text:
(a) The county in which the person resides, except as specified in subdivision (d), shall determine the eligibility of each person pursuant to Sections 14005.1, 14005.4, and 14005.7 and Article 4.4 (commencing with Section 14140), except that the department may contract with the federal Social Security Administration for the determination of Medi-Cal eligibility of persons eligible under Title XVI of the Social Security Act. Upon termination of such assistance, the county shall determine whether the person remains eligible for Medi-Cal coverage under one of these sections.

(b) The department shall institute an eligibility quality control program, to verify the eligibility determination of a sample of persons in each county granted Medi-Cal eligibility under Section 14005.4, 14005.7, or 14005.8 or Article 4. 4 (commencing with Section 14140).

(c) A review period shall be defined as one year and shall coincide with the federal fiscal year. The department shall draw a random sample of cases for each period. The random sample shall be drawn to ensure a minimum number of cases reviewed in each county in each review period according to the following:

(1) All cases shall be sampled in any county with less than 50 Medi-Cal cases.

(2) Fifty cases in any county with greater than 0.01 percent and less than or equal to .50 percent of the Medi-Cal cases.

(3) Seventy-five cases in any county with greater than .50 percent and less than or equal to 1 percent of the Medi-Cal cases.

(4) One hundred cases in any county with greater than 1 percent and less than or equal to 3 percent of the Medi-Cal cases.

(5) One hundred twenty-five cases in any county with greater than 3 percent and less than or equal to 10 percent of the Medi-Cal cases.

(6) Six hundred fifty cases in any county with greater than 10 percent of the Medi-Cal cases.

(d) When family members maintain separate residences, but eligibility is determined as a single unit because of the provisions of Section 14008, the county in which the parent or parents reside shall determine the eligibility for the entire unit.

(e) In administering the provisions of law and regulations related to eligibility determination the director shall impose such fiscal penalties as provided by this section to assure adequate county administrative performance.

(f) The director shall hold counties financially liable for payments made on behalf of ineligible persons or persons with an incorrect spend down of excess income. When a sample case is found to include an ineligible person or a person with an understated spend down of excess income, written notification shall be sent to the county department that describes the error and requests a written response within two weeks. The county shall indicate whether it agrees or disagrees with the findings. If the county disagrees, the department shall reevaluate the error findings, taking into consideration any additional facts contained in the county’s response. The department shall again notify the county of the department’s findings. If the county continues to disagree with the error findings, the county may appeal to the Chief of the Medi-Cal Policy Division, requesting that the department review the case and render a final decision. The director may reduce or waive the fiscal liability of a county if the department is unable to meet the minimum sample required, as defined in subdivision (c), or if an individual county experienced a natural disaster, job actions, or other occurrences that impacted the findings in an individual county as determined by the director.

(g) The department shall utilize the methodology detailed in this subdivision to establish counties’ fiscal penalties. The department shall determine each county’s case error rate for each review period by dividing the number of completed case reviews in that county found in error by the number of case reviews in that county. State caused errors shall be determined by the department and shall not be included in this calculation. Case error rates shall be arrayed from highest to lowest. From this array, the department shall determine the percentage of counties liable as follows:

(1) The 60 percent of counties with the highest case error rates shall be liable if the state’s dollar error rate exceeds the federal standard by 0.01 percent to 1 percent.

(2) The 70 percent of counties with the highest case error rates shall be liable if the state’s dollar error rate exceeds the federal standard by greater than 1 percent and less than or equal to 2 percent.

(3) The 80 percent of counties with the highest case error rates shall be liable if the state’s dollar error rate exceeds the federal standard by greater than 2 percent and less than or equal to 3 percent.

(4) The 90 percent of counties with the highest case error rates shall be liable if the state’s dollar error rate exceeds the federal standard by greater than 3 percent and less than or equal to 4 percent.

(5) All counties shall be liable if the state’s dollar error rate exceeds the federal standard by greater than 4 percent.

As used herein, “the state’s dollar error rate” means the Medicaid dollar error rate reported to the department by the United States Department of Health and Human Services, less any portion of this error rate attributable to state caused errors. The term “federal standard” means the Medicaid dollar error rate standard to which the state is held accountable.

For each county determined liable, the department shall calculate a penalty multiple that shall be the product of a liable county’s case error rate multiplied by the liable county’s percentage of statewide Medi-Cal cases. Each county’s fiscal penalty shall be the product of a county’s penalty multiple divided by the sum of all penalty multiples, multiplied times the penalty bank. The penalty bank includes only quality control federal fiscal sanctions, federal withholds, federal disallowances, and any associated General Fund expenditures, minus the value of any state assumed errors and the General Fund share of the value of client caused errors. The case error rate and penalty multiple shall be adjusted by excluding client errors for the purpose of determining the associated General Fund expenditures.

If, after the department has assessed penalties to counties, the federal government reduces or eliminates any quality control federal fiscal sanction, federal withhold or federal disallowance, the department shall reduce or eliminate the corresponding fiscal penalty assessment including any associated General Fund expenditures to liable counties.

(h) When a county welfare department contravenes state eligibility processing regulations and written instructions in a way that produces increased program benefits or administrative expenses but doesn’t result in an increase in the eligibility dollar error rate, the director shall recoup from that county the additional administrative or program benefit costs above those that would have been incurred had that county not contravened the established state eligibility processing regulations and written instructions. This section shall not be construed to interfere with the rights of counties to out-station eligibility staff.

Notwithstanding the number of counties determined liable for fiscal penalties under this section, individual county corrective action plans as prescribed by the department shall be required from all counties that exceed a 15 percent case error rate.

(i) Any penalties imposed under this system shall be collected through direct repayment from liable counties rather than through any reduction in funds otherwise due to counties.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 117. (AB 118) Effective July 10, 2023.)

article: 1. General Provisions


kind: section

code: WIC

text: If a patient at a health facility operated by the county either directly or through contract is received in a comatose condition or suffering from amnesia and dies before he is able to cooperate in providing information necessary to a determination of Medi-Cal eligibility, the patient shall be presumed eligible. However, such presumption may be rebutted by the department. All costs incurred in providing care to such patient under such presumption shall be reimbursable to the extent permitted by federal statutes and regulations. If such a patient subsequently is determined ineligible, the department shall make reasonable efforts to recover the costs of care incurred during the period of presumptive eligibility and shall have the right to seek restitution in a civil action.

history: (History: Added by Stats. 1978, Ch. 101.)

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) If a person who is incapable of acting on their own behalf and who would otherwise be eligible is discontinued from Medi-Cal eligibility because the guardian or authorized representative of the person fails or refuses to provide information needed to determine eligibility, then anyone with knowledge of the person’s need for Medi-Cal coverage may apply for retroactive eligibility for the applicable retroactive eligibility period described in Section 14019 on behalf of the person. If the necessary information becomes available within three months of the application, the county department shall act on the application to determine the person’s eligibility for the retroactive period.

(b) A provision of subdivision (a) shall become inoperative to the extent that it is found to conflict with federal requirements governing federal reimbursements of state Medicaid costs.

history: (History: Amended by Stats. 2026, Ch. 27, Sec. 80. (SB 164) Effective June 29, 2026.)

article: 1. General Provisions


text: The department shall provide technical assistance to counties in order to maximize the identification of private health care coverage as defined by Section 10020. A county agency shall receive reimbursement for the administrative costs for properly completing a form which identifies such private health care coverage only in those cases where the agency does not receive such reimbursement from the department or the State Department of Social Services. The administrative costs for properly completing the form shall be determined by the department.

history: (History: Added by Stats. 1981, Ch. 102, Sec. 105. Effective June 28, 1981.)

article: 1. General Provisions


text:
The department may enter into an agreement with a county to have the county detect and recover the value of any Medi-Cal benefits which have been improperly received or obtained by any person. Counties shall receive an incentive amount not to exceed 30 percent of the amount remaining after reasonable county costs of the recovery have been deducted from the amount recovered. As the single state agency for state plan purposes, the department is responsible for and has authority to impose procedural requirements necessary for federal compliance.

The administrative costs for the implementation of this section shall be controlled by the department. The department shall establish and maintain a plan whereby costs for counties’ administration of beneficiary collections will be effectively controlled. The plan shall establish standards and performance criteria, including workload, productivity, and support services standards, to which counties shall adhere.

history: (History: Amended by Stats. 1986, Ch. 1052, Sec. 3. Effective September 24, 1986.)

article: 1. General Provisions


text:
(a) At the time of determining or redetermining the eligibility of a Medi-Cal program or Aid to Families with Dependent Children (AFDC) program applicant or beneficiary who resides in an area served by a managed health care plan or pilot program in which beneficiaries may enroll, each applicant or beneficiary shall be informed of the managed care and fee-for-service options available regarding methods of receiving Medi-Cal benefits.

(b) The information described in subdivision (a) shall include all of the following elements:

(1) Each beneficiary or eligible applicant shall be informed that he or she may choose to continue an established patient-provider relationship in the fee-for-service sector.

(2) Each beneficiary or eligible applicant shall be provided with the name, address, telephone number, and specialty, if any, of each primary care provider, and each clinic participating in each prepaid managed health care plan, pilot project, or fee-for-service case management provider option. This information shall be provided under geographic area designations, in alphabetical order by the name of the primary care provider and clinic. The name, address, and telephone number of each specialist participating in each prepaid managed health care plan, pilot project, or fee-for-service case management provider option shall be made available by contacting either the health care options contractor or the prepaid managed health care plan, pilot project, or fee-for-service case management provider.

(3) Each beneficiary or eligible applicant shall be informed that he or she may choose to continue an established patient-provider relationship in a managed care option, if his or her treating provider is a primary care provider or clinic contracting with any of the prepaid managed health care plans, pilot projects, or fee-for-service case management provider options available, has available capacity, and agrees to continue to treat that beneficiary or applicant.

(4) In areas specified by the director, each beneficiary or eligible applicant shall be informed that if he or she fails to make a choice, or does not certify that he or she has an established relationship with a primary care provider or clinic, he or she shall be assigned to, and enrolled in, a prepaid managed health care plan, pilot project, or fee-for-service case management provider.

(c) No later than 30 days following the date a Medi-Cal or AFDC beneficiary or applicant is determined eligible, the beneficiary or applicant shall indicate his or her choice in writing, as a condition of coverage for Medi-Cal benefits, of either of the following health care options:

(1) To obtain benefits by receiving a Medi-Cal card, which may be used to obtain services from individual providers, that the beneficiary would locate, that choose to provide services to Medi-Cal beneficiaries.

The department may require each beneficiary or eligible applicant, as a condition for electing this option, to sign a statement certifying that he or she has an established patient-provider relationship, or in the case of a dependent, the parent or guardian shall make that certification. This certification shall not require the acknowledgment or guarantee of acceptance, by any indicated Medi-Cal provider or health facility, of any beneficiary making a certification under this section.

(2) (A) To obtain benefits by enrolling in a prepaid managed health care plan, pilot program, or fee-for-service case management provider that has agreed to make Medi-Cal services readily available to enrolled Medi-Cal beneficiaries.

(B) At the time the beneficiary or eligible applicant selects a prepaid managed health care plan, pilot project, or fee-for-service case management provider, the department shall, when applicable, encourage the beneficiary or eligible applicant to also indicate, in writing, his or her choice of primary care provider or clinic contracting with the selected prepaid managed health care plan, pilot project, or fee-for-service case management provider.

(d) (1) In areas specified by the director, a Medi-Cal or AFDC beneficiary or eligible applicant who does not make a choice, or who does not certify that he or she has an established relationship with a primary care provider or clinic, shall be assigned to and enrolled in an appropriate Medi-Cal managed care plan, pilot project, or fee-for-service case management provider providing service within the area in which the beneficiary resides.

(2) If it is not possible to enroll the beneficiary under a Medi-Cal managed care plan, pilot project, or a fee-for-service case management provider because of a lack of capacity or availability of participating contractors, the beneficiary shall be provided with a Medi-Cal card and informed about fee-for-service primary care providers who do all of the following:

(A) The providers agree to accept Medi-Cal patients.

(B) The providers provide information about the provider’s willingness to accept Medi-Cal patients as described in Section 14016.6.

(C) The providers provide services within the area in which the beneficiary resides.

(e) If a beneficiary or eligible applicant does not choose a primary care provider or clinic, or does not select any primary care provider who is available, the managed health care plan, pilot project, or fee-for-service case management provider that was selected by or assigned to the beneficiary shall ensure that the beneficiary selects a primary care provider or clinic within 30 days after enrollment or is assigned to a primary care provider within 40 days after enrollment.

(f) (1) The managed care plan shall have a valid Medi-Cal contract, adequate capacity, and appropriate staffing to provide health care services to the beneficiary.

(2) The department shall establish standards for all of the following:

(A) The maximum distances a beneficiary is required to travel to obtain primary care services from the managed care plan, fee-for-service case management provider, or pilot project in which the beneficiary is enrolled.

(B) The conditions under which a primary care service site shall be accessible by public transportation.

(C) The conditions under which a managed care plan, fee-for-service case management provider, or pilot project shall provide nonmedical transportation to a primary care service site.

(3) In developing the standards required by paragraph (2), the department shall take into account, on a geographic basis, the means of transportation used and distances typically traveled by Medi-Cal beneficiaries to obtain fee-for-service primary care services and the experience of managed care plans in delivering services to Medi-Cal enrollees. The department shall also consider the provider’s ability to render culturally and linguistically appropriate services.

(g) To the extent possible, the arrangements for carrying out subdivision (d) shall provide for the equitable distribution of Medi-Cal beneficiaries among participating managed care plans, fee-for-service case management providers, and pilot projects.

(h) If, under the provisions of subdivision (d), a Medi-Cal beneficiary or applicant does not make a choice or does not certify that he or she has an established relationship with a primary care provider or clinic, the person may, at the option of the department, be provided with a Medi-Cal card or be assigned to and enrolled in a managed care plan providing service within the area in which the beneficiary resides.

(i) Any Medi-Cal or AFDC beneficiary who is dissatisfied with the provider or managed care plan, pilot project, or fee-for-service case management provider shall be allowed to select or be assigned to another provider or managed care plan, pilot project, or fee-for-service case management provider.

(j) The department or its contractor shall notify a managed care plan, pilot project, or fee-for-service case management provider when it has been selected by or assigned to a beneficiary. The managed care plan, pilot project, or fee-for-service case management provider that has been selected by, or assigned to, a beneficiary, shall notify the primary care provider or clinic that it has been selected or assigned. The managed care plan, pilot project, or fee-for-service case management provider shall also notify the beneficiary of the managed care plan, pilot project, or fee-for-service case management provider or clinic selected or assigned.

(k) (1) The department shall ensure that Medi-Cal beneficiaries eligible under Title XVI of the federal Social Security Act are provided with information about options available regarding methods of receiving Medi-Cal benefits as described in subdivision (c).

(2) (A) The director may waive the requirements of subdivisions (c) and (d) until a means is established to directly provide the information described in subdivision (a) to beneficiaries who are eligible for the federal Supplemental Security Income for the Aged, Blind, and Disabled Program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of Title 42 of the United States Code).

(B) The director may elect not to apply the requirements of subdivisions (c) and (d) to beneficiaries whose eligibility under the Supplemental Security Income program is established before January 1, 1994.

(l) In areas where there is no prepaid managed health care plan or pilot program that has contracted with the department to provide services to Medi-Cal beneficiaries, and where no other enrollment requirements have been established by the department, no explicit choice need be made, and the beneficiary or eligible applicant shall receive a Medi-Cal card.

(m) The following definitions contained in this subdivision shall control the construction of this section, unless the context requires otherwise:

(1) “Applicant,” “beneficiary,” and “eligible applicant,” in the case of a family group, mean any person with legal authority to make a choice on behalf of dependent family members.

(2) “Fee-for-service case management provider” means a provider enrolled and certified to participate in the Medi-Cal fee-for-service case management program the department may elect to develop in selected areas of the state with the assistance of and in cooperation with California physician providers and other interested provider groups.

(3) “Managed health care plan” and “managed care plan” mean a person or entity operating under a Medi-Cal contract with the department under this chapter or Chapter 8 (commencing with Section 14200) to provide, or arrange for, health care services for Medi-Cal beneficiaries as an alternative to the Medi-Cal fee-for-service program that has a contractual responsibility to manage health care provided to Medi-Cal beneficiaries covered by the contract.

(n) (1) Whenever a county welfare department notifies a public assistance recipient or Medi-Cal beneficiary that the recipient or beneficiary is losing Medi-Cal eligibility, the county shall include, in the notice to the recipient or beneficiary, notification that the loss of eligibility shall also result in the recipient’s or beneficiary’s disenrollment from Medi-Cal managed health care or dental plans, if enrolled.

(2) Whenever the department or the county welfare department processes a change in a public assistance recipient’s or Medi-Cal beneficiary’s residence or aid code that will result in the recipient’s or beneficiary’s disenrollment from the managed health care or dental plan in which he or she is currently enrolled, a written notice shall be given to the recipient or beneficiary.

(o) This section shall be implemented in a manner consistent with any federal waiver required to be obtained by the department in order to implement this section.

(p) (1) If the functionality is available in the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), individuals or their authorized representatives may select Medi-Cal managed care plans via CalHEERS.

(A) Any person that assists a Medi-Cal beneficiary who is eligible for the program based on modified adjusted gross income (MAGI) to select a Medi-Cal managed care plan via CalHEERS shall complete a training program that includes all of the following:

(i) The right to select a plan, to designate a plan at a later date, to have plan choice materials sent by mail, and that if the person does not select a plan, one will be selected for them.

(ii) All plan enrollment options and requirements with regard to MAGI Medi-Cal eligibility.

(iii) Any applicable timeframes in which the plan choice must be designated and the mechanism for designating plan choice.

(iv) How to use provider directories, how to identify which providers are in a particular plan network, and the applicable characteristics of primary care and specialty care providers and providers of other services, such as languages spoken, whether they are accepting new patients, and office locations.

(v) To the extent applicable, how to access Medi-Cal services prior to plan enrollment, including the right to retroactive Medi-Cal benefits.

(B) Any person that assists a Medi-Cal beneficiary who is not eligible for Medi-Cal on the basis of MAGI to select a Medi-Cal managed care plan shall complete a training program that includes all of the following:

(i) All of the information included in the training program described in subparagraph (A).

(ii) The enrollment options and requirements with regard to each Medi-Cal eligibility category, including whether enrollment is mandatory, how to obtain medical exemptions and continuity of care, waiver programs, carved-out services, and the California Children’s Services Program, as applicable.

(2) The department shall consult with a group of stakeholders through either a group currently in existence or convened for this purpose that includes representatives of plans, providers, consumer advocates, counties, eligibility workers, CalHEERS, the California Health Benefit Exchange (Exchange), and the Legislature to review process, timelines, scripts, training curricula, monitoring and oversight plans, and plan marketing and informational materials.

(3) In developing materials, scripts, and processes, the department and the Exchange shall consult with or test the materials, scripts, and processes with stakeholders that have expertise in health plan selection, and in assisting populations of diverse demographic characteristics such as race, ethnicity, language spoken, geographic region, sexual orientation, and gender identity or preference.

(4) The department, CalHEERS, the Exchange, and counties may adopt the recommendations of the advisory body convened in paragraph (2) and specify the reasons if the recommendations are not adopted.

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

history: (History: Repealed (in Sec. 19) and added by Stats. 2013, 1st Ex. Sess., Ch. 3, Sec. 20. (AB 1 1x) Effective September 30, 2013. Section operative January 1, 2014, by its own provisions.)

article: 1. General Provisions


text:
The State Department of Health Care Services shall develop a program to implement subdivision (p) of Section 14016.5 and to provide information and assistance to enable Medi-Cal beneficiaries to understand and successfully use the services of the Medi-Cal managed care plans in which they enroll. The program shall include, but not be limited to, the following components:

(a) (1) Development of a method to inform beneficiaries and applicants of all of the following:

(A) Their choices for receiving Medi-Cal benefits including the use of fee-for-service sector managed health care plans, or pilot programs.

(B) The availability of staff and information resources to Medi-Cal managed health care plan enrollees described in subdivision (f).

(2) (A) Marketing and informational materials, including printed materials, films, and exhibits, to be provided to Medi-Cal beneficiaries and applicants when choosing methods of receiving health care benefits.

(B) The department shall not be responsible for the costs of developing material required by subparagraph (A).

(C) (i) The department may prescribe the format and edit the informational materials for factual accuracy, objectivity, and comprehensibility.

(ii) The department, the California Health Benefit Exchange (Exchange), the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), and entities or persons designated pursuant to subdivision (g) shall use the edited materials in informing beneficiaries and applicants of their choices for receiving Medi-Cal benefits.

(b) Provision of information that is necessary to implement this program in a manner that fairly and objectively explains to beneficiaries and applicants their choices for methods of receiving Medi-Cal benefits, including information prepared by the department.

(c) Provision of information about providers who will provide services to Medi-Cal beneficiaries. This may be information about provider referral services of a local provider professional organization. The information shall be made available to Medi-Cal beneficiaries and applicants at the same time the beneficiary or applicant is being informed of the options available for receiving care.

(d) Training of individuals, including county human services staff, to carry out the program.

(e) Monitoring the implementation of the program at any location, including online at the Exchange or at counties, where choices are made available in order to assure that beneficiaries and applicants may make a well-informed choice, without duress.

(f) Staff and information resources dedicated to directly assist Medi-Cal managed health care plan enrollees to understand how to effectively use the services of, and resolve problems or complaints involving, their managed health care plans.

(g) Notwithstanding any other law, the department, in consultation with the Exchange, may authorize specific persons or entities, including counties, to provide information to beneficiaries concerning their health care options for receiving Medi-Cal benefits and assistance with enrollment. This subdivision shall apply in all geographic areas designated by the director. This subdivision shall be implemented in a manner consistent with federal law.

(h) To the extent otherwise required by Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall adopt emergency regulations implementing this section no later than July 1, 2015. The department may thereafter readopt the emergency regulations pursuant to that chapter. The adoption and readoption, by the department, of regulations implementing this section shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the department is hereby exempted from the requirement that it describe facts showing the need for immediate action and from review by the Office of Administrative Law.

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

history: (History: Amended (as added by Stats. 2013, 1st Ex. Sess., Ch. 3, Sec. 22) by Stats. 2013, Ch. 442, Sec. 11. (SB 28) Effective January 1, 2014.)

article: 1. General Provisions


text:
(a) Managed care contracts entered into by the department under the act adding this section shall include all of the following:

(1) Contractor requirements concerning eligibility and coverage verification.

(2) Utilization controls.

(3) Claims processing.

(b) The contract requirements shall include all of the following:

(1) Standards for prompt response to provider requests for information.

(2) Twenty-four hour response to emergency service authorization requests.

(3) Use of commonly accepted billing forms.

history: (History: Added by Stats. 1991, Ch. 95, Sec. 4. Effective June 30, 1991.)

article: 1. General Provisions


text:
(a) The Legislature finds and declares that the right of every patient to receive basic information necessary to give full and informed consent is a fundamental tenet of good public health policy and has long been the established law of this state. Some hospitals and other providers do not provide a full range of reproductive health services and may prohibit or otherwise not provide sterilization, infertility treatments, abortion, or contraceptive services, including emergency contraception. It is the intent of the Legislature that every patient be given full and complete information about the health care services available to allow patients to make well informed health care decisions.

(b) On or before July 1, 2001, the department shall:

(1) Ensure that all Medi-Cal beneficiaries receive the following statement by the methods described in paragraphs (2) to (6), inclusive:

“Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor or clinic, or call the Medi-Cal managed care plan at (insert the plan’s membership services number or other appropriate number that individuals can call for information) to ensure that you can obtain the health care services that you need.”

(2) Require that each Medi-Cal managed care plan provide the statement described in paragraph (1), in at least 12-point boldface type at the beginning of each provider directory.

(3) Require that each Medi-Cal managed care plan place the statement described in paragraph (1) in a prominent location on any provider directory posted on the plan’s website, if any, and include this statement in a conspicuous place in the plan’s evidence of coverage and disclosure forms, if any.

(4) Require that the statement described in paragraph (1) be included in the health care option activities described in Sections 14016.5, 14087.305, subdivision (e) of Section 14089, and paragraph (2) of subdivision (f) of Section 14408.

(5) Require each county organized health system to provide to Medi-Cal beneficiaries the statement described in paragraph (1). This statement shall be provided in writing in at least 12-point boldface type prior to enrollment, prior to selection of a primary care provider, and on an annual basis.

(6) Ensure that the statement described in paragraph (1) is provided to any other Medi-Cal managed care beneficiary who would not receive the statement under the provisions of paragraphs (2) to (5), inclusive. This statement shall be provided in writing in at least 12-point boldface type prior to enrollment, prior to selection of a primary care provider, and on an annual basis.

(c) The requirement to provide the statement described in paragraph (1) of subdivision (b) shall apply to Medi-Cal managed care programs, including, but not limited to, the following programs:

(1) In areas where the department is contracting with persons or entities that are contracting with, or governed, owned, or operated by, either a county board of supervisors or a county special commission, or a county health authority, operating under Article 2.8 (commencing with Section 14087.5) or Article 7 (commencing with Section 14490) of Chapter 8, or Chapter 3 (commencing with Section 101675) of Part 4 of Division 101 of the Health and Safety Code.

(2) In areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3, including where the department is contracting with prepaid health plans, including prepaid health plans that are contracting with, governed, owned, or operated by a county board of supervisors, a county special commission or county health authority authorized by Sections 14018.7, 14087.31, 14087.316, 14087.35, 14087.36, 14087.38, and 14087.9605.

(3) Where the department has entered into contracts with prepaid health plans or primary care case management providers pursuant to Article 2.9 (commencing with Section 14088) and Chapter 8 (commencing with Section 14200).

(4) Where the department or the California Medical Assistance Commission has entered into contracts with any persons or entities pursuant to Section 14087.47, Article 2.91 (commencing with Section 14089), or Article 2.97 (commencing with Section 14093).

(d) A Medi-Cal managed care plan shall not be required to provide the statement described in paragraph (1) of subdivision (b) in a service area in which none of the hospitals, health facilities, clinics, medical groups, or independent practice associations with which it contracts limit or restrict any of the reproductive services described in the statement.

(e) This section shall not apply to specialized health care service plans.

history: (History: Added by Stats. 2000, Ch. 347, Sec. 4. Effective January 1, 2001.)

article: 1. General Provisions


text: Where determined to be cost effective, the department shall utilize the earnings clearance system to verify the eligibility of persons who have applied for or are receiving benefits pursuant to Sections 14005.4 and 14005.7.

history: (History: Amended by Stats. 1985, Ch. 1354, Sec. 11.)

article: 1. General Provisions


text: The department shall implement the federal requirement under Section 4603 of the Omnibus Budget Reconciliation Act of 1990 (P.L. 101–508) which provides for the continuity of Medi-Cal coverage during pregnancy and the post partum period for pregnant women who were certified as Medi-Cal eligible.

history: (History: Added by Stats. 1991, Ch. 1062, Sec. 1. Effective October 14, 1991.)

article: 1. General Provisions


text: Upon the availability of federal funding, the department shall modify the Medi-Cal program mail-in application form, and other appropriate materials, and the single point-of-entry application form, to allow applicants in counties served by managed care plans to contact the enrollment contractor by using the Health Care Options toll-free telephone number to request and receive enrollment materials before a Medi-Cal eligibility determination has been made.

history: (History: Amended by Stats. 2005, Ch. 22, Sec. 225. Effective January 1, 2006.)

article: 1. General Provisions


text:
(a) It is the intent of the Legislature that Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care health plan make an informed choice that is not the result of confusion, lack of information, or understanding of the choices available to them.

(b) It is the intent of the Legislature that the department strive to increase the level of choice of Medi-Cal beneficiaries required to enroll in a Medi-Cal managed care health plan and that default rates be no greater than 20 percent in any participating county.

(c) In any county in which conversion to managed care plan enrollment has taken place and where the default rate, as defined in subdivision (e), is 20 percent or higher in two consecutive months occurring after conversion upon the effective date of this section, the department shall conduct a one-time survey of beneficiaries aimed at determining the reasons why beneficiaries fail to enroll into a managed care plan when required to do so by the department or its health care options contractor.

(d) The department shall submit the results of the survey to the appropriate legislative policy and budget committees within six months of completion, and implement a plan of correction intended to reduce the rate of beneficiary default. The plan of correction may include, but not be limited to, culturally appropriate outreach and education activities, including the use of community based organization.

(e) For purposes of this section, “default rate” refers to the rate of Medi-Cal beneficiaries defaulting into managed care health plan enrollment by virtue of their failure to make an election, as provided for in Section 14016.5.

history: (History: Added by Stats. 1998, Ch. 310, Sec. 78. Effective August 19, 1998.)

article: 1. General Provisions


text:
On a regional pilot project basis, the department may issue an identification card to a person eligible for Medi-Cal program benefits under Section 14005.1, 14005.4, or 14005.7 who is certified, but is not in possession of a valid California driver’s license or identification card issued by the Department of Motor Vehicles. The identification card shall contain his or her picture, social security number, identifying characteristics, and signature. This provision shall not apply to:

(a) Persons age 12 and under.

(b) Recipients of aid under Title XVI of the Social Security Act.

(c) Persons in long-term institutional status.

history: (History: Amended by Stats. 1982, Ch. 327, Sec. 224. Effective June 30, 1982.)

article: 1. General Provisions


text: The Joint Legislative Audit Committee shall conduct an audit of one or more county eligibility departments.

history: (History: Amended by Stats. 2001, Ch. 745, Sec. 247. Effective October 12, 2001.)

article: 1. General Provisions


text:
The department shall not issue identification cards to Medi-Cal recipients on a statewide basis until (1) a pilot project has been completed which indicates that the General Fund savings from reduced unauthorized use of Medi-Cal cards more than offsets the costs of issuing the identification cards, and (2) the Legislature has specifically appropriated the funds necessary to issue identification cards to Medi-Cal beneficiaries.

If identification cards are issued by the department on a pilot project or statewide basis, the department shall notify providers that current Medi-Cal beneficiaries have been issued identification cards in accordance with Section 14017. At that time, it shall be the responsibility of the provider prior to rendering nonemergency Medi-Cal reimbursable services to persons presenting themselves as Medi-Cal beneficiaries to verify the person’s identity by matching the name and signature on their identification card issued by the department or their valid California driver’s license or California identification card issued by the Department of Motor Vehicles, against a signature executed at the time of service and further by visually verifying their likeness to the photograph on the identification card or driver’s license. If the provider complies in good faith, he or she shall not be held responsible by having payments withheld by the state.

history: (History: Amended by Stats. 1982, Ch. 1014, Sec. 1.)

article: 1. General Provisions


text: For the purposes of this chapter, all references to “the Medi-Cal card,” identified in Section 14017.8, shall be deemed to also be a reference to the benefits identification card, identified in Section 14017.7.

history: (History: Added by Stats. 2001, Ch. 171, Sec. 36. Effective August 10, 2001.)

article: 1. General Provisions


text:
(a) In addition to the issuance of Medi-Cal cards, pursuant to Section 14017.8, the department may issue a benefits identification card for the purpose of identifying an individual who has been determined eligible for health care benefits under this chapter or health care benefits under another health care program administered by the department, including, but not limited to, the Medi-Cal Access Program as described in Chapter 2 (commencing with Section 15810) of Part 3.3, or both.

(b) The department may also issue a benefits identification card for the purpose of identifying an individual who has been determined eligible to receive health care services from a Medi-Cal provider under the Healthy Families Program under Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code, if children are enrolled back into that program pursuant to subdivision (m) of Section 14005.26 or subdivision (q) of Section 14005.27.

(c) In no event shall a benefits identification card be issued to an individual described in subdivision (a) or (b) unless appropriate and adequate safeguards have been implemented to ensure all of the following:

(1) If the individual has been determined eligible for health care benefits under another health care program administered by the department or a program identified in subdivision (b), that health care program pays for any and all health care benefits delivered to the individual by that health care program.

(2) State funds appropriated to or federal Medicaid financial participation claimed by the Medi-Cal program shall only be used for the delivery of health care benefits authorized pursuant to this chapter.

(d) The individual described in subdivision (a) or (b) may present the benefits identification card to obtain health care benefits for which that individual has been determined eligible under this chapter, or health care benefits under another health care program administered by the department or a program identified in subdivision (b), or all of them.

(e) Where applicable, all laws, regulations, restrictions, conditions, and terms of participation regarding the possession, billing, and use of Medi-Cal cards shall also apply to a benefits identification card.

(f) For the purposes of this section, “benefits” includes medically necessary services, goods, supplies, or merchandise.

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

article: 1. General Provisions


text: Each person eligible under Section 14005.1 and each person eligible under Section 14005.4 or 14005.7 who is certified eligible shall be provided, by the department, with a Medi-Cal card certifying his or her status, identification number, expiration date and his or her entitlements, insofar as these do not require specific prior authorization. The department shall determine the form of the Medi-Cal card. The cards shall be for a term as determined by the department and, unless canceled for cause, shall entitle individuals to care and service as indicated. Cause for cancellation shall exist when the person dies, loses state residence, is found to be ineligible, or has been issued a new Medi-Cal card.

history: (History: Added by Stats. 1985, Ch. 1354, Sec. 12.)

article: 1. General Provisions


text:
(a) (1) The Medi-Cal card shall be authorization for payment for health care services rendered, during and subsequent to the month of application of a person eligible under Section 14005.1, or a person eligible under Section 14005.4 or 14005.7 who is certified by the department.

(2) The Medi-Cal card shall be signed and dated in the space provided on the card by the beneficiary upon receipt of the card and prior to presentation of the card for any service. This paragraph shall not apply to either of the following:

(A) Persons 17 years of age and under.

(B) Persons in long-term care.

(b) Notwithstanding subdivision (a), any person with a Medi-Cal card who receives medical assistance for home and facility care may be ineligible for payment for periods of time, including partial months of ineligibility, as determined pursuant to Section 14015 and in accordance with Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).

(c) This section shall be implemented pursuant to the requirements of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) and any regulations adopted pursuant to that act, and only to the extent that federal financial participation is available.

(d) To the extent that regulations are necessary to implement this section, the department shall promulgate regulations using the nonemergency regulatory process described in Article 5 (commencing with Section 11346) of Chapter 3.5 of Part 1 of Division 3 of the Government Code.

(e) It is the intent of the Legislature that the provisions of this section shall apply prospectively to any individual to whom the act applies commencing from the date regulations adopted pursuant to this act are filed with the Secretary of State.

history: (History: Amended by Stats. 2008, Ch. 379, Sec. 11. Effective January 1, 2009.)

article: 1. General Provisions


text: The department shall prospectively notify a Medi-Cal managed care plan of the date of the regularly scheduled annual redetermination of a Medi-Cal beneficiary in a disabled aid category, who is enrolled in that plan and where eligibility redetermination is the responsibility of the department. Nothing in this section shall provide a beneficiary with additional Medi-Cal coverage due to the department’s failure to provide this notice.

history: (History: Added by Stats. 2001, Ch. 742, Sec. 1. Effective January 1, 2002.)

article: 1. General Provisions


text:
(a) Reimbursement shall not be denied to any qualified health care provider for care rendered to an eligible Medi-Cal beneficiary for the sole reason that a proof of eligibility label does not accompany the bill.

Proof of eligibility labels may, however, continue to be used as such and shall be made available to an eligible Medi-Cal beneficiary through the local office which has determined the person’s eligibility or through the department. The provider may submit machine-reproduced copies of the beneficiary Medi-Cal card for billing purposes as long as the copy is made from the original unaltered Medi-Cal card under circumstances controlled by the provider, for example, on the premises of the provider with copying equipment controlled by the provider.

(b) It shall remain the responsibility of a Medi-Cal beneficiary to provide information and evidence of Medi-Cal eligibility, restrictions on the eligibility, and non-Medi-Cal health coverage, to that person’s health care providers, if this information is requested by those providers prior to rendering services to that beneficiary.

(c) It shall be the responsibility of the provider prior to rendering Medi-Cal reimbursable services to persons presenting themselves as Medi-Cal beneficiaries to make a good faith effort to verify the person’s identity, if the person is not known to the provider, by matching the name and signature on his or her Medi-Cal card against the signature on a valid California driver’s license, or California identification card issued by the Department of Motor Vehicles, or another type of picture identification card or other credible document of identification. When the provider verifies the beneficiary’s identity with a signed Medi-Cal card and one of the documents described above, the state will deem this to be a good faith effort. If the provider does not make a good faith effort of reasonable identification prior to rendering Medi-Cal reimbursable services and renders services to a presenting person who is ineligible for those Medi-Cal services, payment for those services may later be disallowed.

This provision shall not apply to:

(1) Persons 17 years of age and under.

(2) Persons in long-term care.

(3) Persons receiving emergency services.

(d) Notwithstanding subdivision (b) of this section, county welfare departments may provide Medi-Cal eligibility information to other governmental agencies and their designated agents as necessary for proper administration of the Medi-Cal program.

(e) If a hospital obtains proof of Medi-Cal eligibility for a patient subsequent to the date of service, it shall be the responsibility of the hospital to provide all information regarding that person’s Medi-Cal eligibility to all hospital-based providers, ambulance transportation services providers, providers that provide ambulance transportation services through the “911” emergency response system, and other hospital-based providers of professional services that bill separately for all services associated with the person’s treatment in the hospital rendered during the same time period for which the hospital is submitting a claim. The hospital may inform the provider that the person’s Medi-Cal eligibility is pending, before a final determination is made on the patient’s Medi-Cal application, to satisfy the requirements of this subdivision. If the provider or the provider’s agent obtains this information from the hospital, the requirement has been satisfied.

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

(1) “Hospital-based provider” means an anesthesiologist, radiologist, pathologist, emergency room physician, or other physician or a group of physicians providing medical services at the hospital.

(2) “Hospital-based professional services” means services performed for a patient while at a hospital, related to the patient’s hospital stay, and known to the hospital, including, but not limited to, diagnostic, laboratory, therapeutic, and radiologic services.

history: (History: Amended by Stats. 2009, Ch. 511, Sec. 1. (AB 1142) Effective January 1, 2010.)

article: 1. General Provisions


text:
(a) Reimbursement shall not be denied to any hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code for care rendered to an eligible Medi-Cal beneficiary for the sole reason that a proof of eligibility label does not accompany the bill, so long as the claim includes other appropriate documentation of eligibility.

(b) The director shall require county welfare departments to issue, upon the request of a hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code providing care to an eligible Medi-Cal beneficiary, replacement Medi-Cal proof of eligibility labels or other appropriate documentation of eligibility to the requester, if all of the following conditions are met:

(1) The hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code attempted to obtain a label from the beneficiary at the time the service was provided.

(2) The hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code made a subsequent attempt to obtain a label or other appropriate documentation from the beneficiary.

(c) Notwithstanding subdivision (a), the director shall require that the replacement proof of eligibility label or other appropriate documentation of eligibility provided pursuant to subdivision (b) accompany the bill of the hospital, the licensed primary care clinic, or the long-term health care facility as defined in Section 1326 of the Health and Safety Code.

(d) This section shall remain in effect only until both the Secretary of the Senate and the Chief Clerk of the Assembly have received certification by registered mail from the Director of Health Services, that the automated eligibility verification system required by Section 14042 is operative for all counties and has been demonstrated to be accurate for each county at the 97-percent level as required by Section 14042 and as of that date is repealed.

history: (History: Amended by Stats. 1987, Ch. 1161, Sec. 3. Repealed as of date prescribed by its own provisions.)

article: 1. General Provisions


text: Notwithstanding any other provision of law, Section 3275 of the Civil Code does not apply to Medi-Cal reimbursement or prior authorization.

history: (History: Added by Stats. 1999, Ch. 146, Sec. 36. Effective July 22, 1999.)

article: 1. General Provisions


text:
(a) Notwithstanding any other provision of law, neither a member of the governing body of the commission nor a member of any advisory panel to the governing body shall be deemed to be interested in a contract entered into by the commission within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all of the following apply:

(1) The board of supervisors or the governing body appointed the individual to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations.

(2) The contract authorizes the individual or the organization the individual represents to provide services under the local initiative.

(3) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the individual was appointed to represent.

(4) The individual does not influence or attempt to influence any advisory panel, the governing body, or any member of the governing body to enter into the contract.

(5) The individual discloses the interest to the governing body and the advisory panel, if applicable, and abstains from voting on the contract.

(6) The governing body and the advisory panel, if applicable, notes the disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for that purpose without counting the vote of the individual.

(b) (1) For purposes of this section, “commission” means a nonprofit corporation established in Kern County to operate the local health plan and other health care programs owned by, or operated in, Kern County.

(2) The commission shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code.

(c) For purposes of this section, “governing body” means the board of directors of the nonprofit corporation established in Kern County, and “board of supervisors” means the Kern County Board of Supervisors.

(d) The commission may enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code.

history: (History: Amended by Stats. 2004, Ch. 228, Sec. 10.3. Effective August 16, 2004.)

article: 1. General Provisions


text:
(a) (1) Notwithstanding Section 14018, except as provided in Section 14019.6, Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law, during any of the three months immediately prior to the month in which application was made, and for which such person would have otherwise been eligible.

(2) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by an applicant described in Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code, or by an applicant for state-funded Medi-Cal coverage who meets the same criteria described in that federal provision, Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during the month immediately prior to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018.

(3) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by any applicant except those described in paragraph (2), Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during either of the two months immediately prior to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018.

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

(c) (1) Paragraphs (2) and (3) of subdivision (a) shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation of this section.

(2) Paragraphs (2) and (3) of subdivision (a) shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and not otherwise jeopardized.

history: (History: Amended by Stats. 2026, Ch. 27, Sec. 81. (SB 164) Effective June 29, 2026.)

article: 1. General Provisions


text:
(a) A beneficiary or any person on behalf of a beneficiary who has paid for medically necessary health care services, otherwise covered by the Medi-Cal program, received by the beneficiary shall be entitled to a return from a provider or directly from the department of any part of the payment that meets all of the following:

(1) Was rendered during the 90-day period prior to application for, his or her Medi-Cal card, or after application for but prior to the issuance of, his or her Medi-Cal card, for which the card authorizes payment under Section 14018 or 14019, or was charged to the beneficiary as excess copayment during the period after issuance of his or her Medi-Cal card.

(2) Is not payable by a third party under contractual or other legal entitlement.

(3) Was not used to satisfy his or her paid or obligated liability for health care services or to establish eligibility.

(b) To the extent permitted by federal law, whether or not a facility actually evicts a beneficiary, a beneficiary who may validly be evicted pursuant to Section 1439.7 of the Health and Safety Code, and who has received and paid for health care services otherwise covered by the Medi-Cal program shall not be entitled to the return from a provider of any part of the payment for which service was rendered during any period prior to the date upon which knowledge is acquired by a provider of the application of a beneficiary for Medi-Cal or the date of application for Medi-Cal, whichever is later.

(c) Upon presentation of the Medi-Cal card or other proof of eligibility, a provider shall submit a Medi-Cal claim for reimbursement, subject to the rules and regulations of the Medi-Cal program.

(d) Notwithstanding subdivision (c), payment received from the state in accordance with Medi-Cal fee structures shall constitute payment in full, except that a provider, after making a full refund to the department of any Medi-Cal payments received for services, may recover all provider fees to the extent that any other contractual entitlement, including, but not limited to, a private group or indemnification insurance program, is obligated to pay the charges for the care provided a beneficiary.

(e) A provider shall return any and all payments made by a beneficiary, or any person on behalf of a beneficiary, other than a third party obligated to pay charges by reason of a beneficiary’s other contractual or legal entitlement for Medi-Cal program covered services upon receipt of Medi-Cal payment.

(f) To the extent permitted by federal law, the department shall waive overpayments made to a pharmacy provider that would otherwise be reimbursable to the department for prescription drugs returned to a pharmacy provider from a nursing facility upon discontinuation of the drug therapy or death of a beneficiary.

(g) The department shall ensure payment to a beneficiary from a provider. A provider shall be notified in writing by the department when a beneficiary has submitted a claim to the department for reimbursement of services provided during the periods specified in paragraph (1) of subdivision (a). If a provider is not currently enrolled in the Medi-Cal program, the department shall assist in that enrollment. Enrollment in the Medi-Cal program may be made retroactive to the date the service was rendered.

(h) If a provider fails or refuses to reimburse a beneficiary for services provided during the periods specified in paragraph (1) of subdivision (a), within 90 days of receipt by the department of a written request by a beneficiary or a representative of a beneficiary, the department may take enforcement action that may include, but shall not be limited to, any or all of the following:

(1) Withholding of future provider payments.

(2) Suspension of a provider from participation in the Medi-Cal program.

(3) Recoupment of funds from a provider.

(i) If a provider fails or refuses to reimburse a beneficiary within 90 days after receipt by the department of a written request from a beneficiary or a representative of a beneficiary, the department shall directly reimburse a beneficiary for medically necessary health care expenses incurred during the periods specified in paragraph (1) of subdivision (a). The department shall reimburse a beneficiary only to the extent that federal financial participation is available and only when the claim meets all of the following criteria:

(1) The service was a covered benefit under the Medi-Cal program.

(2) The provider was an enrolled Medi-Cal provider at the time the service was rendered.

(3) The service was ordered by a health care provider, within the scope of his or her practice.

(4) The beneficiary is eligible for reimbursement, as specified in subdivision (a).

(5) The reimbursement shall be the amount paid by the beneficiary, not to exceed the rate established for that service under the Medi-Cal program.

(j) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of the Government Code, this section may be implemented with a provider bulletin or similar notification, without any further regulatory action.

history: (History: Amended by Stats. 2003, Ch. 230, Sec. 58. Effective August 11, 2003.)

article: 1. General Provisions


text:
(a) A provider of health care services who obtains a label or copy from the Medi-Cal card or other proof of eligibility pursuant to this chapter shall not seek reimbursement nor attempt to obtain payment for the cost of those covered health care services from the eligible applicant or recipient, or a person other than the department or a third-party payor who provides a contractual or legal entitlement to health care services.

(b) Whenever a service or set of services rendered to a Medi-Cal beneficiary results in the submission of a claim in excess of five hundred dollars ($500), and the beneficiary has given the provider proof of eligibility to receive the service or services, the provider shall issue the beneficiary a receipt to document that appropriate proof of eligibility has been provided. The form and content of those receipts shall be determined by the provider but shall be sufficient to comply with the intent of this subdivision. Nursing facilities and all categories of intermediate care facilities for the developmentally disabled are exempt from the requirements of this subdivision.

(c) In addition to being subject to applicable sanctions set forth in law or regulation, a provider of health care services who obtains a label from, or copy of, the Medi-Cal card or other proof of eligibility pursuant to this chapter, and who subsequently pursues reimbursement or payment for the cost of covered services from the beneficiary or fails to cease collection efforts against the beneficiary for covered services as required by subdivision (d), may be subject to a penalty, payable to the department, not to exceed three times the amount payable by the Medi-Cal program. In implementing this subdivision, mitigating circumstances, which include, but are not limited to, clerical error and good faith mistake, shall be considered when assessing the penalty. Providers subject to penalties under this subdivision shall have the right to appeal the assessed penalty, consistent with department procedures.

(d) When a Medi-Cal provider receives proof of a patient’s Medi-Cal eligibility and that provider has previously referred an unpaid bill for services rendered to the patient to a debt collector, the Medi-Cal provider shall promptly notify the debt collector of the patient’s Medi-Cal coverage, instruct the debt collector to cease collection efforts on the unpaid bill for the covered services, and notify the patient accordingly.

(e) If a patient provides proof of Medi-Cal eligibility to a debt collector, and the debt collector fails to notify the provider of this proof, the provider shall not be responsible for ensuring that collection efforts against the patient cease pursuant to subdivision (d) until either the patient or the debt collector provides the provider with proof of the patient’s Medi-Cal eligibility.

(f) A Medi-Cal provider or debt collector shall be deemed to be in violation of subdivision (a) of Section 1785.25 of the Civil Code if more than 30 days after receiving proof of Medi-Cal coverage the provider or debt collector does either of the following:

(1) Furnishes information regarding the rendering of the Medi-Cal covered services to a consumer credit reporting agency.

(2) Fails to provide corrections of, or instructions to delete, as appropriate, information regarding Medi-Cal covered services previously furnished by that Medi-Cal provider or debt collector to a consumer reporting agency.

(g) This section shall not apply to the Medi-Cal spend down of excess income owed by a Medi-Cal beneficiary, unless the beneficiary’s spend down of excess income has been met for the month in which services were rendered.

(h) For purposes of this section, “debt collector” includes any person who regularly engages in debt collection, as defined by Section 1788.2 of the Civil Code, but does not include the original Medi-Cal provider.

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

article: 1. General Provisions


text: Nothing in this chapter shall be construed as imposing any control over the management of any medical or health care facility, except that each such facility shall be required to comply with reasonable standards for certification to participate in the program provided by this chapter.

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

article: 1. General Provisions


text: Notwithstanding any other provision of law, no person, whose property reserve exceeds the property limit, may establish eligibility for the applicable retroactive eligibility period described in Section 14019, by spenddown of such excess property.

history: (History: Amended by Stats. 2026, Ch. 27, Sec. 82. (SB 164) Effective June 29, 2026.)

article: 1. General Provisions


text:
(a) Notwithstanding Section 14019.4 and if permitted by federal law, a relative of a skilled nursing facility resident who is a beneficiary under this chapter may pay an additional amount to the facility to enable the resident to obtain requested noncovered services, such as a private room, telephone, or television, or for bed hold days that exceed a period paid for under the state plan.

(b) The additional charge for requested noncovered services shall not exceed the amount charged to private pay residents. The additional charge for bed hold days shall not exceed the rate paid for by the Medi-Cal program for a covered bed hold day. The additional charge for a private room shall not exceed the difference between the private pay rate for a semiprivate room and a private room.

(c) Prior to accepting supplemental payment for holding a bed for a resident in a facility, a facility shall disclose to the relative the resident’s right under federal law to be readmitted without charge upon the first availability of a bed in a semiprivate room in that facility, other state and federal laws regarding bed hold rights, the average number of bed vacancies at that facility for the past month, and the current number of bed vacancies. Written information regarding bed vacancies shall be provided to the relative at the first available opportunity.

(d) The ability of a resident’s relative to pay an additional amount for noncovered services shall not be a condition of admission.

history: (History: Added by Stats. 2004, Ch. 661, Sec. 2. Effective January 1, 2005.)

article: 1. General Provisions


text: All sections of this chapter shall remain in operation during such times as grants-in-aid are provided or made available to the state on the basis of a state plan approved by the federal government for medical assistance pursuant to provisions of the Federal Social Security Act, as amended.

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

article: 1. General Provisions


text:
Notwithstanding any other provision of this chapter, health care shall include the following mental health and substance use disorder services:

(a) Mental health services provided by a county or a city.

(b) Mental health services provided in a community mental health service or in a community mental health center organized under the federal Community Mental Health Centers Act of 1963. No amount shall be paid for that portion of the total costs of care and services in a federally funded community mental health center which may be compensated by the United States government under the federal Community Mental Health Centers Act of 1963. No amount shall be paid to a community mental health service or a federally funded community mental health center unless the community mental health service or the federally funded community mental health center participates in a county or city mental health performance contract pursuant to Section 5650.

(c) Drug Medi-Cal outpatient substance use disorder services under the jurisdiction of the department provided by a county provider certified under this chapter or a private provider certified under this chapter which has an approved contract with the county or with the department to provide covered substance use disorder services.

(d) Inpatient hospital services in an institution for mental diseases to persons of all ages, provided that the institution for mental diseases is certified as a psychiatric hospital under Title XVIII of the federal Social Security Act and regulations issued thereunder.

Notwithstanding Section 14157, no money in the State Health Care Deposit Fund shall be expended for the purposes of this section unless the Legislature specifically appropriates money for the purposes of this section.

The amendment of this subdivision enacted at the 1972 Regular Session of the Legislature does not constitute a change in, but is declaratory of, the preexisting law.

(e) (1) Other diagnostic, screening, preventive, or remedial rehabilitative services for the maximum restoration of an individual to the best possible functional level.

(2) Paragraph (1) includes any medical or remedial services provided in a facility, home, or other setting, that are recommended by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law.

history: (History: Amended by Stats. 2012, Ch. 36, Sec. 72. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions


text:
(a) The department shall develop a proposal for the United States Secretary of Health and Human Services for selection as a participating state in the time-limited demonstration program pursuant to Section 223 of the federal Protecting Access to Medicare Act of 2014 (Public Law 113-93) in order to improve mental health services furnished by certified community behavioral health clinics to Medi-Cal beneficiaries.

(b) The department shall use the funds appropriated in the act that added this section to pay any costs that will support the development of a competitive proposal, including, but not limited to, establishing actuarially sound rates and providing technical assistance to counties.

(c) If the state is selected as a participating state in the time-limited demonstration program described in subdivision (a), the department, by March 1, 2017, shall provide an update to the Legislature that includes, to the extent it is available, the following information:

(1) The names of the participating counties.

(2) The estimated amount of additional funding each county is expected to receive under the demonstration program.

(3) The proposed uses of the additional funds and the county funds no longer required to be used as the federal match.

(4) A description of the improved partnerships between certified community behavioral health clinics and veterans organizations, primary care providers, health plans, educational agencies, and other organizations that the demonstration program includes.

(5) Other identified benefits from the demonstration program funding and planning process, and recommendations on any components of the demonstration program that could be extended to other counties.

history: (History: Amended by Stats. 2016, Ch. 283, Sec. 2. (AB 168) Effective January 1, 2017.)

article: 1. General Provisions


text: The state plan for medical assistance under Medicaid pursuant to Section 1915(g) of Title 19 of the federal Social Security Act, as amended by Public Law 99-272 (42 U.S.C. Section 1396n(g)), shall include targeted case management services as a benefit under the specialty mental health services Medi-Cal program.

history: (History: Amended (as added by Stats. 1987, Ch. 1385, Sec. 1) by Stats. 2012, Ch. 34, Sec. 222. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

article: 1. General Provisions


text:
(a) California’s plan for federal Medi-Cal grants for medical assistance programs, pursuant to Subchapter XIX (commencing with Section 1396) of Title 42 of the United States Code, shall accomplish the following objectives:

(1) Expansion of the location and type of therapeutic services offered to persons with mental illnesses under Medi-Cal by the category of “other diagnostic, screening, preventative, and rehabilitative services” that is available to states under the federal Social Security Act and its implementing regulations (42 U.S.C. Sec. 1396d(a)(13); 42 C.F.R. 440.130).

(2) Expansion of federal financial participation in the costs of specialty mental health services provided by local mental health plans or under contract with the mental health plans.

(3) Expansion of the location where reimbursable specialty mental health services can be provided, including home, school, and community-based sites.

(4) Expansion of federal financial participation for services that meet the rehabilitation needs of persons with mental illnesses, including, but not limited to, medication management, functional rehabilitation assessments of clients, and rehabilitative services that include remedial services directed at restoration to the highest possible functional level for persons with mental illnesses and maximum reduction of symptoms of mental illness.

(5) Improvement of fiscal systems and accountability structures for specialty mental health services, costs, and rates, with the goal of achieving federal fiscal requirements.

(b) The department’s state plan revision shall be completed with review and comments by the County Behavioral Health Directors Association of California and other appropriate groups.

(c) Services under the rehabilitative option shall be limited to specialty mental health plans certified to provide Medi-Cal under this option.

(d) It is the intent of the Legislature that the rehabilitation option of the state Medicaid plan be implemented to expand and provide flexibility to treatment services and to increase the federal participation without increasing the costs to the General Fund.

(e) The department shall review and revise the quality assurance standards and guidelines required by Section 14725 to ensure that quality services are delivered to the eligible population. Any reviews shall include, but not be limited to, appropriate use of mental health professionals, including psychiatrists, in the treatment and rehabilitation of clients under this model. The existing quality assurance standards and guidelines shall remain in effect until the adoption of the new quality assurance standards and guidelines.

(f) Consistent with services offered to persons with mental illnesses under the Medi-Cal program, as required by this section, it is the intent of the Legislature for the department to include care and treatment of persons with mental illnesses who are eligible for the Medi-Cal program in facilities with a bed capacity of 16 beds or less.

history: (History: Amended by Stats. 2015, Ch. 455, Sec. 51. (SB 804) Effective January 1, 2016.)

article: 1. General Provisions


text:
(a) Notwithstanding any other provision of law, rates for reimbursing specialty mental health and substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall continue to be based on the upper limits allowable under federal law and regulations for services provided prior to July 1, 1980, on the lower of reasonable cost and customary charges for services provided July 1, 1980, through June 30, 1982, and on the lowest of reasonable cost, customary charges, and rates paid by the Medi-Cal program for services provided July 1, 1982, through June 30, 1984.

(b) The Legislature hereby states and declares that this section does not constitute a change in, but is declaratory of, existing law and that rates for reimbursing specialty mental health and substance use disorder services to Medi-Cal beneficiaries under the Medi-Cal program in previous fiscal years were based upon the lower of reasonable costs or customary charges.

(c) The department shall promulgate emergency regulations relating to claims submission and establishing rates and a ratesetting methodology for determining reimbursement of specialty mental health and substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries. The methodology and rates shall reflect the most recently completed cost reports and shall be effective commencing July 1, 1984.

(d) Notwithstanding any other law, rates for reimbursing specialty mental health services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall be effective from July 1 through June 30 of the fiscal year in which these rates are established.

(e) Notwithstanding any other law, rates for reimbursing substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall be effective from July 1 through June 30 of the fiscal year in which these rates are established.

history: (History: Amended by Stats. 2012, Ch. 34, Sec. 224. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

article: 1. General Provisions


text:
(a) For the fiscal years prior to the 2004–05 fiscal year, and subject to the requirements of federal law, the maximum allowable rates for the Drug Medi-Cal Treatment Program shall be determined by computing the median rate from available cost data by modality from the fiscal year that is two years prior to the year for which the rate is being established.

(b) (1) For the 2007–08 fiscal year, and subsequent fiscal years, and subject to the requirements of federal law, the maximum allowable rates for the Drug Medi-Cal Treatment Program shall be determined by computing the median rate from the most recently completed cost reports, by specific service codes that are consistent with the federal Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Sec. 300gg).

(2) For the 2005–06 and 2006–07 fiscal years, if the State Department of Health Care Services determines that reasonably reliable and complete cost report data are available, the methodology specified in this subdivision shall be applied to either or both of those years. If reasonably reliable and complete cost report data are not available, the State Department of Health Care Services shall establish rates for either or both of those years based upon the usual, customary, and reasonable charge for the services to be provided, as the department may determine in its discretion. This subdivision does not modify subdivision (h) of Section 14124.24, which requires certain providers to submit performance reports.

(c) Notwithstanding subdivision (a), for the 1996–97 fiscal year, the rates for nonperinatal outpatient methadone maintenance services shall be set at the rate established for the 1995–96 fiscal year.

(d) Notwithstanding subdivision (a), the maximum allowable rate for group outpatient drug free services shall be set on a per person basis. A group shall consist of a minimum of 2 and a maximum of 12 individuals, at least one of which shall be a Medi-Cal eligible beneficiary. For groups consisting of two individuals, if one of the individuals is ineligible for Medi-Cal, the individual who is ineligible for Medi-Cal shall be receiving outpatient drug free services for a substance use disorder diagnosed by a physician.

(e) The department shall develop individual and group rates for extensive counseling for outpatient drug free treatment, based on a 50-minute individual or a 90-minute group hour, not to exceed the total rate established for subdivision (d).

(f) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of bulletins or similar instructions until the time any necessary regulations are adopted. The department shall adopt regulations by July 1, 2020, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act that added this paragraph, and notwithstanding Section 10231.5 of the Government Code, the department shall, on a semiannual basis and in compliance with Section 9795 of the Government Code, provide a status report to the Legislature until the regulations have been adopted.

(2) Notwithstanding paragraph (1) and Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may annually establish and update the statewide maximum allowable reimbursement rates specified in this section by means of bulletins or similar instructions.

(g) Bills for services under the Drug Medi-Cal Treatment Program shall be submitted no later than 12 months from the date of service.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 119. (AB 118) Effective July 10, 2023.)

article: 1. General Provisions


text:
(a) The department shall amend the state plan for medical assistance under the Medicaid program pursuant to subdivision (g) of Section 1396n of Title 42 of the United States Code, to add targeted case management services for those pregnant and parenting adolescents and their children, targeted by the department, in those localities served on January 1, 1991, by the Adolescent Family Life Program (Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106 of the Health and Safety Code), as a covered benefit under the Medi-Cal program. The department shall submit the amended plan for federal approval by April 1, 1991.

(b) For purposes of this section, the term “targeted case management services” shall be defined as those services provided to pregnant and parenting adolescents pursuant to Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106 of the Health and Safety Code.

(c) Upon federal approval for federal financial assistance, the department shall establish the standards under which targeted case management services qualify as a Medi-Cal reimbursable service, subject to the availability of funding through the budget process, and shall develop an appropriate rate of reimbursement, subject to utilization controls.

history: (History: Amended by Stats. 1996, Ch. 1023, Sec. 469. Effective September 29, 1996.)

article: 1. General Provisions


text: The department may not utilize any information regarding whether a beneficiary’s psychiatric inpatient admission was made on a voluntary or involuntary basis for the purpose of determining eligibility for Medi-Cal claim reimbursement.

history: (History: Added by Stats. 2001, Ch. 506, Sec. 10. Effective January 1, 2002.)

article: 1. General Provisions


text:
(a) Notwithstanding any other law, for the 2009–10 fiscal year, a 10-percent reduction shall be applied to rates for Drug Medi-Cal services developed by the State Department of Alcohol and Drug Programs pursuant to Section 11758.42 of the Health and Safety Code and Sections 14021.35, 14021.5, and 14021.6.

(b) For the 2010–11 and 2011–12 fiscal years, rates for Drug Medi-Cal services shall be the lower of the following:

(1) The rates developed by the State Department of Alcohol and Drug Programs pursuant to Section 11758.42 of the Health and Safety Code and Sections 14021.35, 14021.5, and 14021.6.

(2) The rates applicable in the 2009–10 fiscal year pursuant to subdivision (a), adjusted for the cumulative growth in the Implicit Price Deflator for the Costs of Goods and Services to Governmental Agencies, as reported by the Department of Finance.

(c) For the 2012–13 fiscal year and each fiscal year thereafter, rates for Drug Medi-Cal reimbursable services shall be the lower of the following:

(1) The rates developed pursuant to Sections 14021.35, 14021.51, and 14021.6.

(2) The rates applicable in the 2009–10 fiscal year pursuant to subdivision (a), adjusted for the cumulative growth in the Implicit Price Deflator for the Costs of Goods and Services to Governmental Agencies, as reported by the Department of Finance.

(d) The rate reductions applicable for the 2009–10 fiscal year pursuant to subdivision (a) shall be applied retroactively to July 1, 2009.

history: (History: Amended by Stats. 2012, Ch. 36, Sec. 79. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions


text:
(a) It is the intent of the Legislature to transfer to the State Department of Health Care Services, no later than July 1, 2012, the administration of the Drug Medi-Cal program from the State Department of Alcohol and Drug Programs. It is further the intent of the Legislature that this transfer should happen efficiently and effectively, with no unintended interruptions in service delivery. This transfer is intended to do all of the following:

(1) Improve access to alcohol and drug treatment services, including a focus on recovery and rehabilitation services.

(2) More effectively integrate the financing of services, including the receipt of federal funds.

(3) Improve state accountability and outcomes.

(4) Provide focused, high-level leadership for behavioral health services.

(b) Effective July 1, 2012, the administrative functions for the Drug Medi-Cal program that were previously performed by the State Department of Alcohol and Drug Programs are transferred to the department.

(c) Notwithstanding subdivision (b), the department and the State Department of Alcohol and Drug Programs may conduct transition activities prior to July 1, 2012, that are necessary to ensure the efficient and effective transfer of Drug Medi-Cal program functions by that date in accordance with the transition plan described in Section 14021.31.

(d) After July 1, 2012, and through the quarter ending June 30, 2014, the department shall provide quarterly updates to the Legislature, key stakeholders, and the public on the steps foreseen, planned, and completed for the Drug Medi-Cal transfer, noting areas of concern, delay, or disruption, as the program fully transitions to the State Department of Health Care Services. These updates shall include information on continuity of care for beneficiaries and any access issues to care that arise as a result of or within the Drug Medi-Cal transfer. The State Department of Health Care Services shall convene meetings with interested stakeholders, including legislative representatives, either in preparation for or at the release of these quarterly updates. The first of these quarterly updates shall be released no later than October 1, 2012.

history: (History: Amended by Stats. 2012, Ch. 36, Sec. 73. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions


text:
The department, in collaboration with the State Department of Alcohol and Drug Programs, shall develop an administrative and programmatic transition plan to guide the transfer of the Drug Medi-Cal program to the department effective July 1, 2012.

(a) Commencing no later than July 15, 2011, the department, together with the State Department of Alcohol and Drug Programs, shall convene stakeholders to receive input from consumers, family members, providers, counties, and representatives of the Legislature concerning the transfer of the administration of Drug Medi-Cal functions currently performed by the State Department of Alcohol and Drug Programs to the department. This consultation shall inform the creation of an administrative and programmatic transition plan that shall include, but is not limited to, the following components:

(1) Plans for how to review monthly billing from counties to monitor and prevent any disruptions of service to Drug Medi-Cal beneficiaries during and immediately after the transition, and a description of how the department intends to approach the longer-term development of measures for access and quality of service.

(2) A detailed description of the Drug Medi-Cal administrative functions currently performed by the State Department of Alcohol and Drug Programs.

(3) Explanations of the operational steps, timelines, and key milestones for determining when and how each of these functions will be transferred. These explanations shall also be developed for the transition of position and staff serving the Drug Medi-Cal program and how these will relate to and align with positions for the Medi-Cal program at the department. The department shall consult with the Department of Human Resources in developing this aspect of the transition plan.

(4) A list of any planned or proposed changes or efficiencies in how the functions will be performed, including the anticipated fiscal and programmatic impacts of the changes.

(5) A detailed organization chart that reflects the planned staffing at the department, taking into account the requirements of subparagraphs (A) to (C), inclusive, and includes focused, high-level leadership for behavioral health issues.

(6) A description of how stakeholders were included in the initial planning process to formulate the transition plan, and a description of how their feedback will be taken into consideration after transition activities are underway.

(b) The department, together with the State Department of Alcohol and Drug Programs, shall convene and consult with stakeholders at least once following production of a draft of the transition plan and before submission of that plan to the Legislature. Continued consultation with stakeholders shall occur in accordance with the requirement in subparagraph (F) of paragraph (1).

history: (History: Amended by Stats. 2018, Ch. 903, Sec. 22. (SB 1504) Effective January 1, 2019.)

article: 1. General Provisions


text: A regulation or order concerning the Drug Medi-Cal Treatment Program adopted by the State Department of Alcohol and Drug Programs pursuant to former Chapter 3.4 (commencing with Section 11758.40) of Part 1 of Division 10.5 of the Health and Safety Code, as in effect preceding the effective date of the act that added this section, shall remain in effect and shall be fully enforceable, unless and until the readoption, amendment, or repeal of the regulation or order by the department, or until it expires by its own terms.

history: (History: Added by Stats. 2012, Ch. 36, Sec. 74. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions


text:
(a) The department shall prepare and submit amendments to the Medicaid state plan and apply for any necessary waivers in order to obtain federal financial participation to implement Drug Medi-Cal Treatment Program provisions contained in Section 14124.24.

(b) Upon federal approval for federal financial assistance, the department, in consultation with the State Department of Alcohol and Drug Programs, shall define the Drug Medi-Cal services, as needed, shall establish the standards under which those services qualify as Drug Medi-Cal reimbursable services, and shall develop appropriate rates of reimbursement for those services, subject to utilization controls.

history: (History: Amended by Stats. 2012, Ch. 36, Sec. 75. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

article: 1. General Provisions