text:
(a) Except as otherwise prohibited by law, a contractor that has entered into a contract with the department pursuant to this chapter may make the benefits known to potential enrollees by methods approved by the department.

(b) No prepaid health plan, marketing representative, or marketing organization shall engage in marketing activities prior to written submittal to and approval by the department. All marketing activities, procedures, methods, and places in which any activities will be conducted shall be explicitly described in a marketing plan and approved by the department prior to being used by a prepaid health plan, marketing representative, or marketing organization. The marketing plan shall be updated and submitted for renewed approval on an annual basis. The department may approve, disapprove, or withdraw approval of any marketing activity or procedure. The department shall require the discontinuance of any marketing activity or procedure for which the department withdraws approval. The conduct of activities or procedures not included in an approved marketing plan shall constitute a violation of this article and be subject to sanctions in accordance with Section 14409.

The prepaid health plan shall be responsible for all presentations by its marketing representatives and for their ethical and professional conduct. The department may withdraw certification for participation in the program from, and impose marketing sanctions specified in Section 14409, as applicable, on marketing representatives.

(c) The marketing plan shall meet the standards established by the department. The marketing plan shall include, but not be limited to, an explicit description of the specific marketing activities, the method of identifying individual enrollments by marketing representative, and formal measures to monitor performance of marketing representatives and verify both of the following:

(1) The prepaid health plan’s marketing activities and practices do not violate subdivision (a) of Section 14409.

(2) Beneficiaries receive complete and accurate information about the benefits and limitations of receiving health care services through the prepaid plan in a manner that considers the beneficiary’s level of comprehension.

(d) Each time a marketing representative presents information about the benefits of prepaid health plan enrollment to a beneficiary in order to encourage the beneficiary to enroll, the marketing representative shall leave with the beneficiary printed information identifying the marketing representative by name and prepaid health plan represented.

(e) All printed or illustrated material prepared by the prepaid health plan for dissemination to enrollees or to prospective enrollees shall be submitted to the department prior to dissemination. The department shall acknowledge receipt of the printed or illustrated material within five days, and shall approve or disapprove the material for dissemination within 60 days after the date of notification that the material has been received. The department may withdraw approval of the material previously approved and order its dissemination discontinued. If the department notifies the prepaid health plan of its disapproval or withdrawal of approval, the prepaid health plan shall have the right to meet and confer with the director or his or her designee and demonstrate the purpose and reasonable basis for the distribution of the material to enrollees and potential enrollees.

(f) (1) Any form of door-to-door or in-person marketing that coerces or misleads beneficiaries or selectively enrolls beneficiaries on the basis of their health status is unlawful. In addition, on or after July 1, 1996, door-to-door solicitation of Medi-Cal enrollees shall not be permitted.

(2) On or after July 1, 1996, the health care options presentation required by Sections 14016.5 and 14016.6 or the health care options information required by Sections 14087.305 and 14089 shall be fully operational in counties specified by the director for expansion of the Medi-Cal managed care program or in counties where prepaid health plans are contracting with the department pursuant to Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96, 14089, and 14089.05. In these counties, on or after July 1, 1996, no enrollment of beneficiaries by prepaid health plans shall occur during in-person marketing activities or during health fairs pursuant to paragraph (5) of subdivision (f). Enrollment shall be exclusively performed and transmitted pursuant to the program required by Sections 14016.5, 14016.6, 14087.305, and 14089.

(3) In the event the health care options presentation required by Sections 14016.5 and 14016.6 is not fully operational or the health care options information required by Sections 14087.305 and 14089 is not fully available, as specified in paragraph (2) of subdivision (f), the department shall perform the enrollment-only functions until the health care options presentation or information is fully operational or available.

(4) Nothing in this section shall preclude a prepaid health plan from responding to inquiries initiated by beneficiaries or potential beneficiaries.

(5) Until July 1, 1996, a prepaid health plan may participate in an organized community or neighborhood health fair in a public place only if two or more prepaid health plans are participating, or if the plan is invited by the sponsor of the fair. If there are not two or more prepaid health plans providing services to Medi-Cal beneficiaries in a prepaid health plan’s service area, this subdivision shall not apply. On or after July 1, 1996, a prepaid health plan may participate in an organized community or neighborhood health fair in a public place for marketing purposes.

(g) Any prepaid health plan, marketing representative, or marketing organization that violates subdivision (f) shall be subject to the sanctions set forth in subdivision (b) of Section 14409 and shall be guilty of a misdemeanor and subject to a fine of five hundred dollars ($500) or imprisonment in a county jail for six months, or both, for each violation.

(h) The department shall certify each marketing representative prior to participation in the program in accordance with standards established by the department. Continuing certification for participation in the program shall be contingent upon compliance with this article, as well as guidelines and standards adopted by the department, and may be withdrawn upon their violation, as determined by the department. The department may temporarily decertify any marketing representative when that action is necessary to protect the public welfare or the interests of the Medi-Cal program. Temporary decertification shall be effective immediately upon written notice to the marketing representative and the managed care contractor, and shall remain in effect until the department has made a determination on the merits. Temporary decertification shall be canceled unless the department acts to permanently withdraw certification within 60 days.

(i) No prepaid health plan shall employ in any capacity relating to the marketing operations of the plan a marketing representative whose certification has been withdrawn. Marketing representatives shall not be recertified for participation until the cause for withdrawal of certification has been corrected to the satisfaction of the department. Proof of correction shall be the sole responsibility of the marketing representative.

history: (History: Amended by Stats. 2004, Ch. 183, Sec. 389. Effective January 1, 2005.)

article: 4. Enrollment and Disenrollment


kind: section

code: WIC

text: A prepaid health plan that contracts with Medi-Cal managed care or contracts with the Healthy Families Program may provide application assistance pursuant to Section 12693.325 of the Insurance Code during the eligibility redetermination process in order to allow persons to retain coverage.

history: (History: Added by Stats. 2000, Ch. 93, Sec. 97. Effective July 7, 2000.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 8. Prepaid Plans

article: 4. Enrollment and Disenrollment

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 4. Enrollment and Disenrollment


text:
(a) No prepaid health plan, marketing representative, or marketing organization shall in any manner misrepresent itself, the plans it represents, or the Medi-Cal program. A violation of this section shall include, but is not limited to, all of the following:

(1) False or misleading claims that marketing representatives are employees or representatives of the state, county, or anyone other than the prepaid health plan or the organization by whom they are reimbursed.

(2) False or misleading claims that the prepaid health plan is recommended or endorsed by any state or county agency, or by any other organization which has not certified its endorsement in writing to the prepaid health plan.

(3) False or misleading claims that the state or county recommends that a Medi-Cal beneficiary enroll in a prepaid health plan.

(4) Claims that a Medi-Cal beneficiary will lose their benefits under the Medi-Cal program or any other health or welfare benefits to which they are legally entitled, if they do not enroll in a prepaid health plan.

(b) Violations of this article or regulations adopted by the department pursuant to this article shall result in one or more of the following sanctions that are appropriate to the specific violation, considering the nature of the offense and frequency of occurrence within the prepaid health plan:

(1) Revocation of one or more permitted methods of marketing.

(2) Termination of authorization for a plan to provide application assistance.

(3) Refusal of the department to accept new enrollments for a period specified by the department.

(4) Refusal of the department to accept enrollments submitted by a marketing representative or organization.

(5) Forfeiture by the plan of all or part of the capitation payments for persons enrolled as a result of such violations.

(6) Requirement that the prepaid health plan in violation of this article personally contact each enrollee enrolled to explain the nature of the violation and inform the enrollee of their right to disenroll.

(7) Application of sanctions as provided in Section 14197.7.

(8) Temporarily suspend capitation payments for beneficiaries enrolled in violation of this article, or regulations adopted thereunder, until the prepaid health plan is in substantial compliance with the statutory and regulatory requirements.

(c) Any marketing representative who violates subdivision (a) while engaged in door-to-door solicitation is guilty of a misdemeanor, and shall be subject to a fine of five hundred dollars ($500) or imprisonment in a county jail for six months, or both.

history: (History: Amended by Stats. 2019, Ch. 465, Sec. 9. (AB 1642) Effective January 1, 2020.)

article: 4. Enrollment and Disenrollment


text: No prepaid health plan or marketing representative shall adopt or utilize any procedure to identify prospective enrollees with medical or psychiatric problems in order to exclude them from enrollment in the prepaid health plan, other than medical conditions specifically excluded from coverage by the contract.

history: (History: Added by Stats. 1974, Ch. 983.)

article: 4. Enrollment and Disenrollment


text:
(a) No prepaid health plan or marketing organization shall solicit prospective enrollees on county premises for benefits or services available pursuant to this chapter except under any one of the following conditions:

(1) Such marketing activities are performed by a county employee under an agreement between the county and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.

(2) Such marketing activities are performed by a state employee under an agreement between the department, county, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.

(3) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the county, the prepaid health plan and the department, and all marketing presentations and materials to be used have been approved by the department.

(b) No prepaid health plan or marketing organization shall solicit prospective enrollees on state premises for benefits or services available pursuant to this chapter, except under any one of the following conditions:

(1) Such marketing activities are performed by a state employee under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.

(2) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department.

history: (History: Amended by Stats. 1977, Ch. 1036.)

article: 4. Enrollment and Disenrollment


text:
(a) The enrollment of a Medi-Cal beneficiary in the prepaid health plan shall not be terminated except for loss of eligibility, for good cause as determined by the department, or at the request of the beneficiary.

(b) Enrollment shall be terminated at the request of the Medi-Cal beneficiary, to the extent required by federal law.

(c) Any Medi-Cal beneficiary enrolled in a prepaid health plan who would remain eligible for Medi-Cal program benefits for three additional months pursuant to Section 14005.8 shall remain enrolled in the prepaid health plan and shall not receive a Medi-Cal card unless disenrollment is requested by the beneficiary, and the request is submitted in accordance with state and federal law.

(d) It is the intent of the Legislature that the department shall develop such policies and procedures to maximize continuity of care for persons enrolled in prepaid health plans and to insure that the eligibility determination or redetermination process does not unnecessarily interfere with such enrollment or create gaps in the delivery of health services.

history: (History: Amended by Stats. 1983, Ch. 822, Sec. 1.)

article: 4. Enrollment and Disenrollment


text:
(a) Requests for disenrollment shall be made to an authorized representative of the prepaid health plan or to the department. All requests for disenrollment, except those submitted pursuant to subdivision (c) of Section 14303.1, subdivision (c) of Section 14303.2, or paragraph (6) of subdivision (b) of Section 14409, or for other good cause as determined by the director, shall be processed through the prepaid health plan’s grievance procedure as approved by the department. Disenrollment requests received by the prepaid health plan shall be submitted to the department, on standard disenrollment forms prescribed by the department, within a reasonable time following the date of such signed request, as determined by the director, to permit the department to terminate enrollment effective the beginning of the first calendar month following a full calendar month after the request is made.

(b) All applications for disenrollment shall be processed by the department, and where Medi-Cal eligibility continues or Medi-Cal coverage is extended under Section 14005.8, a Medi-Cal card shall be issued effective not later than the beginning of the first calendar month following a full calendar month after the request for disenrollment is made. Submittal of a request for disenrollment for processing through the grievance procedure of a prepaid health plan shall not be deemed to infringe on this entitlement.

history: (History: Amended by Stats. 2020, Ch. 370, Sec. 287. (SB 1371) Effective January 1, 2021.)

article: 4. Enrollment and Disenrollment


text:
(a) No contract between the department and a prepaid health plan shall be approved or renewed unless the providers and the facilities of the prepaid health plan meet the Medi-Cal program standards for participation as established by the director. In addition, a prepaid health plan shall meet the standards required pursuant to the provisions of the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), standards specifically required by federal law, and the following requirements:

(1) Each prepaid health plan shall establish a grievance procedure under which enrollees may submit their grievances. The procedure shall be approved by the department prior to the approval of the contract. The department shall establish standards for the procedures to insure adequate consideration and rectification of enrollee grievances. A prepaid health plan shall make a finding of fact in the case of each grievance processed, a copy of which shall be transmitted to the enrollee. If the enrollee has an unresolved grievance, the fair hearing provided in Chapter 7 (commencing with Section 10950) of Part 2 shall be available to resolve all grievances regarding care and administration by the prepaid health plan. The findings and recommendations of the department, based on the decision of the hearing officer, shall be binding upon the prepaid health plan. Any changes in a proposed health plan’s grievance procedure must be approved by the department before the changes take effect.

(2) (A) Medi-Cal enrollees shall have the same responsibilities and shall be entitled to the same rights as other enrollees with regard to any requirements for arbitration as a condition of membership in a health plan.

(B) Arbitration requirements shall be clearly disclosed in all of the contractor’s Medi-Cal marketing presentations, materials and brochures, enrollment agreements, evidence of coverage, and disclosure forms.

(3) The prepaid health plan shall provide the director, for their approval, a plan for marketing its services to Medi-Cal beneficiaries which relates the proposed service to the need for services, and the size of the potential population to be served in the proposed service area.

(4) The prepaid health plan shall demonstrate to the department that it has adequate financial resources, administrative abilities and soundness of program design to carry out its contractual obligations.

(b) The requirements of this section shall apply to all managed care plan contracts entered into under any of the following:

(1) The act that added this subdivision.

(2) Any of the following provisions of Chapter 7 (commencing with Section 14000).

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

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

(C) Article 2.91 (commencing with Section 14490).

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

history: (History: Amended by Stats. 2023, Ch. 266, Sec. 4. (AB 614) Effective January 1, 2024.)

article: 5. Standards for Prepaid Health Plans

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 5. Standards for Prepaid Health Plans


text:
(a) No contract between the department and a prepaid health plan that is contracting with, or that is governed, owned, or operated by, a county board of supervisors, shall be approved or renewed unless the standards set forth in Section 1374.16 of the Health and Safety Code are met. The treatment plan developed pursuant to Section 1374.16 of the Health and Safety Code shall be consistent with federal and state medicaid requirements. Nothing in Section 1374.16 of the Health and Safety Code is intended to alter or abrogate any other requirements of federal or state law with regard to medicaid.

(b) The requirements of this section shall apply to all managed care plan contracts entered into under any of the following:

(1) The act that added this subdivision.

(2) Any of the following provisions of Chapter 7 (commencing with Section 14000).

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

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

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

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

history: (History: Added by Stats. 1998, Ch. 31, Sec. 2. Effective January 1, 1999.)

article: 5. Standards for Prepaid Health Plans


text: Services under a prepaid health plan contract shall be provided in accordance with the requirements of the Knox-Keene Health Care Service Plan Act of 1975.

history: (History: Amended by Stats. 2014, Ch. 442, Sec. 39. (SB 1465) Effective September 18, 2014.)

article: 5. Standards for Prepaid Health Plans


text:
(a) A prepaid health plan contractor may not enter into subcontracts when such an action would remove from the contractor his obligation to bear a significant portion of the risk encountered in providing the covered services.

(b) The prepaid health plan may obtain reinsurance for the cost of providing covered services. Such reinsurance shall not limit the contractor’s liability below five thousand dollars ($5,000) per enrollee for any one 12-month period, except that the contractor may also obtain reinsurance for the total cost of services provided to enrollees by noncontractor emergency service providers, and for 90 percent of all costs exceeding 115 percent of its income during any contractor fiscal year.

history: (History: Added by Stats. 1977, Ch. 1036.)

article: 5. Standards for Prepaid Health Plans


text:
(a) (1) All subcontracts shall be entered into pursuant to the requirements of the Knox-Keene Health Care Service Plan Act of 1975 and federal law. All subcontracts shall be in writing, a copy of which shall be transmitted to the department.

(2) Each subcontract shall contain the amount of compensation or other consideration that the subcontractor will receive under the terms of the subcontract with the prepaid health plans. These provisions shall not apply to a provider who is employed or salaried by the prepaid health plan. Unless the department objects, a prepaid health plan may enter into a subcontract in which consideration is determined by a percentage of the primary contractor’s payment from the department. This subdivision shall not be construed to prohibit any subcontract in which consideration is determined on a capitation basis.

(3) Subcontracts between a prepaid health plan and the subcontractor shall be public records on file with the department. The names of the officers and owners of the subcontractor, stockholders owning more than 10 percent of the stock issued by the subcontractor, and major creditors holding more than 5 percent of the debt of the subcontractor shall be submitted by each prepaid health plan to the department and shall be public records on file with the department.

(b) A prepaid health plan that is not a qualified health maintenance organization pursuant to Title XIII of the federal Public Health Service Act shall submit all provider and management subcontracts to the department for approval prior to the subcontract taking effect.

(c) Each subcontract shall require that the subcontractor make all of its books and records pertaining to the goods and services furnished under the terms of the subcontract available for inspection, examination, or copying by the department during normal working hours at the subcontractor’s place of business, or another mutually agreeable location in California.

history: (History: Amended by Stats. 2023, Ch. 266, Sec. 5. (AB 614) Effective January 1, 2024.)

article: 5. Standards for Prepaid Health Plans


text:
Each prepaid health plan shall provide the services of an optometrist and ophthalmologist when the prepaid health plan contract requires the provision of vision care services.

Vision care services shall be provided so that an enrollee may be seen initially by either a physician or an optometrist.

article: 5. Standards for Prepaid Health Plans


text: Where the prepaid health plan agrees to provide dental services such services shall be provided in a manner that does not require the enrollees to receive prior screening or authorization by nondental personnel.

article: 5. Standards for Prepaid Health Plans


text: Each prepaid health plan shall provide the services of a psychologist and psychiatrist when the prepaid health plan contract requires the provision of mental health services. Mental health services shall be provided so that an enrollee may be seen initially by either a physician or a psychologist, or by psychiatric social workers under qualified supervision as otherwise allowed by law.

article: 5. Standards for Prepaid Health Plans


text: Prepaid health plans, or their subcontractors, shall not bill any enrollee for covered benefits provided under this chapter and for which capitation has been paid, except as provided in Article 7 (commencing with Section 14490) of this chapter. Health care providers shall not seek reimbursement from enrollees for any services provided under this chapter.

article: 5. Standards for Prepaid Health Plans


text: In compensating directors and officers, the prepaid health plan shall not compensate at a rate substantially greater than the prevailing charge for similar services in the community. For purposes of this chapter, salaries or other compensation from the prepaid health plan and its subcontractors, excluding reasonable expenses, shall be considered as one.

history: (History: Repealed and added by Stats. 1977, Ch. 1036.)

article: 5. Standards for Prepaid Health Plans


text:
(a) The prepaid health plan shall be liable for all in-area and out-of-area emergency services which are required by the contract and rendered by a nonprepaid health plan provider. Payment for such services shall include treatment of emergency conditions and shall continue until such time as the enrollee may be transferred to any provider of the prepaid health plan.

(b) Where a dispute arises between the prepaid health plan and the nonprepaid health plan provider as to the liability of the prepaid health plan for such services, the nonprepaid health plan provider may submit the matter to the director for determination in the form of a claim documenting as fully as reasonably possible the nature of the emergency, the necessity for the treatment rendered, the appropriateness of the length of stay for inpatient care, the reason the patient could not have been transferred to a provider of the prepaid health plan, and including any response by the prepaid health plan to the claim which resulted in the dispute. The director shall, by regulation, provide for resolution of the dispute in a timely fashion and in a manner guaranteeing the procedural due process requirements of the provisions of Chapter 5 (commencing with Section 11500), Part 1, Division 3, Title 2 of the Government Code, except that the department shall use its own hearing officers. The hearing officer may be assisted by a physician. To the extent feasible, the director shall consolidate the claims of the nonprepaid health plan provider against the prepaid health plan.

In no event, shall the prepaid health plan or the nonprepaid health plan provider bill the enrollee for services which are or have been the subject of review by the director pursuant to this section.

(c) If the director determines that the prepaid health plan is liable for the emergency service, the plan shall reimburse the nonprepaid health plan provider within 30 days. If the prepaid health plan fails to reimburse the nonprepaid health plan provider within 30 days, the director shall arrange to set off the amount of the unpaid claim or claims from no fewer than two future capitation payments owed to the prepaid health plan by the department and the department shall forward such setoff or setoffs to the nonprepaid health plan provider. In making such arrangements to set off, the director shall consult with the affected prepaid health plan in an attempt to minimize the impact of such setoff or setoffs on cash flow. When the claim of the nonprepaid health plan provider is satisfied by setoff or setoffs, the director shall satisfy the claim only with the funds of the prepaid health plan and shall in no event use state funds to satisfy such a claim.

(d) Nothing in this section shall preclude prepaid health plans and nonprepaid health plan providers from entering into voluntary agreements to settle disputed claims for services by means of binding arbitration or by other means acceptable to both parties.

history: (History: Amended by Stats. 1977, Ch. 1121.)

article: 5. Standards for Prepaid Health Plans


text: The prepaid health plan shall maintain a complete unit medical record for each enrollee. Enrollee medical records shall also include records of all treatment received from subcontractors. Such records shall be maintained and preserved in a manner prescribed by the director and shall be available for review by the department and the United States Department of Health, Education, and Welfare.

article: 5. Standards for Prepaid Health Plans


text:
The department shall conduct annual medical audits of each prepaid health plan unless the director determines there is good cause for additional reviews.

The reviews shall use the standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975, as appropriate. Except in those instances where major unanticipated administrative obstacles prevent, or after a determination by the director of good cause, the reviews shall be scheduled and carried out jointly with reviews carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if reviews will be carried out within time periods which satisfy the requirements of federal law.

The department shall be authorized to contract with professional organizations or the Department of Managed Health Care, as appropriate, to perform the periodic review required by this section. The department, or its designee, shall make a finding of fact with respect to the ability of the prepaid health plan to provide quality health care services, effectiveness of peer review, and utilization control mechanisms, and the overall performance of the prepaid health plan in providing health care benefits to its enrollees.

The director shall publicly report the findings of finalized annual medical audits conducted pursuant to this section as soon as possible, but no later than 90 days following completion of any corrective action plan initiated pursuant to the audit, if any, unless the director determines, in his or her discretion, that additional time is reasonably necessary to fully and fairly report the results of the audit.

history: (History: Amended by Stats. 2014, Ch. 573, Sec. 5. (SB 964) Effective January 1, 2015.)

article: 5. Standards for Prepaid Health Plans


text:
(a) The department shall share with the Department of Managed Health Care its findings from medical audits and monthly provider files of a Medi-Cal managed care plan that provides services to Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or this chapter and is subject to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code.

(b) To the extent that the department communicates its preliminary investigative audit findings to the Department of Managed Health Care under subdivision (a), those communications shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code).

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 457. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

article: 5. Standards for Prepaid Health Plans


text:
(a) For purposes of this section, Medi-Cal managed care plan means any prepaid health plan or Medi-Cal managed care plan contracting with the department to provide services to enrolled Medi-Cal beneficiaries under Chapter 7 (commencing with Section 14000) or this chapter, or Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code.

(b) The department shall ensure that coverage is provided for medically necessary prescription medications and related medically necessary medical services that are prescribed by a local mental health plan provider, and are within the Medi-Cal scope of benefits, but are excluded from coverage under Chapter 8.9 (commencing with Section 14700), by doing, at least, all of the following:

(1) Requiring Medi-Cal managed care plans to comply with the following standards:

(A) The decision regarding responsibility and coverage for a prescription drug shall be made by the Medi-Cal managed care plan within 24 hours, or one business day, from the date the request for a decision is received by telephone or other telecommunication device.

(B) The decision regarding responsibility and coverage for services, such as laboratory tests, that are medically necessary because of medications prescribed by a mental health provider, shall be made by the Medi-Cal managed care plan within seven days following the date the request for a decision is received by telephone or other telecommunication device.

(C) If the decision of the Medi-Cal managed care plan on the request is a deferral because of a determination that the Medi-Cal managed care plan needs more information, the Medi-Cal managed care plan shall transmit notice of the deferral, by facsimile or by other telecommunication system, to the pharmacist or other service provider, to the prescribing mental health provider, and to a designated mental health plan representative. The notice shall set out with specificity what additional information is needed to make a medical necessity determination.

(D) Any denial of authorization or payment for a prescription medication or for any services such as laboratory tests that may be medically necessary because of medications ordered by a mental health plan provider shall set forth the reasons for the denial with specificity. The denial notice shall be transmitted by facsimile or other telecommunication system to the pharmacist or other service provider, to the prescribing mental health provider, to a designated mental health plan representative, and by mail to the Medi-Cal beneficiary.

(E) For purposes of subsequent requests for a medication, the local mental health plan provider prescribing the prescription medication shall be treated as a plan provider under subdivision (a) of Section 1367.22 of the Health and Safety Code.

(F) If the decision cannot be made within five working days because of a request for additional information, any Medi-Cal managed care plan licensed pursuant to Division 2 (commencing with Section 1340) of the Health and Safety Code shall inform the enrollee as required by paragraph (5) of subdivision (h) of Section 1367.01 of the Health and Safety Code. In regard to any Medi-Cal managed care plan contract as described pursuant to subdivision (a) that is issued, amended, or renewed on or after January 1, 2001, with a plan not licensed pursuant to Division 2 (commencing with Section 1340) of the Health and Safety Code, if the decision cannot be made within five working days because of a request for additional information as specified in subparagraph (C), the plan shall notify the enrollee, in writing, that the plan cannot make a decision to approve, modify, or deny the request for authorization. All managed care plans shall, upon receipt of all information reasonably necessary for making the decision and that was requested by the plan, approve, modify, or deny the request for authorization within the timeframes specified in subparagraph (A) or (B), whichever applies.

(2) In consultation with the Medi-Cal managed care plans and local mental health plans, establishing a process to recognize credentialing of local mental health plan providers, for the purpose of expediting approval of medications prescribed by a local mental health plan provider who is not contracting with the Medi-Cal managed care plan. In implementing this requirement, the Medi-Cal managed care plan shall not be required to violate licensure, accreditation, or certification requirements of other entities.

(3) Requiring any Medi-Cal managed care plan to enter into a memorandum of understanding with the local mental health plan. The memorandum of understanding shall comply with applicable regulations.

(c) The department may sanction a Medi-Cal managed care plan for violations of this section pursuant to Section 14088.23 or 14197.7.

(d) Every Medi-Cal managed care plan that provides prescription drug benefits and that maintains one or more drug formularies shall provide to members of the public, upon request, a copy of the most current list of prescription drugs on the formulary of the Medi-Cal managed care plan, by therapeutic category, with an indication of whether any drugs on the list are preferred over other listed drugs. If the Medi-Cal managed care plan maintains more than one formulary, the plan shall notify the requester that a choice of formulary lists is available.

(e) This section shall apply to any contracts entered into, amended, modified, or extended on or after January 1, 2001.

history: (History: Amended by Stats. 2019, Ch. 465, Sec. 10. (AB 1642) Effective January 1, 2020.)

article: 5. Standards for Prepaid Health Plans


text:
(a) In addition to the reviews required or authorized by Section 14456, the department shall conduct periodic onsite visits or additional visits after a determination by the director of good cause by departmental representatives to include observation of the general operation of the prepaid health plan, the condition of the facilities for delivering health care, the availability of emergency services, the degree of satisfaction of the enrollees, the operation of the plan’s grievance system, and the administrative and financial aspects of the operation of the prepaid health plan.

(b) Except when reviewing a plan’s grievance system or marketing activities, this evaluation shall use standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975. Except in those instances where major, unanticipated administrative obstacles prevent, or after a determination by the director of good cause, the visits shall be scheduled and carried out jointly with reviews carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if reviews under that act will be carried out within time periods that satisfy the requirements of federal law.

(c) The State Department of Health Services may contract with the Department of Managed Health Care to perform the periodic visits required by this section.

history: (History: Amended by Stats. 2023, Ch. 266, Sec. 6. (AB 614) Effective January 1, 2024.)

article: 5. Standards for Prepaid Health Plans


text: The prepaid health plan shall establish procedures for continuously reviewing the quality of care, performance of medical personnel, the utilization of services and facilities, and costs. Information derived from such review shall be made available to the department.

article: 5. Standards for Prepaid Health Plans


text:
(a) The prepaid health plan shall maintain financial records and shall have an annual audit or additional audits after a determination by the director of good cause, performed by an independent certified public accountant. A prepaid health plan operated by a public entity shall have an annual audit performed in a manner approved by the department. All certified financial statements shall be filed with the department as soon as practical after the end of the prepaid health plan’s fiscal year and in any event, within a period not to exceed 90 days thereafter. These financial statements shall be filed with the department and shall be public records. The department shall perform routine auditing of prepaid health plan contractors and their affiliated subcontractors. Except in those instances where major unanticipated obstacles prevent, or after a determination by the director of good cause, the audits shall be scheduled and carried out jointly with audits carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if audits under that act are carried out within time periods that satisfy the requirements of federal law. The department is authorized to contract with the Department of Managed Health Care to carry out the audits required by this section. The prepaid health plan shall make all of its books and records available for inspection, examination, or copying by the department during normal working hours at the prepaid health plan’s principal place of business or at such other place in California as the department shall designate. For good cause, the department may grant an exception to the time when annual financial statements are to be submitted to the department. The annual report required in Section 14313 shall include an itemization of expenditures made by each prepaid health plan for the following categories of expenditures: physician services, inpatient and outpatient hospital services, pharmaceutical services and prescription drugs, dental services, medical transportation services, vision care services, mental health services, laboratory services, X-ray services, enrollee education programs, marketing and enrollment costs, data-processing costs, other administrative costs and health service expenditures and any payments made to subcontractors, and the purposes of the payments, including, but not limited to, contributions to election campaigns.

(b) The requirements of a financial and administrative review by the department of any health care service plan licensed by the Director of the Department of Managed Health Care pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code may be waived upon submission of the financial audit for the same period conducted by the Department of Managed Health Care pursuant to Section 1382 of the Health and Safety Code.

history: (History: Amended by Stats. 2023, Ch. 266, Sec. 7. (AB 614) Effective January 1, 2024.)

article: 5. Standards for Prepaid Health Plans


text:
(a) As delegated by the federal government, the department has responsibility for monitoring the quality of all Medicaid services provided in the state. A key component of this monitoring function is the performance of annual, independent, external reviews of the quality of services furnished under each state contract with a health maintenance organization, as specified by the federal Centers for Medicare and Medicaid Services.

(b) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall require, through its contracts, that each managed care plan inform the department whether it has been accredited by a private independent accrediting entity.

(c) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall require, through its contracts, that each managed care plan that has received accreditation by a private independent accrediting entity shall authorize the private independent accrediting entity to provide the department a copy of its most recent accreditation review, including all of the following:

(1) Accreditation status, survey type, and level, as applicable.

(2) Accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings.

(3) Expiration date of the accreditation.

(d) The Legislature finds and declares that the final report obtained from the external reviews will provide valid and reliable information regarding health care outcomes and the overall quality of care delivered by the managed care plans.

(e) The department shall make the final report of each external review available, within 30 calendar days of completion, to the fiscal and health policy committees of the Legislature.

(f) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall make the accreditation status for each contracted entity available on its Internet Web site, including whether each entity has been accredited, and if applicable, the name of the accrediting entity, accreditation program, and accreditation level. The department shall update this information at least annually.

(g) Subdivisions (b), (c), and (f) shall be effective for the rating period for managed care plan contracts beginning on or after July 1, 2017.

history: (History: Amended by Stats. 2017, Ch. 511, Sec. 30. (AB 1688) Effective January 1, 2018.)

article: 5. Standards for Prepaid Health Plans


text:
(a) The department shall establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. The list shall specify the benchmarks used by the department to determine whether and the extent to which a dental health plan meets each performance measure. Commencing January 1, 2013, and quarterly thereafter, the list of performance measures established by the department along with each plan’s performance shall be posted on the department’s Internet Web site. The Department of Managed Health Care and the advisory committee established pursuant to Section 14089.08 shall have access to all performance measures and benchmarks used by the department as described in this section.

(1) Commencing April 30, 2017, the quarterly reporting required by this subdivision shall be posted in the following manner:

(A) On or before April 30, 2017, the reporting shall be posted for the July 2016 to September 2016, inclusive, fiscal quarter.

(B) After April 30, 2017, the reporting shall be posted on a quarterly basis on or before April 30, July 31, October 31, and January 31 for the fiscal quarter ending seven months prior.

(2) The performance measures established by the department shall include, but not be limited to, all of the following: provider network adequacy, overall utilization of dental services, annual dental visits, the total number of patients seen on a per-provider basis and the total number of dental services rendered by each provider during each calendar year, use of preventive dental services, use of dental treatment services, use of examinations and oral health evaluations, sealant to restoration ratio, filling to preventive services ratio, treatment to caries prevention ratio, use of dental sealants, use of diagnostic services, and survey of member satisfaction with plans and providers.

(3) The survey of member satisfaction with plans and providers shall be the same dental version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey as used by the Healthy Families Program.

(4) The department shall notify dental health plans at least 30 days prior to the implementation date of these performance measures.

(5) The department shall include the initial list of performance measures and benchmarks in any dental health contracts entered into between the department and a dental health plan pursuant to Section 14204.

(6) The department shall update performance measures and benchmarks and establish additional performance measures and benchmarks in accordance with all of the following:

(A) The department shall consider performance measures and benchmarks established by other states, the federal government, and national organizations developing dental program performance and quality measures.

(B) The department shall notify dental health plans at least 30 days prior to the implementation date of updates or changes to performance measures and benchmarks. The department shall also post these updates or changes on its Internet Web site at least 30 days prior to implementation in order to provide transparency to the public.

(C) To ensure that the dental health needs of Medi-Cal beneficiaries are met, the department shall, when evaluating performance measures and benchmarks for retention on, addition to, or deletion from the list, consider all of the following criteria:

(i) Monthly, quarterly, annual, and multiyear Medi-Cal dental managed care trended data.

(ii) County and statewide Medi-Cal dental fee-for-service performance and quality ratings.

(iii) Other state and national dental program performance and quality measures.

(iv) Other state and national performance ratings.

(b) In establishing and updating the performance measures and benchmarks, the department shall consult the advisory committee established pursuant to Section 14089.08, as well as dental health plan representatives and other stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.

(c) In evaluating a dental health plan’s ability to meet the criteria established through the performance measures and benchmarks, the department shall select specific performance measures from those established by the department in subdivision (a) as the basis for establishing financial or other incentives or disincentives, including, but not limited to, bonuses, payment withholds, and adjustments to beneficiary assignment to plan algorithms. These incentives and disincentives shall be included in the dental health plan contracts.

(d) (1) The department shall designate a qualified external quality review organization (EQRO) that shall conduct external quality reviews for any dental health plan contracting with the department pursuant to Section 14204.

(2) As determined by the department, but at least annually, dental health plans shall arrange for an external quality of care review with the EQRO designated by the department that evaluates the dental health plan’s performance in meeting the performance measures established in this section. Dental health plans shall cooperate with and assist the EQRO in this review. The Department of Managed Health Care shall have direct access to all external quality of care review information upon request to the department.

(3) (A) No later than July 1, 2018, the department shall require that the dental EQRO shall have sufficient information to use in performing the review, and the department shall require the external quality review (EQR) to comply with the following requirements:

(i) The information used to carry out the review shall be obtained from the EQR-related activities in accordance with federal Medicaid regulations, including Section 438.358 of Title 42 of the Code of Federal Regulations, or, if applicable, from a Medicare or private accreditation review as authorized under Section 438.360 of Title 42 of the Code of Federal Regulations.

(ii) For each EQR-related activity, the information gathered for use in the EQR shall include the elements described in federal Medicaid regulations, including the elements described in Section 438.364(a)(2)(i) to (iv), inclusive, of Title 42 of the Code of Federal Regulations.

(iii) The information provided to the EQRO in accordance with this paragraph is obtained through methods consistent with the protocols established by the federal Secretary of Health and Human Services in accordance with federal Medicaid regulations, including Section 438.352 of Title 42 of the Code of Federal Regulations.

(iv) The results of the reviews are made available as specified in federal Medicaid regulations, including Section 438.364 of Title 42 of the Code of Federal Regulations.

(B) The qualified EQRO shall produce and submit to the department an annual EQR technical report in accordance with Section 438.364(a) of Title 42 of the Code of Federal Regulations. The department shall finalize the annual technical report by April 30 of each year.

(C) Once the annual technical report is finalized, the department shall post by April 30 of each year the most recent copy of the annual EQR technical report on the Internet Web site required under Section 438.10(c)(3) of Title 42 of the Code of Federal Regulations.

(D) An external quality of care review shall include, but not be limited to, all of the following: performance on the selected performance measures and benchmarks established and updated by the department, the CAHPS member or consumer satisfaction survey referenced in paragraph (2) of subdivision (a), reporting systems, and methodologies for calculating performance measures. An external quality of care review that includes all of the above components shall be paid for by the dental health plan and posted online annually, or at any other frequency specified by the department, on the department’s Internet Web site. The department shall provide printed or electronic copies of the information specified under Section 438.364(a) of Title 42 of the Code of Federal Regulations, upon request, to interested parties, such as participating health care providers, enrollees and potential enrollees of the managed care plan entity, beneficiary advocacy groups, and members of the general public.

(E) The department shall make the information specified in Section 438.364(a) of Title 42 of the Code of Federal Regulations available in alternative formats for persons with disabilities, when requested.

(e) All marketing methods and activities to be used by dental plans shall comply with subdivision (b) of Section 10850, Sections 14407.1, 14408, 14409, 14410, and 14411, and Title 22 of the California Code of Regulations, including Sections 53880 and 53881 of Title 22 of the California Code of Regulations. Each dental plan shall submit its marketing plan to the department for review and approval.

(f) Each dental plan shall submit its member services procedures, beneficiary informational materials, and any updates to those procedures or materials to the department for review and approval. The department shall ensure that member services procedures and beneficiary informational materials are clear and provide timely and fair processes for accepting and acting upon complaints, grievances, and disenrollment requests, including procedures for appealing decisions regarding coverage or benefits.

(g) Each dental plan shall submit its provider compensation agreements to the department for review and approval.

(h) The department shall post on its Internet Web site a copy of all final reports completed by the Department of Managed Health Care regarding dental managed care plans.

(i) The department shall ensure, to the greatest degree possible, that the categories of data and performance measures selected under this section are consistent with the categories of data and performance measures selected under Section 14132.915.

history: (History: Amended by Stats. 2017, Ch. 511, Sec. 31. (AB 1688) Effective January 1, 2018.)

article: 5. Standards for Prepaid Health Plans


text:
(a) The department shall implement a Management Information System/Decision Support System (MIS/DSS) for the Medi-Cal Program, that shall integrate data from managed care plans to monitor and evaluate the quality of care provided to beneficiaries, including access to services, establish provider rates, and analyze ways to improve both the managed care and fee-for-service systems.

(b) The department shall provide the fiscal and health policy committees of the Legislature with an annual progress and status report on the implementation of the MIS/DSS. The annual progress and status report shall include a description of the current status of the project, including a list of the specific project objectives that have and have not been met at the time of the report and a comparison of the actual progress of the project with the most recent project schedule approved by the Legislature. The report also shall include estimated expenditures and staffing for the current fiscal year and proposed expenditures and staffing for the next fiscal year as well as a summary of cumulative total project expenditures to date and a projection of future expenditures necessary to complete the project.

(c) The department shall provide system or information access to the fiscal and health policy committees of the Legislature, with the most cost-effective technology available, by the conclusion of the third phase of this multiphase project. Access shall include both the management information system and ad hoc report systems, or their equivalent, with safeguards to block access to individual patient identities. Public access shall be provided to at least the management information system summary presentation, or an equivalent, by the time of project completion.

history: (History: Added by Stats. 1997, Ch. 294, Sec. 78. Effective August 18, 1997.)

article: 5. Standards for Prepaid Health Plans


text:
(a) By no later than March 15, 2013, with annual updates thereafter, the department shall provide the fiscal and appropriate policy committees of the Legislature with either a comprehensive report or separate reports on dental managed care in the Counties of Sacramento and Los Angeles. This report shall articulate specific changes and improvements implemented to increase Medi-Cal beneficiary access to preventive services and dental treatment, the utilization of services, and beneficiary satisfaction. Key measures, outcomes, and department findings pertaining to participating dental managed care plans and provider networks shall also be included.

(b) Any report provided pursuant to subdivision (a) on the County of Sacramento shall also provide data regarding the outcomes and findings from the beneficiary dental exception (BDE) process implemented by the department pursuant to Section 14089.09, including the consideration of voluntary enrollment in the County of Sacramento as compared to the existing mandatory enrollment.

(c) The department may seek foundation funding or federal grant funding to facilitate data analysis and reporting as applicable for this purpose.

history: (History: Added by Stats. 2012, Ch. 23, Sec. 115. (AB 1467) Effective June 27, 2012.)

article: 5. Standards for Prepaid Health Plans


text: A schedule of reviews, visits, and audits shall be jointly established by the Department of Managed Health Care or the Department of Insurance, as the case may be, and the State Department of Health Services. Nothing in Section 14456, 14457, or 14459 shall be construed to prohibit the State Department of Health Services from conducting reviews, visits, or audits either jointly or individually, for the purpose of following up on findings resulting from reviews, visits, or audits carried out in accordance with this chapter.

history: (History: Amended by Stats. 2000, Ch. 857, Sec. 96. Effective January 1, 2001.)

article: 5. Standards for Prepaid Health Plans


text: Upon request by the department, each prepaid health plan shall submit to the department a copy of any financial report submitted to any other public or private organization, if such report differs in content or format from any financial report already submitted to the department.

article: 5. Standards for Prepaid Health Plans


text: In accordance with Section 14081.5, the provisions of Section 15459 of the Government Code shall not be applicable to a hospital, whether or not it negotiates to obtain a contract pursuant to Article 2.6 (commencing with Section 14081), if the hospital predominantly serves or will predominantly serve members of a health maintenance organization that has negotiated in good faith to obtain a prepaid contract pursuant to this part or pursuant to Article 2.91 (commencing with Section 14089).

history: (History: Added by Stats. 1983, Ch. 1018, Sec. 3. Effective September 22, 1983.)

article: 5. Standards for Prepaid Health Plans


text:
(a) Except as otherwise provided in this chapter, each prepaid health plan shall be responsible for all of the costs of services rendered under the provisions of this chapter to any Medi-Cal beneficiary enrolled in the plan.

(b) The department shall bear the costs of providing to each Medi-Cal beneficiary enrolled in a prepaid health plan the services covered under the plan, to the extent that the aggregate of these costs, based on Medi-Cal reimbursement levels, and exclusive of third-party recoveries, exceeds the 12-month risk limit. The risk limit shall not exceed twenty-five thousand dollars ($25,000) based on Medi-Cal reimbursement levels, shall be specified in the contract between the department and the plan, and shall be determined concurrently with the annual determination of rates of payment.

The department shall have the authority to adopt regulations to increase the risk limit, to an amount not to exceed thirty-five thousand dollars ($35,000). Regulations to increase the risk limit shall be based upon and supported by changes in prepaid health plan rates paid by the department and changes in the medical component of the Consumer Price Index (CPI) as actuarially determined by the department. It is the intent of the Legislature that these risk limit adjustments are not to exceed thirty-five thousand dollars ($35,000) until the 1986–87 fiscal year or beyond. For plans having contracts in existence on the effective date of this section, the risk limit shall be announced on or before the first day of each state fiscal year, to become effective concurrently with the effective date for the new rates of payment for the next succeeding state fiscal year.

The department may negotiate with a prepaid health plan a mutually agreed-to risk limit in an amount in excess of thirty-five thousand dollars ($35,000).

Within 90 days of the receipt of the documentation required under paragraph (2), the department shall pay the reimbursement provided for by this section to the extent that it determines that the services rendered were medically necessary, and that the amount of the payments sought for those services is reasonable. The department may, if a dispute exists as to whether the services rendered were medically necessary or if the amount of the payments for those services was reasonable, delay paying the reimbursement for such services until a final determination of the dispute is made.

(1) Each prepaid health plan shall arrange and provide initial payment, at Medi-Cal reimbursement levels, for medically necessary care for any Medi-Cal beneficiary enrolled in the plan when the cost for this care exceeds the 12-month risk limit. No person shall be disenrolled by any prepaid health plan for the sole reason that the cost of his or her care under the plan has exceeded the risk limit.

(2) As a condition of reimbursement for costs of care in excess of the risk limit as to a Medi-Cal beneficiary enrolled in a prepaid health plan, the plan must submit to the department, in a format to be designated by the department, documentation of all costs incurred for services to the beneficiary during the 12-month period.

(c) No prepaid health plan may enter into any subcontract that would in any way limit its obligation assumed under this chapter to retain the significant risk of the cost of services rendered under this chapter to any Medi-Cal beneficiary enrolled in the plan.

(d) As a condition of the department’s approval of any subcontract entered into by a prepaid health plan under this chapter, the plan shall specify its retention of significant risk by designating one of the options under subdivision (e) as its operating definition of significant risk, or by any other method approved by the department that would meet the requirement set forth in subdivision (c).

(e) “Significant risk” means financial responsibility for either of the following:

(1) All expenditures in excess of 115 percent of the specified total expenditures estimated under each subcontract.

(2) All inpatient hospitalization expenditures as determined by the department, including expenditures for services connected with hospitalization.

history: (History: Added by renumbering Section 14462 (as amended by Stats. 1985, Ch. 1579) by Stats. 1986, Ch. 248, Sec. 272.)

article: 5. Standards for Prepaid Health Plans


text:
(a) The department may negotiate and establish an individual administrative cost limit in its contracts with each prepaid health plan or Medi-Cal managed care plan contracting under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) providing services to Medi-Cal beneficiary enrollees.

(b) As used in this section, prepaid health plan or Medi-Cal managed care plan “administrative costs” includes net profit or revenue in excess of expenditures, in addition to those items set forth in Section 1300.78 of Title 10 of the California Code of Regulations and those items set forth by the director.

history: (History: Added by Stats. 1995, Ch. 859, Sec. 10. Effective January 1, 1996.)

article: 5. Standards for Prepaid Health Plans


text: For purposes of this article and Section 14454, “emergency services” shall have the same meaning as that established in Section 1317.1 of the Health and Safety Code for “emergency services and care.”

history: (History: Added by Stats. 1992, Ch. 1052, Sec. 1. Effective January 1, 1993.)

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 5.3. Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans


text:
The plan shall make a request to the department to temporarily disenroll any enrollee for the month or months in which the patient is hospitalized and remains in stable condition, and refuses to be transferred from a nonplan provider’s facility to a plan’s facility when it is medically safe to do so.

This section shall only be applicable in Los Angeles County because of problems the county has experienced in treating nonplan Medi-Cal enrollees in county hospitals.

article: 5.3. Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans


text:
(a) No prepaid health plan or pilot program contract shall be approved or renewed by the department pursuant to this chapter if any state officer or state employee or his spouse or minor child has a substantial financial interest, as defined by Section 14478, in any of the following:

(1) The contract or the contracting organization.

(2) Any contract with the contracting organization.

(3) Procurement of a contract for the contracting organization.

(b) As used in subdivision (a), “state officer or state employee” means any person included in Section 14477 and includes any employee in the department who has a direct responsibility for the negotiation, development, or management of a prepaid health plan contracted under the provisions of this chapter. The director shall publish regulations determining the class of employees covered by this subdivision.

article: 6. Conflict of Interest

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 6. Conflict of Interest


text:
The chief executive, sole proprietor, or managing partner of each prepaid health plan shall file with the department an annual statement disclosing any purchases or leases of services, equipment, supplies or real property by the plan from any entity in which any of the following persons have a substantial financial interest as defined by Section 14478:

(a) Any person also having a substantial financial interest in the plan.

(b) Any director, officer, partner, trustee or employee of the plan.

(c) Any member of the immediate family of any person designated in (a) or (b).

history: (History: Added by Stats. 1977, Ch. 1036.)

article: 6. Conflict of Interest


text:
(a) For purposes of this article, “state officer” means a United States Senator or Member of Congress representing California, the Governor, Lieutenant Governor, Secretary of State, Controller, Treasurer, Attorney General, State Superintendent of Public Instruction, a Member of the Legislature, or a secretary of a state agency.

(b) For purposes of this article, “state employee” means any staff member of a state agency secretary who holds a policymaking position, any member of the Governor’s staff who holds a policymaking position, or any administrative aide or committee consultant of the Legislature. “State employee” includes the appointive or civil service employee of the highest class or grade in each department, system, program, section, or other administrative subdivision of the State Department of Health Services as defined in regulations adopted by the department.

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

article: 6. Conflict of Interest


text:
(a) As used in this chapter, “substantial financial interest” means the ownership of common stock, preferred stock, warrants, options, loans, partnership interests, debt instruments, or other ownership interest, if consisting of, or convertible to, equity investments in an entity contracting with the department under the provisions of this chapter or an entity contracting with a current or proposed contractor doing business with the department under the provisions of this chapter, and such ownership interest in terms of fair market value is not less than the greater of the following:

(1) One thousand dollars ($1,000).

(2) Five percent or more of the total fair market value of all equity investments in the entity, including ownership interests convertible to such investments.

A convertible debt includes bonds, notes, debentures, and mortgages.

(b) As used in this chapter, “immediate family” means an individual’s spouse and minor dependent children and any other person over which the individual has legal control.

history: (History: Repealed and added by Stats. 1977, Ch. 1036.)

article: 6. Conflict of Interest


text:
(a) No prepaid health plan or pilot program contract shall be approved, renewed or continued by the department if a state officer or state employee is employed in a management or consultant position by the contractor or a subcontractor to the contractor within one year after the state officer or state employee terminated state employment.

(b) For purposes of this section, “state employee” means any appointive or civil service employee of the department or of the Health and Welfare Agency who, within two years prior to leaving state employment, was responsible for development, negotiation, contract management, or supervision of a prepaid health plan or prepaid health plan contract.

For purposes of this section, employees of the department who are assigned as contract managers shall not be subject to the provisions of this section unless they are employed by a prepaid health plan or a subcontractor of a prepaid health plan for which, within two years prior to leaving state employment, they were responsible for the development, negotiation, contract management, or direct supervision over the prepaid health plan contract. This section shall not apply to any employee, appointee, or person on contract with the department who is employed, appointed, or contracted with by the department either:

(1) To fulfill the purposes of a federal grant, provided that such person does not supervise, develop, manage, or negotiate a prepaid health plan contract; or

(2) To fulfill on a temporary basis, not to exceed 120 days, a specific function for the department which does not include supervising, developing, managing, or negotiating a prepaid health plan contract.

(c) The requirements of this section shall apply to any contract entered into on or after the operative date of this section and to any state officer or state employee who is employed by such contractor or subcontractor thereof on or after such operative date. This section shall not apply to any state officer or employee who terminated state employment prior to such operative date.

article: 6. Conflict of Interest


text: No prepaid health plan or pilot program contract with an existing or proposed contractor shall be approved or renewed if a state officer or state employee provides legal or management services to the contracting organization. For the purposes of this section no state officer or state employee shall share in the income or any remuneration derived from the providing of legal or management services to a contracting organization.

history: (History: Amended by Stats. 1977, Ch. 1036.)

article: 6. Conflict of Interest


text: No prepaid health plan or pilot program contract shall be approved or renewed if any state officer or state employee receives anything of value for the purpose of influencing or attempting to influence the negotiations for approval or renewal of the contract.

article: 6. Conflict of Interest


text:
No prepaid health plan shall contract with any subcontractor other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, or an affiliate of the prepaid health plan whose financial statements are consolidated with that of the prepaid health plan at the time of the annual audit by the independent auditors of the plan and when the quarterly and annual financial statements are filed with the Director of the Department of Managed Health Care, if any of the following persons connected with the plan have a substantial financial interest, as defined by Section 14478, in such subcontractor:

(a) Any person also having a substantial financial interest in the plan.

(b) Any director, officer, partner, trustee, or employee of the plan.

(c) Any member of the immediate family of any person designated in (a) or (b).

history: (History: Amended by Stats. 2000, Ch. 857, Sec. 97. Effective January 1, 2001.)

article: 6. Conflict of Interest


text:
In providing benefits under this chapter and Chapter 7 (commencing with Section 14000), the director shall aggressively seek the development of alternative forms of financing and delivering health care services. In carrying out the intent of this article, the director shall contract with institutional providers, counties, or other organizations to establish pilot programs that demonstrate the value, or lack thereof, of such a program in delivering or financing health care services in such a manner. Each pilot program shall be for a specified duration not to exceed five years, and each pilot program shall be evaluated annually for its efficiency, effectiveness, and quality.

Upon a finding by the director that a pilot program contributes substantially to the availability of high quality health services and that those services are cost-effective, the director shall enter into a contract for a period of up to five years.

Where the director recommends implementation of a pilot program on a permanent basis, but finds that he or she is not able to implement on a permanent basis that program immediately upon conclusion of the program’s term, he or she may extend the duration of the pilot program until the evaluation or permanent implementation can be accomplished. The extension shall be for a term not in excess of one year, but may be renewed for additional one-year terms, provided that the director has completed an evaluation to include findings that would qualify an extension.

history: (History: Amended by Stats. 1997, Ch. 17, Sec. 154. Effective January 1, 1998.)

article: 7. Pilot Programs

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 7. Pilot Programs


text:
The director shall pursue the feasibility of establishing the following as pilot programs:

(a) A capitated, risk-assuming contract with one or more regional fiscal intermediaries.

(b) A capitated, risk-assuming contract with acute care hospitals within a county or region.

(c) A capitated, risk-assuming contract with one or more organizations which provide payment to a specified class or classes of providers.

For purposes of this section, “risk-assuming” means the pilot program contractor agrees to assume the risk of utilization of services or costs of services, or both.

article: 7. Pilot Programs


text: The director shall also consider programs which demonstrate an innovative and economical use of health personnel and are approved pursuant to Article 18 (commencing with Section 429.70), Chapter 2, Part 1, Division 1 of the Health and Safety Code.

article: 7. Pilot Programs


text:
The director may enter into other contracts under this article which do one or more of the following:

(a) Demonstrate an innovative and economical use of health personnel.

(b) Emphasize preventive care.

(c) Stress new methods for controlling utilization of services.

(d) Stress new methods of reviewing provider competency or quality of care.

(e) Stress a more economical organization of health care resources and delivery systems.

(f) Provide an incentive to beneficiaries to seek the most economical level of care.

(g) Demonstrate innovative methods for health care financing, such as prospective budgeting in regard to enrolled population or volume of services.

(h) Test or demonstrate the feasibility of allowing California citizens to purchase Medi-Cal coverage at a premium rate determined by the department on an actuarial basis.

article: 7. Pilot Programs


text:
In establishing pilot programs, the director may do the following:

(a) Provide benefits based on class of recipient, class of benefit, geographical area, or any other reasonable classification.

(b) Modify, to the extent permitted by federal law, the scope and duration of benefits provided by Section 14132. The extent of coverage may be limited to a fixed number of days or to amount or duration of services.

(c) Modify, to the extent permitted by federal law, Medi-Cal eligibility determination processes or criteria.

(d) Allow for the provision of Medi-Cal benefits on a prepaid basis in a given geographical area exclusively by the pilot program.

(e) Assign persons eligible for Medi-Cal benefits to a pilot program or a prepaid health plan on a pilot basis, provided such persons shall be entitled to disenroll for any cause for a period of 30 days following the effective date of enrollment and to receive a Medi-Cal card pursuant to Section 14017.

article: 7. Pilot Programs


text:
(a) The department shall establish a pilot program to provide continuous skilled nursing care as a benefit of the Medi-Cal program, when those services are provided in accordance with an approved federal waiver meeting the requirements of subdivision (b). “Continuous skilled nursing care” means medically necessary care provided by, or under the supervision of, a registered nurse within his or her scope of practice, seven days a week, 24 hours per day, in a health facility participating in the pilot program. This care shall include a minimum of eight hours per day provided by or under the direct supervision of a registered nurse. Each health facility providing continuous skilled nursing care in the pilot program shall have a minimum of one registered nurse or one licensed vocational nurse awake and in the facility at all times.

(b) The department shall submit to the federal Centers for Medicare and Medicaid Services, no later than April 1, 2000, a federal waiver request developed in consultation with the State Department of Developmental Services and the Association of Regional Center Agencies, pursuant to Section 1915(b) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) to provide continuous skilled nursing care services under the pilot program.

(c) (1) The pilot program shall be conducted to explore more flexible models of health facility licensure to provide continuous skilled nursing care to developmentally disabled individuals in the least restrictive health facility setting, and to evaluate the effect of the pilot program on the health, safety, and quality of life of individuals, and the cost-effectiveness of this care. The evaluation shall include a review of the pilot program by an independent agency.

(2) Participation in the pilot program shall include 10 health facilities provided that the facilities meet all eligibility requirements. The facilities shall be approved by the department, in consultation with the State Department of Developmental Services and the appropriate regional center agencies, and shall meet the requirements of subdivision (e). Priority shall be given to facilities with four to six beds, to the extent those facilities meet all other eligibility requirements.

(d) Under the pilot program established in this section, a developmentally disabled individual is eligible to receive continuous skilled nursing care if all of the following conditions are met:

(1) The developmentally disabled individual meets the criteria as specified in the federal waiver.

(2) The developmentally disabled individual resides in a health facility that meets the provider participation criteria as specified in the federal waiver.

(3) The continuous skilled nursing care services are provided in accordance with the federal waiver.

(4) The continuous skilled nursing care services provided to the developmentally disabled individual do not result in costs that exceed the fiscal limit established in the federal waiver.

(e) A health facility seeking to participate in the pilot program shall provide care for developmentally disabled individuals who require the availability of continuous skilled nursing care, in accordance with the terms of the pilot program. During participation in the pilot program, the health facility shall comply with all the terms and conditions of the federal waiver described in subdivision (b), and shall not be subject to licensure or inspection under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code. Upon termination of the pilot program and verification of compliance with Section 1265 of the Health and Safety Code, the department shall immediately reinstate the participating health facility’s previous license for the balance of time remaining on the license when the health facility began participation in the pilot program.

(f) The department shall implement this pilot program only to the extent it can demonstrate fiscal neutrality, as required under the terms of the federal waiver, and only if the department has obtained the necessary approvals to implement the pilot program and receives federal financial participation from the federal Centers for Medicare and Medicaid Services.

(g) In implementing this article, the department may enter into contracts for the provision of essential administration and other services. Contracts entered into under this section may be on a noncompetitive bid basis and shall be exempt from the requirements of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(h) This section shall be repealed if and when the federal Centers for Medicare and Medicaid Services approve a federal waiver pursuant to Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) or approve a state plan amendment to make this pilot program a permanent program. If the federal Centers for Medicare and Medicaid Services provide that approval, the Director of Health Care Services shall execute a declaration stating that this approval has been granted. The director shall retain the declaration and this section shall be repealed on the date that the director executes a declaration pursuant to this subdivision.

history: (History: Amended by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 51. Effective July 28, 2009. Repealed conditionally as prescribed by its own provisions.)

article: 7. Pilot Programs


text:
(a) Alternate methods of payment for a pilot program may include, but shall not be limited to, a prospectively negotiated reimbursement rate, fee-for-service, retainer, capitation, or other basis.

(b) In order to implement expeditiously the budgeting decisions of the Legislature, the director shall, to the extent permitted by federal law, adopt regulations setting rates payable to providers which reflect such decisions 30 days after the enactment of the Budget Act and of any other appropriation which changes the level of funding for Medi-Cal services. The proposed regulations shall be submitted to the Department of Finance five days prior to the date of adoption. With the written approval of the Department of Finance, the director shall adopt such regulations as emergency regulations in accordance with the provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340), Part 1, Division 3, Title 2 of the Government Code). For purposes of such act, the adoption of such regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare.

(c) In order to implement expeditiously the budgeting decisions of the Legislature, the director and the contractor shall, to the extent permitted by federal law, amend the pilot project contract to reflect such decisions 60 days after the enactment of the Budget Act and of any other appropriation which changes the level of funding for Medi-Cal services. Any approvals, ratifications, reviews, or analyses of such amendments required to be undertaken by any state agency or state department shall be completed within the 60-day period specified in this subdivision.

history: (History: Amended by Stats. 1990, Ch. 1516, Sec. 3. Effective September 30, 1990.)

article: 7. Pilot Programs


text: The director shall call a public hearing pursuant to Section 14300 prior to entering into or renewing a pilot program. The director shall make available to the public a statement of objectives, program proposal, pilot program contract, and other details regarding the pilot program not less than five days prior to the public hearing.

article: 7. Pilot Programs


text:
(a) (1) In carrying out the intent of this article, the director shall contract for the operation of one local pilot program. Special consideration shall be given to approving a program contracted through county government in Santa Barbara County.

(2) Notwithstanding the limitations contained in Section 14490, the director may enter into, or extend, contracts with the local pilot program in Santa Barbara County pursuant to paragraph (1) for periods that do not exceed three years.

(b) The establishment of a pilot program pursuant to this section shall be contingent upon the availability of state and federal funding. The program shall include the following components:

(1) Local authority for administration, fiscal management, and delivery of services, but not including eligibility determination.

(2) Physician case management.

(3) Cost containment through provider incentives and other means.

(c) The program for the pilot project shall include a plan and budget for delivery of services, administration, and evaluation. During the first year of the pilot program, the amount of the state contract shall equal 95 percent of total projected Medi-Cal expenditures for delivery of services and for administration based on fee-for-service conditions in the program county. During the remaining years of the pilot project Medi-Cal expenditures in the program county shall be no more than 100 percent of total projected expenditures for delivery of services and for administration based on any combination of the following paragraphs:

(1) Relevant prior fee-for-service Medi-Cal experience in the program county.

(2) The fee-for-service Medi-Cal experience in comparable counties or groups of counties.

(3) Medi-Cal experience of the pilot project in the program county if, as determined by the department, the scope, level, and duration of, and expenditures for, any services used in setting the rates under this paragraph would be comparable to fee-for-service conditions were they to exist in the program county and would be more actuarially reliable for use in ratesetting than data available for use in applying paragraph (1) or (2).

The projected total expenditure shall be determined annually according to an acceptable actuarial process. The data elements used by the department shall be shared with the proposed contractor.

(d) The director shall accept or reject the proposal within 30 days after the date of receipt. If a decision is made to reject the proposal, the director shall set forth the reasons for this decision in writing. Upon approval of the proposal, a contract shall be written within 60 days. After signature by the local contractor, the State Department of Health Care Services and the Department of General Services shall execute the contract within 60 days.

(e) The director shall seek the necessary state and federal waivers to enable operation of the program. If the federal waivers for delivery of services under this plan are not granted, the department is under no obligation to contract for implementation of the program.

(f) For purposes of Section 1343 of the Health and Safety Code, the Santa Barbara Regional Health Authority shall be considered to be a county-operated pilot program contracting with the State Department of Health Care Services pursuant to this article, and notwithstanding any other provision of law, during the period that this contract is in effect, the contractor shall be exempt from the provisions of the Knox-Keene Health Care Service Plan Act of 1975, Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, relative to the services provided to Medi-Cal beneficiaries under the terms and provisions of the pilot program.

(g) Dental services may be included within the services provided in this pilot program.

(h) Any federal demonstration funding for this pilot program shall be made available to the county within 60 days upon notification of the award without the state retaining any portion not previously specified in the grant application as submitted.

(i) (1) (A) The department may negotiate exclusive contracts and rates with the Santa Barbara Regional Health Authority in the implementation of this section.

(B) Contracts entered into under this article may be on a noncompetitive bid basis and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(C) The department shall enter into contracts pursuant to this article, and shall be bound by the terms and conditions related to the rates negotiated by the negotiator.

(2) The department shall implement this subdivision to the extent that the following apply:

(A) Its implementation does not revise the status of the pilot program as a federal demonstration project.

(B) Existing federal waivers apply to the pilot program as revised by this subdivision, or the federal government extends the applicability of the existing federal waivers or authorizes additional federal waivers for the implementation of the program.

(3) The implementation of this subdivision shall not affect the pilot program’s having met any of the requirements of Part 3.5 (commencing with Section 1175) of Division 1 of the Health and Safety Code and this division applicable to the pilot program with respect to the negotiations of contracts and rates by the department.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 93. Effective August 24, 2007.)

article: 7. Pilot Programs


text:
(a) The Santa Barbara Regional Health Authority may arrange with out-of-county Selective Provider Contracting Program hospitals that have negotiated hospital contracts and per diem rates under Article 5.1 (commencing with Section 14165) of Chapter 7, to provide medically justified emergency services or to provide specialized hospital services not available within Santa Barbara County to Medi-Cal beneficiaries who reside in Santa Barbara County. The authority may arrange medically justified inpatient hospital services with out-of-county program hospitals for those beneficiaries whose county of residence for purposes of eligibility determination is Santa Barbara, but who for medical or legal reasons physically reside in a county other than Santa Barbara.

(b) The out-of-county program hospitals shall not charge the authority more than their program negotiated rates when providing hospital services to authority patients under this section, except as provided in subdivision (c).

(c) In cases where an out-of-county program hospital can demonstrate that the cost of the services it is rendering to authority patients was not contemplated in the case mix and acuity assumptions on which the program rates are based, the program hospital and the authority shall negotiate in good faith equitable rates for payment for the provision of hospital services to authority patients. The established program rate shall serve as the base for those negotiations.

(d) (1) Notwithstanding any other provision of law, any records maintained by the authority that would enable a determination to be made regarding rates negotiated pursuant to Article 5.1 (commencing with Section 14165) of Chapter 7, shall be exempt from the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code).

(2) The authority shall establish guidelines to ensure that these rates are maintained as confidential records and that access to these records is restricted.

(3) The authority shall submit the established guidelines to the department for approval.

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 458. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

article: 7. Pilot Programs


text: The department may contract with one or more fiscal intermediaries in order to pay for benefits authorized under this chapter and Chapter 7 (commencing with Section 14000). Contracts entered into pursuant to this article may be awarded on a bid or nonbid basis.

history: (History: Added by Stats. 1985, Ch. 1579, Sec. 4.)

path: 9. PUBLIC SOCIAL SERVICES > 8. Prepaid Plans > 8. Medi-Cal At-Risk Fiscal Intermediaries


text: For the purposes of this article, “fiscal intermediary” means an entity that agrees to pay for covered services provided to Medi-Cal eligibles in exchange for a premium, subscription charge, or capitation payment; to assume an underwriting risk; and is licensed by the Director of the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

history: (History: Amended by Stats. 2015, Ch. 455, Sec. 54. (SB 804) Effective January 1, 2016.)

article: 8. Medi-Cal At-Risk Fiscal Intermediaries


text:
A contract entered into under this article shall provide that a fiscal intermediary meets both of the following criteria:

(a) The fiscal intermediary shall provide or arrange for an adequate number of primary care physicians and supportive specialty care physicians.

(b) The fiscal intermediary shall implement a management and information reporting system in order to determine the costs of each type of health care service rendered to Medi-Cal recipients.


text: In determining the capitated rates to be paid to a fiscal intermediary during the first year of contracting under this article, the department shall utilize an acceptable actuarial process and historical data concerning Medi-Cal recipients in the geographical area which will, or is being, served by the fiscal intermediary. During the remaining years of the contract with the fiscal intermediary, the department shall utilize data concerning Medi-Cal expenditures for delivery of services based on the fee-for-service experience in comparable geographic areas. The capitated rates shall not exceed the total per capita amount (including the cost of adjustments to provide actuarial equivalence) which would be payable for all services and requirements covered under the fiscal intermediary contract adopted pursuant to this article if all those services and requirements were to be furnished to Medi-Cal beneficiaries under the fee-for-service Medi-Cal program provided for by Chapter 7 (commencing with Section 14000).


text: A fiscal intermediary may contract for the provision of services with any provider who would be eligible to provide services if services were to be provided on a fee-for-service basis without the use of a fiscal intermediary pursuant to this article.


text: All services, except those specified for exclusion by the department, received by Medi-Cal recipients residing in the geographical area served by the fiscal intermediary shall be paid for by the fiscal intermediary. Services shall be provided only by providers which have entered into agreements with the fiscal intermediary, unless authorized by the fiscal intermediary.


text: An Office of Family Planning shall be established within the State Department of Health Services. The Office of Family Planning shall be under the control of an executive officer who shall be known as the Coordinator of the Office of Family Planning. The coordinator shall be appointed by the State Director of Health Services and shall be an individual with training and experience in family planning.

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

chapter: 8.5. Family Planning

path: 9. PUBLIC SOCIAL SERVICES > 8.5. Family Planning


text:
(a) It is the intent of the Legislature that family planning includes, but is not limited to, an effective means to improve reproductive health by disease prevention and treatment, to reduce the incidence of unintended pregnancies, and to reduce the demand for abortions. It is the intent of the Legislature that no family planning shall be expended other than for the services enumerated in this chapter. It is also the intent of the Legislature that no funds received pursuant to this chapter be used for abortions or services ancillary to abortions.

(b) For purposes of this chapter, the following definitions shall apply:

(1) “Family planning” means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, natural family planning, abstinence methods, and the management of infertility. Family planning services include preconceptional counseling, maternal and fetal health counseling, and general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, and other services as described in Section 14503, except for abortions and services ancillary to abortions as prohibited in Section 14509. Family planning does not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care which is not incident to the diagnosis of a pregnancy, except as otherwise provided for in this chapter.

(2) “Abortion as a method of family planning” means the deliberate choice of abortion over other methods to limit the number, gender, and spacing of children, including, but not limited to, contraception, abstinence, and natural family planning methods.

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

(4) “Director” means the Director of Health Care Services.

(5) “Grantee” means an agency, institution, or organization approved by the department to provide family planning services pursuant to this chapter.

history: (History: Amended by Stats. 2012, Ch. 23, Sec. 116. (AB 1467) Effective June 27, 2012.)