text:
(a) Consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit pursuant to subdivision (v) of Section 14132 shall include developmental screening services for individuals zero to three years of age, inclusive.

(b) Medi-Cal managed care plans shall ensure, and monitor compliance with, both of the following:

(1) Developmental screening services provided by providers who contract with Medi-Cal managed care plans comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care, as established by the American Academy of Pediatrics, and by any future updates to this material.

(2) Developmental screening tools administered by providers who contract with Medi-Cal managed care plans are administered in their entirety, and in adherence to, the specific tools’ recommended guidelines.

(c) This section does not limit or restrict the scope of the EPSDT benefit, as required to be provided to eligible Medi-Cal beneficiaries under 21 years of age pursuant to Section 1396d(r) of Title 42 of the United States Code.

(d) This section does not limit or restrict blood lead screenings required under Chapter 5 (commencing with Section 105275) of Part 5 of Division 103 of the Health and Safety Code.

history: (History: Added by Stats. 2019, Ch. 387, Sec. 2. (AB 1004) Effective January 1, 2020.)

article: 4. The Medi-Cal Benefits Program


kind: section

code: WIC

text:
(a) (1) Notwithstanding any other law, neither face-to-face contact nor a patient’s physical presence on the premises shall be required for services provided by an enrolled community clinic to a Medi-Cal beneficiary during or immediately following a state of emergency, as described in Section 8628.5 of the Government Code.

(2) Notwithstanding any other law, the department may apply paragraph (1) to services provided by another enrolled fee-for-service Medi-Cal provider, clinic, or facility during or immediately following a state of emergency.

(b) For purposes of this section, the following terms have the following meanings:

(1) (A) “Enrolled community clinic” means a community clinic licensed under subdivision (a) of Section 1204 of the Health and Safety Code, an intermittent clinic exempt from licensure under subdivision (h) of Section 1206 of the Health and Safety Code, a clinic operated by the state or any of its political subdivisions, including, but not limited to, the University of California or a city or county that is exempt from licensure under subdivision (b) of Section 1206 of the Health and Safety Code, a tribal clinic exempt from licensure under subdivision (c) of Section 1206 of the Health and Safety Code, or an outpatient setting conducted, maintained, or operated by a federally recognized Indian tribe, tribal organization, or urban Indian organization, as defined in Section 1603 of Title 25 of the United States Code, that is certified, as applicable, and enrolled in good standing as a Medi-Cal provider or, in the case of an intermittent site, is added to a parent clinic’s provider master file under Section 14043.15.

(B) An outpatient setting that operates as a federally qualified health center (FQHC) or a rural health center (RHC) shall qualify as an enrolled community clinic, regardless of its license type or license-exempt status.

(2) “Immediately following” means up to 90 calendar days, as deemed appropriate by the department, following the termination of the proclaimed state of emergency, as described in Section 8629 of the Government Code. Under extraordinary circumstances, including, but not limited to, the destruction of an enrolled location, as described in subdivision (a), the department may extend, in its discretion or at the direction of the Governor, the period of time immediately following the termination of a state of emergency beyond 90 calendar days and for as long as is necessary for the health and safety of the public.

(3) (A) “Premises” means either of the following, as applicable:

(i) A site located within the four walls of the enrolled community clinic, and at the address listed either on the primary care clinic license or in the provider master file.

(ii) A site located within the four walls of the enrolled fee-for-service Medi-Cal provider, clinic, or facility, and at the address listed either on its license or in the provider master file.

(B) For purposes of an FQHC or RHC, “premises” include a site located outside of the four walls of the FQHC or RHC, and at an address other than the address listed on its license or in the provider master file, but within the boundaries of the proclamation declaring the state of emergency.

(4) “Telehealth” has the same meaning as provided in Section 2290.5 of the Business and Professions Code.

(5) “Telephonic services” means health services provided via telephone with audio component only.

(c) The following services shall be reimbursable when provided by an enrolled community clinic, an enrolled fee-for-service Medi-Cal program provider, clinic, or facility approved by the department pursuant to paragraph (2) of subdivision (a) during or immediately following a state of emergency for any dates of service on or after the date that the department obtains federal approvals and federal matching funds to implement these provisions pursuant to subdivision (f).

(1) Telehealth services, including services provided by the enrolled community clinic or approved enrolled provider, clinic, or facility at a distant site location, whether on or off the premises, to a Medi-Cal beneficiary located at an originating site, which includes the beneficiary’s home, temporary shelter, or any other location, if the services are provided somewhere located within the boundaries of the proclamation declaring the state of emergency.

(2) Telephonic services.

(3) Covered benefit services that are otherwise reimbursable to an FQHC or RHC, but that are provided somewhere off the premises, including, but not limited to, at a temporary shelter, a Medi-Cal beneficiary’s home, or any location other than the premises, but within the boundaries of the proclamation declaring the state of emergency.

(d) For purposes of paragraph (1) of subdivision (c), and consistent with Section 14132.72, the department shall ensure its reimbursement policies reflect the intent of the Legislature to authorize reimbursement for telehealth services appropriately provided by an enrolled community clinic, or, if approved by the department pursuant to paragraph (2) of subdivision (a), by an enrolled fee-for-service Medi-Cal provider, clinic, or facility, respectively, during or immediately following a state of emergency. This subdivision does not limit reimbursement for, or coverage of, or reduce access to, services provided through telehealth on or before the enactment of this section.

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

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

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

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

history: (History: Added by Stats. 2019, Ch. 829, Sec. 1. (AB 1494) Effective January 1, 2020.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 4. The Medi-Cal Benefits Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 4. The Medi-Cal Benefits Program


text:
(a) On or before July 1, 2020, the department shall issue, and shall publish on its internet website, guidance for enrolled community clinics and other enrolled fee-for-service Medi-Cal providers, clinics, or facilities that are subject to Section 14132.723 in order to facilitate reimbursement for services provided pursuant to Section 14132.723, whether those services are provided at a health facility, a shelter, the Medi-Cal beneficiary’s home, or any other location within the boundaries of the emergency proclamation for the state of emergency, as described in Section 8628.5 of the Government Code. This guidance shall include, at a minimum, all of the following information:

(1) Instructions, including examples, describing how enrolled community clinics and other enrolled fee-for-service Medi-Cal providers, clinics, or facilities submit claims for telehealth or telephonic services, as described in Section 14132.723, to Medi-Cal beneficiaries located outside the premises of the enrolled community clinic or other enrolled fee-for-service Medi-Cal provider, clinic, or facility during or immediately following a state of emergency.

(2) Direction to Medi-Cal managed care plans on paying any claims submitted in accordance with the guidance issued under this section, including that Medi-Cal managed care plans contracting with the department under the Medi-Cal program are responsible for ensuring their delegated payers comply with all applicable federal and state laws, regulations, contract requirements, and any department-issued guidance related to the provision of services by enrolled community clinics or other providers, clinics, or facilities during or immediately following a state of emergency.

(3) (A) Identification of services, provided during or immediately following a state of emergency, that may be provided solely through a telephonic visit, and identification of services that require other forms of telehealth, such as a live, synchronous video interaction, asynchronous store and forward, or an interactive telecommunications system.

(B) Identification of telephonic, facsimile, email, or remote patient monitoring devices that may be used and reimbursed as part of a Medi-Cal covered service, including, but not limited to, laboratory, x-ray, or physician services, subject to any required federal approvals or waivers sought under subdivision (d).

(4) Policies for ensuring prompt payment of claims submitted by enrolled community clinics or other enrolled fee-for-service Medi-Cal providers, clinics, or facilities for services provided during or immediately following a state of emergency, including, but not limited to, the temporary waiver of documentation requirements and streamlined billing or appeal processes for commonly owned entities.

(b) For purposes of this section, the following terms have the following meanings:

(1) “Asynchronous store and forward” has the same meaning as provided in Section 2290.5 of the Business and Professions Code.

(2) “Immediately following” has the same meaning as provided in Section 14132.723.

(3) “Interactive telecommunications system” has the same meaning as provided in Section 410.78 of Title 42 of the Code of Federal Regulations.

(4) “Premises” has the same meaning as provided in Section 14132.723.

(5) “Telehealth” has the same meaning as provided in Section 2290.5 of the Business and Professions Code.

(c) The department shall seek federal approval of any necessary state plan amendments or waivers to implement this section, including, but not limited to, any demonstration program or similar opportunities allowing a telephonic visit to be used as a substitute for other forms of telehealth, such as synchronous video interaction, asynchronous store and forward, or an interactive telecommunications system.

(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. The department shall adopt regulations by January 1, 2024, 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.

history: (History: Added by Stats. 2019, Ch. 829, Sec. 2. (AB 1494) Effective January 1, 2020.)

article: 4. The Medi-Cal Benefits Program


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

(1) “Border community” means border areas adjacent to the State of California where it is customary practice for California residents to use medical resources in adjacent areas outside the state. Under these circumstances, program controls and limitations are the same as for services rendered by health care providers within the state.

(2) “Health care provider” has the same meaning as set forth in paragraph (3) of subdivision (a) of Section 2290.5 of the Business and Professions Code, and shall be either enrolled as a Medi-Cal rendering provider, or a nonphysician medical practitioner affiliated with an enrolled Medi-Cal provider group. “Health care provider” also includes any provider type designated by the department pursuant to subparagraph (A) of paragraph (2) of subdivision (b). The enrolled Medi-Cal provider or provider group for which the health care provider renders services via telehealth shall meet all Medi-Cal requirements and shall be located in the state or a border community.

(3) “Health care service plan” has the same meaning as set forth in subdivision (f) of Section 1345 of the Health and Safety Code.

(4) “Medi-Cal managed care plan” has the same meaning as set forth in subdivision (j) of Section 14184.101.

(5) “Network provider” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations.

(6) “Telehealth” has the same meaning as set forth in paragraph (6) of subdivision (a) of Section 2290.5 of the Business and Professions Code.

(b) (1) Subject to subdivision (k), in-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

(2) (A) In implementing this section, the department shall designate and periodically update the covered health care services and provider types, including required licensing and credentialing criteria, as applicable, which may be appropriately delivered via the telehealth modalities described in this subdivision.

(B) Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Subject to subdivision (k), utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

(c) (1) (A) Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice.

(B) (i) The department may provide specific exceptions to the requirement specified in subparagraph (A), based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

(ii) In making exceptions to the requirement specified in subparagraph (A), in addition to the provisions in clause (i), the department may also take into consideration the availability of broadband access based on speed standards set by the Federal Communications Commission, pursuant to Section 706 of the Telecommunications Act of 1996 (Pub. L. No. 104-104) or other applicable federal law or regulation.

(2) Effective on the date designated by the department pursuant to paragraph (1), a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also maintain and follow protocols to do one of the following:

(A) Offer those services via in-person, face-to-face contact.

(B) (i) Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

(ii) Clause (i) does not require a provider to schedule an appointment with a different provider on behalf of a patient.

(3) In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

(4) A health care provider may establish a new patient relationship with a Medi-Cal beneficiary via video synchronous interaction consistent with any requirements imposed by the department.

(5) (A) A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, telephonic (audio-only) synchronous interaction, remote patient monitoring, or other virtual communication modalities, except as set forth in paragraph (4) of subdivision (g) of Section 14132.100.

(B) Notwithstanding the prohibition in subparagraph (A), the department may provide for specific exceptions to this prohibition, the department may provide for specific exceptions described in clauses (i) and (ii), which shall be developed in consultation with affected stakeholders and published in departmental guidance.

(i) Notwithstanding the prohibition in subparagraph (A), a health care provider may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (p) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state law, regulations, and guidance.

(ii) Notwithstanding the prohibition in subparagraph (A), a health care provider may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.

(6) Subject to subdivision (k), the department may establish separate fee schedules for applicable health care services delivered via remote patient monitoring or other permissible virtual communication modalities.

(7) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

(d) In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by a health care provider to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider.

(1) The provider shall document in the patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received.

(2) The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subdivision.

(3) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

(e) (1) The department shall develop, in consultation with affected stakeholders, an informational notice to be distributed to fee-for-service Medi-Cal beneficiaries and for use by Medi-Cal managed care plans in communicating to their enrollees. Information in the notice shall include, but not be limited to, all of the following:

(A) The availability of Medi-Cal covered telehealth services.

(B) The beneficiary’s right to access all medically necessary covered services through in-person, face-to-face visits, and a provider’s and Medi-Cal managed care plan’s responsibility to offer or arrange for that in-person care, as applicable.

(C) An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn by the Medi-Cal beneficiary at any time without affecting their ability to access covered Medi-Cal services in the future.

(D) An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted.

(E) Notification of the beneficiary’s right to make complaints about the offer of telehealth services in lieu of in-person care or about the quality of care delivered through telehealth.

(2) The informational notice shall be translated into threshold languages determined by the department pursuant to subdivision (b) of Section 14029.91 and provided in a format that is culturally and linguistically appropriate.

(3) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

(f) (1) Subject to subdivision (k), the department shall reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

(2) Subject to subdivision (k), for applicable health care services appropriately provided by a network provider via video synchronous interaction, audio-only synchronous interaction modality, or asynchronous store and forward, as applicable, to an enrollee of a Medi-Cal managed care plan, the Medi-Cal managed care plan shall reimburse the network provider at payment amounts that are not less than the amounts the network provider would have received if the services were delivered via in-person, face-to-face contact, unless the Medi-Cal managed care plan and network provider mutually agree to reimbursement in different amounts.

(g) On or before January 1, 2023, the department shall develop a research and evaluation plan that does all of the following:

(1) Proposes strategies to analyze the relationship between telehealth and the following: access to care, access to in-person care, quality of care, and Medi-Cal program costs, utilization, and program integrity.

(2) Examines issues using an equity framework that includes stratification by available geographic and demographic factors, including, but not limited to, race, ethnicity, primary language, age, and gender, to understand inequities and disparities in care.

(3) Prioritizes research and evaluation questions that directly inform Medi-Cal policy.

(h) Applicable health care services provided through asynchronous store and forward, video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities as described in this section shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations.

(i) 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, and make specific this section by means of all-county letters, plan letters, provider bulletins, and similar instructions, without taking any further regulatory action.

(j) Consistent with the requirements of this section and subject to subdivision (k), a PACE organization approved by the department pursuant to Chapter 8.75 (commencing with Section 14591) may use video telehealth to conduct initial assessments and annual reassessments for eligibility for enrollment in the PACE program.

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

(l) This section shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subdivision (k), whichever is later.

(m) This section does not apply to health care services provided via telehealth in an FQHC or RHC visit as described in paragraph (4) of subdivision (g) of Section 14132.100.

history: (History: Amended by Stats. 2023, Ch. 172, Sec. 1. (AB 1241) Effective January 1, 2024. Conditionally operative on or after January 1, 2023, by its own provisions.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) Commencing in 2028 and every two years thereafter, the department shall use Medi-Cal data and other data sources available to the department to produce analyses in a publicly available Medi-Cal telehealth utilization report.

(2) The department may include the analyses described in paragraph (1) in each of the department’s Biennial Telehealth Utilization Reports. A report described in paragraph (1) may be an update to the department’s Biennial Telehealth Utilization Report, if the department continues to publish that report since its inception in 2024, or it may be a different applicable report published by the department.

(b) The analyses described in subdivision (a) shall address telehealth access and utilization data, including all of the following:

(1) Telehealth visits per 100,000 Medi-Cal member months. This information shall be disaggregated by demographics and other metrics, including, but not limited to, age group, race and ethnicity, sex, primary language, county, county size, aid code group, and Medi-Cal managed care plan.

(2) Telehealth visits and all outpatient visits.

(3) Commonly utilized Current Procedural Terminology (CPT) codes for outpatient telehealth visits.

(4) Percentage of Medi-Cal members by number of telehealth claims.

(5) Utilization of telehealth by Medi-Cal members with multiple claims with a higher-than-average rate of use. This information shall be disaggregated by demographics and other metrics, including, but not limited to, age group, race and ethnicity, sex, primary language, aid code group, and number and percentage of telehealth utilizers per reporting period.

(6) Telehealth visits of specialty mental health services and nonspecialty mental health services.

(7) Telehealth visits of outpatient dental services.

(8) New patient telehealth claims utilization by modality mix.

(9) Established patient telehealth claims utilization by modality mix.

(10) Commonly utilized medical outpatient health services delivered via telehealth.

(11) Telehealth visits as a percentage of all medical outpatient health services.

(c) (1) Wherever possible based on the availability of data, the analyses described in subdivision (a) shall be disaggregated by geographic, demographic, and social determinants of health categories to identify disparities.

(2) Social determinants of health categories may be approximated using existing data sources, including the Healthy Places Index or similar indices.

(d) In addition to the data elements described in subdivision (b), the department shall identify other data elements, including, but not limited to, data on patient outcomes and population health, for inclusion in future reports to help to identify and address access-to-care issues or provide greater insight into utilization of telehealth modalities.

history: (History: Added by Stats. 2025, Ch. 437, Sec. 2. (AB 688) Effective January 1, 2026.)

article: 4. The Medi-Cal Benefits Program


text:
(a) A county that enters into a Drug Medi-Cal Treatment Program contract with the department in accordance with Section 14124.20, or the department if entering into a Drug Medi-Cal Treatment Program contract directly with providers or as otherwise described in Section 14124.21, shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction.

(b) A Drug Medi-Cal certified provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other virtual communication modalities, except as set forth in paragraph (4) of subdivision (g) of Section 14132.100. Notwithstanding this prohibition, the department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

(c) Drug Medi-Cal reimbursable services provided through a video synchronous interaction or an audio-only synchronous interaction pursuant to subdivision (a) shall be subject to billing, reimbursement, and utilization management policies imposed by the department.

(d) Drug Medi-Cal reimbursable services provided through a video synchronous interaction or an audio-only synchronous interaction shall be provided in compliance with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, Part 2 of Title 42 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations.

(e) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available.

(f) The department shall adopt regulations by July 1, 2024, to implement this section in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).

(g) Notwithstanding the rulemaking provisions of the Administrative Procedure Act, the department may, if it deems it appropriate, implement, interpret, or make specific this section by means of provider bulletins, written guidelines, or similar instructions from the department, until regulations are adopted.

history: (History: Repealed and added by Stats. 2022, Ch. 47, Sec. 101. (SB 184) Effective June 30, 2022.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Commencing no sooner than July 1, 2022, dyadic behavioral health visits shall be a covered benefit under the Medi-Cal program, subject to utilization controls.

(b) The dyadic services benefit is a family- and caregiver-focused model of care intended to address developmental and behavioral health conditions of children as soon as they are identified, and that fosters access to preventive care for children, rates of immunization completion, coordination of care, child social-emotional health and safety, developmentally appropriate parenting, and maternal mental health. Dyadic behavioral health visits are provided for the child and caregiver or parent at medical visits, providing screening for behavioral health problems, interpersonal safety, tobacco and substance misuse and social determinants of health, such as food insecurity and housing instability, and referrals for appropriate followup care.

(c) This section shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.

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

history: (History: Added by Stats. 2021, Ch. 143, Sec. 392. (AB 133) Effective July 27, 2021.)

article: 4. The Medi-Cal Benefits Program


text:
(a) No treatment authorization request shall be required for the provision of prosthetic devices or for the replacement or repair of prosthetic devices, if the cost does not exceed five hundred dollars ($500).

(b) No treatment authorization request shall be required for the provision of orthotic devices or for the replacement or repair of orthotic devices, if the cost does not exceed two hundred fifty dollars ($250).

(c) The department shall implement subdivisions (a) and (b) commencing March 1, 1994.

(d) Notwithstanding subdivision (c), the department shall implement subdivisions (a) and (b) only if one of the following occurs:

(1) The report required by Section 14132.76 contains a conclusion that the pilot demonstration program required by that section was cost-effective.

(2) The report required by Section 14132.76 is not submitted to the appropriate committees of the Legislature by December 31, 1993.

(d) Notwithstanding subdivisions (a) and (b), the director may reinstate the requirement for prior authorization if the director determines that the elimination of the requirement results in unnecessary utilization, after notice to the Joint Legislative Budget Committee 30 days prior to the reinstatement of the requirement for prior authorization.

history: (History: Added by Stats. 1993, Ch. 460, Sec. 1. Effective January 1, 1994.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Day care habilitative services, pursuant to subdivision (c) of Section 14021, shall be provided only to alcohol- and drug-exposed pregnant women and women in the postpartum period, or as required by federal law.

(b) This section shall become operative on July 1, 2013.

history: (History: Added by Stats. 2013, Ch. 22, Sec. 106. (AB 75) Effective June 27, 2013. Adding action operative July 1, 2013, by Sec. 110 of Ch. 22. Section operative July 1, 2013, by its own provisions.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) The department shall establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. The performance measures shall be designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment.

(2) Prior to establishing the quality and access criteria described in paragraph (1), the department shall consult with stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.

(3) The performance measures established by the department to monitor the dental fee-for-service program for children shall include, but not be limited to, all of the following:

(A) Overall utilization of dental services.

(B) For each provider, all of the following:

(i) Number of annual dental visits.

(ii) Number of annual preventive dental services.

(iii) Number of annual dental treatment services.

(iv) Number of annual examinations and oral health evaluations.

(C) Number of applications of dental sealants and fluoride varnishes.

(D) Continuity of care and overall utilization over an extended period of time.

(E) All of the following ratios:

(i) Sealant to restoration.

(ii) Filling to preventive services.

(iii) Treatment to caries prevention.

(F) No sooner than January 1, 2018, number of beneficiaries requiring general anesthesia to perform procedures.

(4) The performance measures established by the department to monitor the dental fee-for-service program for adults shall include, but not be limited to, all of the following:

(A) Overall utilization of dental services.

(B) For each provider, all of the following:

(i) Number of annual dental visits.

(ii) Number of annual preventive dental services.

(iii) Number of annual dental treatment services.

(iv) Number of annual examinations and oral health evaluations.

(C) Treatment to caries prevention ratio.

(5) The performance measures shall be reported as aggregate numbers and as percentages, if appropriate, using standards that are as equivalent to those used by managed care entities as feasible. Performance measures for the dental fee-for-service program for children shall be reported by age groupings if appropriate.

(b) The department shall include the initial list of performance measures in any dental contract entered into between the department and a fee-for-service contractor on or after enactment of this section.

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

(1) Annual and multiyear Medi-Cal dental fee-for-service trended data.

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

(3) Other state and national performance ratings.

(d) On October 1, 2014, for the 2013 calendar year, and on or before October 1, 2016, for the 2015 calendar year, the list of performance measures established by the department along with the data of the dental fee-for-service program performance shall be posted on the department’s Internet Web site.

(e) Commencing January 31, 2017, for the 2015–16 fiscal year, and annually on or before January 31 for each preceding fiscal year thereafter, the list of performance measures established by the department along with the data of the dental fee-for-service program shall be posted on the department’s Internet Web site.

(f) Commencing April 30, 2017, for the July 2016 to September 2016, inclusive, fiscal quarter, and quarterly thereafter on or before April 30, July 31, October 31, and January 31 for the fiscal quarter ending seven months prior, the data of the dental fee-for-service program performance shall be posted on the department’s Internet Web site.

(g) The department may amend or remove performance measures and establish additional performance measures in accordance with all of the following:

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

(2) The department shall notify a fee-for-service contractor, at least 30 days prior to the implementation date, of any updates or changes to performance measures. The department shall also post these updates or changes on its Internet Web site at least 30 days prior to implementation in order to maintain transparency to the public.

(3) In establishing the performance measures, the department shall consult with stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties.

(h) The department shall annually prepare a summary report of the nature and types of complaints and grievances regarding access to, and quality of, dental services, including the outcome. Commencing January 31, 2017, for the prior fiscal year, and annually thereafter, for each preceding fiscal year, this report shall be posted on the department’s Internet Web site.

(i) The department shall ensure, to the greatest degree possible, that the categories of data and performance measures selected under this section are consistent with the categories of data and performance measures selected under Section 14459.6.

(j) No sooner than July 1, 2019, the department shall annually publish utilization data from the preceding calendar year and post this material on its Internet Web site. The utilization data shall be made publicly available for both the dental fee-for-service and dental managed care programs. The utilization data shall include all of the following information:

(1) Number of patients seen on a per-provider basis.

(2) Number of annual preventative dental services, dental treatment services, examinations, and oral health evaluations rendered by each provider during each calendar year.

(3) Number of beneficiaries who received general anesthesia services.

history: (History: Amended by Stats. 2016, Ch. 613, Sec. 1. (AB 2207) Effective January 1, 2017.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) Notwithstanding any other provision of law or regulation to the contrary, to the extent federal financial participation is available, in furtherance of Section 14105.06 and subdivisions (a) and (c) of Section 14132.92, effective July 1, 2007, a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall be responsible for providing day treatment and transportation services consistent with Section 14105.06 and subdivision (a) of Section 14132.92, that are selected and authorized through the individual program plan process pursuant to Sections 4646 and 4646.5 and applicable regulations, for each beneficiary receiving those services who resides in that licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled.

(2) (A) The services described in paragraph (1) shall be arranged by the regional center pursuant to Sections 4646 and 4646.5 and applicable regulations.

(B) The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center for the full costs of making the disbursements to day treatment and transportation service providers.

(3) Nothing in this section shall authorize the licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled to substitute day treatment or transportation services not selected and authorized through the individual program plan process pursuant to Sections 4646 and 4646.5 and applicable regulations.

(b) (1) The State Department of Developmental Services shall be responsible for reimbursing a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled for the costs of reimbursing the regional center for the full cost of making disbursements for day treatment and transportation services, plus a coordination fee which will include an administrative fee and reimbursement for increased costs associated with the quality assurance fee. This payment shall be a supplement to the Medi-Cal payment from the State Department of Health Care Services described in Sections 14105.06 and 14132.92.

(2) A licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled may authorize the regional center to invoice the State Department of Developmental Services on its behalf for the services described in subdivision (a).

(3) (A) The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center for the full costs of making disbursements for day treatment and transportation services within 30 days of receipt of payment from the State Department of Developmental Services pursuant to instructions from the State Department of Developmental Services.

(B) If there is a failure to reimburse the regional center within 30 days of receipt of payment from the State Department of Developmental Services, for all or part of the costs associated with disbursement for day treatment and transportation services, the outstanding amount shall be recovered by any of the following methods:

(i) Lump sum payment by the provider.

(ii) Offset against current payments due to the provider from the State of California.

(iii) A repayment agreement between the provider and the State of California.

(c) (1) A licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall report the costs incurred pursuant to subdivision (a) according to instructions from the State Department of Health Care Services.

(2) 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 this subdivision by means of a provider bulletin or similar instruction.

(d) (1) If the services meeting the conditions of subdivision (a) have been provided to a Medi-Cal beneficiary on or after July 1, 2007, and, notwithstanding Section 14115, a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled may authorize the regional center to invoice the State Department of Developmental Services on its behalf for arranging for the services described in subdivision (a). The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center the full cost of making disbursements for day treatment and transportation services within 30 days of receipt of payment from the State Department of Developmental Services pursuant to instruction from the State Department of Developmental Services. If a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled fails to reimburse the regional center within 30 days of receipt of payment from the State Department of Developmental Services, for all or part of the costs associated with the day treatment and transportation services, the outstanding amount shall be recovered by any of the following methods:

(A) Lump sum payment by the provider.

(B) Offset against current payments due to the provider from the State of California.

(C) A repayment agreement between the provider and the State of California.

(2) The department shall seek federal financial participation, including any moneys available pursuant to the American Recovery and Reinvestment Act of 2009 (Public Law 111-5), pursuant to a federally approved state plan amendment authorizing reimbursement for costs incurred pursuant to subdivision (a) for day treatment and transportation services provided on or after July 1, 2007.

(3) Upon approval of the state plan amendment, the reimbursement payments made pursuant to this section by the State Department of Developmental Services to a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall be subject to the quality assurance fee imposed upon designated intermediate care facilities pursuant to Article 7.5 (commencing with Section 1324) of Chapter 2 of Division 2 of the Health and Safety Code.

(4) If federal financial participation is not made available for day treatment and transportation services provided on or after July 1, 2007, the services nonetheless shall be reimbursed from the General Fund by the State Department of Developmental Services.

(e) The State Department of Health Care Services shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this section. The Director of Health Care Services, with the concurrence of the Director of Developmental Services, may alter the methodology specified in this section to the extent necessary to meet the requirements of federal law or regulations or to obtain federal approval. If after seeking federal approval, federal approval is not obtained or federal financial participation is no longer available, this section and Section 4646.55 shall not be implemented or shall become inoperative.

history: (History: Added by Stats. 2010, Ch. 717, Sec. 157. (SB 853) Effective October 19, 2010. Conditionally inoperative as provided in subd. (e).)

article: 4. The Medi-Cal Benefits Program


text:
(a) It is the intent of the Legislature that the State Department of Health Services seek approval of a Medicaid waiver under the federal Social Security Act in order that the services available under Article 7 (commencing with Section 12300) of Chapter 3, known as the In-Home Supportive Services program, may be provided as a Medi-Cal benefit under this chapter, to the extent federal financial participation is available. The waiver shall be known as the “IHSS Plus waiver.”

(b) To the extent feasible, the IHSS Plus waiver described in subdivision (a) shall incorporate the eligibility requirements, benefits, and operational requirements of the In-Home Supportive Services program. The director shall have discretion to modify eligibility requirements, benefits, and operational requirements as needed to secure approval of the Medicaid waiver.

(c) Upon implementation of the IHSS Plus waiver, and to the extent federal financial participation is available, the services available through the In-Home Supportive Services program shall be furnished as benefits of the Medi-Cal program through the IHSS Plus waiver to persons who meet the eligibility requirements of the IHSS Plus waiver. The benefits shall be limited by the terms and conditions of the IHSS Plus waiver and by the availability of federal financial participation.

(d) Upon implementation of the IHSS Plus waiver:

(1) A person who is eligible for the IHSS Plus waiver shall no longer be eligible to receive services under the In-Home Supportive Services program to the extent those services are available through the IHSS Plus waiver.

(2) A person shall not be eligible to receive services pursuant to the IHSS Plus waiver to the extent those services are available pursuant to Section 14132.95.

(e) Services provided pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program.

(f) Services shall not be provided to residents of facilities licensed by the department, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the State Department of Social Services.

(g) To the extent permitted by federal law, reimbursement rates for services shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

(h) (1) Notwithstanding the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the provisions of this section through all-county welfare director letters or similar publications. Actions taken to implement, interpret, or make specific this section shall not be subject to the Administrative Procedure Act or to the review and approval of the Office of Administrative Law. Upon request of the department, the Office of Administrative Law shall publish the regulations in the California Code of Regulations. All county welfare director letters or similar publications authorized pursuant to this section shall remain in effect for no more than 18 months.

(2) The department may also adopt emergency regulations implementing the provisions of this section. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted. The department shall seek input from the entities listed in Section 12305.72 when developing the regulations, all county welfare director letters, or similar publications.

(i) In the event of a conflict between the terms of the IHSS Plus waiver and any provision of this part or any regulation, all-county welfare directors letters or similar publications adopted for the purpose of implementing this part, the terms of the waiver shall control to the extent that the services are covered by the waiver. If the department determines that a conflict exists, the department shall issue updated instructions to counties for the purposes of implementing necessary program changes. The department shall post a copy of, or a link to, the instructions on its Web site.

(j) (1) Notwithstanding subdivision (b) or any other provision of this section, the department shall not waive or modify the provisions of Section 12301.2, 12301.6, 12302.25, 12306.1, or 12309.

(2) Upon receipt of the IHSS Plus waiver, the director shall report to the Legislature on any modifications in benefits or eligibility and operational requirements of the In-Home Supportive Services program required for receipt of the waiver.

history: (History: Amended by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 45. Effective July 28, 2009.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The department shall seek approval of an amendment to the Medicaid state plan pursuant to Section 1396n(j) of Title 42 of the United States Code to provide self-directed personal assistance services under the state plan in order that the services available under Article 7 (commencing with Section 12300) of Chapter 3, known as the In-Home Supportive Services (IHSS) program, may be provided as a Medi-Cal benefit under this chapter, to the extent that federal financial participation is available. This program shall be known as the “IHSS Plus option.”

(b) To the extent feasible, the IHSS Plus option shall incorporate the eligibility requirements, benefits, and operational requirements of the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. The director shall have the discretion to modify these eligibility requirements, benefits, and operational requirements to the extent necessary to secure federal approval of the Medicaid state plan amendment.

(c) The services available through the IHSS Plus waiver pursuant to Section 14132.951 shall be furnished as benefits under the IHSS Plus option to the extent that federal financial participation is available to persons who meet the eligibility requirements of the IHSS Plus option. Upon implementation of the IHSS Plus option, a person who is eligible for services under the IHSS Plus option shall no longer be eligible to receive services under Section 14132.951.

(d) Upon implementation of the IHSS Plus option:

(1) A person who is eligible for the IHSS Plus option shall not be eligible to receive services under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3 to the extent those services are available through the IHSS Plus option.

(2) A person shall not be eligible to receive services pursuant to the IHSS Plus option to the extent those services are available pursuant to Section 14132.95.

(e) Services provided pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program.

(f) Services shall not be provided to residents of facilities licensed by the State Department of Public Health, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the State Department of Social Services.

(g) To the extent permitted by federal law, reimbursement rates for services under the IHSS Plus option shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

(h) (1) Notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) the department may implement the provisions of this section through all-county welfare director letters or similar publications. Actions taken to implement, interpret, or make specific this section shall not be subject to the Administrative Procedure Act or to the review and approval of the Office of Administrative Law. Upon request of the department, the Office of Administrative Law shall publish the regulations in the California Code of Regulations. All county welfare director letters or similar publications authorized pursuant to this section shall remain in effect for no more than 18 months.

(2) The department may also adopt emergency regulations implementing the provisions of this section. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review and approval by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted. The department shall seek input from the entities listed in Section 12305.72 when developing the regulations, all-county welfare director letters, or similar publications.

(i) (1) Notwithstanding subdivision (b) or any other provision of this section, the department shall not waive or modify the provisions of Section 12301.2, 12301.6, 12302.25, 12306.1, or 12309.

(2) Upon the federal Centers for Medicare and Medicaid Services’ approval of the Medicaid state plan amendment known as the “IHSS Plus option,” the director shall notify the Legislature of any modifications in benefits or eligibility and operational requirements of the In-Home Supportive Services program required for that Medicaid state plan amendment to become effective.

history: (History: Added by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 46. Effective July 28, 2009.)

article: 4. The Medi-Cal Benefits Program


text:
Personal care services that are provided pursuant to Section 14132.95 shall include services in the recipient’s place of employment if both of the following conditions are met:

(a) The personal care services are limited to those that are currently authorized for the recipient in the recipient’s home and those services are to be utilized by the recipient at the recipient’s place of employment to enable the recipient to obtain, retain, or return to, work. Authorized services utilized by the recipient at the recipient’s place of employment shall be services that are relevant and necessary in supporting and maintaining employment. However, work place services shall not be used to supplant any reasonable accommodations required of an employer by the Americans with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) or other legal entitlements or third-party obligations.

(b) The provision of personal care services at the recipient’s place of employment shall be authorized only to the extent that the total hours utilized at the work place are within the total personal care services hours authorized for the recipient in the home. Additional personal care services hours may not be authorized in connection with a recipient’s employment.

history: (History: Added by Stats. 2002, Ch. 1088, Sec. 9. Effective January 1, 2003.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The department shall assess and determine whether it would be cost efficient for the state to exercise the option made available under Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)). When performing this assessment, the department shall collaborate and consult with the State Department of Social Services, the State Department of Developmental Services, the California Department of Aging, and any other state agency that the department believes can assist in its determination whether it would be cost efficient for the state to exercise this option. If the department determines that it would be cost efficient for the state to exercise the federal option, it shall seek a Medi-Cal State Plan amendment to provide home- and community-based attendant services and supports that include assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks pursuant to Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)).

(b) If the department determines that it would be cost efficient to exercise the option made available under Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)), the department shall establish a development and implementation council that shall include, as a majority of its members, persons with disabilities and elderly individuals, and their representatives. The department shall consult and collaborate with the council when developing and implementing a Medi-Cal State Plan amendment to exercise this option.

(c) Services and supports pursuant to this section may be rendered under the administrative direction of other state departments in accordance with the Medi-Cal State Plan amendment and subject to the department’s authority as the designated single state agency for the administration or supervision of the administration of the Medi-Cal program.

(d) (1) Notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) the department, and any other state department pursuant to subdivision (c), may implement this section through all-county letters or similar instructions from the director, until regulations are adopted.

(2) The department, and any other state department rendering services and supports pursuant to subdivision (c), shall adopt emergency regulations implementing this section within 24 months from the date federal approval pursuant to this section is received. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review and approval by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted.

history: (History: Added by Stats. 2011, Ch. 8, Sec. 36. (SB 72) Effective March 24, 2011.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Services provided by a physician assistant are a covered benefit under this chapter to the extent authorized by federal law and subject to utilization controls.

(b) Subject to subdivision (a), all services performed by a physician assistant within his or her scope of practice that would be a covered benefit if performed by a physician and surgeon shall be a covered benefit under this chapter.

(c) The department shall not impose chart review, countersignature, or other conditions of coverage or payment on a physician and surgeon supervising physician assistants that are more stringent than requirements imposed by Chapter 7.7 (commencing with Section 3500) of Division 2 of the Business and Professions Code or regulations of the Medical Board of California promulgated under that chapter.

history: (History: Added by Stats. 2007, Ch. 376, Sec. 7. Effective January 1, 2008.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) Pharmacist services are a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services.

(2) The department shall establish a fee schedule for the list of pharmacist services.

(3) The rate of reimbursement for pharmacist services shall be at 85 percent of the fee schedule for physician services under the Medi-Cal program, except for medication therapy management (MTM) pharmacist services as described in Section 14132.969.

(b) (1) The following services are covered pharmacist services that may be provided to a Medi-Cal beneficiary:

(A) Furnishing travel medications, as authorized in clause (3) of subparagraph (A) of paragraph (10) of subdivision (a) of Section 4052 of the Business and Professions Code.

(B) Furnishing naloxone hydrochloride, as authorized in Section 4052.01 of the Business and Professions Code.

(C) Furnishing self-administered hormonal contraception, as authorized in subdivision (a) of Section 4052.3 of the Business and Professions Code.

(D) Initiating and administering immunizations, as authorized in Section 4052.8 of the Business and Professions Code.

(E) Providing tobacco cessation counseling and furnishing nicotine replacement therapy, as authorized in Section 4052.9 of the Business and Professions Code.

(F) Initiating and furnishing preexposure prophylaxis, as authorized in Section 4052.02 of the Business and Professions Code.

(G) Initiating and furnishing postexposure prophylaxis, as authorized in Section 4052.03 of the Business and Professions Code.

(H) Providing MTM pharmacist services in conjunction with the dispensing of qualified specialty drugs, as described in Section 14132.969.

(2) Covered pharmacist services shall be subject to department protocols and utilization controls.

(c) A pharmacist shall be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement pursuant to this section.

(d) (1) The director shall seek any necessary federal approvals to implement this section. This section shall not be implemented until the necessary federal approvals are obtained and shall be implemented only to the extent that federal financial participation is available.

(2) This section neither restricts nor prohibits any services currently provided by pharmacists as authorized by law, including, but not limited to, this chapter, or the Medicaid state plan.

(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. By July 1, 2021, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2017, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.

history: (History: Amended by Stats. 2024, Ch. 1, Sec. 4. (SB 339) Effective February 6, 2024.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Subject to an annual appropriation for this express purpose, the department shall implement a medication therapy management (MTM) reimbursement methodology for covered pharmacist services related to the dispensing of qualified specialty drugs by an eligible pharmacy contracted with the department pursuant to subdivision (c). MTM reimbursement pursuant to this section is intended to supplement Medi-Cal payments made to eligible pharmacies for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories, as identified by the department pursuant to paragraph (2) of subdivision (b).

(b) In implementing this section, the department shall do all of the following:

(1) Establish and maintain protocols and utilization controls for covered MTM pharmacist services.

(2) Establish and maintain a list of covered specialty drug therapy categories for which MTM pharmacist services reimbursement is available.

(3) Establish and maintain rates of reimbursement for covered MTM pharmacist services under contracts with participating pharmacies pursuant to subdivision (c).

(4) Establish and maintain the eligibility criteria and conditions for receipt of MTM pharmacist services reimbursement pursuant to this section.

(c) (1) MTM pharmacist services reimbursement pursuant to this section shall only be available to a Medi-Cal enrolled pharmacy that enters into an MTM pharmacist services contract with the department.

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

(d) (1) This section shall apply to dates of service on or after July 1, 2021, or to dates of service on or after the effective date reflected in any necessary federal approvals obtained by the department pursuant to paragraph (2), whichever is later.

(2) The department shall seek any necessary federal approvals to implement this section.

(3) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.

(e) This section neither restricts nor prohibits any services currently provided by pharmacists as authorized by law, including, but not limited to, this chapter, or the Medicaid state plan.

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

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

(1) “Medication therapy management” or “MTM” means a distinct service or group of services, as determined by the department, that are provided by pharmacists to improve health outcomes of beneficiaries who are at risk of treatment failure due to noncompliance, nonadherence, or other factors found to negatively affect drug therapy outcomes.

(2) “Specialty drugs” has the same meaning as set forth in paragraph (13) of subdivision (a) of Section 14105.45.

history: (History: Added by Stats. 2021, Ch. 143, Sec. 395. (AB 133) Effective July 27, 2021.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The county, or the public authority or nonprofit consortium established pursuant to Section 12301.6, shall be deemed to be the employer to meet and confer in good faith, in accordance with Chapter 10 (commencing with Section 3500) of Division 4 of Title 1 of the Government Code, regarding wages, benefits, and other terms and conditions of employment of individuals providing waiver personal care services pursuant to Section 14132.97. For purposes of this section, bargaining unit placement pursuant to Section 3507.1 of the Government Code, and waiver personal care services, individuals providing waiver personal care services shall be deemed a part of the established bargaining unit of in-home supportive services providers of an employer of record described in Section 12301.6 in the county in which the individual delivers waiver personal care services.

(b) Recipients shall retain the right to hire, fire, and supervise the work of any waiver personal care services personnel providing services to them.

(c) For service dates on or after the effective date specified in the applicable federal approval obtained by the department pursuant to subdivision (e), wages, benefits, and all other terms and conditions of employment for individuals providing waiver personal care services pursuant to Section 14132.97 shall be equal to the wages, benefits, and other terms and conditions of employment in the respective county for the individual provider mode of services in the In-Home Supportive Services (IHSS) program pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

(d) If eligibility for benefits requires a provider to work a threshold number of hours, eligibility shall be determined based on the aggregate number of monthly hours worked between IHSS and waiver personal care services.

(e) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.

history: (History: Added by Stats. 2018, Ch. 35, Sec. 34. (AB 1811) Effective June 27, 2018.)

article: 4. The Medi-Cal Benefits Program


text: For services provided pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, Section 14499.5, or Chapter 1 (commencing with Section 101525) to Chapter 4 (commencing with Section 101825), inclusive, of Part 4 of Division 101 of the Health and Safety Code, the cost for services defined in Section 1370.6 of the Health and Safety Code and Sections 14087.11 and 14132.98 of this code shall be provided by state-only funds if federal financial participation is not available.

history: (History: Added by renumbering Section 14132.99 (as amended by Stats. 2002, Ch. 664, Sec. 237) by Stats. 2015, Ch. 303, Sec. 615. (AB 731) Effective January 1, 2016.)

article: 4. The Medi-Cal Benefits Program


text:
(a) When renewing the Nursing Facility/Acute Hospital Transition and Diversion Waiver, as authorized by subdivision (t) of Section 14132, the director may take the following actions, among others:

(1) Contract with one or more organizations, referred to as a care management contractor, qualified to provide or arrange for delivery of care management and waiver services, including, but not limited to, personal needs assessments, and arranging for services available through public and private agencies, including services available under the waiver, for the waiver participants and applicants. The contract with the care management contractor, the care management contract, may require the care management contractor or their subcontractor, or both, to do all of the following, among other things:

(A) Provide, arrange for, or subcontract with community-based providers for the provision of, waiver services to waiver participants.

(B) Recognize program and service linkages, coordinate service delivery mechanisms and promote prevention of avoidable institutional placement, emergency room visits or inpatient hospital stays, or both, and coordination between health, social, and long-term services and supports by person-centered care planning.

(C) Provide or arrange for, care management to each waiver participant to stabilize their health care, and provide access to home- and community-based services, including managing and anticipating episodes of medical crisis in which transitional care management is needed.

(D) Carry out the waiver’s person-centered model of care, pursuant to the requirements set forth in Sections 441.720, 441.725, and 441.540 of Title 42 of the Code of Federal Regulations.

(E) Submit all information and reports required by the department, including, but not limited to, annual financial statements in the timeframe specified by the department.

(F) Pay any providers of waiver services who are not directly employed by or contracted with the care management contractor no less than the rates specified in the waiver or the department’s fee schedule, whichever is less, for the provider type.

(G) Bill the department, at the rate established by the state, for all services the care management contractor provides to waiver participants, directly or through a subcontractor or other direct service provider.

(H) Comply with the requirements of the waiver, including any other requirements established by the department regarding waiver operations, including, but not limited to, requirements regarding care coordination. These requirements may be set forth in the care management contract, care management manual, all-county letters, plan letters, plan or provider bulletins or policy letters, or similar instructions.

(2) Propose that the waiver provide for achievement of annual cost neutrality in the aggregate to allow enrollment and authorization of waiver services based on the medical necessity of the waiver services on a case-by-case basis.

(3) Expand the number of waiver slots up to 5,000 additional slots, the director may seek federal approval to amend the waiver to add additional slots or make changes to the waiver model with approval from the Department of Finance.

(4) Require care management contractors to enroll at least 60 percent of all total annual enrollments from either of the following:

(A) Hospital, nursing facility, or other institutional settings assisting members with transitions back to the home or community, or both, setting.

(B) Individuals who had been continuously receiving in home care services, of the type offered under the waiver, under the Early and Periodic Screening, Diagnosis, and Treatment State Plan benefit, California Children Services or Pediatric Palliative Care programs for children, for at least the prior three months but have at the time of transition exceeded the age limit for that benefit.

(5) If the director determines that the care management contractor is not fiscally solvent, or is in danger of becoming fiscally insolvent, the director has the option to immediately terminate the contract with the care management contractor.

(6) Terminate or refuse to renew, in whole or in part, a care management contract when the director determines that the action is necessary to protect the health of the beneficiaries or funds appropriated to the Medi-Cal program.

(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 all-county letters, plan letters, plan or provider bulletins, policy letters, or other similar instructions, without taking regulatory action.

(c) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and shall be exempt from the review or approval of any division of the Department of General Services.

(d) The department shall implement this section only to the extent it can demonstrate federal cost neutrality as required under the terms of the waiver, and only to the extent any necessary federal approvals are obtained and federal financial participation is available.

history: (History: Added by Stats. 2017, Ch. 52, Sec. 49. (SB 97) Effective July 10, 2017.)

article: 4. The Medi-Cal Benefits Program


text:
(a) This section applies to the Home- and Community-Based Alternatives Waiver (HCBA), the Assisted Living Waiver (ALW), and, to the extent that the dependent child or spouse of an active duty military service member is deemed eligible for the Medi-Cal program, the Home- and Community-Based Services for the Developmentally Disabled (HCBS-DD) 1915(c) waiver programs, pursuant to state law and Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)).

(b) (1) If a dependent child or spouse of an active duty military service member is currently included on the waiting list for a waiver program specified in subdivision (a) and transfers out of state with the military service member on official military orders, the dependent child or spouse shall retain their place on the waiting list for the applicable waiver program if the child or spouse subsequently reestablishes residence in this state. The dependent child’s or spouse’s place on the waiting list shall advance as the waiting list advances during the time they are out of the state.

(A) In order for the place on the waiting list to be saved after the dependent child or spouse leaves the state, the dependent child or spouse shall notify the department or its designee that they are leaving the state due to the military service member’s transfer orders and that they are requesting to remain on the waiver program’s waiting list.

(B) While the dependent child or spouse resides out of state and is in the first place on the waiver program’s waiting list, and has not informed the department or its designee that the military service member has received official military orders to relocate back to the state, waiver applicants with places farther down the waiting list shall continue to be processed for intake into the waiver program without regard to the dependent child’s or spouse’s place on the waiting list.

(C) If a dependent child or spouse who is on the waiver program’s waiting list informs the department or its designee that the military service member has received official military orders to return to the state and that the dependent child or spouse would like to enroll in the waiver program, the department or its designee shall take action on the dependent child’s or spouse’s waiver program application in accordance with their place on the waiver program’s waiting list.

(2) If a dependent child or spouse of an active duty military service member enrolled in a waiver program specified in subdivision (a) transfers out of state with the military service member on official military orders, and then returns to the state with the military service member on official military orders, the dependent child or spouse shall be reenrolled in the applicable waiver program if there is an open slot in the waiver program, or shall be placed in the first place on the waiver program’s waiting list if there is no open slot in the waiver program, subject to the dependent child or spouse meeting all of the following conditions:

(A) The dependent child or spouse reestablishes residence in this state.

(B) The dependent child or spouse submits an application for enrollment in the waiver program and is found to be eligible for the applicable waiver program.

(i) If no more than three years have passed since the dependent child or spouse left the waiver program, they may apply for reenrollment in the waiver program using an abbreviated waiver program enrollment form developed by the department.

(ii) If more than three years have passed since the dependent child or spouse left the waiver program, they shall apply for reenrollment in the waiver program using the standard waiver program enrollment form for that waiver program.

(iii) The dependent child or spouse shall follow the regular Medi-Cal eligibility and enrollment processes to obtain Medi-Cal enrollment.

(c) An individual applying for a waiver program specified in subdivision (a) who is a dependent child or spouse of an active duty military service member and is residing out of state with that military service member may submit the individual’s application to enroll in that waiver program as soon as the military service member receives official military orders to transfer to this state and before moving to this state. A copy of the order shall be submitted with the application for the Medi-Cal program and the applicable waiver program. The department or its designee may work with the dependent child or spouse, or their family, prior to their actual relocation to the state in order to evaluate the waiver program application with the goal of having medically necessary waiver program services in place as soon as possible when the family relocates to the state.

(d) (1) This section is not intended to authorize the provision of services to a dependent child or spouse of an active duty military service member through a waiver program specified in subdivision (a) while the dependent child or spouse is transferred to, and living, out of state with the military service member, or has not yet transferred to this state. Waiver program services provided to a dependent child or spouse under this section shall only be provided upon their establishing residence in this state and enrolling in Medi-Cal and the waiver program.

(2) This section is not intended to prevent another individual from receiving services through a waiver program described in subdivision (a) due to lack of space in the applicable waiver program on the sole basis that a dependent child or spouse described in this section is placed on the waiting list for that waiver program while the dependent child or spouse is transferred to, and living, out of state with the military service member, or has not yet transferred to this state.

(e) For purposes of this section, “dependent child” means an individual, whether a minor or an adult, who is a dependent of a parent or guardian.

(f) (1) This section shall be implemented only to the extent that any necessary federal approvals have been obtained and that federal financial participation is available.

(2) The department may seek amendments to the waiver programs specified in subdivision (a), or take other action, as necessary to implement this section.

(3) 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 letters or other similar instructions, without taking regulatory action.

history: (History: Added by Stats. 2019, Ch. 846, Sec. 1. (SB 289) Effective January 1, 2020.)

article: 4. The Medi-Cal Benefits Program


text: A Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, shall cover COVID-19 screening, testing, immunizations, and therapeutics in accordance with applicable statutes, regulations, all plan letters, the Medi-Cal provider manual, Medi-Cal managed care plan contracts with the department pursuant to this chapter or Chapter 8 (commencing with Section 14200), and other guidance.

history: (History: Added by Stats. 2025, Ch. 21, Sec. 106. (AB 116) Effective June 30, 2025.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding any other law, vaccines and immunizations are covered in accordance with a recommendation from the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians or any modification or supplement to that recommendation adopted pursuant to Section 120164 of the Health and Safety Code, with respect to the individual involved.

(b) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.

(c) Notwithstanding any other law, the department, without taking any further regulatory action, may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.

history: (History: Added by Stats. 2025, Ch. 105, Sec. 61. (AB 144) Effective September 17, 2025.)

article: 4. The Medi-Cal Benefits Program


text:
Utilization controls that may be applied to the services set forth in Section 14132 which are subject to utilization controls shall be limited to:

(a) Prior authorization, which is approval by a department consultant, of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Prior authorization includes authorization for multiple services which are requested and granted on the basis of an extended treatment plan where there is a need for continuity in the treatment of a chronic or extended condition.

(b) Postservice prepayment audit, which is review for medical necessity and program coverage after service was rendered but before payment is made. Payment may be withheld or reduced if the service rendered was not a covered benefit, deemed medically unnecessary or inappropriate. Nothing in this subdivision shall supersede the claims processing deadlines provided by Section 14104.3.

(c) Postservice postpayment audit, which is review for medical necessity and program coverage after service was rendered and the claim paid. The department may take appropriate steps to recover payments made if subsequent investigation uncovers evidence that the claim should not have been paid.

(d) Limitation on number of services, which means certain services may be restricted as to number within a specified time frame.

(e) Review of services pursuant to Professional Standards Review Organization agreements entered into in accordance with Section 14104.

history: (History: Amended by Stats. 1979, Ch. 373.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding any other law, the director or his or her designee may apply prior authorization by designing a sampling methodology that will result in a generally acceptable audit standard for approval of a treatment authorization request (TAR), or a class of TARs. The director or his or her designee shall determine the applicable sampling methodology based upon health care industry standards and discussions with applicable Medi-Cal providers or their representatives. This sampling methodology shall be implemented by no later than July 1, 2005, and an outline of the methodology shall be provided to the fiscal and policy committees of both houses of the Legislature. It is the intent of the Legislature for the department to review the sampling methodology on an ongoing basis and update the methodology as applicable on a periodic basis in order to keep abreast of health care industry trends and the need to manage an efficient and effective Medi-Cal program.

(b) The department shall pursue additional means to improve and streamline the treatment authorization request process including, where applicable, those identified by independent analyses such as the July 2003 report by the California HealthCare Foundation entitled Medi-Cal Treatment Authorizations and Claims Processing: Improving Efficiency and Access to Care, and those identified by Medi-Cal providers. It is the Legislature’s intent that any identified improvements be cost beneficial to the state and to the Medi-Cal program as a whole.

(c) (1) By July 1, 2016, or a subsequent date determined by the department, treatment authorization requests, excluding treatment authorization requests submitted by dental providers enrolled in the Medi-Cal Dental program, shall be submitted in an electronic format determined by the department and shall be submitted via the department’s Internet Web site or other electronic means designated by the department. The department may implement this requirement in phases.

(2) The department shall consider the capacity of independent sole practitioners, small independent provider-owned clinics, and rural providers to comply with the requirements of this section, and shall implement the electronic submission process in a manner that offers these providers both of the following:

(A) Reasonable time to establish the infrastructure necessary for the generation of electronic treatment authorization requests.

(B) An opportunity to participate in education and training regarding the generation and submission of electronic treatment authorization requests provided by the department or its agents.

(3) The department shall designate an alternate format for submitting requests for authorization of services when the department’s Internet Web site or other electronic means designated in paragraph (1) are unavailable due to a system disruption.

(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking regulatory action, implement, interpret, or make specific, this section and any applicable waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions. Thereafter, the department shall adopt regulations by July 1, 2017, 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. The department shall consult with interested parties and appropriate stakeholders in implementing this section.

history: (History: Amended by Stats. 2014, Ch. 849, Sec. 3. (SB 1457) Effective January 1, 2015.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any specific service or group of services which are subject to utilization controls. Each utilization control shall be reasonably related to the purpose for which it is imposed.

(b) Except as provided in Sections 14103.6 and 14133.15, neither prior authorization nor the limitation specified in subdivision (d) of Section 14133 shall be required for the first two services per month which are included among the services listed in subdivision (a) of Section 14132, or for the first two drug prescriptions purchased during any one month, provided that the prescription drugs are included in the Medi-Cal Drug Formulary and the prescription otherwise conforms to applicable formulary requirements.

(c) The director shall, after a determination of cost benefit, modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment which costs less than one hundred dollars ($100), except for prescribed drugs, provided that the requirement of prior authorization for treatment, supplies, or equipment may be reinstituted upon a finding by the department that the elimination of the requirement has resulted in unnecessary utilization, and upon notice to the Joint Legislative Budget Committee 30 days prior to the reinstitution of the requirement of prior authorization. Modification of the utilization controls may include establishing prior authorization review thresholds at levels other than one hundred dollars ($100) if indicated by the cost-benefit analysis.

history: (History: Amended by Stats. 1986, Ch. 775, Sec. 1.)

article: 4. The Medi-Cal Benefits Program