text:
(a) The long-term care services agency shall be responsible and at risk for implementing the administrative action plan. The long-term care services agency shall do all of the following:

(1) Respond, or provide for response to, consumer needs on a 24-hour, seven-day-a-week basis.

(2) Conduct comprehensive assessments.

(3) Determine eligibility for long-term care services based on the assessment information.

(4) Provide for contractual arrangements for the provision of, and payment for, sufficient services to meet the long-term care needs of the eligible beneficiary in his or her home, community, residential facility, nursing facility, or other location based on the mix of programs or services included in the administrative action plan.

(5) Provide linkages to acute care hospitals.

(6) Maintain control over utilization of services that are authorized.

(7) Monitor the quality of care provided to consumers.

(8) Maintain a consumer grievance process.

(9) Manage the overall cost-effectiveness of the pilot project for its duration.

(b) Services may be provided through contracts with community-based providers. In instances where a specific service does not exist in the community, the long-term care services agency may facilitate the development of local programs that provide these services or may provide the services directly, if doing so can be demonstrated to be cost effective.


kind: section

code: WIC

text:
The Legislature finds and declares that:

(a) Long-term care services in California include an uncoordinated array of categorical programs offering medical, social, and other support services that are funded and administered by a variety of federal, state, and local agencies and are replete with gaps, duplication, and little or no emphasis on the specific concerns of individual consumers.

(b) Although the need for a coordinated continuum of long-term care services has long been apparent, numerous obstacles prevent its development, including inflexible and inconsistent funding sources, economic incentives that encourage the placement of consumers in the highest levels of care, lack of coordination between aging, health, and social service agencies at both state and local levels, and inflexible state and federal regulations.

(c) The office of the Legislative Analyst and others have pointed out that California’s systems of service delivery in a number of areas are dysfunctional, due to the fragmentation of responsibility and funding for interrelated services. Principles proposed by the Legislative Analyst to guide the restructuring of these systems include recognizing program linkages, coordinating service delivery mechanisms, removing barriers to innovation, and instilling financial incentives to promote prevention and coordination.

(d) It is both more efficient and more humane to restructure long-term care services so that duplicative and confusing eligibility criteria, assessments, intake forms, and service limitations will not inhibit consumer satisfaction, impede improvements in consumer health status, and result in the ineffective use of resources.

(e) There is a growing interest in community-directed systems of funding and organizing the broad array of health, support, and community living services needed by persons of all ages with disabilities.

(f) It is in the interest of those in need of long-term care services, and the state as a whole, to develop a long-term care system that provides dignity and maximum independence for the consumer, creates home and community based alternatives to unnecessary out-of-home placement, and is cost effective.

history: (History: Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.3. Long-Term Care Integration Pilot Program


text: The department shall set a capitated rate of payment that is actuarially sound and that is based on the number of beneficiaries who are eligible for Medi-Cal benefits to be enrolled in the pilot project, the mix of provided services and programs being integrated, and past Medi-Cal expenditures for services. The rate shall reflect, and the contract shall delineate, the rate at which the local long-term care services agency shall assume the total risk and the mechanisms that shall be used, which may include, but are not limited to, risk corridors, reinsurance, or alternative methods of risk assumption.

article: 4.3. Long-Term Care Integration Pilot Program


text:
(a) It is the intent of the Legislature that local entities that are potential participants in this pilot program shall be assured of sufficient time to plan their pilot projects, and that the selected pilot project sites shall be assured of sufficient time to phase in the implementation of their programs. To that end, it is the intent of the Legislature that the department, in consultation with potential pilot project sites and the pilot program working group, shall develop a realistic timeline with guidelines for the planning and implementation of pilot projects.

(b) Nothing in this chapter shall prohibit the department, in consultation with the pilot program working group, from establishing a two-stage selection process in which local pilot project sites may be selected on a preliminary basis. Final selection of local pilot project sites shall be based on the completion of an administrative action plan that the department determines satisfactorily meets the selection criteria.


text:
The goals of this pilot program shall be to:

(a) Provide a continuum of social and health services that foster independence and self-reliance, maintain individual dignity, and allow consumers of long-term care services to remain an integral part of their family and community life.

(b) If out-of-home placement is necessary, to ensure that it is at the appropriate level of care, and to prevent unnecessary utilization of acute care hospitals.

(c) If family caregivers are involved in the long-term care of an individual, to support caregiving arrangements that maximize the family’s ongoing relationship with, and care for, that individual.

(d) Deliver long-term care services in the least restrictive environment appropriate for the consumer.

(e) Encourage as much self direction as possible by consumers, given their capability and interest, and involve them and their family members as partners in the development and implementation of the pilot project.

(f) Identify performance outcomes that will be used to evaluate the appropriateness and quality of the services provided, as well as the efficacy and cost effectiveness of each pilot project, including, but not limited to, the use of acute and out-of-home care, consumer satisfaction, the health status of consumers, and the degree of independent living maintained among those served.

(g) Test a variety of models intended to serve different geographic areas, with differing populations and service availability.

(h) Achieve greater efficiencies through consolidated screening and reporting requirements.

(i) Allow each pilot project site to use existing funding sources in a manner that it determines will meet local need and that is cost-effective.

(j) Allow the pilot project sites to determine other services that may be necessary to meet the needs of eligible beneficiaries.

(k) Identify ways to expand funding options for the pilot program to include medicare and other funding sources.


text: It is the intent of the Legislature that the costs of this pilot program to the General Fund will not exceed the direct and indirect costs that existing programs would expect to incur had the integrated services not been provided through this pilot program. If the Department of Finance determines, and informs the director in writing, that the implementation of this pilot program will result in any additional costs to the state relative to the provision of long-term care services to eligible beneficiaries, the department may terminate the operation of all or any part of this pilot program. The state shall not be held liable for any additional costs incurred by a pilot project site. Any such determination made by the Department of Finance shall be available to any party upon request.


text:
(a) Any contract entered into pursuant to this article may be renewed if the long-term care services agency continues to meet the requirements of this article and the contract. Failure to meet these requirements shall be cause for nonrenewal of the contract. The department may condition renewal on timely completion of a mutually agreed upon plan of corrections of any deficiencies.

(b) The department may terminate or decline to renew a contract in whole or in part when the director determines that the action is necessary to protect the health of the beneficiaries or the funds appropriated to the Medi-Cal program. The administrative hearing requirements of Section 14123 do not apply to the nonrenewal or termination of a contract under this article.

(c) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore, contracts under this article shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(d) The Director of the Department of Managed Health Care shall, at the director’s request, immediately grant an exemption from Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out any contract entered into pursuant to this article.

history: (History: Amended by Stats. 2000, Ch. 857, Sec. 90. Effective January 1, 2001.)


text: The department may accept funding from federal agencies, foundations or other nongovernmental sources and may contract with qualified consultants to assist with the provision of technical assistance, the development of data collection, reporting, and analysis systems, or any other purposes that further the goals of this demonstration program. The department shall not accept funds from any entity that stands to gain financially from implementation of the pilot program. In contracting with consultants to assist with the pilot program, the department shall specify timelines and delivery dates so as to ensure the continued implementation of the pilot program.


text:
(a) The department shall convene a working group that shall include the Director of Health Care Services, the Director of Social Services, and the Director of the California Department of Aging, or the program staff from each of those departments who have direct responsibility for the programs listed in subdivision (b) of Section 14139.32, and may include the Director of Rehabilitation, or program staff from those departments with direct responsibilities for programs that may be included as a service in any pilot project site, and representatives from each pilot project site upon its selection.

(b) The department shall consult with the working group during the designing of the pilot program, in the selection of the pilot project sites, and in the monitoring of the program under this article, and shall utilize the working group as a resource for problem solving and a means of maintaining interdepartmental and intersite communication.

(c) The working group shall strive to ensure that the pilot program under this article makes maximum use of home-based and community-based services, and throughout the continuum of care for each beneficiary, encourages the use of the least restrictive environment in which the beneficiary can receive appropriate care.

history: (History: Amended by Stats. 2012, Ch. 438, Sec. 20. (AB 1468) Effective September 22, 2012.)


text: Upon the implementation of the pilot program, responsibility for administering the programs integrated within the pilot program shall be transferred to the department, and shall be specified in an interagency agreement between participating departments. Prior requirements for any program integrated within this pilot program shall be deemed to have been met through compliance with the requirements established by this article, by the department for the pilot program by each county’s approved plan, and by the approved applicable federal waivers.


text: The department shall seek all federal waivers necessary to allow for federal financial participation in the pilot program implemented pursuant to this article. This article shall not be implemented unless and until the director has executed a declaration that the approval of all necessary federal waivers has been obtained by the department.


text: Notwithstanding any other provision of this article, costs to the General Fund shall not exceed the amount that would have been expended in the absence of the pilot program.


text: In order to be selected, a pilot project site shall demonstrate that it has an active advisory committee that includes consumers of long-term care services, representatives of local organizations of persons with disabilities, seniors, representatives of local senior organizations, representatives of employees who deliver direct long-term care services, and representatives of organizations that provide long-term care services. At least one-half of the members of the advisory committee must be consumers of services provided under this chapter or their representatives.


text:
(a) The administrative action plan shall identify the funds to be transferred into the consolidated long-term care services fund.

(b) The funds shall include Medi-Cal long-term institutional care, the Medi-Cal Personal Care Services Program, and the In-Home Supportive Services Program and may include funds from the following programs and services:

(1) Multipurpose Seniors Services Program.

(2) Alzheimer’s Day Care Resources Centers Program.

(3) Linkages Program.

(4) Respite Program.

(5) Adult Day Health Care Program.

(6) Medi-Cal home health agency services.

(7) Medi-Cal home-based and community-based waiver programs.

(8) Medi-Cal hospice services.

(9) Medi-Cal acute care hospital services.

(10) Other Medi-Cal services, including, but not limited to, primary, ancillary, and acute care.

(c) Optional program funds enumerated in subdivision (b) of Section 14139.32 shall be included in the long-term care services fund in any case where a program was funded prior to its integration into the pilot project.

(d) In determining which project sites to select for participation in the pilot program, the department shall give preference to those sites that include funds from the largest number of programs existing within the project site at the time the site applies for selection, provided the administrative action plan meets all other selection criteria. With the exception of up to one rural county, preference shall be given to project sites that include primary, ancillary, and acute care in the consolidated fund, provided their administrative action plan meets all other selection criteria.


text:
The administrative action plan shall delineate the services to be provided to all eligible beneficiaries. At a minimum, services to be provided shall include all of the following:

(a) Care or case management, including assessment, development of a service plan in conjunction with the consumer and other appropriate parties, authorization and arrangement for purchase of services or linkages with other appropriate entities, service coordination activities, and followup to determine whether the services received were appropriate and consistent with the service plan. Service coordination activities shall ensure that the records of each beneficiary are maintained in a consistent and complete manner and are accessible to the beneficiary or his or her family, and providers involved in his or her care. This shall be the case whether a beneficiary resides in his or her own home or in a licensed facility.

(b) Education of beneficiaries, their families, and others in their informal support network, including independent living skills training to maximize the independence of the beneficiary.

(c) In-home services.

(d) Adult day services.

(e) Institutional long-term care.

(f) Hospice services.

(g) Linkages to acute care services and primary care services, if they are not included in the integrated plan.


text:
The administrative action plan may also include any of the following services:

(a) Transportation.

(b) Home modification.

(c) Medical services, including, but not limited to, primary, ancillary, and acute care.

(d) Housing and residential services.

(e) Other services determined by the pilot project to be necessary to meet the needs of eligible beneficiaries.


text:
The department may exempt a pilot project site from the requirements of subdivisions (d) and (f) of Section 14139.33 if both the following conditions are met:

(a) State funds were not being used in the geographic area covered by the pilot projects to provide those services at the time of application to the pilot program.

(b) The pilot project site can demonstrate to the department how it plans to develop these services, and within what timeframe, during the pilot program.


text:
(a) If primary, ancillary, and acute care are not included among the services offered by a pilot project site, the administrative action plan shall include all of the following:

(1) A mechanism for tracking the usage of these services by beneficiaries of the plan.

(2) Provisions for the future inclusion of those services in the integrated plan, including the process and timeline by which they will be integrated.

(b) The department shall, in consultation with the pilot project sites, apply to the federal health care financing administration for a waiver that allows the pilot projects to include medicare funds in the long-term care services fund. Upon receipt of the waiver, within a time period to be designated by the department specific to each site, each pilot project site shall assume responsibility for primary, ancillary, and acute care services.


text: The administrative action plan shall delineate specifically how the pooled funds will be used to deliver services to all eligible recipients in the geographic area covered by the pilot project site.


text: Participating counties shall continue their financial maintenance of effort for each of the programs integrated within the pilot program under this article. The amount of a county’s maintenance of effort shall be the same as if the program were not integrated within the pilot program pursuant to this article, and funds equal to this amount shall be deposited in the local consolidated long-term care services fund.


text:
(a) For purposes of this chapter, “eligible beneficiaries” shall be defined as persons meeting all the following criteria:

(1) Are Medi-Cal eligible.

(2) Are functionally or cognitively impaired. For purposes of this paragraph “cognitively impaired” means having an impairment caused by organic brain disorder or disease.

(3) Are adults.

(4) Need assistance with two or more activities of daily living or are unable to remain living independently without the long-term care services provided through the pilot program operated pursuant to this article.

(b) To the extent eligible beneficiaries also receive services from a regional center that serves a pilot project site, the pilot project shall delineate in its administrative action plan how services will be coordinated by the two agencies.


text:
(a) Each pilot project site shall serve all eligible beneficiaries who live in the geographic area served by the long-term care services agency. In order to eliminate duplicative administrative costs and to achieve a more efficient delivery system, pilot project sites shall also serve non-Medi-Cal eligible individuals who, but for the implementation of the pilot project, would have received services from programs whose funds are included in the consolidated long-term care services fund.

(b) Funding sources allocated for persons who are not eligible for Medi-Cal benefits may be integrated into the consolidated long-term care services fund. To the extent those funds are spent on services for persons who are not eligible for Medi-Cal benefits, they shall be segregated from capitated funds for Medi-Cal beneficiaries. No funds derived from the capitated Medi-Cal rate may be used for persons who are not eligible for Medi-Cal.


text: This article shall not preclude a long-term care services agency from entering into additional agreements, separate from the pilot project, to serve additional individuals or populations.


text: Pilot project sites shall ensure provider reimbursement rates that are adequate to maintain compliance with applicable federal and state requirements.


text:
If the department determines that a program or programs cannot reasonably be capitated, funds may be transferred separately from the capitation payment. The amount of those noncapitated funds shall be based on amounts that would have been expended by the state for those programs in the absence of the pilot program implemented under this article.

It is the intent of the Legislature that, if any local pilot project experiences net savings, those savings shall be used for project expansion and improvement, or to build the required tangible net equity, or if there is no need for expansion or improvement or to build tangible net equity, may be shared by the long-term care services agency and the state.


text:
(a) The department shall develop criteria to ensure that pilot project sites maintain fiscal solvency, including, but not limited to, the following:

(1) The capability to achieve and maintain sufficient fiscal tangible net equity within a timeframe to be specified by the department for each pilot project site.

(2) The capability to maintain prompt and timely provider payments.

(3) A management information system that is approved by the department and is capable of meeting the requirements of the pilot program.

(b) Any pilot project established under this article shall immediately notify the department in writing of any fact or facts that are likely to result in the pilot project or the long-term care services agency being unable to meet its financial obligations. The written notice shall describe the fact or facts, the anticipated financial consequences, and the actions that will be taken to address the anticipated consequences, and shall be made available upon request unless otherwise prohibited by law.

history: (History: Amended by Stats. 2000, Ch. 858, Sec. 4. Effective January 1, 2001.)


text: The department may adopt emergency regulations as necessary to implement this article in accordance with the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The initial adoption of emergency regulations shall be deemed to be an emergency and considered by the Office of Administrative Law as necessary for the immediate preservation of the public peace, health and safety, or general welfare. Emergency regulations adopted pursuant to this section shall remain in effect for no more than 180 days.


text:
Contingent on the availability of funding, the department shall evaluate the effectiveness of each pilot project on a schedule that coincides with federal waiver reporting requirements, and shall make this information available upon request. The department’s evaluation shall include, but not be limited to, the following:

(a) Whether or not the pilot project has reduced the fragmentation and improved the coordination of the long-term care delivery system in the pilot project area.

(b) Whether or not the long-term care delivery system is more efficient and makes better use of available resources.

(c) Whether or not the goals identified in Section 14139.11 have been met.


text:
The following definitions shall apply to the provisions of this article:

(a) “Net worth” means:

(1) Personal property, which consists of cash, savings accounts, securities, and similar items; notes, mortgages, and deeds of trust; the cash surrender value of life insurance on the life of the applicant or beneficiary, on the life of the spouse, or any member of the family, except as provided in Section 11158; motor vehicles, except one which meets the transportation needs of the person or family; any other property or equity other than real estate, except that property specified in subdivisions (1), (2), and (3) of Section 11155.

(2) Real property, including any interest in land of more than nominal interest which does not constitute the home of the applicant for aid under this chapter. The home of the applicant shall be exempt from consideration as net worth under this section to the extent of ten thousand dollars ($10,000) in assessed valuation, as assessed by the county assessor.

(3) “Income” which consists of the sum of adjusted gross income as used for purposes of the Federal Income Tax Law.

(b) “Family unit” means:

(1) In the case of a patient who is not married or in a registered domestic partnership and is under 21 years of age living with his or her parent or parents, the patient and his or her parents.

(2) In the case of a patient who is married or in a registered domestic partnership and is under 21 years of age, the patient and his or her spouse.

(3) In the case of a patient over 21 years of age, the patient, and if married or in a registered domestic partnership, the patient’s spouse.

history: (History: Amended by Stats. 2016, Ch. 50, Sec. 123. (SB 1005) Effective January 1, 2017.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services


text: Net worth liability shall be determined as of the time of the initial dialysis or parenteral hyperalimentation treatment and shall be reevaluated each year by the department.

history: (History: Amended by Stats. 1980, Ch. 1240, Sec. 2.)

article: 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services


text:
Notwithstanding Section 14005.4 or 14005.7, a person who is otherwise eligible for dialysis and related services under Section 14005.4 or 14005.7, except for his or her income and resource eligibility, is eligible for dialysis and related services under Medi-Cal pursuant to this article, as follows:

(a) A person in a family unit with a net worth of less than five thousand dollars ($5,000) shall not be liable to pay for dialysis and related services.

(b) A person in a family unit with a net worth of five thousand dollars ($5,000) or above shall pay 2 percent of the cost of dialysis and related services for each five thousand dollars ($5,000) of net worth, up to a maximum net worth of two hundred fifty thousand dollars ($250,000). Persons in a family unit with a net worth above two hundred fifty thousand dollars ($250,000) shall not be eligible to receive dialysis under Medi-Cal.

history: (History: Amended by Stats. 1990, Ch. 833, Sec. 1. Effective September 14, 1990.)


text:
Notwithstanding Section 14005.4 or 14005.7, a person requiring parenteral hyperalimentation and related services is eligible for these services under Medi-Cal pursuant to this section, as follows:

(a) A person in a family unit with a net worth of less than five thousand dollars ($5,000) shall not be liable to pay for parenteral hyperalimentation and related services.

(b) A person in a family unit with a net worth of five thousand dollars ($5,000) or above shall pay 2 percent of the cost of parenteral hyperalimentation and related services for each five thousand dollars ($5,000) of net worth, up to a maximum net worth of two hundred fifty thousand dollars ($250,000). Persons in a family unit with a net worth above two hundred fifty thousand dollars ($250,000) shall not be eligible to receive parenteral hyperalimentation under Medi-Cal.

history: (History: Added by Stats. 1990, Ch. 833, Sec. 2. Effective September 14, 1990.)


text: The health care benefits and services specified in this article, to the extent that such benefits and services are neither provided under any other federal or state law nor provided nor available under other contractual or legal entitlements of the person, shall be provided to any dialysis or parenteral hyperalimentation patient who is a resident of this state and is made eligible by the provisions of this article. After such dialysis or parenteral hyperalimentation patient has utilized such contractual or legal entitlements, the percentages of payment liability under Section 14142 shall then be applied to the remaining cost of dialysis or parenteral hyperalimentation.

history: (History: Amended by Stats. 1980, Ch. 1240, Sec. 4.)


text: The provisions of this article do not apply to indigent dialysis or parenteral hyperalimentation patients who are otherwise eligible for Medi-Cal or to any person eligible for renal dialysis under the provisions of Public Law 92-603 (H.R. 1).

history: (History: Amended by Stats. 1980, Ch. 1240, Sec. 5.)


text: Notwithstanding any provision of this article or of any other statute to the contrary, any person who is eligible under Section 14005.4 or 14005.7 for dialysis, parenteral hyperalimentation, and related services and who is employed and individually earning an amount which exceeds the minimum needs standard, and who receives dialysis services either through a self-dialysis unit of a dialysis clinic or through home dialysis or who receives parenteral hyperalimentation services through self-parenteral hyperalimentation, shall be eligible for dialysis, parenteral hyperalimentation , and related services under Medi-Cal pursuant to this article and shall, after utilizing other contractual or legal entitlements pursuant to Section 14143, be liable to pay only the amounts specified in subdivision (b) of Section 14142, except that such percentage obligations shall be 1 percent for each five thousand dollars ($5,000) of family unit net worth up to a maximum net worth of five hundred thousand dollars ($500,000). Persons eligible for services under this section shall not be subject to Section 14144.

history: (History: Added by renumbering Section 14145 (as amended by Stats. 1980, Ch. 1240) by Stats. 1981, Ch. 714, Sec. 474.)


text:
(a) Beginning with the 1998–99 fiscal year and contingent on appropriation of funds through the Budget Act, the department may contract with a nonprofit entity, incorporated in California that has been formed for the purpose of serving as the center for long-term care integration. The center may serve as a focal point for facilitating the development of community-based local organizing groups through a public-private partnership.

(b) The nonprofit center may do all of the following:

(1) Serve in an advisory capacity to the key stakeholders in long-term care integration, including consumers, consumer advocacy groups, researchers, representatives of service providers and purchasers, and local and state policymakers.

(2) Assemble, organize, and make available technical information, data, expertise, and models on long-term care integration from across the state and nation.

(3) Assist local communities with long-term care planning and analysis, development of service delivery and financing systems, statewide data sharing, and private fund development.

(4) Coordinate goals and activities with the State Department of Health Services.

(c) The center may build and sustain working partnerships by developing and supporting a cross-county, statewide network of consumers, providers and funders, as well as maintaining an ongoing relationship with the state.

(d) The center may assist the local organizing groups (LOGs) in seeking local financial support, as well as to obtain foundation matching funds for statewide grant-making.

(e) The center may coordinate and disseminate long-term care planning information by identifying key long-term care development issues, and disseminating the information to local planning groups, as needed.

(f) The center may facilitate implementation by identifying and sharing useful tools and resources, designing models for service protocols of the local long-term care integration pilot projects, coordinating information systems, standardizing assessment elements, and providing low-cost training and technical assistance to the LOGs as they progress through common tasks necessary for local development and implementation.

(g) The center may collect and track information across LOG sites.

(h) The center may prepare annual progress reports, and shall provide these reports to the department and the budget committees of the Legislature.

history: (History: Added by Stats. 1998, Ch. 310, Sec. 108. Effective August 19, 1998.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects


text:
(a) The department may administer grants for purposes of this article, that shall be awarded through a request for application process.

(1) Grants may be awarded to local organizing groups (LOGs) that are existing or new community-based nonprofit organizations or government entities for purposes of implementing long-term care integration pilot projects, pursuant to Article 4.05 (commencing with Section 14139.05).

(2) Grants may be available for LOGs in the planning phase, or the development phase of the project, or both. Planning phase grants shall be limited to a maximum award of fifty thousand dollars ($50,000). Development phase grants shall be limited to a maximum award of one hundred fifty thousand dollars ($150,000). The planning phase includes activities related to initial planning for a long-term care integration pilot project (LTCIPP). The development phase includes activities for implementing the planning phase, up to actual implementation of the pilot project.

(b) Criteria for grant selection shall include, but not be limited to, the following:

(1) For planning phase grants:

(A) Identification of a LOG committed to development of a LTCIPP that includes major stakeholders, including, but not limited to, consumers, community-based providers, institutional providers, and public entities.

(B) Evidence of local government support for development of a LTCIPP.

(C) A description of current and planned consumer involvement.

(D) A plan for the use of funds.

(E) Specification of goals and objectives, and a work plan for achieving them.

(F) A proposed strategy for project evaluation.

(2) For development phase grants:

(A) Identification of the authorized grantee sanctioned by the local government entity.

(B) Identification of an entity for operation of the LTCIPP.

(C) Definition of a governance structure.

(D) An adopted work plan that includes all of the following:

(i) A vision statement describing the long-term care system for the community.

(ii) Description of the covered scope of services and programs to be integrated at the local level.

(iii) Description of the target population.

(iv) Plan for integration of funding for those services.

(E) Specific work goals for the development phase.

(F) A work schedule for completion.

(G) A proposed strategy for project evaluation.

(3) Both planning phase and development phase grant funds may be used for, but are not limited to, the following purposes:

(A) Staff support.

(B) Consulting contracts.

(C) Community organizing support.

(D) Data analysis.

(c) Grantees shall be required to match a portion of the grant awarded, either with cash, or in-kind contributions totaling 20 percent of the total grant. The match required by this subdivision shall be supplemental to the funds appropriated for the LTCIPP.

history: (History: Amended by Stats. 2001, Ch. 745, Sec. 256. Effective October 12, 2001.)

article: 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects


text:
(a) The department shall develop at least, but not limited to, one alternative model to the Long-Term Care Integration Pilot Program authorized under Article 4.3 (commencing with Section 14139.05) that shall be designed to achieve the goals set forth in Section 14139.11.

(b) The department or, at the discretion of the department, the center for long-term care integration referred to in subdivision (a) of Section 14145, shall consult with an established waiver technical advisory committee to assist in the development of an alternative model or models pursuant to subdivision (a).

(c) No reimbursement or compensation shall be provided to committee members referred to in subdivision (b).

(d) The department shall report the recommendations of the waiver technical advisory committee to the Legislature on or before December 1, 2003.

history: (History: Added by Stats. 2002, Ch. 537, Sec. 1. Effective January 1, 2003.)


text:
(a) (1) The department shall work with identified stakeholders to conduct a study to identify current requirements for medical interpretation services as well as education, training, and licensure requirements, analyze other state Medicaid programs, and make recommendations on strategies that may be employed regarding the provision of medical interpretation services for Medi-Cal beneficiaries who are limited English proficient (LEP), in compliance with applicable state and federal requirements.

(2) The study also shall assess and make recommendations based on pilot projects, studies, and available data that would further the objectives of this article, including funding for those activities and the allowable use of federal funding.

(b) (1) The department shall work with identified stakeholders to establish a pilot project concurrent with the study.

(2) A pilot project shall include up to four separate sites to evaluate the provision of medical interpretation services for LEP Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans and in fee-for-service Medi-Cal. In identifying sites, the department shall take into account the need for those services, the availability of a pool of medical interpreters that meet the language needs of the Medi-Cal population for use by providers and managed care plans, and the studies and available data identified under paragraph (2) of subdivision (a).

(c) (1) The department may use or contract with an external vendor, vendors, or other contracted subject matter experts to implement the activities described in this section, including the pilot project. However, the vendor for the study shall not be used for the pilot project. The department shall consult with identified stakeholders regarding the draft initial scope of work that shall be used to seek and evaluate proposals pursuant to this section.

(2) At a minimum, the pilot project shall be designed to evaluate all of the following:

(A) Whether Medi-Cal beneficiary satisfaction is greater than for those beneficiaries without access to in-person medical interpretation.

(B) Whether the satisfaction of physicians and surgeons, nurse practitioners, physician assistants, and other health professionals acting within their scope of practice increases.

(C) Whether noncompliance with treatment regimens or avoidable medical errors are reduced.

(D) Whether disparities in care are reduced, with respect to LEP Medi-Cal beneficiaries compared with Medi-Cal beneficiaries who are proficient in English.

(E) Whether the Medi-Cal managed care plans identify improvements in quality of care.

(F) The utilization of medical interpreters by providers and Medi-Cal managed care plans.

(d) (1) Each year, commencing in 2017, during the annual state budget process, the department shall provide an update to the budget committees of the Legislature on the implementation of this article.

(2) Any report submitted under this subdivision shall be submitted in compliance with Section 9795 of the Government Code.

(e) (1) For activities under this section, the department may expend up to three million dollars ($3,000,000) under Provision 14 of Item 4260-101-0001 of Section 2.00 of the Budget Act of 2016 (Chapter 23 of the Statutes of 2016) for the support of activities related to a medical interpreters pilot project, study, or both. In addition, the department shall expend up to five million dollars ($5,000,000) for the pilot project under Provision 15 of Item 4260-101-0001 of Section 2.00 of the Budget Act of 2019 (Chapter 23 of the Statutes of 2019), which shall be available for expenditure, encumbrance, and liquidation until June 30, 2026.

(2) The department may seek any available federal funding for support of activities relating to medical interpretation services as provided under this section.

(3) Expenditure or encumbrance of the funds described in this subdivision is contingent upon approval by the Department of Finance.

history: (History: Amended by Stats. 2025, Ch. 105, Sec. 62. (AB 144) Effective September 17, 2025. Inoperative July 1, 2026, pursuant to Section 14146.5. Repealed as of January 1, 2027, pursuant to Section 14146.5.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.6. Medi-Cal Medical Interpretation Services


text: This article shall become inoperative on July 1, 2026, and, as of January 1, 2027, is repealed.

history: (History: Amended by Stats. 2025, Ch. 105, Sec. 63. (AB 144) Effective September 17, 2025. Repealed as of January 1, 2027, by its own provisions. Note: Repeal affects Article 4.6, commencing with Section 14146.)

article: 4.6. Medi-Cal Medical Interpretation Services


text:
(a) (1) (A) Except as provided in subparagraph (B), the department shall adopt the federal option provided under Section 4101 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) to extend eligibility for medical assistance under Medicaid to all pregnant individuals and infants with family incomes not in excess of 185 percent of the federal poverty level.

(B) Effective January 1, 2014, the federal poverty level percentage income eligibility threshold used pursuant to subdivision (c) of Section 14005.64 to determine eligibility for medical assistance under this section pursuant to subparagraph (A) shall equal 208 percent of the federal poverty level.

(C) Effective January 1, 2022, eligibility for medical assistance to pregnant individuals with family incomes not in excess of 208 percent of the federal poverty level, before the application of the 5-percent income disregard pursuant to subdivision (b) of Section 14005.64, shall be as described in Section 14005.22.

(2) If a premium is imposed, the amount of the premium shall not exceed 10 percent of the amount by which the family’s income, less actual child care costs, exceeds 150 percent of the federal poverty level as provided in Section 1916(c) of the federal Social Security Act (42 U.S.C. Sec. 1396o(c)) as determined, counted, and valued in accordance with the requirements of Section 14005.64. The department shall implement this section by emergency regulation.

(b) Upon order of the Department of Finance, the Controller shall transfer funds from Item 4260-101-001 of the Budget Act of 1988 to Item 4260-111-001 of the Budget Act of 1988 during the 1988–89 fiscal year for the purpose of funding outreach efforts for perinatal services.

(c) Notwithstanding subdivision (a), the state may limit implementation of this section during the 1988–89 fiscal year, based upon the availability of department funds. The department may use maternal and child health funds to finance the increased costs of implementing an expansion of Medi-Cal eligibility to pregnant individuals and to children with incomes of up to 185 percent of federal poverty levels if both of the following conditions exist:

(1) The department has allocated for expenditure at least sixteen million dollars ($16,000,000) in funds redirected from the Medi-Cal program for that expansion.

(2) If, and to the extent, the department determines that estimates of costs based on actual data indicate that the funds are needed to cover costs.

(d) To assist Medi-Cal eligible pregnant individuals in receiving prenatal care promptly, all pregnant individuals applying for Medi-Cal shall be determined to have an immediate need. Counties, within existing resources, shall expedite the eligibility determination process for all pregnant individuals on the basis of their immediate needs. Upon determination of eligibility, a Medi-Cal card shall be issued immediately.

(e) The amendments made to subdivision (a) by Senate Bill 508 during the 2013–14 Regular Session shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained.

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 123. (SB 184) Effective June 30, 2022.)

article: 4.7. Perinatal Services Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.7. Perinatal Services Program


text: To maximize federal financial participation, the department shall seek flexibility in implementing the requirements of Section 121 of the Immigration Reform and Control Act of 1986 (Public Law 99-603) for Medi-Cal eligible people with confirmed pregnancies.

history: (History: Amended by Stats. 2023, Ch. 372, Sec. 3. (AB 1481) Effective January 1, 2024.)

article: 4.7. Perinatal Services Program


text: In order to assure access to obstetrical providers in the Medi-Cal program, the state department shall explore and adopt policies which improve provider relations with Medi-Cal maternity care providers. Policies to be considered shall include, but not be limited to, those which reduce the annual percentage of obstetrical billings going to the department’s suspense file, simplify provider claim forms, establish toll-free telephone lines for the exclusive use of maternity care providers, and establish clear reimbursement guidelines. In addition, the department shall explore policies to assure that obstetrical claims are processed on a prompt and predictable basis, the feasibility of establishing a special claims processing unit for obstetrical claims, and the adequacy of current reimbursement levels and services reimbursed. The department shall advise the Chairs of the Assembly Health Committee and the Senate Health and Human Services Committee by July 1, 1989, on steps taken to improve provider relations and the impact these steps have had on provider participation.

history: (History: Added by Stats. 1988, Ch. 980, Sec. 3.)

article: 4.7. Perinatal Services Program


text:
(a) Pursuant to options provided in federal law and notwithstanding any other provision of law, the form used by a provider to collect information about a pregnant person pursuant to the Medi-Cal temporary benefits program under Section 14148.7 as that program is implemented on January 1, 2003, shall itself qualify as a simplified application for the Medi-Cal program for pregnant people, or, if necessary to ensure federal financial participation, the form shall be modified to add only those elements required for federal financial participation and be as simple as the department considers practicable.

(b) For purposes of this section, the department shall determine whether to grant eligibility for temporary benefits under Section 14148.7 and the county shall make the final eligibility determination for the Medi-Cal program. The department shall develop and adopt a process for transferring the application to the county and a followup process that is as simple as the department considers practicable to be used by the county if followup is necessary. Based on the department’s instructions, the county shall make a determination whether followup is necessary to determine the pregnant person’s final eligibility for the Medi-Cal program or to refer the pregnant person to the Medi-Cal Access Program.

(c) The department shall adopt an electronic enrollment process for pregnant people to use when applying for the Medi-Cal program from a provider’s office. The application form for this electronic enrollment shall use the elements of the application form described in subdivision (a) and the procedures specified in subdivision (b). This electronic enrollment process shall be known as the Prenatal Gateway. In developing the Prenatal Gateway required by this subdivision, the department shall consult with consumer, provider, county, and health plan representatives.

(d) The purpose of this section is to begin eligibility and benefits at the time of an eligible pregnant person’s visit to a provider and to continue eligibility and benefits until a final eligibility determination is made without the submission of any other application form to the department, the county, or a single point of entry and to make the followup process as simple as the department considers practicable.

(e) The Prenatal Gateway may not be adopted until both of the following occur:

(1) Sufficient moneys have been deposited in the Special Funds Account of the Gateway Fund to defray the costs of developing the Prenatal Gateway.

(2) Sufficient new staff, not to exceed a total of three personnel years, is available at the department for the purposes of this section and Section 14148.04 and is funded through nonstate General Fund sources. Notwithstanding any other provision of law, the department may hire staff necessary to implement this section.

(f) The department shall implement the Prenatal Gateway within 12 months after the date upon which both of the conditions required under subdivision (e) have occurred.

(g) To implement this section, the department may contract with public or private entities, or utilize existing health care service provider enrollment and payment mechanisms, including the Medi-Cal program’s fiscal intermediary, only if services provided under the program are specifically identified and reimbursed in a manner that appropriately claims federal financial reimbursement. Contracts, including the Medi-Cal fiscal intermediary contract for the Child Health and Disability Prevention Program, and including any contract amendment, any system change pursuant to a change order, and any project or systems development notice shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, former Chapter 7 (commencing with Section 11700) of Part 1 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and any policies, procedures, or regulations authorized by these laws.

history: (History: Amended by Stats. 2023, Ch. 372, Sec. 2. (AB 1481) Effective January 1, 2024.)

article: 4.7. Perinatal Services Program


text: The department shall seek federal approval to implement obstetrical case management for Medi-Cal eligible pregnant people when provided through the Child Health and Disability Prevention program authorized under Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.

history: (History: Amended by Stats. 2023, Ch. 372, Sec. 4. (AB 1481) Effective January 1, 2024.)

article: 4.7. Perinatal Services Program


text:
(a) The department shall adopt, as specified in this section, an electronic process for families to enroll a deemed eligible newborn in the Medi-Cal program from hospitals that have elected to participate in the process. The electronic enrollment process adopted pursuant to this section shall be known as the Newborn Hospital Gateway.

(b) With respect to the enrollment of a child under one year of age who is deemed to have applied and is deemed eligible for Medi-Cal benefits under Section 1396a(e)(4) of Title 42 of the United States Code, the enrollment procedures of the Newborn Hospital Gateway shall specifically include procedures for confirming the eligibility of, and issuing a Medi-Cal card to, that child.

(c) In developing the Newborn Hospital Gateway required by this section, the department shall consult with consumer, provider, county, and health plan representatives.

(d) The Newborn Hospital Gateway may not be adopted until both of the following occur:

(1) Sufficient moneys have been deposited in the Special Funds Account of the Gateway Fund to defray the costs of developing the Newborn Hospital Gateway.

(2) Sufficient new staff, not to exceed a total of three personnel years, is available at the department for the purposes of this section and Section 14148.03 and is funded through nonstate General Fund sources. Notwithstanding any other provision of law, the department may hire staff necessary to implement this section.

(e) The department shall implement the Newborn Hospital Gateway within 12 months after the date upon which both of the conditions required under subdivision (d) have occurred.

(f) To implement this section, the department may contract with public or private entities, or utilize existing health care service provider enrollment and payment mechanisms, including the Medi-Cal program’s fiscal intermediary, only if services provided under the program are specifically identified and reimbursed in a manner that appropriately claims federal financial reimbursement. Contracts, including the Medi-Cal fiscal intermediary contract for the Child Health and Disability Prevention Program and including any contract amendment, any system change pursuant to a change order, and any project or systems development notice shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and any policies, procedures, or regulations authorized by these laws.

(g) This section shall become inoperative on July 1, 2024, or the effective date for implementation of the Children’s Presumptive Eligibility Program portal pursuant to Section 14011.7, whichever is later, and shall be repealed on January 1 directly following that date.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 150. (AB 118) Effective July 10, 2023. Conditionally inoperative on or after July 1, 2024, by its own provisions. Repealed as of January 1 following the inoperative date. See later operative version added by Sec. 151 of Stats. 2023, Ch. 42.)

article: 4.7. Perinatal Services Program


text:
(a) The department shall adopt, as specified in this section, an electronic process for families to enroll a deemed eligible newborn in the Medi-Cal program from hospitals that have elected to participate in the process. The electronic enrollment process adopted pursuant to this section shall be known as the Newborn Hospital Gateway and shall be accessed through existing presumptive eligibility portals.

(b) All qualified Medi-Cal providers participating in presumptive eligibility programs shall use the Newborn Hospital Gateway system to report a Medi-Cal eligible newborn born in their facilities, including hospitals, birthing centers, or other birthing settings, within 72 hours after birth, or one business day after discharge, whichever is sooner.

(c) With respect to the enrollment of a child under one year of age who is deemed to have applied and is deemed eligible for Medi-Cal benefits under Section 1396a(e)(4) of Title 42 of the United States Code, the enrollment procedures of the Newborn Hospital Gateway shall specifically include procedures for confirming the eligibility of, and issuing a Medi-Cal card to, that child.

(d) In developing the Newborn Hospital Gateway required by this section, the department shall consult with consumer, provider, county, and health plan representatives.

(e) To implement this section, the department may contract with public or private entities, or utilize existing health care service provider enrollment and payment mechanisms, including the Medi-Cal program’s fiscal intermediary, only if services provided under the program are specifically identified and reimbursed in a manner that appropriately claims federal financial reimbursement. Contracts, including the Medi-Cal fiscal intermediary contract for presumptive eligibility programs and including any contract amendment, any system change pursuant to a change order, and any project or systems development notice shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and any policies, procedures, or regulations authorized by these laws.

(f) This section shall become operative on July 1, 2024, or the effective date for implementation of the Children’s Presumptive Eligibility Program portal pursuant to Section 14011.7, whichever is later.

history: (History: Repealed (in Sec. 150) and added by Stats. 2023, Ch. 42, Sec. 151. (AB 118) Effective July 10, 2023. Conditionally operative on or after July 1, 2024, by its own provisions.)

article: 4.7. Perinatal Services Program


text:
(a) The department shall eliminate the Medi-Cal reimbursement differential for obstetrical services by equalizing the rates of reimbursement for Caesarean section and non-Caesarean section care and delivery services. In implementing this section, savings that otherwise would have accrued due to lowered rates of reimbursement for Caesarean section services shall be used to fund across-the-board rate increases for all maternity care and delivery services.

(b) Revisions to the existing rate structure required to implement this section 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. The adoption of these regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted to implement this act 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.

history: (History: Repealed and added by Stats. 1989, Ch. 348, Sec. 2.)

article: 4.7. Perinatal Services Program


text:
(a) There is hereby created in the State Treasury the Gateway Fund.

(b) Moneys in the fund may be expended, upon appropriation by the Legislature, exclusively for purposes of establishing and maintaining the Prenatal Gateway, as provided for in Section 14148.03, and the Newborn Hospital Gateway, as provided for in Section 14148.04, and in accordance with subdivision (c).

(c) The fund shall consist of the following accounts:

(1) The Special Funds Account, which shall consist of all funds received by the Controller for purposes of Sections 14148.03 and 14148.04 from private foundations and other nongovernmental sources and interest accrued thereon. Moneys in this account shall be used exclusively for the purposes of Sections 14148.03 and 14148.04. The department shall not be responsible for securing funding from private foundations or other nongovernmental sources.

(2) The Other Public Funds Account, which shall consist of all public funds, other than federal or state general funds, received by the Controller for purposes of Sections 14148.03 and 14148.04 from state or local sources, including, but not limited to, funds received under the California Families and Children Act of 1998, Division 108 (commencing with Section 130100) of the Health and Safety Code (Proposition 10), and the interest accrued thereon.

(3) The Federal Funds Account, which shall consist of all public funds received by the Controller for purposes of Sections 14148.03 and 14148.04 from federal sources, and the interest accrued thereon.

history: (History: Added by Stats. 2003, Ch. 895, Sec. 4. Effective January 1, 2004.)

article: 4.7. Perinatal Services Program


text:
(a) State-funded perinatal services shall be provided under the Medi-Cal program to pregnant persons and state-funded medical services to infants up to one year of age in families with incomes above 185 percent, but not more than 208 percent, of the federal poverty level, in the same manner that these services are being provided to the Medi-Cal population, including eligibility requirements and integration of eligibility determinations and payment of claims. When determining eligibility under this section, an applicant’s or beneficiary’s income and resources shall be determined, counted, and valued in accordance with the methodology set forth in Section 14005.64.

(b) Services provided under this section shall not be subject to any spend down of excess income requirements.

(c) (1) The department, in implementing the Medi-Cal program and public health programs, may provide for outreach activities in order to enhance participation and access to perinatal services. Funding received pursuant to the federal provisions shall be used to expand perinatal outreach activities. These outreach activities shall be implemented if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute.

(2) Those outreach activities authorized by paragraph (1) shall be targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or uninsured pregnant persons and infants. Outreach activities may include, but not be limited to, all of the following:

(A) Education of the targeted persons on the availability and importance of early prenatal care and referral to Medi-Cal and other programs.

(B) Information provided through toll-free telephone numbers.

(C) Recruitment and retention of perinatal providers.

(d) Notwithstanding any other law, contracts required to implement this section shall be exempt from the approval of the Director of General Services and from the Public Contract Code.

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

history: (History: Amended (as amended by Stats. 2023, Ch. 42, Sec. 152) by Stats. 2025, Ch. 21, Sec. 108. (AB 116) Effective June 30, 2025. Operative January 1, 2026, by its own provisions.)

article: 4.7. Perinatal Services Program


text:
(a) State-funded perinatal services shall be provided under the Medi-Cal program to pregnant persons and state-funded medical services to infants up to one year of age in families with incomes above 185 percent, but not more than 208 percent, of the federal poverty level, in the same manner that these services are being provided to the Medi-Cal population, including eligibility requirements and integration of eligibility determinations and payment of claims. When determining eligibility under this section, an applicant’s or beneficiary’s income shall be determined, counted, and valued in accordance with the methodology set forth in Section 14005.64.

(b) Services provided under this section shall not be subject to any spend down of excess income requirements.

(c) (1) The department, in implementing the Medi-Cal program and public health programs, may provide for outreach activities in order to enhance participation and access to perinatal services. Funding received pursuant to the federal provisions shall be used to expand perinatal outreach activities. These outreach activities shall be implemented if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute.

(2) Those outreach activities authorized by paragraph (1) shall be targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or uninsured pregnant persons and infants. Outreach activities may include, but not be limited to, all of the following:

(A) Education of the targeted persons on the availability and importance of early prenatal care and referral to Medi-Cal and other programs.

(B) Information provided through toll-free telephone numbers.

(C) Recruitment and retention of perinatal providers.

(d) Notwithstanding any other law, contracts required to implement this section shall be exempt from the approval of the Director of General Services and from the Public Contract Code.

(e) 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. 153) by Stats. 2025, Ch. 21, Sec. 109. (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. 108 of Stats. 2025, Ch. 21.)

article: 4.7. Perinatal Services Program


text: The department shall engage in outreach activities in order to enhance participation in and access to perinatal services.

history: (History: Added by Stats. 1989, Ch. 1446, Sec. 4. Effective October 2, 1989.)

article: 4.7. Perinatal Services Program


text:
(a) The department shall implement the federal options authorized by federal law to assist in the delivery of timely and continuing prenatal care by establishing the option of presumptive eligibility under Section 1396r-1 of Title 42 of the United States Code.

(b) The program shall be known, and may be cited, as “Presumptive Eligibility for Pregnant People (PE4PP).”

(c) For a pregnant person covered under PE4PP who applies for full-scope Medi-Cal benefits, if the application is submitted at any time from the date of their presumptive eligibility determination through the last day of the subsequent calendar month, the department shall ensure the pregnant person is covered under PE4PP until the pregnant person is either enrolled in full-scope Medi-Cal benefits or has received a written denial notice in response to their application for full-scope Medi-Cal benefits.

(d) The department shall require providers participating in the PE4PP program to provide information to pregnant persons enrolled in PE4PP on how to contact the person’s county to expedite the county’s determination of a Medi-Cal application.

history: (History: Amended by Stats. 2023, Ch. 372, Sec. 5. (AB 1481) Effective January 1, 2024.)

article: 4.7. Perinatal Services Program


text:
(a) (1) The State Department of Health Care Services shall provide Medi-Cal reimbursements to alternative birth centers for facility-related delivery costs at a statewide all-inclusive rate per delivery that shall not exceed 80 percent of the average Medi-Cal reimbursement received by general acute care hospitals with Medi-Cal contracts and shall be based on an average hospital length of stay of 1.7 days. The reimbursement rate shall be updated annually and shall be based on the California Medical Assistance Commission’s annually published legislative report of average contract rates for general acute care hospitals with Medi-Cal contracts. However, the reimbursement shall not exceed the alternative birth center’s charges to any non-Medi-Cal patient for similar services. This paragraph shall apply to Medi-Cal reimbursement for facility-related delivery costs of alternative birth centers until the effective date of any necessary federal approval obtained by the department pursuant to paragraph (2).

(2) Effective no earlier than July 1, 2017, the department shall reimburse facility-related Medi-Cal delivery costs of eligible alternative birth centers based on a statewide all-inclusive rate per delivery that shall not exceed 80 percent of the average diagnosis-related groups (DRG) Level 1 rates received by general acute care hospitals pursuant to Section 14105.28 and the applicable provisions of the Medi-Cal State Plan. Reimbursement pursuant to this paragraph shall not exceed the alternative birth center’s charges to any non-Medi-Cal patient for similar services. The department shall seek any federal approvals necessary to implement this paragraph. This paragraph shall not be implemented until any necessary federal approvals are obtained. This paragraph shall not be construed to make inoperative any existing payment reductions that are applicable to alternative birth center services, including, but not limited to, the payment reductions imposed pursuant to Section 14105.192, subject to paragraph (3).

(3) Effective July 1, 2022, or the effective date specified in any necessary federal approvals obtained by the department to implement subparagraph (B) of paragraph (13) of subdivision (h) of Section 14105.192, whichever is later, reimbursement to alternative birth centers shall be exempt from the payment reductions imposed by subdivision (d) of Section 14105.192.

(b) In order to be eligible for reimbursement pursuant to this section, an alternative birth center shall satisfy the following criteria as determined by the state department:

(1) The facility shall meet all applicable requirements of Section 1204.3 of the Health and Safety Code.

(2) The facility may utilize licensed midwives, certified nurse-midwives, certified nurse practitioners, and clinical nurse specialists when appropriate.

(3) The facility shall meet the standards for certification established by the American Association of Birth Centers, or at least equivalent standards as determined by the department, including those relating to the proximity and involvement of hospitals, obstetricians, and pediatricians.

(c) 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 provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action.

(d) This section does not alter the scope of practice for any health care professional or authorize the delivery of health care services in a setting or in a manner not authorized by the Health and Safety Code or the Business and Professions Code.

(e) 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.

history: (History: Amended by Stats. 2025, Ch. 595, Sec. 2. (AB 55) Effective January 1, 2026.)

article: 4.7. Perinatal Services Program


text:
(a) The Legislature finds and declares that there is a strong statistical relationship between early entry into prenatal care and healthy birth outcomes. An investment in early intervention is highly cost-effective and prevents untold suffering.

(b) It is the intent of the Legislature that the goals of the program established pursuant to this article, in combination with other programs for pregnant women and children, shall be as follows:

(1) To improve access to and quality of prenatal care by making existing programs serving poor women more accessible through outreach, coordination, and removal of barriers to care.

(2) To combine efforts with other programs to measurably reduce the number of women who smoke, use drugs, or engage in other unhealthy practices during pregnancy.

(c) In order to achieve these goals, it is the intent of the Legislature to improve and coordinate existing programs for pregnant women and infants and to remove barriers to care with an intense focus on women who are at high risk of delivering a low or high birth weight baby or a baby who will suffer from major health problems or disabilities.

(d) The program implemented pursuant to this article shall focus on those target populations that are comprised of pregnant high risk women or potentially pregnant teenagers, pregnant women, and women of childbearing age who are likely to become pregnant who smoke, consume alcoholic beverages, or use controlled substances, Black, Hispanic, Native American, and Asian-Pacific Island women who are pregnant or of childbearing age, and uninsured women of childbearing age.

history: (History: Amended (as added by Stats. 1991, Ch. 278) by Stats. 2006, Ch. 538, Sec. 706. Effective January 1, 2007.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.8. Perinatal Outreach, Coordination, and Expansion Services


text: At the earliest date that it is administratively feasible, the department shall adopt the federal medicaid option under Section 1902(l)(3) of the federal Social Security Act (42 U.S.C. Sec. 1396a(l)(3)) to waive the use of a resource standard for determining the eligibility of pregnant women, infants, and children.

history: (History: Amended by Stats. 1997, Ch. 624, Sec. 5. Effective January 1, 1998.)

article: 4.7. Perinatal Services Program


text: The department shall provide for the receipt and initial processing of Medi-Cal applications from pregnant people and from children born after September 30, 1983, who have not yet attained 19 years of age, at facilities other than the county welfare department as described in Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 and following).

history: (History: Amended by Stats. 2023, Ch. 372, Sec. 6. (AB 1481) Effective January 1, 2024.)

article: 4.7. Perinatal Services Program


text:
(a) No later than March 15 of each year, the department shall report to the appropriate committees of the Legislature and the Governor, on a statewide and county-by-county basis, the most recent data on all of the following:

(1) The number of live births to women receiving prenatal care in the first trimester, in the second trimester, and in the third trimester, as well as an analysis of barriers to care to the extent available.

(2) The number of maternal deaths by race and ethnic group.

(3) The number of live births by county, race, and ethnic group.

(4) The number of fetal deaths of infants over 20 weeks’ gestation by race and ethnic group.

(5) The number of infant deaths by county, race, and ethnic group from birth to 28 days postpartum.

(6) The number of infant deaths by county, race, and ethnic group from 29 days postpartum to one year.

(7) The number of live births under 2,500 grams and over 4,500 grams by race and ethnic group.

(8) The number of live births under 1,500 grams by race and ethnic group.

(9) The number of women eligible for prenatal, delivery, or postpartum care under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code in the past year.

(10) The source of payment for prenatal care and delivery.

(b) No later than March 15 of each year, the department shall report to the appropriate committees of the Legislature and the Governor on a statewide basis, to the extent data are available, all of the following:

(1) The number of infants eligible for services under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.

(2) The number of newborn babies screened or diagnosed with Fetal Alcohol Syndrome.

(3) The number of babies born with drug dependencies, HIV infection, and sexually transmitted diseases.

(4) Whether the mother smoked, consumed alcoholic beverages, or used controlled substances without a prescription, during pregnancy.

(c) (1) The department, in consultation with the Legislative Analyst, shall contract, using appropriate state administrative funds, with an appropriate entity for a one-time, statistical survey of the income of mothers, utilizing a statistically valid sample linked to the birth certificate.

(2) The State Department of Health Services shall not use more than one hundred thousand dollars ($100,000) of administrative funds for the survey required by paragraph (1).

(3) The income information required by paragraph (1) shall be categorized according to the following income categories:

(A) Persons whose family income does not exceed 150 percent of the official federal poverty line.

(B) Persons whose family income exceeds 150 percent of the official federal poverty line but does not exceed 185 percent of the official federal poverty line.

(C) Persons whose family income exceeds 185 percent of the official federal poverty line but does not exceed 200 percent of the official federal poverty line.

(D) Persons whose family income exceeds 200 percent of the official federal poverty line but does not exceed 225 percent of the official federal poverty line.

(E) Persons whose family income exceeds 225 percent of the official federal poverty line.

(F) Persons whose family income exceeds 250 percent of the official federal poverty line level but does not exceed 300 percent of the official federal poverty line.

(d) The department shall, in addition to the information required by subdivision (a), report on trends in private insurance coverage of maternity care, to the extent the data is available.

history: (History: Amended by Stats. 2004, Ch. 183, Sec. 388. Effective January 1, 2005.)

article: 4.8. Perinatal Outreach, Coordination, and Expansion Services


text: No funds from the Health Education Account in the Cigarette and Tobacco Products Surtax Fund may be used in a manner that violates paragraph (1) of subdivision (b) of Section 30122 of the Revenue and Taxation Code.

history: (History: Added by Stats. 1991, Ch. 1170, Sec. 13. Effective October 14, 1991.)


text:
(a) It is the intent of the Legislature in enacting this article, to expand eligibility for Medi-Cal benefits, with the exception of prescription drug benefits provided by the AIDS Drug Assistance Program (ADAP), to persons with HIV who are enrolled in ADAP and who are not disabled, but who, if disabled, would qualify for Medi-Cal benefits.

(b) It is further the intent of the Legislature that this expansion of the existing Medi-Cal program be funded by cost savings achieved through the voluntary enrollment into the existing Medi-Cal managed care program of persons who are disabled as a result of AIDS, and who are either receiving Medi-Cal benefits on a fee-for-service basis as of January 1, 2003, or who become eligible to receive Medi-Cal benefits on or after January 1, 2003.

(c) It is further the intent of the Legislature that the State Department of Health Services encourage the voluntary enrollment into the existing Medi-Cal managed care program of persons described in subdivision (b) in order to obtain sufficient cost savings to provide Medi-Cal benefits to the maximum feasible number of persons with HIV subject to the constraints of this article.

(d) It is further the intent of the Legislature that all protections of state and federal law and regulations that apply to the state’s Medi-Cal managed care program shall apply to those persons who become eligible for Medi-Cal pursuant to this article.

history: (History: Added by Stats. 2002, Ch. 684, Sec. 1. Effective January 1, 2003.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV


text:
(a) Subject to subdivisions (b) and (c), paragraph (2) of subdivision (f), and subdivision (k), the department shall, commencing July 1, 2003, or the date that all necessary federal waivers have been obtained, whichever is later, expand eligibility for benefits under this chapter, with the exception of those prescription drug benefits provided pursuant to ADAP, to any person with HIV who meets both of the following criteria:

(1) The person is enrolled in the ADAP program pursuant to Section 120960 of the Health and Safety Code, and maintains enrollment in that program.

(2) The person would otherwise qualify for Medi-Cal benefits if the person were disabled as defined in subdivision (h).

(b) Any person eligible for benefits pursuant to subdivision (a), and seeking enrollment in Medi-Cal pursuant to this article shall be enrolled on a first-come-first-served basis pursuant to an allocation mechanism that shall be developed by the department.

(c) Any person who is eligible for enrollment in Medi-Cal pursuant to this article shall be required to elect a Medi-Cal managed care plan in those counties in which a managed care plan is available, unless the department determines that the cost-neutrality requirements provided for in subdivision (f) and the enrollment goals provided for in this article can be achieved without this requirement.

(d) In implementing this article, the department shall ensure that all of the following standards are met:

(1) All state and federal laws and regulations that apply to the state’s Medi-Cal managed care program shall apply to the expansion provided by this article and to the beneficiaries eligible for Medi-Cal pursuant to this article.

(2) The Medi-Cal benefits provided under this article shall include prescription drugs not provided by the AIDS Drug Assistance Program.

(3) All participating plans that assume full risk for all health care services, including inpatient and outpatient services, shall be licensed pursuant to the Knox-Keene Act (Article 1 commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), except as provided in Section 1343 of the Health and Safety Code.

(4) Health care service plans participating in the Medi-Cal managed care program shall comply with the applicable sections of the Knox-Knee Act (Article 1 (commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), including Sections 1367 and 1374.16 of the Health and Safety Code and the regulations adopted pursuant to Section 1374.16 of the Health and Safety Code.

(5) Primary care case management plans participating in the Medi-Cal managed care program shall comply with the applicable sections of Article 2.9 ( commencing Section 14088). Primary care case management plans are required to maintain grievance and appeal procedures consistent with the existing Medi-Cal managed care program, to address beneficiary grievances.

(e) The department shall establish capitation rates to be paid to Medi-Cal managed care plans for services provided pursuant to this section. These capitation rates may not exceed 95 percent of the fee-for-service equivalent costs to the Medi-Cal program for medical services for persons with HIV.

(f) (1) The department shall meet federal revenue neutrality requirements through the savings generated by the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS, and who are either receiving Medi-Cal benefits on a fee-for-service basis as of January 1, 2003, or who become eligible to receive Medi-Cal benefits on or after January 1, 2003. The savings generated by increased voluntary enrollments in Medi-Cal managed care shall be used to fund enrollment by individuals eligible for the expansion of Medi-Cal eligibility provided for pursuant to subdivision (a). Nothing in this subdivision shall preclude the department from implementing other means of meeting the federal revenue neutrality requirements, provided that all requirements of this article are met.

(2) The department may not enroll individuals described in subdivision (a) until the department can ensure sufficient savings, pursuant to paragraph (1), equal to or greater than the cost of providing benefits to these individuals.

(g) The department shall encourage the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS. The department shall conduct all outreach and awareness activities necessary to implement this requirement in a manner consistent with Section 14407 to ensure that persons who enroll in managed care do so voluntarily. These outreach and awareness activities shall include information on how electing managed care may alter provider relationships and how persons may revert to fee-for-service if they prefer to return to fee-for-service.

(h) For the purposes of this section, “disabled” means a person who meets the eligibility criteria for the federal Supplemental Security Income for the Aged, Blind and Disabled program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of Title 42 of the United States Code).

(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article, without taking any regulatory action, by means of an all-county letter or similar instruction. Thereafter, 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.

(j) Commencing January 1, 2003, the department shall seek the appropriate federal waiver under Section 1115 of the Social Security Act (42 U.S.C. Sec. 1315) to implement the expansion of eligibility provided for pursuant to this section. The department shall maximize the federal reimbursement received for services provided under this article to those eligible pursuant to this section.

(k) This article shall be implemented only if, and to the extent that, the department determines that federal financial participation is available pursuant to Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).

article: 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV


text:
(a) The department shall expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. The department shall pursue and implement all of the following activities, to the extent permitted by federal law:

(1) Create a dental-specific enrollment form.

(2) Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental fee-for-service contractor or an administrative services contractor for the purpose of providing services as a commercial provider.

(3) Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet.

(4) To the extent that the department expedites the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process, the department shall publish the criteria for those processes in applicable provider bulletins and manuals.

(b) (1) The department shall maintain the provider network on a monthly basis by deactivating a billing provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered.

(2) Prior to deactivating a provider described in paragraph (1), the department shall send a notice to the provider informing the provider that the provider shall be deactivated from the dental program unless the provider requests reactivation within six months after the date of the notice. The department shall not disenroll a provider until six months after the date of that notice. This paragraph shall not be implemented until the date the department implements and programs the necessary system changes to the California Dental Medicaid Management Information Systems to implement this paragraph, or no sooner than July 1, 2017, whichever is later.

(3) In order to improve the quality of the dental provider network, the department also shall exercise additional measures as appropriate and permitted by law, including, but not limited to, temporary suspensions. The parameters and criteria developed by the department for additional measures for deactivations and disenrollments shall be published in applicable provider bulletins and manuals.

(c) (1) The department shall monitor access and utilization of Medi-Cal dental services in the fee-for-service and managed care delivery systems to assess opportunities to improve access and utilization, including an annual review of the treatment authorization review process.

(2) The department shall assess opportunities to develop and implement innovative payment reform proposals within the Medi-Cal dental programs.

(d) The department shall explore additional opportunities to improve the Medi-Cal Dental Program, in consultation with stakeholders and as deemed appropriate by the department and to the extent permitted by federal law, including, but not limited to, the following:

(1) Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services.

(2) Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity.

(3) Expanding the scope of beneficiary outreach activities required by an entity that is contracted with the department to more broadly address underutilization throughout the state.

(e) Prior to implementing an action pursuant to subdivision (d), the department shall post the proposed action on its Internet Web site at least 30 days before implementation.

(f) The department shall work with dental managed care plans that contract with the department for the purposes of implementing the Medi-Cal Dental Program, which includes, but is not limited to, contracts authorized pursuant to Sections 14087.46, 14089, and 14104.3, to provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members.

(g) A Medi-Cal managed care health plan shall do all of the following:

(1) Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment.

(2) Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider.

(3) Identify plan liaisons available to dental managed care contractors and dental fee-for-service contractors to assist with referrals to health plan covered services.

(h) In accordance with Section 438.230(c)(3) of Title 42 of the Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plans provide that the department, the federal Centers for Medicare and Medicaid Services, the federal Office of the Inspector General, the federal Comptroller General, and their designees may, at any time, inspect and audit any records or documents of the managed care entity, or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this subdivision exists for 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later.

(i) In accordance with Section 438.230(c)(3) of Title 42 of Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plan contractors retain, and require its subcontractors to retain, as applicable, all of the following information for a period of no less than 10 years:

(1) Enrollee grievance and appeal records.

(2) Base data.

(3) Medical loss ratio reports.

(4) The data, information, and documentation specified in federal Medicaid regulations, including Sections 438.604, 438.606, 438.608, and 438.610 of Title 42 of the Code of Federal Regulations.

(j) (1) To increase the efficiency and timeliness of changes, any contract amendment, modification, or change order to any contract entered into by the department for the purposes of implementing the state Medi-Cal Dental Program shall be exempt, except as provided in paragraph (2), from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, as well as Sections 11545 and 11546 of the Government Code, in addition to any policies, procedures, or regulations authorized by those provisions.

(2) Paragraph (1) shall not exempt the department from establishing a competitive bid process for awarding new contracts pursuant to Section 14104.3, as well as for awarding new dental contracts pursuant to Sections 14087.46 and 14089.

(k) Prior to implementing any change pursuant to this section, the department shall consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.

(l) (1) 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, or make specific policies and procedures pertaining to the dental fee-for-service program and dental managed care plans, as well as applicable federal waivers and state plan amendments, including the provisions set forth in this section, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted.

(2) No later than December 31, 2018, 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. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.

(m) This section shall be implemented only to the extent that all of the following occur:

(1) The department obtains any federal approvals necessary to implement this section.

(2) The department obtains federal matching funds to the extent permitted by federal law.

history: (History: Amended by Stats. 2017, Ch. 511, Sec. 28. (AB 1688) Effective January 1, 2018.)

article: 4.10. Medi-Cal Dental Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.10. Medi-Cal Dental Program


text:
(a) It is the intent of the Legislature that the department pursue policies and programs to assist Medi-Cal beneficiaries in preventing or delaying the onset of type 2 diabetes.

(b) (1) The department shall establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems.

(2) A Medi-Cal managed care plan shall make the DPP available to enrolled beneficiaries in accordance with this article.

(c) In implementing the DPP, the department shall require that Medi-Cal providers offering DPP services comply with guidelines issued by the federal Centers for Disease Control and Prevention (CDC) and obtain CDC recognition in connection with the National Diabetes Prevention Program.

(d) The DPP shall be an evidence-based, lifestyle change program designed to prevent or delay the onset of type 2 diabetes among individuals with prediabetes.

(e) The DPP shall be made available to Medi-Cal beneficiaries no sooner than July 1, 2018.

(f) A Medi-Cal provider may identify and recommend participation in the DPP to a beneficiary who meets the eligibility requirements of the federal Centers for Disease Control and Prevention Diabetes Prevention Recognition Program.

(g) In implementing the DPP, the department shall require Medi-Cal providers offering DPP services to use a CDC-approved lifestyle change curriculum that does all of the following:

(1) Emphasizes self-monitoring, self-efficacy, and problem solving.

(2) Provides for coach feedback.

(3) Includes participant materials to support program goals.

(4) Requires participant weigh-ins to track and achieve program goals.

(h) DPP services shall be provided by peer coaches, who promote realistic lifestyle changes, emphasize weight loss through healthy eating and physical activity, and implement the DPP curriculum. A trained peer coach may be a physician, a nonphysician practitioner, or an unlicensed person who has been trained to deliver the required curriculum content and possesses the skills, knowledge, and qualities specified in the National Diabetes Prevention Program guidelines.

(i) A beneficiary who participates in the DPP shall be allowed to participate in 22 peer coaching sessions over a period of at least one year. Thereafter, the department shall provide a participating beneficiary who achieves and maintains a required minimum weight loss of 5 percent from the first core session, in accordance with CDC standards, with less intensive, ongoing maintenance sessions to help the beneficiary continue healthy behaviors.

(j) (1) The department shall develop payment methodologies, or adjust existing methodologies, for reimbursing DPP services and activities in the Medi-Cal fee-for-service delivery system, not to exceed 80 percent of the federal Medicare Program reimbursement for comparable service, billing, and diagnosis codes under the federal Medicare Program.

(2) For purposes of reimbursement under the Medi-Cal fee-for-service delivery system, an unlicensed peer coach shall have an arrangement with an enrolled Medi-Cal provider for purposes of reimbursement for rendered DPP services.

(k) This article shall be implemented only to the extent that the department obtains federal financial participation to the extent permitted by federal law, and obtains any necessary federal approvals.

(l) For the purposes 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. A contract may be statewide or on a more limited geographic basis. A contract entered into or amended pursuant to this subdivision shall be exempt from all of the following:

(1) Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code.

(2) Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code.

(3) Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code.

(4) Review or approval of any division of the Department of General Services.

(m) 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, or make specific this article, policies and procedures pertaining to the DPP, and applicable waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department, by July 1, 2020, 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. Beginning six months after the effective date of this article, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.

history: (History: Amended by Stats. 2018, Ch. 34, Sec. 31. (AB 1810) Effective June 27, 2018.)

article: 4.11. Diabetes Prevention Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4.11. Diabetes Prevention Program