text:
(a) For purposes of this chapter, “Drug Medi-Cal reimbursable services” means the substance use disorder services described in the California Medicaid State Plan and includes, but is not limited to, all of the following services, administered by the department, and to the extent consistent with state and federal law:

(1) Narcotic treatment program services, as described in subdivision (a) of Section 14021.51.

(2) Intensive outpatient treatment services.

(3) Perinatal residential services for pregnant women and women in the postpartum period.

(4) Naltrexone services.

(5) Outpatient drug-free services.

(6) Other services upon approval of a federal Medicaid state plan amendment or waiver authorizing federal financial participation.

(b) (1) While seeking federal approval for any federal Medicaid state plan amendment or waiver associated with Drug Medi-Cal services, the department shall consult with the counties and stakeholders in the development of the state plan amendment or waiver.

(2) Upon federal approval of a federal Medicaid state plan amendment authorizing federal financial participation for the following services, and subject to appropriation of funds, “Drug Medi-Cal reimbursable services” shall also include the following services, administered by the department, and to the extent consistent with state and federal law:

(A) Medication-assisted treatment services, including both of the following:

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

(ii) Counseling services and behavioral therapy.

(B) Case management services, including supportive services to assist a person with substance use disorder diagnoses in gaining access to medical, social, educational, and other needed services.

(C) Aftercare services.

(c) (1) The nonfederal share for Drug Medi-Cal services shall be funded through a county’s Behavioral Health Subaccount of the Support Services Account of the Local Revenue Fund 2011, and any available county funds eligible under federal law for federal Medicaid reimbursement. The funds contained in each county’s Behavioral Health Subaccount of the Support Services Account of the Local Revenue Fund 2011 shall be considered state funds distributed by the principal state agency for the receipt of the federal block grant funds for prevention and treatment of substance abuse found at Subchapter XVII of Chapter 6A of Title 42 of the United States Code. Pursuant to applicable federal Medicaid law and regulations, including Section 433.51 of Title 42 of the Code of Federal Regulations, a county may claim allowable Medicaid federal financial participation for Drug Medi-Cal services based on the county’s certification of their actual total funds expenditures for eligible Drug Medi-Cal services to the department.

(2) (A) If the director determines that a county’s provision of Drug Medi-Cal treatment services are disallowed by the federal government or by state or federal audit or review, the impacted county shall be responsible for repayment of all disallowed federal funds. In addition to any other recovery methods available, including, but not limited to, offset of Medicaid federal financial participation funds owed to the impacted county, the director may offset these amounts in accordance with Section 12419.5 of the Government Code.

(B) A county subject to an action by the director pursuant to subparagraph (A) may challenge that action by requesting a hearing in writing no later than 30 days from receipt of notice of the department’s action. The proceeding shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, and the director shall have the powers granted therein. Upon a county’s timely request for hearing, the county’s obligation to make payment as determined by the director shall be stayed pending the county’s exhaustion of administrative remedies provided but no longer than necessary to ensure the department’s compliance with Section 1903(d)(2)(C) of the federal Social Security Act (42 U.S.C. Sec. 1396b).

(d) Drug Medi-Cal services are only reimbursable to a Drug Medi-Cal provider with an approved Drug Medi-Cal contract.

(e) A county shall negotiate contracts only with providers certified to provide Drug Medi-Cal services.

(f) The department shall develop methods to ensure timely payment of Drug Medi-Cal claims.

(g) (1) A county or a contracted provider, except for a provider subject to the requirements of subdivision (h), shall submit accurate and complete cost reports for the previous fiscal year by November 1, following the end of the fiscal year. The department may settle Drug Medi-Cal reimbursable services, based on the cost report as the final amendment to the approved county Drug Medi-Cal contract.

(2) Any amount paid for any service provided to a Drug Medi-Cal beneficiary shall be audited by the department in the manner and form described in Section 14170.

(3) Administrative appeals to review grievances or complaints arising from the findings of an audit or examination made pursuant to this section shall be subject to Section 14171.

(h) A certified narcotic treatment program provider that is exclusively billing the state or the county for services rendered to persons subject to Section 1210.1 or 3063.1 of the Penal Code or Section 14021.52 shall submit accurate and complete performance reports for the previous state fiscal year by November 1 following the end of that fiscal year. That provider shall estimate its budgets using the uniform state daily reimbursement rate. The format and content of the performance reports shall be mutually agreed to by the department, the County Behavioral Health Directors Association of California, and representatives of the treatment provider.

(i) Any contract entered into pursuant to this section shall be exempt from the requirements of Chapter 1 (commencing with Section 10100) and Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(j) Annually, the department shall publish procedures for contracting for Drug Medi-Cal services with certified providers and for claiming payments, including procedures and specifications for electronic data submission for services rendered.

(k) If the department commences or concludes a preliminary criminal investigation of a certified provider, the department shall promptly notify each county that currently contracts with the provider for Drug Medi-Cal services that a preliminary criminal investigation has commenced or concluded.

(1) Notice of the commencement and conclusion of a preliminary criminal investigation shall be made to the county behavioral health director or their equivalent.

(2) Communication between the department and a county specific to the commencement or conclusion of a preliminary criminal investigation shall be confidential and shall not be subject to any disclosure request, including, but not limited to, the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code), the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), requests pursuant to a subpoena, or for any other public purpose, including, but not limited to, court testimony.

(3) Information shared by the department with a county on a preliminary criminal investigation shall be maintained in a manner to ensure protection of the confidentiality of the criminal investigation.

(4) The information provided to a county pursuant to this section shall only include the provider name, national provider identifier number, address, and the notice that an investigation has commenced or concluded.

(5) A county shall not take any adverse action against a provider based solely upon the preliminary criminal investigation information disclosed to the county.

(6) In the event of a preliminary criminal investigation of a county owned or operated program, the department has the option, but is not required, to notify the county when the department commences or concludes a preliminary criminal investigation.

(7) This section does not limit the voluntary or otherwise legally mandated or contractually mandated sharing of information between the department and a county of information on an audit or investigation of a Drug Medi-Cal provider.

(8) “Commenced” means the time at which a complaint or allegation is assigned to an investigator for a field investigation.

(9) “Preliminary criminal investigation” means an investigation to gather information to determine if criminal law or statutes have been violated.

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

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

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

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 453. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

article: 3.2. Drug Medi-Cal Treatment Program


kind: section

code: WIC

text: Service providers may assist Medi-Cal beneficiaries, upon request, to file a fair hearing request in accordance with Chapter 7 (commencing with Section 10950) of Part 2, or may inform Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans about the Department of Managed Health Care’s toll-free telephone number for health care service plan members or the department’s ombudsman for Medi-Cal beneficiaries enrolled in a Medi-Cal managed care plan.

history: (History: Added by Stats. 2012, Ch. 36, Sec. 80. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 3.2. Drug Medi-Cal Treatment Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3.2. Drug Medi-Cal Treatment Program


text:
(a) Except as provided in subdivisions (b) and (c), regulations adopted by the State Department of Alcohol and Drug Programs pursuant to former Sections 11758.40 to 11758.47, inclusive, of the Health and Safety Code shall remain in effect unless amended or repealed by regulation adopted pursuant to this article.

(b) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, for purposes of the Drug Medi-Cal Treatment Program, the department may implement, interpret, or make specific this article to the extent that this article differs from former Sections 11758.40 to 11758.47, inclusive, of the Health and Safety Code by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions from the department until regulations are adopted pursuant to that chapter of the Government Code.

(c) (1) The department shall adopt emergency regulations no later than July 1, 2014. The department may subsequently readopt any emergency regulation authorized by this section that is the same as or is substantially equivalent to an emergency regulation previously adopted pursuant to this section.

(2) The initial adoption of emergency regulations implementing this article and the one readoption of emergency regulations authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. Initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.

article: 3.2. Drug Medi-Cal Treatment Program


text:
(a) If the department seeks a waiver pursuant to subdivision (a) of Section 14021.35, the department shall pursue federal approvals to address the need for greater capacity in both short-term residential treatment facilities and hospital settings for short-term voluntary inpatient detoxification, including, but not limited to, licensed chemical dependency recovery hospitals.

(b) Nothing in this section shall be construed to limit the authority of the department pursuant to Section 14021.35.

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

history: (History: Added by Stats. 2014, Ch. 486, Sec. 2. (SB 1161) Effective January 1, 2015.)

article: 3.2. Drug Medi-Cal Treatment Program


text:
Title

This article shall be known and may be cited as the Protect Patients Now Act of 2024.

history: (History: Added November 5, 2024, by initiative Proposition 34, Sec. 1. Effective December 18, 2024. Approved in Proposition 34 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14124.52.)

article: 3.3. Protect Patients Now Act of 2024

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3.3. Protect Patients Now Act of 2024


text:
Findings and Declarations

(a) In 1992, the federal government established a program giving safety net health care providers access to discounted prescription drugs. The intent of the law was for safety net health care providers to use the discounted drugs to treat patients who are “medically uninsured, on marginal incomes and have no other sources to turn to for preventive and primary care services” and to “reach[] more eligible patients and provide[] more comprehensive services” to “low-income and most vulnerable patients.” (H.R. Rep. No. 102-384 (Part 2), at 12 (1992)(Conf. Rep.).) The program was not intended to be used by safety net health care providers to accumulate massive fortunes running into the hundreds of millions of dollars or more.

(b) Unfortunately, some safety net health care providers have manipulated the program to receive enormous markups on the discounted prescription drugs they receive and then stick taxpayers with the added cost. Instead of using this massive windfall to help patients, the worst offenders have used their fortunes to purchase luxury coastal condominiums, wasted hundreds of millions of dollars on failed political campaigns, put elected politicians on their payrolls, and acquired low-income multifamily housing complexes that are operated as slums. Abusing net revenues generated through the discount prescription drug program in this manner does not result in better health care for low-income patients. Instead, it cheats low-income patients out of the care they deserve and scams taxpayers who end up footing the bill.

(c) Governor Newsom has already ended this type of prescription drug scamming in the Medi-Cal program through Executive Order N-01-19, which requires the Department of Health Care Services to transition Medi-Cal pharmacy services away from arrangements that are susceptible to price scams. Known as the Medi-Cal Rx program, it achieves cost savings for prescription drug purchases made by the state, standardizes the pharmacy benefit statewide for all Medi-Cal patients, increases overall access, and eliminates the ability of prescription drug price manipulators to game the system through Medi-Cal. However, other vulnerabilities in taxpayer-funded drug programs that price manipulators still exploit have not yet been addressed.

(d) California needs to make the cost-savings achieved through the Medi-Cal Rx program permanent. Furthermore, additional reforms are necessary to protect taxpayer dollars and help the neediest patients by ensuring that prescription drug price manipulators are required to end other scams in order to continue operating in our state.

article: 3.3. Protect Patients Now Act of 2024


text:
Statement of Intent

In enacting this article, the purpose and intent of the people of the State of California is to do all of the following:

(a) To permanently authorize the Medi-Cal Rx program so that its expanded patient access and cost-savings can be continued in perpetuity.

(b) To protect patients and taxpayers by putting an end to other prescription drug pricing scams that are still being perpetrated in our state through the discount prescription drug program.

(c) To impose strict accountability on prescription drug price manipulators by requiring them to spend at least 98 percent of their net revenues generated in this state through the discount prescription drug program on direct patient care.

(d) To ensure that health care providers that have a track record of scamming the discount prescription drug program refocus on providing direct patient care or lose their state-provided privileges and benefits, including suspension and revocation of licenses, loss of state and local grant funding, and elimination of California tax-exempt status.

article: 3.3. Protect Patients Now Act of 2024


text:
Permanent Authorization for the Medi-Cal Rx Program

The State Department of Health Care Services is authorized to provide and administer Medi-Cal pharmacy services under a single statewide fee-for-service delivery system.

article: 3.3. Protect Patients Now Act of 2024


text:
Limitation on Pharmacy Sales Agreements Involving Prescription Drug Price Manipulators

(a) On and after January 1, 2025, a prescription drug price manipulator shall not enter into, or participate in, a pharmacy sales agreement that applies to, operates in, or intends or proposes to operate in or apply to, this state unless the prescription drug price manipulator is in compliance with Section 14124.44.

(b) Any pharmacy sales agreement that involves a prescription drug price manipulator not in compliance with Section 14124.44 is, as of January 1, 2025, contrary to public policy and is void and unenforceable to the extent that the pharmacy sales agreement applies to, operates in, or intends or proposes to operate in or apply to, this state.

article: 3.3. Protect Patients Now Act of 2024


text:
Patient Protection Requirements Imposed on Prescription Drug Price Manipulators

Notwithstanding any other provision of law, on and after January 1, 2025, a prescription drug price manipulator shall only be eligible for tax-exempt status in this state or to be licensed to operate as a pharmacy, a health care service plan, or a clinic in this state if it complies with all of the following requirements:

(a) In the prior calendar year, the prescription drug price manipulator spent at least 98 percent of the net revenues it generated in California from participation in the discount prescription drug program on direct patient care.

(b) In the prior calendar year, the prescription drug price manipulator was not engaged in any unprofessional conduct, dishonest dealing, or conduct inimical to the public health, welfare, or safety of the people of the State of California.

article: 3.3. Protect Patients Now Act of 2024


text:
Oversight of Prescription Drug Price Manipulators

(a) (1) In order to determine compliance with Section 14124.44, on and after January 1, 2025:

(A) A prescription drug price manipulator that holds tax-exempt status in this state shall annually submit to the Attorney General a detailed accounting for the prior calendar year of both its California statewide and nationwide gross and net revenues generated from participation in the discount prescription drug program as well as how those net revenues were spent.

(B) A prescription drug price manipulator that holds a pharmacy license in this state shall annually submit to the California State Board of Pharmacy a detailed accounting for the prior calendar year of both its California statewide and nationwide gross and net revenues generated from participation in the discount prescription drug program as well as how those net revenues were spent.

(C) A prescription drug price manipulator that holds a health care service plan license in this state shall annually submit to the Department of Managed Health Care a detailed accounting for the prior calendar year of both its California statewide and nationwide gross and net revenues generated from participation in the discount prescription drug program as well as how those net revenues were spent.

(D) A prescription drug price manipulator that holds a clinic license in this state shall annually submit to the State Department of Public Health a detailed accounting for the prior calendar year of both its California statewide and nationwide gross and net revenues generated from participation in the discount prescription drug program as well as how those net revenues were spent.

(2) The people of California hereby find and declare that, similar to the need for out-of-state information under Chapter 17 (commencing with Section 25101) of Part 11 of Division 2 of the Revenue and Taxation Code, it is necessary for prescription drug price manipulators to provide information on both California statewide and nationwide gross and net revenues in order to ensure proper allocation of in-state and out-of-state revenues.

(b) In addition to any other authority granted by this article, the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health may do either of the following:

(1) Standardize the necessary contents of the detailed accounting required to be submitted pursuant to this section.

(2) Request from a prescription drug price manipulator any other information deemed necessary or convenient to determine compliance with the requirements set forth in Section 14124.44.

(c) All information submitted pursuant to this section shall be submitted under penalty of perjury.

(d) (1) All financial information submitted to the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health pertaining to either of the following shall be treated as confidential and sensitive business information exempt from public disclosure:

(A) Specific prices or amounts paid by, or charged to, a prescription drug price manipulator for specific prescription drugs acquired by the prescription drug price manipulator through the discount prescription drug program.

(B) Specific prices or amounts charged by, or paid to, a prescription drug price manipulator for specific prescription drugs it obtained through the discount prescription drug program.

(2) (A) Total aggregated gross and net revenues generated by a prescription drug price manipulator through the discount prescription drug program are not covered by this subdivision so long as the figures do not reveal the specific information described in subparagraph (A) or (B) of paragraph (1).

(B) After removing or anonymizing the specific information described in subparagraphs (A) and (B) of paragraph (1), the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health shall make total aggregated statewide and nationwide gross and net revenues figures publicly available upon request.

(e) (1) The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health shall cooperatively establish the deadline each year for a prescription drug price manipulator to submit the information required by this section.

(2) For calendar year 2025, the deadline shall not be later than December 31, 2025.

(3) A prescription drug price manipulator that fails to submit required information by the deadline established pursuant to this subdivision shall be deemed to be out of compliance with the requirements of Section 14124.44 for the applicable calendar year, according to the procedures set forth in subdivision (b) of Section 14124.46.

(f) The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health may each impose a fee on a prescription drug price manipulator for the costs associated with concluding whether the prescription drug price manipulator was in compliance with the requirements of Section 14124.44 during the prior calendar year. The charges shall not exceed the reasonable regulatory costs to the respective agency incident to performing the investigations, inspections, and audits required by this article, including any administrative enforcement and adjudication thereof.

(g) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health may implement this article by means of bulletins, notices, or other similar instructions, without taking further regulatory action.

(2) Actions taken pursuant to an interagency agreement entered into pursuant to subdivision (c) of Section 14124.46 shall be covered by paragraph (1).

article: 3.3. Protect Patients Now Act of 2024


text:
Conclusions Regarding Compliance

(a) (1) Within 60 calendar days of the deadline established pursuant to subdivision (e) of Section 14124.45, the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health shall each separately issue an independent written conclusion regarding whether or not the prescription drug price manipulator is in compliance with the requirements of Section 14124.44. Failure to reach a conclusion within 60 calendar days shall not excuse noncompliance with Section 14124.44.

(2) The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health shall only be required to issue an independent written conclusion pursuant to this subdivision if the prescription drug price manipulator was required to submit information to the relevant official, board, or department pursuant to subdivision (a) of Section 14124.45.

(b) (1) If, within the 60-calendar day period set forth in paragraph (1) of subdivision (a), the information submitted by a prescription drug price manipulator is found to be incomplete or insufficient by the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health for issuance of a written conclusion required by this section, then the relevant official, board, or department shall issue to the prescription drug price manipulator a written notice to correct. The notice to correct shall contain a description of the additional information required.

(2) The prescription drug price manipulator shall have 10-calendar days from the date of the notice to correct to provide complete or sufficient information. If the prescription drug price manipulator fails to remedy the incompleteness or insufficiency within 10-calendar days, then the prescription drug price manipulator shall be deemed to be out of compliance with the requirements of Section 14124.44 for the applicable calendar year and the relevant official, board, or department shall issue a written conclusion to that effect immediately upon the expiration of the 10-calendar-day period.

(c) The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health may, either collectively or separately, enter into an interagency agreement with the California State Auditor’s Office for assistance in reaching a conclusion about a prescription drug price manipulator’s compliance with the requirements of Section 14124.44. Costs incurred pursuant to an interagency agreement under this subdivision may be recovered pursuant to subdivision (f) of Section 14124.45.

(d) (1) If the Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, or the State Department of Public Health concludes a prescription drug price manipulator is not in compliance with the requirements of Section 14124.44, then a written notice of noncompliance shall be provided to the prescription drug price manipulator notifying it of that conclusion. The written notice of noncompliance shall provide instructions on requesting a hearing pursuant to subdivision (e).

(2) If a hearing is not requested pursuant to subdivision (e), then a conclusion issued pursuant to this section shall become a final determination.

(e) (1) (A) A prescription drug price manipulator may request a hearing in response to a written notice of noncompliance issued pursuant to paragraph (1) of subdivision (d).

(B) The request shall be submitted in writing and must be made within 30-calendar days of the date of the written notice of noncompliance.

(2) (A) Except as otherwise provided in this article, hearings shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.

(B) The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health may consolidate hearings on written notices of noncompliance pertaining to the same prescription drug price manipulator for the same calendar year and may mutually appoint a single hearing officer therefor. The hearing may be conducted by a hearing officer appointed by an official, board, or department that issued a written notice of noncompliance.

(C) The prescription drug price manipulator may be represented by counsel at any of the stages of the proceedings.

(3) (A) If judicial review is not sought pursuant to subdivision (f), then the decision of the hearing officer shall become a final determination.

(B) If the hearing officer’s decision is that the prescription drug price manipulator is not in compliance with the requirements of Section 14124.44, then any exemption from California state taxation and any licenses described in subdivision (a) of Section 14124.45 held by the prescription drug price manipulator shall be immediately suspended. If judicial review is thereafter sought pursuant to subdivision (f), the state tax exemption and licenses shall remain suspended pending judicial review pursuant to subdivision (f).

(f) (1) Any party aggrieved by the decision of the hearing officer may seek review pursuant to Section 1094.5 of the Code of Civil Procedure within 30-calendar days of issuance of the hearing officer’s decision.

(2) If review is sought pursuant to Section 1094.5 of the Code of Civil Procedure, the final determination shall be based upon the outcome of that review.

article: 3.3. Protect Patients Now Act of 2024


text:
Final Determinations

Notwithstanding any other provision of law, if a prescription drug price manipulator is finally determined pursuant to the procedures set forth in this article to have violated the requirements of Section 14124.44, then all of the following shall apply:

(a) Any and all California pharmacy licenses, health care service plan licenses, or clinic licenses held by the prescription drug price manipulator shall be permanently revoked.

(b) The prescription drug price manipulator shall be prohibited from applying for, or obtaining or possessing, a California pharmacy license, health care service plan license, or clinic license for a period of 10 years.

(c) Any person serving as an owner, chief executive officer, chief financial officer, chief administrative officer, chief operating officer, president, or any other similar position exercising significant influence or control over the prescription drug price manipulator at the time the violation of Section 14124.44 occurred shall be prohibited from serving as an owner, officer, director, or employee of a California licensed pharmacy, health care service plan, or clinic for a period of 10 years.

(d) The prescription drug price manipulator shall lose, and no longer be eligible for, tax-exempt status in the State of California, including under Chapter 4 (commencing with Section 23701) of Part 11 of Division 2 of the Revenue and Taxation Code, and shall instead be subject to the Revenue and Taxation Code and other state laws as a taxable organization. The prescription drug price manipulator shall be prohibited from reapplying for, or again being granted, tax-exempt status in this state for a period of 10 years.

(e) The prescription drug price manipulator shall be ineligible to receive any new or renewed state or local grants or contracts for a period of 10 years.

article: 3.3. Protect Patients Now Act of 2024


text:
Definitions

For purposes of this article, as used in both the singular and plural form, the following definitions shall apply:

(a) “Clinic” means an entity operating as one or more of the clinics described in Section 1204 of the Health and Safety Code.

(b) “Direct patient care” means the provision of medical services, dental services, pharmaceutical services, or behavioral health services directly administered to individual patients being treated for, or suspected of having, medical or behavioral health conditions. Direct patient care includes preventive care that is directly administered to patients. Further, in order to qualify as “direct patient care,” the services must be health care services that are regularly provided by other health care providers in the community or nonprofit community-based organizations that are also receiving reimbursements or payments from the Medi-Cal, Medicaid, or Medicare programs.

(c) “Discount prescription drug program” means the program established by Section 602 of the Veterans Health Care Act of 1992, P.L. 102-585 Sec. 602, the Public Health Service Act (Sec. 340B; 42 U.S.C. Sec. 256b) that is administered by the Office of Pharmacy Affairs in the Health Resources and Services Administration within the United States Department of Health and Human Services.

(d) “Enforcement agency” means any department of a state, county, or city agency within California that has the authority to inspect a multifamily dwelling and enforce health, safety, or building codes including, but not limited to, a building department or building division, a housing department, a housing and community investment department, a fire department or fire district, and a health department.

(e) “Entity” means a natural person, corporation, or other legal or corporate organization of any kind, whether nonprofit or for profit, and includes any parent, subsidiary, or affiliate of the entity.

(f) “Health care service plan” means an entity operating as a health care service plan under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

(g) “Medi-Cal Rx Program” means the program initially established pursuant to paragraph (1) of Executive Order N-01-19 and permanently authorized by Section 14124.42.

(h) “Multifamily dwelling” means any structure located in this state designed or used for human habitation or occupancy that has been divided into two or more independent living quarters.

(i) “Owner-operator of highly dangerous properties” means an entity, including any parent, subsidiary, or affiliate of that entity, that, either currently or previously, owns, operates, or is the responsible party for one or more multifamily dwellings that meet or met the following conditions during the time of the entity’s ownership, operation, or responsibility:

(1) One or more of the multifamily dwellings was inspected on one or more occasions by an enforcement agency or officer thereof.

(2) The enforcement agencies or officers issued one or more notices or inspection reports identifying violations affecting the health and safety of occupants of the multifamily dwellings.

(3) Cumulatively across all of the multifamily dwellings, the notices or inspection reports described in paragraph (2) identified a combined total of at least 500 violations that were categorized in violation severity level “high.”

(j) “Pharmacy” means an entity operating pursuant to Chapter 9 (commencing with Section 4000) of Division 2 of the Business and Professions Code.

(k) (1) “Pharmacy sales agreement” means any agreement involving a pharmacy and another entity that purchases, authorizes, or obtains prescription drugs through the discount prescription drug program where both of the following conditions exist:

(A) The pharmacy dispenses drugs negotiated by the other entity through or pursuant to the discount prescription drug program.

(B) The price charged by the pharmacy for the drugs described in subparagraph (A), excluding dispensing fees, exceeds the purchase price negotiated or paid by the other entity pursuant to or through the discount prescription drug program.

(2) A pharmacy sales agreement can exist between unrelated entities, or between related entities that are parents, subsidiaries, or affiliates of one another or otherwise under common ownership or control.

(l) “Prescription drug price manipulator” means an entity, including any parent, subsidiary, or affiliate of that entity, that individually or collectively with one or more of its parents, subsidiaries, or affiliates meets all of the following requirements:

(1) The entity purchases, negotiates, authorizes, or obtains prescription drugs through the discount prescription drug program.

(2) During any 10-calendar-year period of its existence, the entity spent more than one hundred million dollars ($100,000,000) on purposes that do not qualify as direct patient care.

(3) The entity currently is, or has previously been, an owner-operator of highly dangerous properties.

(4) The entity meets at least one of the following conditions:

(A) The entity currently has, or previously had, one or more licenses to operate as a health care service plan.

(B) The entity currently contracts, or has previously contracted, with the State Department of Health Care Services as a primary care case management organization pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 of Part 3 of Division 9.

(C) The entity currently contracts, or has previously contracted, with the federal Centers for Medicare and Medicaid Services to provide services in the Medicare Program as a Medicare special needs plan.

(D) The entity currently has, or previously had, one or more licenses to operate as a pharmacy.

(E) The entity currently has, or previously had, one or more licenses to operate as a clinic.

article: 3.3. Protect Patients Now Act of 2024


text:
Unprofessional Conduct, Dishonest Dealing, and Conduct Inimical to Public Health, Welfare, or Safety

(a) In addition to any other conduct, standard, or requirement described in Article 7 (commencing with Section 1386) of Chapter 2.2 of Division 2 of the Health and Safety Code or any other statute or regulation, it shall constitute dishonest dealing for a health care service plan that qualifies as a prescription drug price manipulator to fail to submit timely, accurate information required or requested pursuant to Section 14124.45.

(b) In addition to any other conduct, standard, or requirement described in Article 19 (commencing with Section 4300) of Chapter 9 of Division 2 of the Business and Professions Code, Section 1762 of Title 16 of the California Code of Regulations, or any other statute or regulation, it shall constitute unprofessional conduct for a pharmacy that qualifies as a prescription drug price manipulator to fail to submit timely, accurate information required or requested pursuant to Section 14124.45.

(c) In addition to any other conduct, standard, or requirement described in Article 5 (commencing with Section 1240) of Chapter 1 of Division 2 of the Health and Safety Code or any other statute or regulation, it shall constitute conduct inimical to the public health, welfare, or safety of the people of the State of California for a clinic that qualifies as a prescription drug price manipulator to fail to submit timely, accurate information required or requested pursuant to Section 14124.45.

article: 3.3. Protect Patients Now Act of 2024


text:
State and Local Grants and Contracts Eligibility

(a) (1) The people of California hereby find and declare that their state and local tax dollars should not be awarded to prescription drug price manipulators that violate the discount prescription drug program’s intent to treat patients who are medically uninsured, on marginal incomes and have no other sources to turn to for preventive and primary care services and to reach more eligible patients and provide more comprehensive services to low-income and most vulnerable patients.

(2) The people of California further find and declare that protecting their state and local tax dollars in this manner is a matter of statewide concern.

(b) Therefore, in addition to the requirements of subdivision (e) of Section 14124.47, a prescription drug price manipulator shall only be eligible to receive any new or renewed state or local grants or contracts if, in the prior calendar year, the prescription drug price manipulator spent at least 98 percent of the net revenues it generated nationwide from participation in the discount prescription drug program on direct patient care.

article: 3.3. Protect Patients Now Act of 2024


text:
Public Input

The Attorney General, the California State Board of Pharmacy, the Department of Managed Health Care, and the State Department of Public Health shall invite, and provide a process for submission of, public comments and information relating to entities that qualify as a prescription drug price manipulator or an owner-operator of highly dangerous properties. Information that can be submitted pursuant to this section includes, but is not limited to, records of expenditures and written notices or inspection reports identifying violations affecting the health and safety of occupants at multifamily dwellings.

article: 3.3. Protect Patients Now Act of 2024


text:
Effective Date and Severability

(a) This article shall take effect on the next January 1 following its adoption by the voters.

(b) The provisions of this article are severable. If any portion, section, subdivision, paragraph, subparagraph, clause, subclause, sentence, phrase, word, or application of this article is for any reason held to be invalid by a decision of any court of competent jurisdiction, that decision shall not affect the validity of the remaining portions of this article. The people of the State of California hereby declare that they would have adopted this article and each and every portion, section, subdivision, paragraph, subparagraph, clause, subclause, sentence, phrase, word, and application not declared invalid or unconstitutional without regard to whether any part of this article or application thereof would be subsequently declared invalid.

(c) To the extent a court of competent jurisdiction determines it is legally impossible to comply with any date or deadline set forth in this article during the first calendar year after this article takes effect, the people of the State of California hereby declare their intent for this article to be implemented and applied at the earliest possible date consistent with state and federal law.

history: (History: Added November 5, 2024, by initiative Proposition 34, Sec. 1. Effective December 18, 2024. Approved in Proposition 34 at the November 5, 2024, election.)

article: 3.3. Protect Patients Now Act of 2024


text:
As used in this article:

(a) “Carrier” includes any insurer as defined in Section 23 of the Insurance Code, including any private company, corporation, mutual association, trust fund, reciprocal or interinsurance exchange authorized under the laws of this state to insure persons against liability for injuries caused to another, and also any insurer providing benefits under a policy of bodily injury liability insurance covering liability arising out of the ownership, maintenance or use of a motor vehicle which provides uninsured motorist endorsement or coverage, pursuant to Section 11580.2 of the Insurance Code.

(b) “Beneficiary” means any person who has received benefits or will be provided benefits under this chapter because of an injury for which another person or party may be liable. It includes such beneficiary’s guardian, conservator or other personal representative, his estate or survivors.

(c) “Reasonable value of benefits” means both of the following:

(1) Except in a case in which services were provided to a beneficiary under a managed care arrangement or contract, “reasonable value of benefits” means the Medi-Cal rate of payment, for the type of services rendered, under the schedule of maximum allowances authorized by Section 14106 or, the Medi-Cal rate of payment, for the type of services rendered, under regulations adopted pursuant to this chapter, including but not limited, to Section 14105.

(2) If services were provided to a beneficiary under a managed care arrangement or contract, “reasonable value of benefits” means the rate of payment to the provider by the plan for the services rendered to the beneficiary, except in cases where the plan pays the provider on a capitated or risk sharing basis, in which case it means the value of the services rendered to the beneficiary calculated by the plan as the usual customary and reasonable charge made to the general public by the provider for similar services.

(d) “Lien” means the director’s claim for recovery, from a beneficiary’s tort action or claim, of the reasonable value of benefits provided on behalf of the beneficiary.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 30. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3.5. Third Party Liability


text:
(a) When benefits are provided or will be provided to a beneficiary under this chapter because of an injury for which another party is liable, or for which a carrier is liable in accordance with the provisions of any policy of insurance issued pursuant to Section 11580.2 of the Insurance Code, the director shall have a right to recover from such a party or carrier the reasonable value of benefits so provided. The Attorney General, or counsel for the fiscal intermediary under the Medi-Cal program with the permission of the Attorney General, or a contractor pursuant to Section 14124.80, or a county through its civil legal adviser, may, to enforce such right, institute and prosecute legal proceedings against the third party or carrier who may be liable for the injury in an appropriate court, either in the name of the director or in the name of the injured person, his guardian, conservator, personal representative, estate, or survivors.

(b) The director may:

(1) Compromise, or settle and release any such claim in whole or in part with any such party or carrier, or

(2) Waive any such claim, in whole or in part, for the convenience of the director, or if the director determines that collection would result in undue hardship upon the person who suffered the injury, or in a wrongful death action upon the heirs of the deceased.

(c) No action taken on behalf of the director pursuant to this section or any judgment rendered in such action shall be a bar to any action upon the claim or cause of action of the beneficiary, his guardian, conservator, personal representative, estate, dependents, or survivors against the third party who may be liable for the injury, or shall operate to deny to the beneficiary the recovery for that portion of any damages not covered hereunder.

(d) The cost of a service provided to an eligible developmentally disabled Medi-Cal beneficiary under Section 14132.44 may be recovered by the director from a liable third party or carrier.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 31. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
(a) If an action is brought by the director pursuant to Section 14124.71, it shall be commenced within the period prescribed in Section 338 of the Code of Civil Procedure.

(b) The death of the beneficiary does not abate any right of action established by Section 14124.71.

(c) When an action or claim is brought by persons entitled to bring such actions or assert such claims against a third party who may be liable for causing the death of a beneficiary, any settlement, judgment or award obtained is subject to the director’s right to recover from that party the reasonable value of the benefits provided to the beneficiary under the Medi-Cal program, as provided in subdivision (d).

(d) The director’s claim for reimbursement of the benefits provided to the beneficiary shall be limited to the amount of the director’s lien, as defined in subdivision (d) of Section 14124.70. If the action or claim is brought by the beneficiary alone and the beneficiary incurs a personal liability to pay attorney’s fees and costs of litigation, the amount of the director’s lien that is reimbursed shall be reduced by 25 percent, which represents the director’s reasonable share of attorney’s fees paid by the beneficiary, and that portion of the cost of litigation expenses determined by multiplying the actual litigation expenses by the ratio of the amount reimbursed to the director as satisfaction of the director’s lien, prior to deducting reasonable attorney’s fees and litigation expenses, to the full amount of the settlement, judgment, or award.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 32. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
(a) If either the beneficiary or the director brings an action or claim against such third party or carrier, the beneficiary or the director shall within 30 calendar days of filing the action give to the other written notice by personal service, registered mail, or other means of communication deemed appropriate by the department of the action or claim, and of the name of the court or state or local agency in which the action or claim is brought. The purpose of the notice is to provide the beneficiary and the director, as applicable, the opportunity to ensure their interests are adequately represented in an action or claim against a liable third party or carrier. Proof of such notice shall be filed in such action or claim. If an action or claim is brought by either the director or the beneficiary, the other may, at any time before trial on the facts, become a party to, or shall consolidate his action or claim with the other if brought independently.

(b) If an action or claim is brought by the director pursuant to subdivision (a) of Section 14124.71, written notice to the beneficiary, guardian, conservator, personal representative, estate or survivor given pursuant to this section shall advise him of his right to intervene in the proceeding, his right to obtain a private attorney of his choice, and the director’s right to recover the amount of the director’s lien, as defined in subdivision (d) of Section 14124.70.

(c) Notification of either the beneficiary or the director of an action or claim against a third party or carrier shall include, at a minimum, the following information:

(1) The date of the beneficiary’s injury.

(2) The beneficiary’s Medi-Cal identification number.

(3) The name and contact information of the liable third party or carrier against whom the action or claim has been filed.

(4) The name and contact information of the carrier for the party identified in paragraph (3) against which a claim has been or will be filed for the beneficiary’s injury, the carrier’s unique claim identifier for the claim, and the name and contact information of the party responsible for adjudicating the claim on the carrier’s behalf, to the extent these are known by the party providing notice under subdivision (a) at the time such notice is provided.

(d) If any information required pursuant to paragraph (4) of subdivision (c) is not known to the party at the time notice pursuant to subdivision (a) is provided, the party providing such notice shall provide such information to the notice recipient within 15 calendar days of obtaining the information.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 33. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
In the event of a settlement, judgment, or award in a suit or claim against a third party or carrier:

(a) If the action or claim is prosecuted by the beneficiary alone, the court or agency shall first order paid from any settlement, judgment, or award the reasonable litigation expenses incurred in preparation and prosecution of the action or claim, together with reasonable attorney’s fees, when an attorney has been retained. After payment of these expenses and attorney’s fees the court or agency shall, on the application of the director, allow as a first lien against the amount of the settlement, judgment, or award the amount that the director is entitled to recover as satisfaction of the director’s lien, as provided in subdivision (d) of Section 14124.72, and as a second lien, the amount of any claims, pursuant to Section 14019.3, owed to a provider, as provided in Section 14124.791.

(b) If the action or claim is prosecuted both by the beneficiary and the director, the court or agency shall first order paid from any settlement, judgment, or award, the reasonable litigation expenses incurred in preparation and prosecution of the action or claim, together with reasonable attorney’s fees based solely on the services rendered for the benefit of the beneficiary. After payment of these expenses and attorney’s fees, the court or agency shall first apply out of the balance of the settlement, judgment, or award an amount sufficient to reimburse the amount that the director is entitled to recover as satisfaction of the director’s lien, as provided under subdivision (d) of Section 14124.72, and then an amount sufficient to reimburse a provider who has filed a lien for any claims for services rendered to the beneficiary, as provided under Section 14124.791.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 34. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text: The court or agency shall, upon further application at any time before the judgment or award is satisfied, allow as a further lien the reasonable value of additional benefits provided arising out of the same cause of action or claim provided on behalf of the beneficiary under the Medi-Cal Program, where such benefits were provided or became payable subsequent to the original order.

history: (History: Amended by Stats. 1998, Ch. 310, Sec. 102. Effective August 19, 1998.)

article: 3.5. Third Party Liability


text:
(a) No settlement, judgment, or award in any action or claim by a beneficiary to recover damages for injuries, where the director has an interest, shall be deemed final or satisfied without first giving the director notice and a reasonable opportunity to perfect and to satisfy the director’s lien. Recovery of the director’s lien from an injured beneficiary’s action or claim is limited to that portion of a settlement, judgment, or award that represents payment for medical expenses, or medical care, provided on behalf of the beneficiary. All reasonable efforts shall be made to obtain the director’s advance agreement to a determination as to what portion of a settlement, judgment, or award that represents payment for medical expenses, or medical care, provided of behalf on the beneficiary. Absent the director’s advance agreement as to what portion of a settlement, judgment, or award represents payment for medical expenses, or medical care, provided on behalf of the beneficiary, the matter shall be submitted to a court for decision. Either the director or the beneficiary may seek resolution of the dispute by filing a motion, which shall be subject to regular law and motion procedures. In determining what portion of a settlement, judgment, or award represents payment for medical expenses, or medical care, provided on behalf of the beneficiary and as to what the appropriate reimbursement amount to the director should be, the court shall be guided by the United States Supreme Court decision in Arkansas Department of Health and Human Services v. Ahlborn (2006) 547 U.S. 268 and other relevant statutory and case law.

(b) If the beneficiary has filed a third-party action or claim, the court where the action or claim was filed shall have jurisdiction over a dispute between the director and the beneficiary regarding the amount of a lien asserted pursuant to this section that is based upon an allocation of damages contained in a settlement or compromise of the third-party action or claim. If no third-party action or claim has been filed, any superior court in California where venue would have been proper had a claim or action been filed shall have jurisdiction over the motion. The motion may be filed as a special motion and treated as an ordinary law and motion proceeding and subject to regular motion fees. The reimbursement determination motion shall be treated as a special proceeding of a civil nature pursuant to Part 3 (commencing with Section 1063) of the Code of Civil Procedure. When no action is pending, the person making the motion shall be required to pay a first appearance fee. When an action is pending, the person making the motion shall pay a regular law and motion fee. Notwithstanding Section 1064 of the Code of Civil Procedure, either the beneficiary or the director may appeal the final findings, decision, or order.

(c) The court shall issue its findings, decision, or order, which shall be considered the final determination of the parties’ rights and obligations with respect to the director’s lien, unless the settlement is contingent on an acceptable allocation of the settlement proceeds, in which case, the court’s findings, decision, or order shall be considered a tentative determination. If the beneficiary does not serve notice of a rejection of the tentative determination, which shall be based solely upon a rejection of the contingent settlement, within 30 days of the notice of entry of the court’s tentative determination, subject to further consideration by the court pursuant to subdivision (d), the tentative determination shall become final. Notwithstanding Section 1064 of the Code of Civil Procedure, either the beneficiary or the director may appeal the final findings, decision, or order.

(d) If the beneficiary does not accept the tentative determination, which shall be based solely upon a rejection of the contingent settlement, any party may subsequently seek further consideration of the court’s findings upon application to modify the prior findings, decision, or order based on new or different facts or circumstances. The application shall include an affidavit showing what application was made before, when, and to what judge, what order or decision was made, and what new or different facts or circumstances, including a different settlement, are claimed to exist. Upon further consideration, the court may modify the allocation in the interest of fairness and for good cause.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 71. Effective August 24, 2007.)

article: 3.5. Third Party Liability


text: When the director has perfected a lien upon a judgment or award in favor of a beneficiary against any third party for an injury for which the beneficiary has received benefits under the Medi-Cal Program, the director shall be entitled to a writ of execution as lien claimant to enforce payment of said lien against such third party with interest and other accruing costs as in the case of other executions. In the event the amount of such judgment or award so recovered has been paid to the beneficiary, the director shall be entitled to a writ of execution against such beneficiary to the extent of the director’s lien, with interest and other accruing costs as in the case of other executions.

history: (History: Added by Stats. 1976, Ch. 621.)

article: 3.5. Third Party Liability


text: Notwithstanding any other provision of law, in no event shall the director recover more than the beneficiary recovers after deducting, from the settlement judgment, or award, attorney’s fees and litigation costs paid for by the beneficiary. If the director’s recovery is determined under this section, the reductions in subdivision (d) of Section 14124.72 shall not apply.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 72. Effective August 24, 2007.)

article: 3.5. Third Party Liability


text: In the event that the beneficiary, his guardian, conservator, personal representative, estate or survivors or any of them brings an action against the third person who may be liable for the injury, notice of institution of legal proceedings, notice of settlement and all other notices required by this code shall be given to the director in Sacramento except in cases where the director specifies that notice shall be given to the Attorney General. All such notices shall be given by insurance carriers, as described in Section 14124.70, having liability for the beneficiary’s claim, and by the attorney retained to assert the beneficiary’s claim, or by the injured party beneficiary, his guardian, conservator, personal representative, estate or survivors, if no attorney is retained.

history: (History: Amended by Stats. 2003, Ch. 230, Sec. 69. Effective August 11, 2003.)

article: 3.5. Third Party Liability


text:
(a) The department shall administer the provisions of Sections 14124.82 to 14124.86, inclusive, pertaining to the State Department of Health Care Services’ administration of the personal injury and workers’ compensation recovery programs.

(b) An attorney or the beneficiary, guardian, personal representative, estate, or survivors of any of those, who are mandated under Section 14124.79 to report Medi-Cal involvement are excluded from any further remuneration benefits under Sections 14124.82 to 14124.86, inclusive.

history: (History: Repealed and added by Stats. 2017, Ch. 52, Sec. 38. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
(a) The department, in its reasonable discretion, may execute one or more at-risk performance contracts to identify, quantify, or recover, or any combination thereof, Medi-Cal payments from responsible third parties and carriers that may be subject to a claim for reimbursement.

(b) Priority, by the terms of the contract or contracts, shall be given to the identification and recovery of claims nearing the statute of limitation, prior adjudicated claims, and prior existing injury claims. However, all claims that are older, in whole or part, than 12 months, at the time of discovery and notification by the contractor to the department, shall be subject to contractual lien recovery unless departmental personnel have previously identified these claims and have filed appropriate liens, notices, or other payment demands. A claim arises and the 12-month period begins when the department or its fiscal agent has first made payment for medical services related to the personal or workers’ compensation action on behalf of a given recipient. The department may waive any time requirement, if it concludes that it will not otherwise discover the claim and be able to effect recovery.

(c) To implement this section, the department may contract with public or private entities. Contracts or amendments entered into under this section may be on an exclusive or nonexclusive basis, and on a noncompetitive bid basis. The contracts and amendments shall be exempt from all of the following:

(1) Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and any policies, procedures, or regulations authorized by that part.

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

(3) Review or approval of contracts by the Department of General Services.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 39. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
The agreement shall include, but is not limited to, the following provisions:

(a) The agreement shall stipulate when the contractor may identify, quantify, or recover amounts owing by third parties that may be subject to a claim for reimbursement.

(b) Payment to the contractor shall be based upon a no cost percentage of recovery formula, which shall not exceed 25 percent of the gross recovery upon the claim. It is the intent of the Legislature that “no cost” include all considerations for court costs, legal fees, and the universe of the case processing activity, not including, however, departmental processing.

(c) Payment for amounts determined to be owed to the state by third parties and carriers shall be made directly to the state.

(d) A bond in the amount required by the state for collection agencies shall be sufficient.

(e) Contractor’s files shall be subject to audit, pursuant to the contract, but shall remain the property of the contractor. At the request of the department, the contractor shall provide copies of any claims related to a particular recovery.

(f) The contractor shall report periodically to the department concerning its progress in the discovery of cases and the recovery of amounts subject to claim, and shall provide other information as the department may require, and at a reasonable frequency, to adequately monitor the progress of the contractor.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 40. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text: The department shall provide the contractor with such information as is reasonably necessary for the contractor to perform its obligations under the contract, including accounting data and other information the contractor may request.

history: (History: Added by Stats. 1981, Ch. 102, Sec. 122. Effective June 28, 1981.)

article: 3.5. Third Party Liability


text: The contractor shall retain its rights to compensation upon recovery for completed duties under the contract with respect to any claims or liens processed in whole or in part prior to the termination date of the agreement.

history: (History: Repealed and added by Stats. 2017, Ch. 52, Sec. 43. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
(a) (1) This section applies to all of the following entities:

(A) Health insurer, or any health care entity licensed through the Department of Insurance.

(B) Self-insured plan.

(C) Group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974.

(D) Service benefit plan.

(E) Managed care organization, including a health care service plan as defined in subdivision (f) of Section 1345 of the Health and Safety Code, licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

(F) Pharmacy benefit manager.

(G) Third-party administrator.

(H) Union trust.

(I) Other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

(2) The entities listed in paragraph (1) shall, upon request of the department for any records, or any information contained in records pertaining to an individual or group health insurance policy or plan issued by such insurer or plan against, or pertaining to the medical or dental benefits paid by or claims made against such insurer or plan under a policy or plan, make the requested records or information available upon a certification by the department that the individual is an applicant for or recipient of services under this chapter or is a person who is legally responsible for such an applicant or recipient.

(b) The entities listed in paragraph (1) of subdivision (a) shall enter into a cooperative agreement with the department setting forth mutually agreeable procedures for the provision of appropriate information, not inconsistent with any law pertaining to the confidentiality and privacy of medical records, at no cost to the department, within 90 days of the department’s request.

(c) The information required to be made available pursuant to this section shall be limited to information necessary to determine whether health benefits have been or should have been claimed and paid pursuant to a health insurance policy or plan with respect to items of medical care and services received by a particular individual for which Medi-Cal coverage would otherwise be available.

(d) Not later than the date upon which the procedures agreed to pursuant to subdivision (b) become effective, the director shall establish guidelines to assure that information relating to an individual certified to be an applicant for or recipient of medical assistance, furnished to any insurer or plan pursuant to this section, is used only for the purpose of identifying the records or information requested in such manner so as not to violate the confidentiality of an applicant or recipient.

history: (History: Amended by Stats. 2021, Ch. 143, Sec. 381. (AB 133) Effective July 27, 2021.)

article: 3.5. Third Party Liability


text:
(a) (1) It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has third-party health coverage or insurance, the State Department of Health Care Services shall be the payer of last resort.

(2) In order to assess overlapping or duplicate health coverage and adjudicate claims, all of the following entities shall maintain a centralized file of the eligibility and coverage information for each subscriber, policyholder, enrollee, or insured:

(A) Health insurer or any health care entity licensed through the Department of Insurance.

(B) Self-insured plan.

(C) Group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974.

(D) Service benefit plan.

(E) Managed care organization, including a health care service plan as defined in subdivision (f) of Section 1345 of the Health and Safety Code, licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

(F) Pharmacy benefit manager.

(G) Third-party administrator.

(H) Union trust.

(I) Other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

(b) (1) The eligibility and coverage information shall include, at a minimum, all of the following information about a subscriber, policyholder, enrollee, or insured:

(A) Full name.

(B) Address.

(C) Date of birth.

(D) Social security number.

(E) Policy number.

(F) Group identification number.

(G) Policy or plan type.

(H) Types of covered services under the policy or plan.

(I) Effective dates of coverage.

(J) Policy or plan termination date.

(2) For any other persons covered under the policy or plan, if any, the eligibility and coverage information shall include, at a minimum, all of the following information:

(A) Full name.

(B) Social security number.

(C) Date of birth.

(D) Place of birth.

(E) Parents’ names, if applicable.

(c) The information described in subdivision (b) shall be provided to the State Department of Health Care Services at least once a month, in a format provided by the department. The information shall also be provided to the department’s agents and contracted Medi-Cal managed care plans, upon reasonable request, to perform cost avoidance on behalf of the department.

(d) An entity listed in subdivision (a) shall provide to the department access to real-time, electronic eligibility verification, at no cost, and in a form and manner specified by the department, as is necessary to conduct its coordination of benefits responsibilities pursuant to this section.

(e) Notwithstanding Section 20134 of the Government Code, the Board of Administration of the California Public Employees’ Retirement System and affiliated systems or contract agencies shall permit data matches with the state department to identify Medi-Cal beneficiaries with third-party health coverage or insurance. A recipient’s Medi-Cal identification card shall, where information is available, contain information advising providers of health care services of any third-party health coverage for the recipient. Providers shall seek reimbursement from available third-party health coverage before billing the Medi-Cal program.

(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 policy letter, information notice, or other similar instruction, without taking any further regulatory action.

history: (History: Repealed and added by Stats. 2021, Ch. 143, Sec. 383. (AB 133) Effective July 27, 2021.)

article: 3.5. Third Party Liability


text: The State Department of Health Services shall, whenever it is cost-effective, pay the premium for third-party health coverage for beneficiaries under this chapter. The State Department of Health Services shall, when a beneficiary’s third-party health coverage would lapse due to loss of employment or change in health status, lack of sufficient income or financial resources, or any other reason, continue the health coverage by paying the costs of continuation of group coverage pursuant to federal law or converting from a group to an individual plan, whenever it is cost-effective. Notwithstanding any other provision of a contract or of law, the time period for the department to exercise either of these options shall be 60 days from the date of lapse of the policy.

history: (History: Amended by Stats. 1992, Ch. 722, Sec. 109. Effective September 15, 1992. Note: The amendment by Stats. 2003, Ch. 673, did not take effect because Ch. 673 was rejected as referendum Proposition 72 at the November 2, 2004, election.)

article: 3.5. Third Party Liability


text:
(a) The department may pay administrative expenses and make incentive payments to any county, state, or federal agency, or a contracting agent of the department for identifying and reporting third-party health care coverage held or offered to beneficiaries under this chapter.

(b) Unless the third-party health care coverage identified is excluded under subdivision (d) from the incentive payment plan, an agency or contractor may be entitled to an incentive payment if the agency or contractor does all of the following:

(1) Identifies a case of which the department was not previously aware.

(2) Provides to the department adequate and necessary information relevant to the third-party health care coverage in order to make a claim for benefits or reimbursement for services rendered that would otherwise be paid by Medi-Cal.

(3) Reports to the department the identified third-party health care coverage within 30 days of the date of discovery on a form approved by the department.

(c) In no event shall any one incentive for each case identified exceed one month of savings received by the department for benefits paid by the third-party health care coverage.

(d) Third-party health care coverage that does not qualify for the incentive payment plan under this section shall be identified by the department based on policy limitations and cost-effectiveness. The types of coverage that do not qualify under this section include those that to which any of the following apply:

(1) Not specifically intended to provide third-party health care coverage, such as coverage that provides life or car insurance benefits, periodic benefits for disability or hospitalization, or income protection.

(2) Coverage is limited to a specific diagnosis, unless the beneficiary has been diagnosed with a condition or disease specified in the coverage.

(3) Coverage is limited to a specific circumstance, such as accidental injury or dismemberment.

(4) Coverage is limited to one specific category of service.

(e) For the purposes of this section, “third-party health care coverage” means health care service plans, benefits, insurance policies, and funds, including those described in Section 14124.90.

history: (History: Added by Stats. 1992, Ch. 722, Sec. 110. Effective September 15, 1992.)

article: 3.5. Third Party Liability


text:
(a) When the rights of a Medi-Cal beneficiary to health care benefits from an insurer have been assigned to the department, an insurer shall not impose any requirement on the department that is different from any requirement applicable to an agent or any assignee of the covered beneficiary.

(b) The department, in the administration of the Medi-Cal program, may garnish the wages, salary, or other employment income of, and withhold amounts from state tax refunds from, any person to whom both of the following apply:

(1) The person is required by a court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under the Medi-Cal program.

(2) The person has received payment from a third party for the costs of the health services for the child, but he or she has not used the payments to reimburse, as appropriate, either the other parent or the person having custody of the child, or the provider of the health services, to the extent necessary to reimburse the department for expenditures for those costs under the Medi-Cal program. All claims for current or past due child support shall take priority over claims made by the department for the costs of Medi-Cal services.

(c) For purposes of this section, “insurer” includes every health insurer, self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, including health care service plans as defined in subdivision (f) of Section 1345 of the Health and Safety Code, licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 77. Effective August 24, 2007.)

article: 3.5. Third Party Liability


text: The director’s recovery is limited to the amount derived from applying Section 14124.72, 14124.76, or 14124.78, whichever is less, to the total settlement, judgment, or award amount upon resolution of all actions or claims associated with the injury with regard to each and every defendant. All statutes of limitations related to the recovery of the director’s lien are tolled until the director receives notification of the resolution of all actions or claims associated with the injury with regard to each and every defendant.

history: (History: Amended by Stats. 2017, Ch. 52, Sec. 35. (SB 97) Effective July 10, 2017.)

article: 3.5. Third Party Liability


text:
(a) Subject to the director’s prior right of recovery, a provider who has rendered services to a beneficiary because of an injury for which a third party is liable and who has received payment under the Medi-Cal program shall be entitled to file a lien for all fees for services provided to the beneficiary against any judgment, award, or settlement obtained by the beneficiary or the director against that third party. A provider may only recover upon the lien if the provider has made a full reimbursement of any fees paid by the department for those services.

(b) If either the beneficiary or the director brings an action or claim against the third party, the party bringing the action shall, within 30 days of bringing the action, give written notice to any provider who is eligible to file a lien under subdivision (a) of the action and of the name of the court or state or local agency in which the action or claim is brought. Notice shall be given by personal service or registered mail, and proof of service shall be filed in the action or claim.

(c) The provider’s claim for reimbursement for fees for services rendered to the beneficiary shall be limited to the amount of the fees less 25 percent, which represents the provider’s reasonable share of attorneys’ fees for prosecution of the action and of the cost of litigation expense.

(d) No claim authorized by this section shall be permitted to the extent that the claim would reduce the director’s right to recover pursuant to Section 14124.78.

history: (History: Amended by Stats. 1992, Ch. 722, Sec. 108.7. Effective September 15, 1992.)

article: 3.5. Third Party Liability


text: If any provision of this article, or the application of any provision of this article to any person, firm, corporation, or other entity or to any circumstance or situation, shall be held invalid, the remaining provisions of this article shall not be affected thereby, and shall be given effect.

history: (History: Added by Stats. 2007, Ch. 188, Sec. 74. Effective August 24, 2007.)

article: 3.5. Third Party Liability


text: It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has other available health coverage or insurance, the Medi-Cal program shall be the payer of last resort. Notwithstanding any other provision of law, any carrier described in Section 14124.70, including automobile, casualty, property, and malpractice insurers, shall enter into an agreement with the department to permit and assist the matching of the department’s Medi-Cal eligibility file against the carrier’s claim files, utilizing, if necessary, social security numbers as common identifiers for the purpose of determining whether Medi-Cal benefits were provided to a beneficiary because of an injury for which another person is liable, or for which a carrier is liable in accordance with the provisions of any policy of insurance. The carrier shall maintain a centralized file of claimants’ names, mailing addresses, and social security numbers or dates of birth. This information shall be made available to the department upon the department’s reasonable request. The agreement described in this section shall include financial arrangements for reimbursing carriers for necessary costs incurred in furnishing requested information.

history: (History: Added by Stats. 2003, Ch. 230, Sec. 70. Effective August 11, 2003.)

article: 3.5. Third Party Liability


text:
(a) The purpose of this article is to establish provider reimbursement rates for incontinence medical supplies covered by the Medi-Cal program. Reimbursement for incontinence medical supplies shall consist of the negotiated contract prices within each product category, plus a markup fee equal to 38 percent of the contract price.

(b) (1) In establishing the list of incontinence medical supplies, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis with manufacturers, distributors, dispensers, or suppliers of incontinence medical supplies.

(2) To ensure that the health needs of Medi-Cal beneficiaries are met, the department shall, when evaluating a decision to execute a contract, and when evaluating incontinence medical supplies for retention on, addition to, or deletion from, the list of incontinence medical supplies, consider all of the following criteria:

(A) The safety of the product.

(B) The effectiveness of the product.

(C) The essential need for the product.

(D) The potential for misuse of the product.

(E) The immediate or long-term cost-effectiveness of the product.

(3) The deficiency of a product when measured by one of the criteria specified in paragraph (2) may be sufficient to support a decision that the product should be deleted from, should not be added to, or should not be retained on, the list of medical supplies. However, the superiority of a product under one criterion may be sufficient to warrant the addition or retention of the product, notwithstanding a deficiency in another criterion.

(4) In the evaluation of the effectiveness of a product, the department may require the manufacturer, distributor, dispenser, or supplier to submit their products to testing by an independent laboratory. For the purposes of this section, “independent laboratory” means an analytical laboratory that is not a subsidiary of, affiliated with, or on retainer for, the manufacturer, distributor, dispenser, or supplier.

(c) The department may use Healthcare Common Procedure Code System codes or Universal Product Number codes for the processing and payment of incontinence medical supplies.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 78. Effective August 24, 2007.)

article: 3.7. Incontinence Medical Supplies

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3.7. Incontinence Medical Supplies


text:
Unless the context requires otherwise, the definitions set forth in this section shall govern the construction and meaning of the terms and phrases used in this article.

(a) “Incontinence medical supplies” means disposable medical supplies that are covered benefits under the Medi-Cal program pursuant to subdivision (s) of Section 14132 when prescribed by a physician for the treatment of individuals who are incontinent. Incontinence medical supplies include, but are not limited to, disposable diapers, briefs, underpads, undergarments, liners or pads, pant and pad systems, and skin care products.

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

(c) “Manufacturer” means any person, partnership, or corporation who assembles or combines the components of incontinence supplies into a final product sold to dealers.

(d) “Principal labeler” means any person, partnership, or corporation who purchases from a manufacturer an assembled product which is sold to dealers under the principal labeler’s label.

(e) “Dealer” means any person, partnership, corporation, or other entity that is recognized by the manufacturer or principal labeler as a provider or retail outlet for its line of incontinence medical supplies, and which provide these supplies directly to consumers. The term “dealer” includes a retailer.

history: (History: Amended by Stats. 1992, Ch. 722, Sec. 112. Effective September 15, 1992.)

article: 3.7. Incontinence Medical Supplies


text:
(a) (1) To qualify for Medi-Cal coverage a product shall be in general retail distribution, sold to the general public, and comply with any standards for products established by law or regulation. No product that is manufactured, distributed, or otherwise promoted for the exclusive use of beneficiaries of the Medi-Cal program shall be a Medi-Cal benefit.

(2) For purposes of this section, “product” means any product which is in general retail distribution.

(3) For purposes of this subdivision, “general retail distribution” means either of the following:

(A) The product is included in a listing of approved products for purchase either by the federal or state government.

(B) The product is on display and available for purchase by customers for private payment at licensed pharmacies or licensed medical supply dealers within California which are physical locations open to the general public.

(b) In order to qualify as a Medi-Cal provider of incontinence medical supplies, a dealer shall have an established place of business that is readily identifiable as a medical supply business, be open to the general public at regularly established business hours, have incontinence supplies in stock on the premises or in a warehouse under the provider’s direct control, and meet all local laws and ordinances regarding business licensing and operations. The department shall establish additional rules and regulations for participation in the Medi-Cal program as it deems necessary to ensure adequate safeguards to the integrity of the Medi-Cal program.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 79. Effective August 24, 2007.)

article: 3.7. Incontinence Medical Supplies


text:
The department shall reduce the weighted average of the negotiated contract prices within each product category in effect on June 30, 1992, as follows:

(a) For all premium underpads, as defined by the department, by 24 percent.

(b) For all other incontinence medical supply products, as defined by the department, by 14 percent.

history: (History: Repealed and added by Stats. 1992, Ch. 1106, Sec. 4. Effective January 1, 1993.)

article: 3.7. Incontinence Medical Supplies


text:
(a) No later than January 1, 1994, the department shall establish utilization controls that limit expenditures for incontinence medical supplies per beneficiary to no more than one hundred sixty-five dollars ($165) per month. Incontinence creams and washes shall be excluded from this limitation. The expenditure limit established by this section may be adjusted in the annual Budget Act to reflect changes in wholesale prices. These utilization controls shall be published in provider bulletins.

(b) The department shall, by prior authorization, allow a beneficiary to exceed the utilization limits established by this section when justified to the department’s satisfaction not later than January 1, 1994.

(c) Notwithstanding any other provision of law, no regulations shall be necessary to define the incontinence medical supplies subject to the reductions required in Section 14125.3, or to establish and implement the utilization controls required in this section.

history: (History: Amended by Stats. 1994, Ch. 813, Sec. 3. Effective January 1, 1995.)

article: 3.7. Incontinence Medical Supplies


text:
(a) In order to more fully identify the owner or owners of companies or corporations that apply to be or currently are providers of incontinence medical supplies, within 30 days of the receipt of a request from the department, or a request to the department from the Department of Justice, the applicant or provider shall provide, as part of the application process or as a condition of continued participation in the Medi-Cal program, the following:

(1) The name of the corporation, the official titles of the applicants, and a list of all the corporate officers.

(2) The California driver’s license or California identification card number of the applicants, coowners, corporate officers, and financially interested parties.

(3) The applicant’s business permit control number, issued by the State Board of Equalization, for the business location where services are rendered to the public.

(4) A statement of all current sources of capital, identity of all investors, disclosure of all manufacturers, suppliers, and providers currently doing business with the applicant, and disclosure of all entities to whom the applicant has extended a line of credit.

(5) A statement certifying that all information supplied pursuant to this section is accurate.

(b) A Medi-Cal provider of incontinence supplies shall not submit a claim for goods or services to the department prior to the date the goods or services are delivered to the Medi-Cal beneficiary. The date of delivery to a beneficiary shall be the earlier of the date the beneficiary actually received the goods or services, or the date the goods were posted or otherwise dispatched from the provider’s premises and control. A claim submitted to the department prior to the date of delivery shall not be paid. Violation of this subdivision shall be grounds for expulsion from the Medi-Cal program.

(c) The department may implement a 180-day moratorium on the enrollment of new providers or new business addresses for incontinence medical supply dealers when the department determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 80. Effective August 24, 2007.)

article: 3.7. Incontinence Medical Supplies


text: Nothing in this article shall be interpreted as limiting or interfering in any way with the department’s authority to contract for the provision of incontinence medical supplies pursuant to subdivision (b) of Section 14105.3.

history: (History: Amended by Stats. 2006, Ch. 538, Sec. 705. Effective January 1, 2007.)

article: 3.7. Incontinence Medical Supplies


text: This article shall be known as the Medi-Cal Long-Term Care Reimbursement Act.

history: (History: Repealed and added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2027, pursuant to Section 14126.036.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3.8. Medi-Cal Long-Term Care Reimbursement Act


text:
(a) It is the intent of the Legislature to devise a Medi-Cal long-term care reimbursement methodology that more effectively ensures individual access to appropriate long-term care services, promotes quality resident care, advances decent wages and benefits for nursing home workers, supports provider compliance with all applicable state and federal requirements, and encourages administrative efficiency.

(b) The department shall implement a facility-specific ratesetting system, subject to federal approval and the availability of federal funds, that reflects the costs and staffing levels associated with quality of care for residents in nursing facilities, as defined in subdivision (c) of Section 1250 of the Health and Safety Code, except that the ratesetting system shall not apply to a unit that provides pediatric subacute services in a skilled nursing facility, or to a skilled nursing facility that is designated as an institution for mental diseases, as defined in Section 1396d(i) of Title 42 of the United States Code. The facility-specific ratesetting system shall be effective commencing on August 1, 2005, and shall be implemented commencing on the first day of the month following federal approval. The department may retroactively increase and make payment of rates to facilities.

(c) In implementing this section, the department may contract as necessary, on a bid or nonbid basis, for professional consulting services from nationally recognized higher education and research institutions, or other qualified individuals and entities not associated with a skilled nursing facility, with demonstrated expertise in long-term care reimbursement systems. The ratesetting system specified in subdivision (b) shall be developed with all possible expedience. This subdivision establishes an accelerated process for issuing contracts pursuant to this section and contracts entered into pursuant to this subdivision shall be exempt from the requirements of Chapter 1 (commencing with Section 10100) and Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(d) The department shall implement a facility-specific ratesetting system by August 1, 2004, subject to federal approval and availability of federal or other funds, that reflects the costs and staffing levels associated with quality of care for residents in hospital-based nursing facilities.

history: (History: Amended by Stats. 2005, Ch. 508, Sec. 8. Effective October 4, 2005. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2027, pursuant to Section 14126.036.)

article: 3.8. Medi-Cal Long-Term Care Reimbursement Act


text: The department shall develop and implement a cost-based reimbursement rate methodology using the cost categories as described in Section 14126.023, for freestanding nursing facilities pursuant to this article, excluding nursing facilities that are a distinct part of a facility that is licensed as a general acute care hospital as identified pursuant to subdivision (d) of Section 14126.02. The cost-based reimbursement rate methodology shall be effective on August 1, 2005, and shall be implemented on the first day of the month following federal approval.

history: (History: Added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2027, pursuant to Section 14126.036.)