Managed Care Plans


text:
(a) (1) A Medi-Cal managed care plan that has received approval from the department to utilize an alternative access standard pursuant to subdivision (f) of Section 14197, upon the request of an enrollee who is required to travel farther than the time or distance standards, as established in subdivision (c) of Section 14197, shall assist that enrollee in obtaining an appointment with an appropriate specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197.

(2) For purposes of complying with the requirement to assist an enrollee, as specified in paragraph (1), a Medi-Cal managed care plan shall do either of the following:

(A) Make its best effort to establish a member-specific case agreement, at the Medi-Cal fee-for-service rate or a rate mutually agreed upon by the specialist provider and the plan, with an appropriate specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197.

(B) Arrange for an appointment with a network specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197, and the appointment time standards established pursuant to subdivision (d) of Section 14197.

(3) The requirements of paragraph (1) shall not apply if there is not a specialist provider with an office location within the applicable time or distance standards in relation to the area within which the enrollee resides or the Medi-Cal managed care plan has attempted to establish a member-specific case agreement with the specialist provider for any enrollee pursuant to subparagraph (A) of paragraph (2) in the most recent fiscal year and the provider refused to enter into a member-specific case agreement.

(b) If a specialist provider is unavailable to render necessary health care services pursuant to subdivision (a) to an enrollee within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197, as specified in subdivision (a), the Medi-Cal managed care plan or the Medi-Cal fee-for-service program, as determined appropriate by the department, shall arrange for Medi-Cal covered transportation for an enrollee to obtain covered Medi-Cal services pursuant to Section 14132.

(c) A Medi-Cal managed care plan that has received approval from the department to utilize an alternative access standard pursuant to subdivision (f) of Section 14197 shall inform its affected members of the approved alternative access standards in a manner and timeframe, as determined by the department.

(d) (1) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(A) Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46.

(B) Article 2.8 (commencing with Section 14087.5).

(C) Article 2.81 (commencing with Section 14087.96).

(D) Article 2.82 (commencing with Section 14087.98).

(E) Article 2.91 (commencing with Section 14089).

(F) Chapter 8 (commencing with Section 14200), including dental managed care plans.

(G) Chapter 8.9 (commencing with Section 14700).

(H) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver, as applicable.

(2) “Specialist provider” has the same meaning as “specialist” as defined in paragraph (2) of subdivision (i) of Section 14197.

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 133. (SB 184) Effective June 30, 2022.)

article: 6.3. Medi-Cal Managed Care Plans