text:
(a) For purposes of this section, “narcotic treatment program services” includes, but is not limited to, all of the following:

(1) Admission, physical evaluation, and diagnosis.

(2) Drug screening.

(3) Pregnancy tests.

(4) Narcotic replacement therapy dosing.

(5) Any medication approved under Section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), and all biological products licensed under Section 351 of the Public Health Service Act (42 U.S.C. 262) to treat opioid use disorders.

(6) (A) Intake assessment, treatment planning, and counseling services.

(B) The frequency of counseling, behavioral therapy, or medical psychotherapy, outcomes, and rates shall be addressed through guidance issued by the department pursuant to subdivision (k). For purposes of this paragraph, these services include substance use services to pregnant and postpartum Medi-Cal beneficiaries.

(b) (1) The department shall establish a narcotic replacement therapy dosing fee for methadone.

(2) In addition to the narcotic replacement therapy dosing fee specified in paragraph (1), a narcotic treatment program shall be reimbursed for the ingredient costs of methadone dispensed to a Medi-Cal beneficiary. These costs may be determined on an average daily dose of methadone, as set forth by the department.

(c) Reimbursement for narcotic treatment program services shall be based on a per capita uniform statewide daily reimbursement rate for each individual patient, as established by the department. The uniform statewide daily reimbursement rate for narcotic treatment program services shall be based upon, if available and appropriate, all of the following:

(1) The outpatient rates for the same or similar services under the fee-for-service Medi-Cal program.

(2) Cost report data.

(3) Other data deemed reliable and relevant by the department.

(4) The rate studies completed pursuant to Section 54 of Chapter 197 of the Statutes of 1996.

(d) The uniform statewide daily reimbursement rate for ancillary services shall not exceed, for individual services or in the aggregate, the outpatient rates for the same or similar services under the fee-for-service Medi-Cal program.

(e) The uniform statewide daily reimbursement rate shall be established after consultation with narcotic treatment program providers and county alcohol and drug program administrators.

(f) Reimbursement for narcotic treatment program services shall be limited to those services specified in state law and any authorized federally approved Medicaid state plan amendments or waivers related to the Drug Medi-Cal program, and shall be provided in accordance with federal and state law governing the licensing and administration of narcotic treatment programs.

(g) Reimbursement under this section shall be limited to claims for narcotic treatment program services at the uniform statewide daily reimbursement rate for these services. These rates shall be exempt from the requirements of Section 14021.6.

(h) (1) Reimbursement to a narcotic treatment program provider shall be limited to the lower of the uniform statewide daily reimbursement rate, pursuant to subdivision (c), or the provider’s usual and customary charge to the general public for the same or similar service.

(2) (A) Reimbursement paid by a county to a narcotic treatment program provider for services provided to any person subject to Section 1210.1 or 3063.1 of the Penal Code, and for which the individual client is not liable to pay, is not a usual and customary charge to the general public for the purposes of this section.

(B) Subparagraph (A) is not a change in, but is declaratory of, existing law.

(i) A program shall not be reimbursed for services or medications not rendered to or received by a patient of a narcotic treatment program.

(j) Reimbursement for narcotic treatment program services shall be administered by the department and any county electing to participate in the program. Utilization and payment for these services shall be subject to federal Medicaid and state utilization and audit requirements.

(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this section, in whole or in part, by means of bulletins or similar instructions, until the time that any necessary regulations are adopted.

(l) The department shall adopt regulations necessary to implement this section by July 1, 2023.

(m) This section shall be implemented to the extent that any necessary federal approval of state plan amendments or other federal approvals, including waivers, are obtained, and federal financial participation is available and not otherwise jeopardized.

history: (History: Amended by Stats. 2020, Ch. 12, Sec. 50. (AB 80) Effective June 29, 2020.)

article: 1. General Provisions


kind: section

code: WIC

text:
(a) (1) The Legislature finds and declares all of the following:

(A) Medical treatment for indigent patients who are not eligible for Medi-Cal is essential to protecting the public health.

(B) The Legislature supports the adoption of standardized and simplified forms and procedures in order to promote the drug treatment of indigent patients who are not eligible for Medi-Cal.

(C) Providers should not be required by the state to subsidize the medical treatment provided to indigent patients who are not eligible for Medi-Cal.

(D) The Legislature supports the therapeutic value of indigent patients who are not eligible for Medi-Cal contributing some level of fees for drug treatment services in order to support the goals of those drug treatment services.

(2) It is the intent of the Legislature in enacting this section to encourage narcotic treatment program providers to serve indigent patients who are not eligible for Medi-Cal. It is also the intent of the Legislature that the department allow narcotic treatment program providers to charge therapeutic fees for providing drug treatment to indigent patients who are not eligible for Medi-Cal if the providers establish a fee scale that complies with the documentation requirements established pursuant to this section and federal law.

(b) (1) The Legislature recognizes that narcotic treatment program providers are reimbursed for controlled substances provided under the Drug Medi-Cal Treatment Program, also known as Drug Medi-Cal, and pursuant to federal law at a rate that is the lower of the per capita uniform statewide daily reimbursement or Drug Medi-Cal rate, or the provider’s usual and customary charge to the general public for the same or similar services.

(2) It furthers the intent of the Legislature to ensure that narcotic treatment programs in the state are able to serve indigent clients and that there is an exception to the reimbursement requirements described in paragraph (1), as the federal law has been interpreted by representatives with the federal Centers for Medicare and Medicaid Services. Pursuant to this exception, if a narcotic treatment program provider that is serving low-income non-Drug Medi-Cal clients complies with a federal requirement for the application of a sliding indigency scale, the reduced charges under the sliding indigency scale shall not lower the provider’s usual and customary charge determination for purposes of Medi-Cal reimbursement.

(c) A licensed narcotic treatment program provider that serves low-income non-Drug Medi-Cal clients shall be deemed in compliance with federal and state law, for purposes of the application of the exception described in paragraph (2) of subdivision (b), and avoid audit disallowances, if the provider implements a sliding indigency scale that meets all of the following requirements:

(1) The maximum fee contained in the scale shall be the provider’s full nondiscounted, published charge and shall be at least the rate that Drug Medi-Cal would pay for the same or similar services provided to Drug Medi-Cal clients.

(2) The sliding indigency scale shall provide for an array of different charges, based upon a client’s ability to pay, as measured by identifiable variables. These variables may include, but need not be limited to, financial information and the number of dependents of the client.

(3) Income ranges shall be in increments that result in a reasonable distribution of clients paying differing amounts for services based on differing abilities to pay.

(4) A provider shall obtain written documentation that supports an indigency allowance under the sliding indigency scale established pursuant to this section, including a financial determination. In cases where this written documentation cannot be obtained, the provider shall document at least three attempts to obtain this written documentation from a client.

(5) The provider shall maintain all written documentation that supports an indigency allowance under this section, including, if used, the financial evaluation form set forth in Section 14021.53.

(6) Written policies shall be established and maintained that set forth the basis for determining whether an indigency allowance may be granted under this section and establish what documentation shall be requested from a client.

(d) In developing the sliding indigency scale, a narcotic treatment program provider shall consider, but need not include, any or all of the following components:

(1) Vertically, the rows would reflect increments of family or household income. There would be a sufficient number of increments to allow for differing charges, such as a six hundred dollar ($600) increase per interval.

(2) Horizontally, the columns would provide for some other variable, such as family size, in which case, the columns would reflect the number of people dependent on the income, including the client.

(3) Each row, except the first and last rows, would contain at least two different fee amounts and each of the columns, four or more in number, would contain at least six different fee amounts.

(4) The cells would contain an array of fees so that no fee would be represented in more than 25 percent of the cells.

(e) A narcotic treatment program provider that uses the financial evaluation form instructions and financial form set forth in Section 14021.53 in obtaining written documentation that supports an indigency allowance as required under paragraph (4) of subdivision (c) shall be deemed in compliance with that paragraph.

history: (History: Added by Stats. 2012, Ch. 36, Sec. 77. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 1. General Provisions

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 1. General Provisions


text:
A narcotic treatment program provider may use the following instructions and financial evaluation form to comply with the requirements of paragraph (4) of subdivision (c) of Section 14021.52: FINANCIAL EVALUATION FORM INSTRUCTIONS MONTHLY INCOME DATA—This data should specify the source and the amount and be supported by sufficient documentation. Income data may include, but are not limited to, income received as a paid employee, unemployment benefits, disability benefits, pension payments, family income, savings income, or other sources.

MONTHLY EXPENSES DATA—This data is not required unless there is no evidence or documentation of income data. Expense data may include, but are not limited to, any known expenses related to the following:

(1) Court-ordered payments, such as child support, fines, debts, restitution, or other payments.

(2) Housing-related expenses, such as rent, mortgage, insurance, utilities, or other obligations.

(3) Transportation costs, such as any related expenses, including automobile payments or automobile insurance payments.

(4) Insurance coverage should also be noted if it produces either an expense or benefit to the client.

CLIENT MONTHLY TREATMENT FEE—The following applies to this data:

(1) The amount box indicates the client’s fee according to his or her location on the sliding scale.

(2) The adjusted client monthly fee box is to be filled only if the fee to be charged differs from the fee indicated by the client’s location on the sliding scale.

(3) If the fee is adjusted from what the sliding scale would indicate, a reason for the adjustment must be provided. (Valid reasons might include extraordinary medical expenses for a client suffering from HIV/AIDS, etc.)

PLEASE NOTE—The documentation for this form requires that the provider make at least three documented attempts to collect documentation from a client. Any questions on this form may be directed to the department at (____).

history: (History: Added by Stats. 2012, Ch. 36, Sec. 78. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions


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

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

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

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

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

(d) This section shall become operative only upon the date of which Section 1902(a)(4)(C) of the federal Social Security Act, as added by Public Law 95-559 is repealed, held invalid by a court of appeal, or otherwise made inoperative.

history: (History: Amended by Stats. 2015, Ch. 303, Sec. 606. (AB 731) Effective January 1, 2016. Section conditionally operative by its own provisions. Note: Until this section is operative, see related provisions in Article 1.6, commencing with Section 14047.)

article: 1. General Provisions


text: Any nursing facility or any category of intermediate care facility for the developmentally disabled participating in the Medi-Cal program shall supply to the department full and complete information as to the identity (a) of each person having, directly or indirectly, an ownership interest of 10 percent or more in the facility, or, who is owner, in whole or part, of any mortgage, deed of trust, note, or other obligation secured, in whole or part, by the facility, or any of the property or assets of the facility, (b) in case a facility is organized as a corporation, of each officer and director of the corporation, and (c) in case a facility is organized as a partnership, of each partner; and shall promptly report any changes which would affect the current accuracy of the information so required to be supplied.

history: (History: Amended by Stats. 1990, Ch. 1329, Sec. 13. Effective September 26, 1990.)

article: 1. General Provisions


text: Long-term health care facilities shall reveal to applicants for admission, or their designated representatives, orally and in writing and prior to admission, whether the facility participates in the Medi-Cal program, and the circumstances under which the law permits a Medi-Cal recipient to be transferred involuntarily.

history: (History: Added by Stats. 1985, Ch. 11, Sec. 19. Effective March 6, 1985.)

article: 1. General Provisions


text:
(a) Any nursing facility or any category of intermediate care facility for the developmentally disabled currently certified to participate in the Medi-Cal program may not voluntarily withdraw from the program unless all of the following conditions are met:

(1) The facility shall file with the department a notice of intent to withdraw from the Medi-Cal program.

(2) Except for patients to be transferred or discharged only for medical reasons, or for patients’ welfare or that of other patients, or for nonpayment for his or her stay, the facility shall not subsequently evict any Medi-Cal recipient or private pay patient residing in the facility at the time the notice of intent to withdraw from the Medi-Cal program is filed.

(3) Patients admitted to the facility on or after the date of the notice of intent to withdraw from the Medi-Cal program shall be advised orally and in writing of both the following:

(A) That the facility intends to withdraw from the Medi-Cal program.

(B) That notwithstanding Section 14124.7, the facility is not required to keep a new resident who converts from private pay to Medi-Cal.

(b) Subdivision (a) shall not apply to facilities that have filed, prior to May 1, 1987, a notice of intent to withdraw from the Medi-Cal program.

(c) The department shall notify the appropriate substate ombudsmen monthly as to which facilities have filed a notice of intent to withdraw from the Medi-Cal program. This information shall also be made available to the public and noted in facility files available in each district office.

(d) The facility may formally withdraw from the Medi-Cal program when all patients residing in the facility at the time the facility filed the notice of intent to withdraw from the Medi-Cal program no longer reside in the facility.

(e) If a facility that has withdrawn as a Medi-Cal provider pursuant to this section subsequently reapplies to the department to become a Medi-Cal provider, the department shall require as a condition of becoming a Medi-Cal provider that the facility enter into a five-year Medi-Cal provider contract with the department.

(f) This section shall be inoperative in the event federal law or federal or state appellate judicial decisions prohibit implementation or invalidate any part of this section.

(g) (1) This section does not apply to any facility which ceases operations entirely.

(2) For purposes of this subdivision, “ceases operations entirely” means not being in operation for a period of not less than 12 months.

history: (History: Amended by Stats. 2012, Ch. 728, Sec. 198. (SB 71) Effective January 1, 2013. Conditionally inoperative as provided in subd. (f).)

article: 1. General Provisions


text:
(a) It is the intent of the Legislature to recognize the challenges and unique dental treatment needs of the developmentally disabled population that cannot be addressed within the current structure of benefits, frequency of allowable procedures, and treatment authorization procedures for assistance programs relating to dental benefits.

(b) The department shall work in cooperation with the State Department of Developmental Services, and in consultation with the California Dental Association, to provide existing data directly to the fiscal and policy committees of the Legislature specified in subdivision (c), by April 1, 2003, describing the characteristics of dental services received by Medi-Cal beneficiaries who are eligible to receive dental services under the Lanterman Developmental Disability Services Act (Division 4.5 (commencing with Section 4500)), who can be easily identified, including, but not limited to, the frequency of utilization of dental procedures and services, and types of dental procedures and services.

(c) The committees to whom the data shall be provided include all of the following:

(1) The Senate Committee on Health and Human Services.

(2) The Senate Budget Subcommittee Number 3 on Health, Human Services, Labor, and Veterans Affairs.

(3) The Assembly Committee on Health.

(4) The Assembly Committee on Human Services.

(5) The Assembly Budget Subcommittee Number 1 on Health and Human Services.

(d) It is the intent of the Legislature that the information described in subdivision (b) will be used to identify possible program modifications that are more appropriate to serve the population described in subdivision (b), and that are more efficient and more effective in serving this population, while remaining cost-neutral.

history: (History: Added by Stats. 2002, Ch. 522, Sec. 1. Effective January 1, 2003.)

article: 1. General Provisions


text:
(a) Any applicant for coverage under this chapter who at the time of application has any other contractual or legal entitlement to any health care service defined in Section 14053, and who willfully fails at that time to disclose the fact of such other entitlement, or falsely represents that he or she does not have such other entitlement, is guilty of a misdemeanor.

(b) Any person eligible under this chapter who, subsequent to the date of application for such assistance or coverage under this chapter, acquires any other contractual or legal entitlement to any health care service defined in Section 14053, and willfully fails or refuses to give notice thereof to his county welfare department within 10 days of such acquisition, is guilty of a misdemeanor.

(c) Any person eligible under this chapter who has any other contractual or legal entitlement to any health care service defined in Section 14053, and who knowing that he or she must use such entitlement first, obtains any such service under Medi-Cal without first having utilized and exhausted his or her other contractual or legal entitlement thereto or therefor, is guilty of a misdemeanor.

(d) Any applicant shall by virtue of becoming eligible under this chapter have irrevocably assigned the benefits of any contractual or legal entitlement for health care to the State Director of Health Services to the extent that the services were paid for under this chapter.

history: (History: Amended by Stats. 1985, Ch. 1354, Sec. 14.)

article: 1. General Provisions


text: Any provider of service seeking payment for health care services for a person eligible for these services under this chapter shall first seek to obtain payment from any private or public health insurance coverage to which the person is entitled, where the provider is aware of this coverage and to the extent the coverage extends to these services, prior to submitting a claim to the department for the payment of any unpaid balance for these services. In the event that a claim submitted to a private or public health insurer has not been paid within 90 days of billing by the provider, a claim may be submitted to the department.

history: (History: Added by Stats. 1983, Ch. 323, Sec. 125.4. Effective July 1, 1983.)

article: 1. General Provisions


text:
When health care services are provided to a person under this chapter who at the time the service is provided has any other contractual or legal entitlement to such services, the director shall have the right to recover from the person, corporation, or partnership who owes such entitlement, the amount which would have been paid to the person entitled thereto, or to a third party in his behalf, or the value of the service actually provided, if the person entitled thereto was entitled to services. The Attorney General may, to recover under this section, institute and prosecute legal proceedings against the person, corporation, or partnership owing such entitlement in the appropriate court in the name of the director.

To the extent permitted by federal law and subject to the director’s prior right to recover upon any contractual or legal entitlement or other third-party liability for the cost incurred in rendering care, the provider of services shall remain entitled to recover remaining unpaid charges to the extent that any third party is obligated to pay the charges by reason of the beneficiary’s other contractual entitlement. Any claim shall not be permitted to the extent that the claim would reduce the director’s right to recover pursuant to Section 14124.78.

The provider of services shall be required to notify the department of any potential contractual or legal entitlement or other third-party liability within 60 days of discovery. A provider who has obtained proof of Medi-Cal eligibility and who makes a claim for payment by any third party shall disclose in the claim that the patient is a Medi-Cal beneficiary.

history: (History: Amended by Stats. 1985, Ch. 776, Sec. 3.)

article: 1. General Provisions


text:
(a) Any person who buys or sells a Medi-Cal card, Medi-Cal label, or Medi-Cal beneficiary identification number is guilty of a public offense punishable by imprisonment in the county jail for not more than one year, or in the state prison, or by a fine not exceeding five thousand dollars ($5,000), or by both the fine and imprisonment.

(b) Any person who barters for the purpose of resale or commercial exchange a Medi-Cal card, Medi-Cal label, or Medi-Cal beneficiary identification number is guilty of a public offense punishable by imprisonment in the county jail for not more than one year, or in the state prison, or by a fine not exceeding five thousand dollars ($5,000), or by both the fine and imprisonment.

(c) This section shall not apply to any peace officer or any other person working under the peace officer’s immediate direction, supervision, or instruction while investigating Medi-Cal fraud or other related crimes in the performance of his or her official duties.

history: (History: Added by Stats. 1989, Ch. 1267, Sec. 1.)

article: 1. General Provisions


text:
(a) It is a misdemeanor for a Medi-Cal beneficiary to furnish, give, or lend his Medi-Cal card or labels to any person other than a provider of service as required under Medi-Cal regulations.

(b) It is a misdemeanor for any person to use a Medi-Cal card other than the one which was issued to him or her to obtain health care services. This subdivision shall not apply to the use of a Medi-Cal card of a family member by another family member if the person using the card is, in fact, eligible under this chapter.

(c) This section shall not apply to any peace officer while investigating Medi-Cal fraud or other crimes in performance of his official duties or to any person working under the peace officer’s immediate direction, supervision, or instruction when such peace officer has been issued a Medi-Cal card pursuant to Section 14026.5.

history: (History: Amended by Stats. 1984, Ch. 752, Sec. 1.)

article: 1. General Provisions


text:
(a) The State Director of Health Services may issue Medi-Cal cards to Medi-Cal fraud investigators for the purpose of conducting investigations of Medi-Cal fraud, or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code upon written request to the State Director of Health Services, or his or her designee, from the head of the requesting agency stating the purpose of the investigation. The request shall be based upon a specific complaint or information alleging Medi-Cal fraud. The request shall be based upon a specific complaint or information from an outside agency pursuant to its standard procedure for referring cases to another agency where there is suspicion of Medi-Cal fraud.

(b) (1) Upon a complaint by any individual alleging information creating a reasonable suspicion that any person is engaging in Medi-Cal fraud, the State Director of Health Services shall issue Medi-Cal cards for the purpose of conducting investigations of Medi-Cal fraud, or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, upon an order of a magistrate issued upon a showing of reasonable suspicion that the person being investigated has committed or is committing Medi-Cal fraud or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.

(2) For purposes of this section, “reasonable suspicion” means that a peace officer subjectively entertains such a suspicion and that it is objectively reasonable for him or her to do so. The facts shall be those that would cause any reasonable peace officer in a like position drawing when appropriate on his or her training and experience, to suspect the same criminal activity and the same involvement by the person in question. A showing of reasonable suspicion may be made either by written statement under penalty of perjury or by oral statement taken under oath, recorded and transcribed.

(c) Nothing in this section shall be construed to mean that it is the exclusive method for conducting investigations for Medi-Cal fraud or for violations of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code.

(d) The State Department of Health Services shall report to the Legislature every six months commencing June 1, 1981, on the utilization of Medi-Cal cards issued pursuant to this section. The report shall include, among other matters, a description of the types of criminal investigations conducted pursuant thereto.

history: (History: Amended by Stats. 2004, Ch. 193, Sec. 238. Effective January 1, 2005.)

article: 1. General Provisions


text:
(a) The department may designate participating county health service agencies as health care service providers of home nursing services, subject to appropriate statutory licensing and certification requirements.

(b) Any county designated as a health care provider of home nursing services pursuant to subdivision (a) shall act as a fiscal intermediary for the provision of home nursing services and pass through to the licensed individuals rendering those nursing services, in total, all Medi-Cal reimbursements received for those nursing services.

(c) The Medi-Cal reimbursement rate applicable to nursing services reimbursed through a designated county health service agency shall be the current Medi-Cal rate applicable to those services.

(d) For purposes of this section, “designated provider of home nursing services” means any participating county health services agency designated as a provider of home nursing services pursuant to subdivision (a).

history: (History: Added by Stats. 1988, Ch. 1161, Sec. 1.)

article: 1. General Provisions


text:
(a) (1) In order to ensure appropriate oversight of psychotropic medications prescribed for children, pursuant to Section 2245 of the Business and Professions Code, the department and the State Department of Social Services, pursuant to a data-sharing agreement that shall meet the requirements of all applicable state and federal laws and regulations, shall provide the Medical Board of California with information regarding Medi-Cal physicians and their prescribing patterns of psychotropic medications and related services for individuals described in subparagraphs (B) and (C) of paragraph (1) of subdivision (c). The data concerning psychotropic medications and related services shall be drawn from existing data sources maintained by the departments. Every five years, the Medical Board of California, the department, and the State Department of Social Services shall consult and revise the methodology, if determined to be necessary.

(2) At minimum, the department, on an annual basis, shall share with the Medical Board of California data, including, but not limited to, pharmacy claims data for all foster children who are or have been on three or more psychotropic medications for 90 days or more. Prior to the release of this data, personal identifiers such as name, date of birth, address, and social security number shall be removed and a unique identifier shall be submitted. For each foster child who falls into these categories, the department shall submit the following information to the board:

(A) A list of the psychotropic medications prescribed.

(B) The start and stop dates, if any, for each psychotropic medication prescribed.

(C) The prescriber’s name and contact information.

(D) The child’s or adolescent’s year of birth.

(E) Any other information that is deidentified and necessary to the Medical Board of California to allow the board to exercise its statutory authority as an oversight entity.

(F) The unit and quantity of the medication and the number of days’ supply of the medication.

(b) The Medical Board of California shall contract for consulting services from, if available, a psychiatrist who has expertise and specializes in pediatric care for the purpose of reviewing the data provided to the board pursuant to subdivision (a). The consultant shall consider the treatment guidelines published by the department and the State Department of Social Services when assessing prescribing patterns.

(c) The Medical Board of California, pursuant to subdivision (a), shall analyze prescribing patterns by population for both of the following:

(1) Children adjudged as dependent children under Section 300 and placed in foster care.

(2) A minor adjudged a ward of the court under Section 601 or 602 who has been removed from the physical custody of the parent and placed into foster care.

(d) This section shall remain in effect only until January 1, 2027, and as of that date is repealed, unless a later enacted statute, that is enacted before January 1, 2027, deletes or extends that date.

history: (History: Added by Stats. 2016, Ch. 840, Sec. 3. (SB 1174) Effective January 1, 2017. Repealed as of January 1, 2027, by its own provisions.)

article: 1. General Provisions


text: Whenever a request for services authorized pursuant to subdivision (s), (t), or (v) of Section 14132 is made to the department for a child who is being case-managed by the California Children’s Services program, any decision to transfer the child to the home setting shall be made only in consultation with the California Children’s Services program case manager for the child.

history: (History: Added by Stats. 1997, Ch. 294, Sec. 59. Effective August 18, 1997.)

article: 1. General Provisions


text:
(a) (1) Commencing January 1, 2008, immediately following the issuance of an order of the juvenile court, pertaining to the disposition of a ward of the county, committing that ward to a juvenile hall, camp, or ranch for 30 days or longer, the county juvenile detention facility shall provide the appropriate county welfare department with the ward’s name, his or her scheduled or actual release date, any known information regarding the ward’s Medi-Cal status prior to disposition, and sufficient information, when available, for the county welfare department to begin the process of determining the ward’s eligibility for benefits under this chapter, including, if the ward is a minor, contact information for the ward’s parent or guardian, if available.

(2) If the ward is a minor, prior to providing information to the county welfare department pursuant to paragraph (1), the county juvenile detention facility shall notify the parent or guardian, in writing, of its intention to submit the information required by that paragraph to the county welfare department. The parent or guardian shall be given a reasonable time to opt out of the Medi-Cal eligibility determination provided for under this section, in which case the county juvenile detention facility shall not comply with paragraph (1).

(3) For purposes of this section, “ward” means a person in the custody of a county juvenile detention facility.

(b) (1) Upon receipt of the information described in paragraph (1) of subdivision (a), and pursuant to the protocols and procedures developed pursuant to subdivision (c), the county welfare department shall initiate an application for any ward not already enrolled in the Medi-Cal program, and determine the individual’s eligibility for benefits under the Medi-Cal program. If the ward is a minor, the county welfare department shall promptly contact the parent or guardian to arrange for completion of the application. If the cooperation of the minor’s parent or guardian is necessary to complete the application, but the parent or guardian fails to cooperate in completing the application, the county welfare department shall deny the application in accordance with due process requirements. The county shall expedite the application of a ward who, according to the information provided pursuant to paragraph (1) of subdivision (a), is scheduled to be released in fewer than 45 days.

(2) If the county welfare department determines that the ward does not meet the eligibility requirements for the Medi-Cal program, the county welfare department, with the consent of the ward’s parent or guardian, if the ward is a minor, shall forward the ward’s information to the appropriate entity to determine eligibility for the Healthy Families Program, or other appropriate health coverage program, as determined by the department.

(3) If the county welfare department determines that a ward meets eligibility requirements for the Medi-Cal program, the county shall provide sufficient documentation to enable the ward to obtain necessary medical care upon his or her release from custody.

(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of all-county letters or similar instructions, without taking any further regulatory action. Thereafter, the department shall adopt regulations, as necessary, to implement this section in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.

(d) The department shall seek any federal waivers necessary for the implementation of this section.

history: (History: Amended by Stats. 2008, Ch. 546, Sec. 2. Effective January 1, 2009.)

article: 1. General Provisions


text: Section 124260 of the Health and Safety Code shall not apply to the receipt of benefits under the Medi-Cal program.

history: (History: Added by Stats. 2010, Ch. 503, Sec. 2. (SB 543) Effective January 1, 2011.)

article: 1. General Provisions


text:
(a) The department shall require all managed care plans contracting with the department to provide Medi-Cal services to provide language assistance services to limited-English-proficient (LEP) Medi-Cal beneficiaries who are mandatorily enrolled in managed care in the following manner:

(1) (A) Oral interpretation services shall be provided in any language on a 24-hour basis at key points of contact.

(B) Oral interpretation services shall be provided by an interpreter that, at a minimum, meets all of the following qualifications:

(i) Demonstrated proficiency in speaking and understanding both spoken English and the language spoken by the LEP beneficiary.

(ii) The ability to interpret effectively, accurately, and impartially, both receptively and expressly, to and from the language spoken by the LEP beneficiary and English, using any necessary specialized vocabulary, terminology, and phraseology.

(iii) Adherence to generally accepted interpreter ethics principles, including client confidentiality.

(C) A managed care plan shall not require an LEP beneficiary to provide the beneficiary’s own interpreter or rely on a staff member who does not meet the qualifications described in subparagraph (B) to communicate directly with the LEP beneficiary.

(D) A managed care plan shall not rely on an adult or minor child accompanying the LEP beneficiary to interpret or facilitate communication except under either of the following circumstances:

(i) In an emergency, as defined by the department, and an interpreter who meets the qualifications described in subparagraph (A) is not immediately available for the LEP beneficiary.

(ii) If the LEP beneficiary specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide that assistance, and reliance on that accompanying adult for that assistance is appropriate under the circumstances.

(2) Translation services shall be provided to the language groups identified by the department.

(3) Written notice of the availability of free language assistance services shall be provided in English and in the top 15 languages spoken by LEP individuals in California, as determined by the department, and consistent with the requirements identified in Part 92 of Title 45 of the Code of Federal Regulations and Section 1557 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18116).

(b) The department shall determine when an LEP population meets the requirement for translation services using one of the following numeric thresholds:

(1) A population group of at least 3,000 or 5 percent of the beneficiary population, whichever is fewer, mandatory managed care Medi-Cal beneficiaries, residing in the service area, who indicate their primary language as other than English.

(2) A population group of mandatory managed care Medi-Cal beneficiaries, residing in the service area, who indicate their primary language as other than English, and that meet a concentration standard of 1,000 beneficiaries in a single ZIP Code or 1,500 beneficiaries in two contiguous ZIP Codes.

(c) The department shall make this determination if any of the following occurs:

(1) A nonmanaged care county becomes a new managed care county.

(2) A new population group becomes a mandatory Medi-Cal managed care beneficiary population.

(3) A period of three years has passed since the last determination.

(d) The department shall instruct managed care plans, by means of incorporating the requirement into plan contracts, all-plan letters, or similar instructions, of the language groups that meet the numeric thresholds.

(e) A managed care plan shall notify beneficiaries, prospective beneficiaries, and members of the public of all of the following information:

(1) The availability of language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner, when those services are necessary to provide meaningful access to health care programs or activities to LEP beneficiaries.

(2) The availability of appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities.

(3) A managed care plan does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

(4) The availability of a grievance procedure and how to file a grievance, including identification of, and contact information for, the designated managed care plan representative.

(5) How to file a discrimination complaint with the United States Department of Health and Human Services Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex.

(f) (1) The information described in paragraph (3) of subdivision (a) and subdivision (e) shall be provided in the following manner:

(A) In the evidence of coverage.

(B) Posted in conspicuous physical locations where the managed care plan interacts with the public.

(C) On the internet website published and maintained by the managed care plan in a manner that allows a beneficiary, prospective beneficiary, and members of the public to easily locate the information.

(2) To the extent the information described in paragraph (3) of subdivision (a) and subdivision (e) is not included in existing informational notices, a managed care plan shall add this information at the time of the next regularly scheduled update of the applicable publication.

(g) The amendments made to this section by the act that added this subdivision shall be implemented by the department only to the extent that federal financial participation is available and is not otherwise jeopardized.

(h) This section does not apply to mental health plans contracting with the department pursuant to Section 14712.

(i) For purposes of this section, a person is “limited-English-proficient” if the person speaks English less than very well.

history: (History: Amended by Stats. 2019, Ch. 497, Sec. 314. (AB 991) Effective January 1, 2020.)

article: 1. General Provisions


text:
(a) The department shall notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public of all of the following information:

(1) The availability of language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner, when those services are necessary to provide meaningful access to individuals with limited English proficiency.

(2) The availability of appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities.

(3) The department does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

(4) The availability of the grievance procedure and how to file a grievance, including identification of, and contact information for, the designated department representative.

(5) How to file a discrimination complaint with the United States Department of Health and Human Services Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex.

(b) Written notice of the availability of free language assistance services shall be provided in English and in the top 15 languages spoken by limited-English-proficient individuals in California, as determined by the department, and consistent with the requirements identified in Part 92 of Title 45 of the Code of Federal Regulations and Section 1557 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18116).

(c) (1) The information described in subdivisions (a) and (b) shall be provided in the following manner:

(A) In the department’s Medi-Cal informational publications.

(B) Posted in conspicuous physical locations where the department interacts with the public.

(C) On the department’s Internet Web site, in a manner that allows beneficiaries, prospective beneficiaries, and members of the public to easily locate the information.

(2) To the extent the information described in subdivisions (a) and (b) is not included in existing informational notices, the department shall add this information at the time of the next regularly scheduled update of the applicable publication.

(d) This section shall be implemented only to the extent that federal financial participation is available and is not otherwise jeopardized.

history: (History: Amended by Stats. 2018, Ch. 92, Sec. 235. (SB 1289) Effective January 1, 2019.)

article: 1. General Provisions


text:
(a) Each contract for fiscal intermediary services shall allow, to the extent practicable, providers to utilize electronic means for transmitting claims to the fiscal intermediary contractor. Means of transmission, and the manner and format used, shall be approved by the director. In determining which electronic means are acceptable, the director shall consider magnetic tape, computer-to-computer via telephone, diskettes, and any other methods which may become available through technological advancements.

(b) A provider, as defined in Section 14043.1, may assign signature authority for transmission of claims to the provider’s authorized representative or the registered billing agent of the provider identified to the department pursuant to subdivision (c) of Section 14040.5.

(c) The department shall develop reasonable standards for participation and continued participation by providers and billing agents in the use of claims transmission methods utilized pursuant to this section. These standards shall be designed to ensure that providers and billing agents submit technically complete claims and to reduce the potential for fraud and abuse. The department shall notify providers and billing agents of any planned changes to the claims transmission standards prior to the implementation of the changes. A “technically complete claim” means any billing request for payment from a provider or the billing agent of the provider, including an original claim, claim inquiry, or appeal, that is submitted on the correct Medi-Cal claim form or electronic billing format, is fully and accurately completed, and includes all information and documentation required to be submitted on or with the claim pursuant to Medi-Cal billing and documentation requirements.

(d) To the extent required by federal and state law, the fiscal intermediary shall retain claim data submitted by providers or the billing agent of the provider pursuant to this section. The department shall, however, return to a provider or the billing agent of the provider original tapes, diskettes, and any other similar devices that are used by the provider or the billing agent of the provider pursuant to this section.

(e) In order to reduce the amount of paperwork or attachments which are required to be completed by a provider or the billing agent of the provider submitting a claim for reimbursement under this chapter to the fiscal intermediary, the department shall direct the fiscal intermediary to investigate and develop the means to incorporate as much information as possible on the electronic format.

(f) Each provider and billing agent submitting claims shall be responsible for ensuring that each claim submitted for reimbursement for services, goods, supplies, or merchandise rendered or supplied by the provider to a Medi-Cal beneficiary or under the Medi-Cal program meets the standards established by the department pursuant to this section.

history: (History: Amended by Stats. 2000, Ch. 322, Sec. 13. Effective January 1, 2001.)

article: 1. General Provisions


text:
(a) “Billing agent” or “billing agent of the provider” means any individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of any partnership, group, association, corporation, institution, or entity, that submits claims on behalf of the provider, as defined in Section 14043.1, for reimbursement for services, goods, supplies, or merchandise rendered or provided directly or indirectly to a Medi-Cal beneficiary or under the Medi-Cal program. As used in this section a billing agent shall not include an authorized representative of a provider billing solely for that provider, a provider wholly owned entity billing solely for the provider, or a clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code when preparing and submitting claims for services provided on behalf of the clinic. For purposes of this subdivision, an authorized representative shall be either an individual who is an employee of the provider or an individual with a familial relationship to the provider. For purposes of this section and Section 14040.5, an authorized representative, a provider wholly owned entity billing solely for the provider, or a clinic that is licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code, when preparing and submitting claims for services provided on behalf of the clinic, shall be considered a provider.

(b) The department shall establish standards for the registration or continued registration of each billing agent. The standards shall establish time periods, no longer than a year from the date the standards become effective, after which, no billing agent shall submit a claim on behalf of a provider, as defined in Section 14043.1, for reimbursement for services, goods, supplies, or merchandise rendered or provided directly or indirectly by the provider to a Medi-Cal beneficiary or under the Medi-Cal program, unless that billing agent has been registered with the department. The department shall establish the standards for the registration or continued registration of billing agents pursuant to this subdivision, in consultation with interested parties, by the adoption of emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The adoption of these emergency regulations or readoption of the regulations shall be deemed to be an emergency necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 (commencing with Section 11340 of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted or readopted pursuant to this subdivision shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this subdivision shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations.

(c) The department may complete a background check on applicants for registration or continued registration as a billing agent, for the purpose of verifying the accuracy of information provided by an applicant for registration or continued registration as a billing agent or in order to prevent fraud and abuse. The background check may include, but not be limited to, onsite inspection, review of business records, and data searches.

(d) As a condition of registration, or continued registration, as a billing agent, an applicant for registration as a billing agent shall provide to the department a surety bond of not less than fifty thousand dollars ($50,000). This subdivision shall become operative only if the director executes a declaration, that shall be retained by the director, stating that the surety bonds described in this paragraph are commercially offered throughout the state and by more than one vendor.

history: (History: Added by Stats. 2000, Ch. 322, Sec. 14. Effective January 1, 2001.)

article: 1. General Provisions


text:
(a) A provider may, by written contract, do either of the following:

(1) Authorize a billing agent to submit claims, including electronic claims, on behalf of the provider for reimbursement for services, goods, supplies, or merchandise provided by the provider to the Medi-Cal program or a Medi-Cal beneficiary.

(2) Assign signature authority for transmission of the claims by the authorized billing agent.

(b) If a contract as described in subdivision (a) is entered into, the contract shall meet the requirements of Section 447.10 of Title 42 of the Code of Federal Regulations or shall have been approved by the federal Health Care Financing Administration for purposes of the Medicare program.

(c) Any provider intending to use a billing agent to submit claims for reimbursements to the Medi-Cal program shall provide, at least 30 days prior to the submission of any claims for reimbursement by the billing agent, written notification to the director of the name, including known legal and any known fictitious or “doing business as” names used by the billing agent, the address, and the telephone number of the billing agent.

(d) Billing agents shall register with the director and shall obtain a unique identifier prior to submitting any claims for reimbursement. This unique identifier shall be part of each claim for reimbursement submitted by the billing agent.

(e) (1) Any Medi-Cal claim submitted by a billing agent or provider failing to comply with the requirements of this section or Section 14040 or 14040.1, or the regulations adopted pursuant to these sections, shall be subject to denial by the director.

(2) The director may deny, suspend, or revoke the registration or continued registration of a billing agent based upon any of the following grounds:

(A) Failure of the billing agent to comply with this section or Section 14040.1 or the regulations adopted under these sections.

(B) Involvement of a billing agent in illegal submission of claims.

(C) The billing agent is under investigation for fraud or abuse, as defined in Section 14043.1, by the department or any federal, state, or local law enforcement agency.

(3) The director may immediately revoke or suspend the registration or continued registration of a billing agent upon the involvement of that billing agent in the filing of false or misleading information on claims submitted for services allegedly rendered, or when a billing agent has demonstrated a pattern of filing claims that are not technically complete claims as defined in subdivision (c) of Section 14040. The director shall not take action to revoke or suspend a billing agent’s registration or continued registration when the falsity or misleading nature of the information was the result of the provider’s actions and not the billing agent’s.

(4) Proceedings for suspension or revocation of the registration or continued registration of a billing agent pursuant to this section shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, except that hearings may be conducted by departmental hearing officers appointed by the director. The director may periodically contract with the Office of Administrative Hearings to conduct these hearings.

(5) The director shall provide written notification outlining the reasons for the proposed action to the billing agent 30 days in advance of a proposed suspension or revocation and shall allow the billing agent to demonstrate within those 30 days by comment why the suspension or revocation notice should not be issued.

(6) If after consideration of the billing agent’s comment, the director determines that the suspension or revocation is nonetheless warranted, the director shall notify the billing agent of the suspension or revocation and the effective date thereof and at the same time shall serve the billing agent with an accusation. In addition, the director shall send each provider utilizing the services of the billing agent written notice of the suspension or revocation of the billing agent. The suspension or revocation of the billing agent shall take effect 15 days from the date of the notification of the billing agent and service of the accusation. To the extent allowed by federal law, the director may waive any claims submission requirement to assist a provider in submitting or resubmitting claims to the Medi-Cal program when they are delayed because of a billing agent’s suspension or revocation. Upon receipt of a notice of defense by the billing agent, the director shall set the matter for hearing within 30 days of the receipt of the notice. The suspension or revocation shall remain in effect until the hearing is completed and the director has made a final determination on the merits. The suspension or revocation shall, however, be deemed vacated if the director fails to make a final determination on the merits within 60 days of the completion of the original hearing.

(7) Paragraph (4) of this subdivision shall not apply where the suspension or revocation of a billing agent is based upon the conviction for any crime involving fraud, abuse of the Medi-Cal program, or suspension from the federal Medicare or medicaid programs, or where the billing agent has entered into a settlement in lieu of conviction for fraud or abuse in any government program, within the previous 10 years. In those instances, suspension or revocation shall be automatic and not subject to administrative appeal or hearing. In those instances, the director shall send each provider utilizing the services of the billing agent written notice of the automatic suspension or revocation of the billing agent. To the extent allowed by federal law, the director may waive any claims submission requirement to assist a provider in submitting or resubmitting claims to the Medi-Cal program when they are delayed because of a billing agent’s automatic suspension or revocation.

(8) Notwithstanding Section 100171 of the Health and Safety Code, proceedings for the denial of the registration of a billing agent pursuant to this section shall be conducted in accordance with Section 14043.65. This subdivision shall not apply where the denial is based upon conviction of any crime involving fraud or abuse of the Medi-Cal program or the federal medicaid or Medicare programs, or exclusion by the federal government from the medicaid or Medicare programs. In this case, the denial shall be automatic and not subject to administrative appeal or hearing.

(f) For purposes of this section, “billing agent” has the same meaning as defined in Section 14040.1.

(g) As used in this section “provider” has the same meaning as defined in Section 14043.1.

history: (History: Amended by Stats. 2000, Ch. 322, Sec. 15. Effective January 1, 2001.)

article: 1. General Provisions


text:
(a) The director shall develop and implement standards for the timely processing and payment of each claim type. The standards shall be sufficient to meet minimal federal requirements for the timely processing of claims.

(b) It is the intent of the Legislature that claim forms for use by physicians and hospitals be the same as claim forms in general use by other payors, including Medicare, to the extent compatible with the following:

(1) Requirements for maximum federal matching funds.

(2) The reasonable needs of the mechanized claims processing system.

(3) Maximum billing efficiency.

(4) The convenience of providers.

history: (History: Amended by Stats. 1987, Ch. 996, Sec. 1.)

article: 1. General Provisions


text:
(a) Notwithstanding any other provision of law, and to the extent not otherwise conflicting with federal law, the department may hold for a period of one month, or direct the medical fiscal intermediary for the Medi-Cal program to hold for a period of one month, payments to providers or their designated agents for health care services that are provided pursuant to this chapter, and payments to entities that contract with the department pursuant to this chapter, Chapter 8 (commencing with Section 14200) and Chapter 8.75 (commencing with Section 14591) for the delivery of health care services.

(b) The authority described in subdivision (a) shall be limited to payments for one month only, and only for a month ending prior to June 30, 2009.

history: (History: Amended by Stats. 2011, Ch. 367, Sec. 9. (AB 574) Effective January 1, 2012.)

article: 1. General Provisions


text:
(a) The department shall develop, disseminate, and update, on a periodic basis, claims preparation and processing software programs that may be used on computers at individual provider or billing service sites. The software shall be made available, to the extent feasible, for the most common computers used in the provider community for use, on an optional basis, by clerical or billing personnel to facilitate the preparation and submission of Medi-Cal claims for services rendered.

(b) The software programs specified in subdivision (a) shall, to the extent possible:

(1) Contain all necessary validity edits utilized by the fiscal intermediary.

(2) Be designed to reasonably reduce common submission and billing errors.

(3) Contain features that provide options for the provider to use provider-developed files to reduce data entry requirements and improve reporting accuracy.

(4) Provide, at the provider’s discretion, for the electronic or paper transmission of claims to the Medi-Cal fiscal intermediary.

(c) The department shall consult with affected provider groups prior to developing, disseminating, and updating claims preparation and processing software pursuant to this section.

(d) The department shall report to the Chairpersons of the Senate Health and Human Services Committee and Assembly Health Committee by April 1, 1990, on a plan and timetable for implementing this section. The plan and timetable shall identify provider groups for which the department plans to develop, disseminate, and update claims preparation and processing software.

(e) Notwithstanding the plan and timetable required by subdivision (d), the department shall develop and begin disseminating claims processing software programs to physician providers no later than January 1, 1991.

(f) The department shall, as part of implementing this section, provide technical assistance to providers, including, but not limited to, a user hotline and appropriate training materials. These materials shall cover the installation of the programs, use of the software to enter Medi-Cal claims data, and submission procedures.

(g) The software programs for the submission of Medi-Cal claims shall be made available to all interested parties for a reasonable initial fee, plus an annual subscription fee for updates, maintenance, and support provided to users. Fees shall be set so as to recover, as nearly as possible, the development, distribution, and ongoing support costs of software programs, instructional materials, or subsequent updates.

(h) Third-party vendors may obtain and enhance these programs for resale and provisions of value-added services to Medi-Cal providers. However, the state or any of its officials, employees, or agents shall bear no liability for software provided through any third party that has been altered or misused by any third party.

(i) Neither the state nor any of its officials, employees, or agents shall be responsible for any of the following:

(1) A provider’s failure to meet Medi-Cal documentation and billing requirements, including timely billing pursuant to Section 14115.

(2) Alteration or misuse of the software in the submission of claims to the Medi-Cal program.

(3) Use of the software for any purpose other than the submission of claims to the Medi-Cal program.

(4) This subdivision shall not apply to any failure to meet Medi-Cal documentation and billing requirements that is substantiated as resulting from the use of software that is directly provided by the department and that contains proven flaws or defects that significantly contribute to the failure to meet those requirements.

(j) A provider or third party’s eligibility to bill claims electronically by using software programs made available pursuant to this section shall be governed by Section 14040 and Section 14040.5, and any rules and regulations adopted by the director pursuant to these sections.

history: (History: Amended by Stats. 2004, Ch. 193, Sec. 239. Effective January 1, 2005.)

article: 1. General Provisions


text:
Each contract for fiscal intermediary services shall provide for an automated system for verifying the eligibility of Medi-Cal recipients. The automated eligibility verification system shall provide the health care provider with a unique method of identifying the eligibility of the beneficiary. The provider shall include the eligibility identifier on the claim for payment. Where a recipient’s eligibility has been verified by the automated system and the provider provides a unique identifier on the claim form, the director may not require any label, card impression, or any other evidence to establish the recipient’s eligibility. The automated system for eligibility verification shall provide for the continuous updating of recipient eligibility determination.

The department shall periodically test the automated system for verifying recipient eligibility for completeness and accuracy, and report the findings of such testing to the Legislature. Unless and until the automated system for verifying recipient eligibility is accurate in at least 97 percent of the cases tested, the director shall provide for the issuance of proof-of-eligibility labels, or identity cards from which an identifying impression may be taken, or other evidence of eligibility to be used as a secondary recipient eligibility verification system. Notwithstanding the inability to provide verification of a recipient’s eligibility through use of the automated system for eligibility verification, presentation of a claim for service with evidence of recipient eligibility as is provided for by the secondary system shall conclusively establish the recipient’s eligibility.

On-line access shall be available to providers, at their discretion, upon the payment of a reasonable fee. The department shall establish the amount of the fees charged to providers for on-line access, which shall be based upon the costs of providing on-line access to providers.

history: (History: Added by Stats. 1982, Ch. 1508, Sec. 1.)

article: 1. General Provisions


text:
(a) No earlier than January 1, 2018, the State Department of Health Care Services shall establish a Medically Tailored Meals Pilot Program to operate for a period of four years from the date the program is established, or until funding is no longer available for the program, whichever date is earlier.

(1) The department shall determine the number of eligible participants and providers in the program and shall use data from the Medi-Cal program to identify eligible beneficiaries for participation in the program.

(2) The program shall provide medically tailored meal intervention services to Medi-Cal participants with one or more of the following health conditions: congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.

(3) The department may establish additional eligibility requirements based on acuity and other selection criteria. Each participant in the program shall receive a standard intervention, as determined by the department, of up to 21 meals per week for 12 to 24 weeks. The provided meals shall be medically tailored and designed to meet the specific nutritional needs of the participant’s specific illness.

(4) The program shall be conducted in the Counties of Alameda, Los Angeles, Marin, San Diego, San Francisco, San Mateo, Santa Clara, and Sonoma.

(5) (A) At the conclusion of the program, the department shall use the data from the Medi-Cal program on the program participants to evaluate what impact, to the extent it can be determined, the program had on hospital readmissions, decreased admissions to long-term care facilities, and emergency room utilization.

(B) The department shall send a report containing its evaluation to the Legislature within 12 months after the end of the four-year program.

(C) The legislative report submitted pursuant to subparagraph (B) shall be submitted in compliance with Section 9795 of the Government Code.

(b) For the purposes of this section, “medically tailored meals” means a specifically tailored diet to address the participant’s specific medical condition and associated symptoms.

(c) The department shall develop a methodology for reimbursing contractors, or other entities, as applicable, for services or activities provided pursuant to this section based on, and not to exceed, the aggregate amount of funds allocated per year for purposes of the program. The department may use up to 20 percent of the funds allocated per year for the program to support its administration and evaluation.

(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of policy letters, all-county letters, plan letters, or other similar instructions, without taking regulatory action.

(e) For purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services.

(f) The department shall seek any federal approvals necessary to implement this section, including any waivers it deems necessary to obtain federal financial participation for the program, and shall claim federal financial participation to the full extent permitted by law. If federal financial participation is unavailable, the department shall implement the program using available state-only funds, subject to annual appropriation by the Legislature.

(g) (1) For the 2021–2022 fiscal year, in addition to the Medically Tailored Meals Pilot Program specified under subdivisions (a) to (f), inclusive, the department shall implement the Short-Term Medically Tailored Meals Intervention Services Program to award funds to qualified entities providing medically tailored meals intervention services to eligible Medi-Cal beneficiaries who reside in a county identified in paragraph (4) with one or more of the following health conditions described in subparagraphs (A) to (H), inclusive, when meal services are unavailable under the Medically Tailored Meals Pilot Program:

(A) Diabetes.

(B) Chronic obstructive pulmonary disease.

(C) Renal disease.

(D) Chronic kidney disease.

(E) Cancer.

(F) Malnutrition.

(G) Human immunodeficiency virus or acquired immune deficiency syndrome.

(H) Congestive heart failure.

(2) The Short-Term Medically Tailored Meals Intervention Services Program shall cease to be operative when the funding allocated under the Budget Act of 2021 has been exhausted, or on June 30, 2022, whichever is sooner.

(3) (A) To the extent funding is available, an eligible Medi-Cal beneficiary shall receive medically tailored meals intervention services as specified in subparagraph (B).

(B) (i) For the 2021–2022 fiscal year, medically tailored meals intervention services shall be available to an eligible Medi-Cal beneficiary, and they shall receive up to 21 meals per week for 12 to 52 weeks, for a maximum of 52 weeks, depending on the medical diagnosis and need. The meals shall be medically tailored and designed to meet the specific nutritional needs of the Medi-Cal beneficiary’s specific health condition.

(ii) To the extent funding is available, the medically tailored meals intervention services shall include medical nutrition therapy or counseling for the program’s participants.

(C) The department may implement, as specified in subdivision (d), and in consultation with medically tailored meals providers, additional eligibility requirements for individuals to receive services under the Short-Term Medically Tailored Meals Intervention Services Program, based on acuity and other selection criteria.

(4) Funds appropriated for the Short-Term Medically Tailored Meals Intervention Services Program shall be awarded based on a methodology developed by the department to nonprofit and community-based organizations that have expertise as medically tailored meals providers in the Counties of Alameda, Contra Costa, Fresno, Kings, Los Angeles, Madera, Marin, San Diego, San Francisco, San Mateo, Santa Clara, Santa Cruz, Sonoma, and Tulare.

(5) Providers that are awarded funding to provide short-term medically tailored meals intervention services shall monitor and document the impacts of the Short-Term Medically Tailored Meals Intervention Services Program, including, but not limited to, the effect of this program on hospital readmissions, emergency room utilization, and health outcomes, to the extent data is available, and shall provide that information to the department upon request, and in a form and manner specified by the department. This information shall not be included in the data considered in evaluating the Medically Tailored Meals Pilot Program, as described in paragraph (5) of subdivision (a).

(6) The department shall develop a methodology for reimbursing contractors or other entities, as applicable, for services or activities provided pursuant to this subdivision based on, and not to exceed, the aggregate amount of funds allocated for purposes of this subdivision. The department shall allocate 5 percent of the funds to a nonprofit organization fiscal sponsor that shall coordinate the program to support its administration. The fiscal sponsor shall work with nonprofit members in relevant regions.

(7) To the extent permitted under applicable federal and state law, the department may use data from the Medi-Cal program to identify Medi-Cal beneficiaries eligible to receive services under the Short-Term Medically Tailored Meals Intervention Services Program.

(8) This subdivision shall be implemented only to the extent the department determines that federal financial participation under the Medi-Cal program is not jeopardized.

(h) This section shall remain in effect until the department submits its report containing its evaluation of the Medically Tailored Meals Pilot Program to the Legislature pursuant to subparagraph (B) of paragraph (5) of subdivision (a), or 12 months after the end of the Medically Tailored Meals Pilot Program or the Short-Term Medically Tailored Meals Intervention Services Program, whichever occurs last, and as of that date is repealed.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 368. (AB 133) Effective July 27, 2021. Section repealed on date prescribed by its own provisions.)

article: 1. General Provisions


text:
(a) The Legislature finds and declares the following:

(1) The Medi-Cal Managed Care Ombudsman helps resolve issues between Medi-Cal managed care members and health plans, assists members with managed care related questions and problems, and answers questions from members.

(2) A pattern of inquiries, complaints, and grievances may be indicators of systemic problems regarding coverage and problems with access to care and warrant consideration.

(b) On a quarterly basis, the State Department of Health Care Services shall report on calls received by the Medi-Cal Managed Care Ombudsman. At a minimum, the report shall include the following:

(1) The number of contacts received, separated by inquiries and complaints.

(2) The average wait time for callers to answer.

(3) The number of calls abandoned.

(4) The result of contacts, including destination of referred calls, when possible.

(5) The average call time.

(6) Complaints, by issue type.

(7) The number of calls referred to another area of the department or to the Department of Managed Health Care for resolution.

(c) All data collected and reported shall include demographic information of beneficiaries, including race, ethnicity, age, gender, preferred language, language members were assisted in, and county of residence, and health plans of beneficiaries, to the extent known to the department at the time of the call. The department shall request, but not require, this information from members during the calls.

(d) The quarterly report shall include contacts from county mental health plan beneficiaries, as defined in Section 14700, including the requirements of subdivisions (a) and (b).

(e) The quarterly report shall be posted on the department’s internet website.

(f) The fourth quarterly report issued each year also shall include information pertaining to the following:

(1) Training protocols for staff, including cultural and linguistic competency.

(2) Assessment of contacts trends and actions taken by the State Department of Health Care Services as a result of contacts received.

(3) Consumer assistance protocols, procedures, and referral tools.

history: (History: Added by renumbering Section 14043.1 (as added by Stats. 2017, Ch. 52, Sec. 23) by Stats. 2019, Ch. 497, Sec. 320. (AB 991) Effective January 1, 2020.)

article: 1. General Provisions


text: In order to ensure the proper and efficient administration of the Medi-Cal program, every applicant, as defined in subdivision (b) of Section 14043.1, and every provider, as defined in subdivision (o) of Section 14043.1, shall be subject to the requirements of this article.

history: (History: Amended by Stats. 2010, Ch. 192, Sec. 1. (AB 1783) Effective January 1, 2011. Note: Sections 14040 to 14042 are located following Section 14029.91, at the end of Article 1.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 1.3. Provider Enrollment, Application, and Participation


text:
As used in this article:

(a) “Abuse” means either of the following:

(1) Practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to the federal Medicaid and Medicare programs, the Medi-Cal program, another state’s Medicaid program, or other health care programs operated, or financed in whole or in part, by the federal government or a state or local agency in this state or another state.

(2) Practices that are inconsistent with sound medical practices and result in reimbursement by the federal Medicaid and Medicare programs, the Medi-Cal program or other health care programs operated, or financed in whole or in part, by the federal government or a state or local agency in this state or another state, for services that are unnecessary or for substandard items or services that fail to meet professionally recognized standards for health care.

(b) “Applicant” means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the department for enrollment as a provider in the Medi-Cal program.

(c) “Application or application package” means a completed and signed application form, signed under penalty of perjury or notarized pursuant to Section 14043.25, a disclosure statement, a provider agreement, and all attachments or changes in the form, statement, or agreement.

(d) “Appropriate volume of business” means a volume that is consistent with the information provided in the application and any supplemental information provided by the applicant or provider, and is of a quality and type that would reasonably be expected based upon the size and type of business operated by the applicant or provider.

(e) “Business address” means the location where an applicant or provider provides services, goods, supplies, or merchandise, directly or indirectly, to a Medi-Cal beneficiary. A post office box or commercial box is not a business address. The business address for the location of a vehicle or vessel owned and operated by an applicant or provider enrolled in the Medi-Cal program and used to provide services, goods, supplies, or merchandise, directly or indirectly, to a Medi-Cal beneficiary shall either be the business address location listed on the provider’s application as the location where similar services, goods, supplies, or merchandise would be provided or the applicant’s or provider’s pay to address.

(f) “Convicted” means any of the following:

(1) A judgment of conviction has been entered against an individual or entity by a federal, state, or local court, regardless of whether there is a posttrial motion, an appeal pending, or the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed.

(2) A federal, state, or local court has made a finding of guilt against an individual or entity.

(3) A federal, state, or local court has accepted a plea of guilty or nolo contendere by an individual or entity.

(4) An individual or entity has entered into participation in a first offender, deferred adjudication, or other program or arrangement where judgment of conviction has been withheld.

(g) “Debt due and owing” means 60 days have passed since a notice or demand for repayment of an overpayment or another amount resulting from an audit or examination, for a penalty assessment, or for another amount due to the department was sent to the provider, regardless of whether the provider is an institutional provider or a noninstitutional provider and regardless of whether an appeal is pending.

(h) “Enrolled or enrollment in the Medi-Cal program” means authorized under any processes by the department or its agents or contractors to receive, directly or indirectly, reimbursement for the provision of services, goods, supplies, or merchandise to a Medi-Cal beneficiary.

(i) “Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

(j) “Location” means a street, city, or rural route address or a site or place within a street, city, or rural route address, and the city, county, state, and nine-digit ZIP Code.

(k) “Not currently enrolled at the location for which the application is submitted” means either of the following:

(1) The provider is changing location and moving to a different location than that for which the provider was issued a provider number.

(2) The provider is adding a business address.

(l) (1) “Individual dentist practice” means a dentist licensed by the Dental Board of California enrolled or enrolling in Medi-Cal as an individual provider who is a sole proprietor of his or her practice or is a corporation owned solely by the individual dentist and the only dentist practitioner is the owner. An individual dentist practice may include nondentist allied dental health professionals employed and supervised by the dentist.

(2) “Individual physician practice” means a physician and surgeon licensed by the Medical Board of California or the Osteopathic Medical Board of California enrolled or enrolling in Medi-Cal as an individual provider who is sole proprietor of his or her practice or is a corporation owned solely by the individual physician and the only physician practitioner is the owner. An individual physician practice may include nonphysician medical practitioners employed and supervised by the physician.

(m) “Preenrollment period” or “preenrollment” includes the period of time during which an application package for enrollment, continued enrollment, or for the addition of or change in a location is pending.

(n) “Professionally recognized standards of health care” means statewide or national standards of care, whether in writing or not, that professional peers of the individual or entity whose provision of care is an issue recognize as applying to those peers practicing or providing care within a state. When the United States Department of Health and Human Services has declared a treatment modality not to be safe and effective, practitioners that employ that treatment modality shall be deemed not to meet professionally recognized standards of health care. This subdivision shall not be construed to mean that all other treatments meet professionally recognized standards of care.

(o) “Provider” means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to a Medi-Cal beneficiary and that has been enrolled in the Medi-Cal program.

(p) “Resolution of an investigation for fraud or abuse” means there is no documentation to indicate either that a charge or accusation has been filed against the provider and either (1) the investigation has not been active at any time during the previous 12 months or (2) the department has made a documented good faith effort and has been unable, for a period of 12 months, to contact an investigator or responsible representative of any agency investigating the provider.

(q) “Unnecessary or substandard items or services” means those that are either of the following:

(1) Substantially in excess of the provider’s usual charges or costs for the items or services.

(2) Furnished, or caused to be furnished, to patients, whether or not covered by Medicare, Medicaid, or any of the state health care programs to which the definitions of applicant and provider apply, and which are substantially in excess of the patient’s needs, or of a quality that fails to meet professionally recognized standards of health care. The department’s determination that the items or services furnished were excessive or of unacceptable quality shall be made on the basis of information, including sanction reports, from the following sources:

(A) The professional review organization for the area served by the individual or entity.

(B) State or local licensing or certification authorities.

(C) Fiscal agents or contractors or private insurance companies.

(D) State or local professional societies.

(E) Any other sources deemed appropriate by the department.

history: (History: Amended by Stats. 2015, Ch. 271, Sec. 1. (SB 299) Effective September 4, 2015.)

article: 1.3. Provider Enrollment, Application, and Participation


text:
(a) Whether or not regulations for certification are adopted under Section 14043.15, in order to be enrolled as a provider, or for enrollment as a provider to continue, an applicant or provider may be required to sign a provider agreement and shall disclose all information as required in federal Medicaid regulations and any other information required by the department. Applicants, providers, and persons with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their date of birth and their social security number or numbers to the department, to the full extent allowed under federal law. Corporations with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their taxpayer identification number and all business address locations and post office box addresses. The director may designate the form of a provider agreement by provider type. Failure to disclose the required information, or the disclosure of false information, shall result in denial of the application for enrollment or shall make the provider subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number or numbers, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program.

(b) The director shall notify the provider of the temporary suspension and deactivation of the provider’s number or numbers, including all business addresses used by the provider, and the effective date thereof. Notwithstanding Section 100171 of the Health and Safety Code and Section 14123, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65.

history: (History: Amended by Stats. 2012, Ch. 797, Sec. 6. (SB 1529) Effective January 1, 2013.)


text: A provider shall be required to reimburse those Medi-Cal funds received during any period for which material information was not reported, or reported falsely, to the department.

history: (History: Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)


text: If discrepancies are found to exist during the preenrollment period, the department may conduct additional inspections prior to enrollment. Failure of a provider to remediate discrepancies as prescribed by the director may result in denial of the application for enrollment. The department may deactivate all of the provider’s business addresses if the department determines that the discrepancies are material to the provider’s continued enrollment and the provider’s compliance with program requirements at the additional business addresses.

history: (History: Amended by Stats. 2015, Ch. 271, Sec. 7. (SB 299) Effective September 4, 2015.)


text: Subject to Article 4 (commencing with Section 19130) of Chapter 5 of Division 5 of Title 2 of the Government Code, the department may enter into contracts to secure consultant services or information technology including, but not limited to, software, data, or analytical techniques or methodologies for the purpose of fraud or abuse detection and prevention. Contracts under this section shall be exempt from the Public Contract Code.


text:
(a) Except as provided in subdivision (b), the department shall automatically suspend, as a provider in the Medi-Cal program, any individual who, or any entity that, has a license, certificate, or other approval to provide health care, which is revoked or suspended by a federal, California, or another state’s licensing, certification, or approval authority, has otherwise lost that license, certificate, or approval, or has surrendered that license, certificate, or approval while a disciplinary hearing on that license, certificate, or approval was pending. The automatic suspension shall be effective on the date that the license, certificate, or approval was revoked, lost, or surrendered.

(b) The department may elect to not suspend an individual or entity as a provider in the Medi-Cal program pursuant to subdivision (a) if the revocation, suspension, or loss of the individual or entity’s license, certification, or approval authority in another state or the pending disciplinary hearing during which the individual or entity surrendered the license, certification, or approval authority in another state is based solely on conduct that is not deemed to be unprofessional conduct under California law. The department shall seek any federal approvals it deems necessary to implement this subdivision. This subdivision shall be implemented only to the extent that the department obtains any necessary federal approvals and federal financial participation under the Medi-Cal program is available and not otherwise jeopardized.

(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific subdivision (b), in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or similar written instructions.

history: (History: Amended by Stats. 2023, Ch. 261, Sec. 4. (SB 487) Effective January 1, 2024.)