text:
(a) The commission shall obtain licensure as a health care service plan under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code.

(b) Commencing on the date that the commission first receives Medi-Cal capitated payments for the provision of health care services to Medi-Cal beneficiaries and the commission is in full compliance with all of the requirements regarding tangible net equity applicable to a health care service plan licensed under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code, all of the following provisions shall apply:

(1) The commission is authorized to select and design its automated management information system, subject to the requirement that the department, in cooperation with the commission, prior to making capitated payments, approve the system. The department shall test the system to ensure that the system is capable of producing detailed, accurate, and timely financial information on the financial condition of the commission, and any other information that is generally required by the department in its contracts with other local initiatives and with health care service plans.

(2) In addition to the reports required by the Department of Managed Health Care under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code and the rules of the Director of the Department of Managed Health Care adopted and promulgated thereunder, the commission shall provide, on a monthly basis, to the department, the Department of Managed Health Care, and the members of the commission a copy of the automated report described in subdivision (a) and a projection of assets and liabilities, including those that have been incurred but not reported, with an explanation of material increases or decreases in current or projected assets and liabilities. The explanation of increases and decreases in assets or liabilities shall be provided, upon request, to a hospital, independent physicians’ practice association, or community clinic that has contracted with the commission to provide health care services.

(3) In addition to the reporting and notification requirements to which the commission is subject under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code, the chief executive officer or director of the commission shall immediately notify the department, the Department of Managed Health Care, and the members of the commission, in writing, of any fact or facts that, in the chief executive officer’s or director’s reasonable and prudent judgment, is likely to result in the commission being unable to meet its financial obligations. The written notice shall describe the fact or facts, the anticipated financial consequences, and the actions that will be taken to address the anticipated consequences.

(4) In no event shall the Department of Managed Health Care waive or vary, nor shall the department request the Department of Managed Health Care to waive or vary, the tangible net equity requirements for a commission under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code after three years after the date of the commencement of capitated payments to the commission. Until the commission is in compliance with all of the tangible net equity requirements under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code and the rules of the Director of the Department of Managed Health Care adopted and promulgated thereunder, the commission shall develop a stop-loss program that is appropriate to the risks of the commission. The stop-loss program shall be subject to the approval of the department and the Department of Managed Health Care.

(5) In the event the commission votes to file a petition of bankruptcy, or the board of supervisors notifies the department that it intends to terminate the commission, the department shall immediately transfer the commission’s Medi-Cal beneficiaries to other managed care contractors, when the contractors are available, and the contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees. To the extent that other managed care providers are unavailable or the department determines that the transfer to the other contractors to a fee-for-service reimbursement system is in the best interest of any particular beneficiary, the department shall make that transfer to the fee-for-service system, pending the availability of managed care contractors that can demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees, or until the department determines that providing care to any particular beneficiary pursuant to a fee-for-service reimbursement system is no longer necessary to protect the continuity of care or other interests of the beneficiary. Beneficiaries who have been or who are scheduled to be transferred to a fee-for-service reimbursement system or managed care contractor may make a choice to be enrolled in another managed care system, if one is available, in full compliance with federal freedom-of-choice requirements.

(6) The commission shall submit to a review of financial records when the department determines, based on data reported by the commission or other data received by the department, that the commission will not be able to meet its financial obligations to health care providers contracting with the commission. If the department, pursuant to a review of financial records under this paragraph, determines that the commission will not be able to meet its financial obligation to contracting health care providers for the provision of health care services, the Director of Health Services shall immediately terminate the contract between the commission and the department and shall immediately transfer the commission’s Medi-Cal beneficiaries in accordance with paragraph (5) in order to ensure uninterrupted provision of health care services to beneficiaries and to minimize financial disruption. Beneficiary eligibility for Medi-Cal shall not be affected by this action. Beneficiaries who have been or who are scheduled to be transferred under paragraph (5) may make a choice to be enrolled in another managed care plan, if one is available, in full compliance with federal freedom-of-choice requirements.

(7) It is the intent of the Legislature that the department shall implement Medi-Cal capitated enrollments in a manner that ensures that appropriate levels of health care services will be provided to Medi-Cal beneficiaries and that appropriate levels of administrative services will be furnished to health care providers. The contract between the department and the commission shall authorize the department to administer the number of covered Medi-Cal enrollments in a manner that ensures that the commission’s provider network and administrative structure are able to provide appropriate and timely services to beneficiaries and to participating providers.

(8) In the event a commission is terminated, files for bankruptcy, or otherwise no longer functions for the purposes for which it was established, the county shall, with respect to compensation for provision of health care services to beneficiaries, occupy no greater or lesser status than any other health care provider in the disbursement of assets of the commission.

(9) Nothing in this section shall be construed to impair or diminish the authority of the Director of the Department of Managed Health Care under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code, nor shall any thing in this section be construed to reduce or otherwise limit the obligation of a commission licensed as a health care plan under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code to comply with the requirements of that chapter, and the rules of the Director of the Department of Managed Health Care adopted thereunder.

history: (History: Amended by Stats. 2000, Ch. 857, Sec. 86. Effective January 1, 2001.)


kind: section

code: WIC

text: The Legislature intends that implementation of this article shall involve consultation and cooperative activities among various agencies of the state and county, and the commission. The Legislature finds and declares that those activities are in furtherance of the state’s goals and efforts. The activities of the commission and its local initiative shall be recognized as state action for purposes of all statutes and regulations relating to business competition.

history: (History: Added by Stats. 1994, Ch. 632, Sec. 2.5. Effective September 20, 1994.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.81. Managed Health Care System for Los Angeles County


text:
(a) If the commission established pursuant to this article no longer functions for the purposes for which it was established, when the commission’s existing obligations have been satisfied or the commission’s assets have been exhausted, the board of supervisors may, by ordinance, resolution, or other action, terminate the commission.

(b) Prior to the termination of the commission, the board of supervisors shall notify the department of its intent to terminate the commission. Within 30 days of the notification, the department shall conduct an audit of the records of the commission to determine the liabilities and assets of the commission. The department shall report its findings to the board of supervisors within 10 days of the completion of the audit. The board of supervisors shall prepare a plan to liquidate or otherwise dispose of the assets of the commission and to pay the liabilities of the commission to the extent of the commission’s assets, and shall present the plan to the department within 30 days after receiving the department’s audit findings.

(c) Upon termination of the commission by the board of supervisors, the county shall manage any remaining assets of the commission until superseded by a plan approved by the department.

(d) All assets of the commission remaining after the payment of the liabilities of the commission pursuant to subdivision (b) shall be disposed of pursuant to the contract entered into between the state and the commission pursuant to Section 14087.

article: 2.81. Managed Health Care System for Los Angeles County


text:
(a) Nothing in this article shall be construed as amending the requirements of Section 17000.

(b) Nothing in this article shall be construed to preclude the department from expanding Medi-Cal managed care in ways other than those expressly provided in this article.


text:
(a) In an effort to determine whether children’s access to, and utilization of, vision care services can be increased by providing vision care services at schools, the department shall establish a pilot program in the County of Los Angeles that enables school districts to allow students enrolled in Medi-Cal managed care plans to receive vision care services at the schoolsite through the use of a mobile vision service provider. The vision care services available under this pilot program are limited to vision examinations and providing eyeglasses.

(b) The Medi-Cal managed care plans in the County of Los Angeles shall jointly identify and develop standards and participation criteria that the participating mobile vision service provider shall meet in order to be deemed qualified to participate in the pilot program, in consultation with the department and consistent with any applicable federal requirements governing Medicaid managed care contracts. In the event the Medi-Cal managed care plans have not developed standards and participation criteria by January 1, 2015, or by the scheduled start date of the pilot program if later, the department shall determine the standards and participating criteria for purposes of this pilot program.

(c) This section shall not be construed to preclude Los Angeles County school district students not enrolled in Medi-Cal managed care from accessing vision care services from a mobile vision service provider participating in this pilot program.

(d) Under the pilot program, if a school district in the County of Los Angeles enters into a written memorandum of understanding with a mobile vision care service provider allowing the provider to offer the vision care services described in this section to students, all of the following shall apply:

(1) The two Medi-Cal managed care plans in the County of Los Angeles shall contract with one or more mobile vision care service providers that meets the standards and participation criteria developed pursuant to subdivision (b) for the delivery of those vision care services to any student enrolled in the Medi-Cal managed care plan who chooses to receive his or her vision care services from the provider at that schoolsite. This contracting requirement is contingent upon agreement between each of the two Medi-Cal managed care plans in the County of Los Angeles and a mobile vision care service provider with respect to reimbursement rates applicable to the services under this pilot.

(2) Neither this pilot program nor the Medi-Cal managed care plan shall require that a Medi-Cal beneficiary receive the vision care services described in this section through a mobile vision care provider onsite at the school.

(3) Prior to a Medi-Cal beneficiary receiving mobile vision care services at the schoolsite, the parents, guardians, or legal representative of the student shall consent in writing to the Medi-Cal beneficiary receiving the services through a mobile vision care provider onsite at the school.

(e) An optometrist or ophthalmologist prescribing glasses to a Medi-Cal managed care beneficiary as part of services provided at a schoolsite by a mobile vision care service provider pursuant to this pilot program shall be enrolled in the Medi-Cal program as an Ordering/Referring/Prescribing provider. For any other purposes under the pilot program, the licensed health professional shall satisfy all requirements for enrollment as a provider in the Medi-Cal program.

(f) (1) The Medi-Cal managed care plan shall compensate the mobile vision services provider for the cost of the vision examination, dispensing of the lenses, and eyeglass frames.

(2) Ophthalmic eyeglasses lenses prescribed by optometrists or ophthalmologists for a Medi-Cal managed care plan enrollee as part of the services provided at a schoolsite by a mobile vision services provider shall be fabricated through optical laboratories the department contracts with pursuant to subdivision (b) of Section 14105.3.

(g) (1) The department shall annually adjust capitation rates for the Medi-Cal managed care plans operating in the County of Los Angeles as necessary to account for projected changes in the costs and utilization of the services provided pursuant to this section by mobile vision service providers.

(2) Capitation rate adjustments pursuant to this section shall be actuarially based and developed using projections of contingent events including targeted populations who will receive these services, and shall otherwise be in accordance with requirements necessary to secure federal financial participation.

(3) Capitation rate adjustments pursuant to this section shall be limited to those related to vision examinations, dispensing of lenses, and eyeglass frames. The fabrication of optical lenses pursuant to this section shall be paid on a fee-for-service basis in accordance with the department’s applicable contract under subdivision (b) of Section 14105.3.

(h) The pilot program shall last three years, starting no sooner than January 1, 2015, and concluding December 31, 2017, or three years from the start date of the pilot if later. The department shall evaluate the impact of the pilot program on access to, and utilization of, vision care services by children by monitoring the managed care plan utilization data for vision services, as well as the lens fabrication data.

(i) The department may terminate the pilot program at any time with 90 days advance notice to the Medi-Cal managed care plans for reasons that include, but are not limited to, any of the following:

(1) The department determines that the pilot program is resulting in a lower level of access to, or use of, vision care services for children under the participating health plans.

(2) The department determines that the pilot program is resulting in fraud, waste, or abuse of Medi-Cal funds.

(3) The department determines there is a lack of funding for the vision care services provided in the pilot program.

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

(k) The department shall obtain any federal approvals necessary to implement this section and to obtain federal matching funds to the maximum extent permitted by federal law.

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

(m) This section shall be implemented only to the extent an annual appropriation is made available to the department each fiscal year for the specific purpose of implementing this section.

(n) If the department determines, pursuant to subdivision (h), that the pilot program is having a positive impact on access and utilization and that additional funds are available, the director may extend the pilot program described in this section to Medi-Cal managed care plans in other counties and applicable local jurisdictions. Any extension shall be implemented only to the extent that any additional and necessary federal approvals are obtained, and if sufficient funds are made available to participating plans for this purpose. The department may accept funding from private foundations in order to implement an extension under this subdivision to the extent that federal financial participation is available.

(o) The department shall post on its Internet Web site a notice that has terminated or expanded the pilot program, including identification of the geographic locations, and shall notify appropriate fiscal and policy committees of both houses of the Legislature.

history: (History: Added by Stats. 2014, Ch. 40, Sec. 4. (SB 870) Effective June 20, 2014. Note: See related declaration of intent in Stats. 2014, Ch. 40, Sec. 11.)


text:
(a) The purpose of this article is to ensure that the Medi-Cal program shall be operated in the most cost-effective and efficient manner possible with the optimum number of Medi-Cal providers, and shall ensure quality of care and known access to services.

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

(1) “Primary care provider” means either of the following:

(A) (i) Any internist, general practitioner, obstetrician-gynecologist, pediatrician, family physician and surgeon, nonphysician medical practitioner, or any primary care clinic, rural health clinic, community clinic or hospital outpatient clinic currently enrolled in the Medi-Cal program, which agrees to provide case management to Medi-Cal beneficiaries.

(ii) For purposes of this subparagraph, “family physician” means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school.

(B) A county or other political subdivision that employs, operates, or contracts with, any of the primary care providers listed in subparagraph (A), and that agrees to use that primary care provider for the purposes of contracting under this article.

(2) “Primary care case management” means responsibility for the provision of referral, consultation, ordering of therapy, admission to hospitals, followup care, and prepayment approval of referred services.

(3) “Designation form” or “form” means a form supplied by the department to be executed by a Medi-Cal beneficiary and a primary care provider or other entity eligible pursuant to this article who has entered into a contract with the department pursuant to this article, setting forth the beneficiary’s choice of contractor and an agreement to be limited by the case management decisions of that contractor and the contractor’s agreement to be responsible for that beneficiary’s case management and medical care, as specified in this article.

(4) “Emergency services” means health care services rendered by an eligible Medi-Cal provider to a Medi-Cal beneficiary for those health services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which if not immediately diagnosed and treated could lead to disability or death.

(5) “Modified primary care case management” means primary care case management wherein capitated services are limited to primary care practitioner office visits only.

(6) “Service area” means an area designated by either a single federal Postal ZIP Code or by two or more Postal ZIP Codes that are contiguous.

(c) For purposes of Medi-Cal managed care plans, as defined in subdivision (m) of Section 14016.5, “nonphysician medical practitioner” means a physician assistant performing services under physician and surgeon supervision in compliance with Chapter 7.7 (commencing with Section 3500) of Division 2 of the Business and Professions Code, a certified nurse-midwife performing services under physician and surgeon supervision in compliance with Article 2.5 (commencing with Section 2746) of Chapter 6 of Division 2 of the Business and Professions Code, or a nurse practitioner performing services in collaboration with a physician and surgeon pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of the Business and Professions Code.

history: (History: Amended by Stats. 2019, Ch. 632, Sec. 16. (AB 1622) Effective January 1, 2020.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.9. Primary Care Provider Case Management


text: The primary care provider or other entity eligible pursuant to this article with whom a contract has been entered into pursuant to this article shall have responsibility for providing for case management as defined, pursuant to Section 14088.

history: (History: Amended by Stats. 1992, Ch. 1212, Sec. 3. Effective January 1, 1993.)

article: 2.9. Primary Care Provider Case Management


text:
(a) No reimbursement shall be provided, for any beneficiary receiving case management services, for any services covered by the contract entered into pursuant to this article, except emergency services and dental services, not authorized pursuant to case management decisions made by the appropriate contractor.

(b) Notwithstanding subdivision (a), a provider shall be reimbursed for covered services rendered to a beneficiary, when the department’s automated eligibility verification system, developed pursuant to Section 14042, fails to indicate that the beneficiary is subject to receiving case management services, provided that claims for these services meet all other requirements for valid claims under the program.

history: (History: Amended by Stats. 1992, Ch. 1212, Sec. 5. Effective January 1, 1993.)


text: For purposes of this article, “primary care case management plan” means a primary care provider or other entity who has contracted with the department pursuant to this article.

history: (History: Amended by Stats. 1995, Ch. 859, Sec. 3. Effective January 1, 1996.)


text: The beneficiary shall be permitted to disenroll from any contract entered into pursuant to this article upon request, except where prohibited under the provisions of any federal waivers obtained by the department.

history: (History: Amended by Stats. 1992, Ch. 1212, Sec. 6. Effective January 1, 1993.)


text: In order to achieve maximum cost savings, the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore, contracts under this article may be on a nonbid basis and shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

history: (History: Amended by Stats. 1998, Ch. 834, Sec. 6. Effective January 1, 1999.)


text: Primary care providers and other entities with whom a contract has been entered into pursuant to this article shall be exempt from Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out the contracts.

history: (History: Amended by Stats. 1992, Ch. 1212, Sec. 7. Effective January 1, 1993.)


text:
(a) The department may establish modified primary care case management contracts pursuant to this article. This authority shall be subject to the department seeking and obtaining all necessary federal waivers to implement this section.

(b) In establishing modified primary care case management contracts pursuant to this article, the department may enter into contracts with providers whose application to develop a full primary care case management contract has been accepted by the department and who are working with the department to document, develop, and install the required systems, policies, and procedures. These contracts may provide for the following:

(1) The modified primary care case management contract would have effect only until the contractor’s full primary care case management contract is executed.

(2) The scope of services covered and the case management and utilization control responsibilities of the contractor may be more limited than under a full primary care case management.

(3) Formal enrollment of Medi-Cal beneficiaries with the contractor would occur but the contractor could be reimbursed on a fee-for-service basis for the services the contractor provides to them. Beneficiaries enrolling under the modified primary care case management contract would remain enrolled under the full primary care case management contract entered into by the contractor.

(4) Contractor quality of care requirements could be modified to reflect the contractor’s fee-for-service managed care mode of health care delivery.

(5) Evaluation by the department of the contractor’s efficiency, case management effectiveness and the calculation of any savings and savings sharing would reflect the temporary fee-for-service approach under which the contractor is operating.

(c) Contracts shall not be entered into by the department unless the waivers or revision to any existing waiver are granted by the federal government. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented, but provisions for which waivers are either obtained or found to be unnecessary shall be unaffected by the inability to obtain federal waivers for other provisions.

history: (History: Amended by Stats. 1992, Ch. 722, Sec. 81. Effective September 15, 1992.)


text: Primary care case management contractors shall establish, maintain, and conduct an active, ongoing outreach and recruitment effort to add primary care and specialty providers to their networks to the extent necessary to meet the health care needs of their enrollees. Contractors shall submit to the department documentation regarding the participation and availability of primary care and specialty providers added to their network on or after enactment of this section. The department may enter into primary care case management contracts with children’s hospitals.

history: (History: Added by Stats. 1992, Ch. 722, Sec. 78. Effective September 15, 1992.)


text: The department shall approve those Medi-Cal services for which the contractor is at risk that shall be provided in any contract or contracts for services under the primary care provider case management program. Medi-Cal services provided under any contract or contracts for services under this article shall be subject to review and approval by the department.

history: (History: Added by Stats. 1988, Ch. 1348, Sec. 11.)


text: The department may enter into contracts pursuant to this article with nurse practitioners, acting within the scope of practice of a nurse practitioner, certified nurse midwives, acting within the scope of practice of a certified nurse midwife, and, for the purpose of providing services to populations with special medical problems, with any physician who has specialized in an area of medicine relevant to the special population to be served and who is currently enrolled in the Medi-Cal program.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 55. Effective August 24, 2007.)


text: A plan shall not use false advertising or false statements to induce enrollment. No solicitation of enrollees shall include the granting or offering of any monetary or other valuable consideration for enrollment.

history: (History: Added by Stats. 1992, Ch. 1056, Sec. 3. Effective September 29, 1992.)


text:
The department or a county which has contracted for the provision of services pursuant to this article may, within service areas designated by the department, enter into contracts with primary care providers. The contracts shall be on a capitated rate or risk-sharing basis, or a combination of both. The rate of payment for services shall not vary solely according to the category of licensure of the facility in which the services are rendered by providers within each service area. The rate of payment established under the contract shall not exceed the total per capita amount which the department estimates would be payable for all services and requirements covered under the contract if all such services and requirements were to be furnished Medi-Cal beneficiaries under the Medi-Cal fee-for-service program.

Prior to entering into any contract for primary care case management under this chapter, the department shall provide public notice of its intent to enter into such a contract. Furthermore, the department shall develop specific criteria for evaluating potential contractors which ensure that all types of primary care providers are given equal consideration in the contractor selection process.

history: (History: Added by renumbering Section 14088.1 by Stats. 1988, Ch. 1348, Sec. 7.)


text:
(a) The department may contract under this article, on an exclusive or nonexclusive basis, with an established professional organization with a membership which consists of physicians who engage in the types of practices or who provide services in the locations set forth in subdivision (a) of Section 14088.

(b) (1) A contract under this section shall be implemented in a manner consistent with any federal waivers which are obtained by the department to enable such an arrangement.

(2) Where federal waivers permit restrictions on beneficiary freedom of choice, the contract shall provide covered Medi-Cal beneficiaries with an initial choice of a primary care physician and a procedure through which a beneficiary may change primary care physicians with good cause.

(c) This section shall apply only to the provision of services to beneficiaries who, for purposes of Medi-Cal eligibility determination, are residents of Lake County, Mendocino County, or Sonoma County.

history: (History: Added by Stats. 1988, Ch. 745, Sec. 1.)


text:
(a) In order to increase the number of nonprofit providers under this article, the department may enter into contracts each fiscal year under this section with eligible nonprofit organizations to provide a one-time interest-bearing loan, repayable at the Pooled Money Investment Account rate, to that eligible organization.

(b) Contracts entered into pursuant to this section shall be limited to contracts within those counties where the department does not have contracts authorized by this article on the effective date of this section.

(c) Any loan entered into pursuant to this section shall not exceed one hundred thousand dollars ($100,000).

(d) The department shall adopt standards and procedures for loan applications and repayment of the loans made pursuant to this section.

(e) The department shall make no loan pursuant to this section until the department has made savings payments to contractors who have entered into contracts under this article on or before the effective date of this section.

(f) For purposes of this section, “eligible nonprofit organization” means any organization which meets all of the following requirements:

(1) The organization is exempt from taxation under Section 501(c)(3) or 501(c)(25)(C)(iii) of the federal Internal Revenue Code.

(2) The organization is organized to provide health care to the medically underserved and to provide services in service areas.

history: (History: Amended by Stats. 1998, Ch. 834, Sec. 5. Effective January 1, 1999.)


text:
(a) The department may enter into primary care case management contracts pursuant to this article with any health care service plan that is licensed by the Director of the Department of Managed Health Care 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).

The terms of the contracts entered into pursuant to this section shall be exempt from those provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code that regulate health care service plan contracts. Nothing in this section shall preclude the Director of the Department of Managed Health Care from otherwise regulating a health care service plan subject to the Knox-Keene Health Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

(b) When a health care service plan enters into a contract pursuant to this article and also pursuant to Chapter 8 (commencing with Section 14200), there shall be no duplication of service areas between the two contracts without prior written approval by the department.

history: (History: Amended by Stats. 2000, Ch. 857, Sec. 87. Effective January 1, 2001.)


text: Sections 14408, 14409, 14410, and 14411 shall apply to primary care case management plans.

history: (History: Amended by Stats. 1995, Ch. 859, Sec. 4. Effective January 1, 1996.)


text:
(a) The department may apply one or more of the following sanctions against any contractor for failure to comply with the requirements of this article, regulations adopted by the department, the contract between the contractor and the department, or for other good cause shown. Good cause includes, but is not necessarily limited to, three repeated and uncorrected findings of serious deficiencies that have the potential to endanger patient care, as defined by the department in accordance with this section, identified in the medical audits conducted by the department:

(1) Terminate the contract.

(2) Suspend enrollment and marketing activities.

(3) Require the contractor to suspend or terminate personnel of the contractor or to terminate participation by subcontractors specified by the department.

(4) Impose civil penalties not to exceed ten thousand dollars ($10,000) per violation pursuant to regulations adopted by the director. Unless imposed in error, penalties shall not be returned to the plan.

(5) Take other appropriate action as determined necessary by the department.

(b) The department shall give the contractor and any other persons who may be directly interested not less than 30 days’ notice of its intention to impose any of the sanctions authorized by this section.

(c) The notice required by subdivision (b) shall be written, and shall specify each requirement that has not been met, the proposed effective date of the sanction or sanctions, and the amount and duration of each proposed sanction.

(d) (1) Within five working days after the receipt of the written notice required by subdivision (b), the contractor may submit notice of its intent to comply with the requirements specified in the written notice.

(2) If the contractor submits the notice of intent authorized by paragraph (1), the department shall allow the contractor to demonstrate its compliance with the requirements specified in the department’s written notice. Substantial compliance shall be achieved within 30 calendar days from the date of the submission of the notice of intent to comply by the contractor. Within 15 days following the completion of the 30-day compliance correction period, the department shall review the corrective actions taken by the contractor and, if appropriate, approve those actions.

(3) If a contractor subject to notice to apply sanctions under subdivision (b) does not demonstrate appropriate corrective compliance within the 30-day corrective action period or does not submit a notice of intent to comply with the requirements specified in the notice required by subdivision (b), the department shall notify the contractor, in writing, of the effective date and terms of the sanction or sanctions applied pursuant to this section.

(4) The department may make one or more of the following temporary suspension orders as an immediate sanction: temporarily suspend enrollment activities, temporarily suspend marketing activities, require the contractor temporarily to suspend specified personnel of the contractor, or require the contractor temporarily to suspend participation by a specified subcontractor. The temporary suspension orders may be effective beginning on the first day after the expiration of the 30-day compliance correction period, if the contractor submitted a notice of intent to comply, but has not demonstrated appropriate corrective action, or beginning on the first day after the notice required by subdivision (b) if the contractor did not submit a notice of intent to comply. All other sanctions shall be effective no earlier than 20 days after the notice specified in paragraph (3).

(5) If the department issues a temporary suspension order as an immediate sanction, it shall notify the contractor of the nature and effective date of the temporary suspension and at the same time shall serve the provider with an accusation. Upon receipt of a notice of defense filed by the contractor, the department shall, within 15 days, set the matter for hearing, which shall be held as soon as possible, but not later than 30 days after receipt of the notice of hearing by the contractor. The hearing may be continued at the request of the contractor if a continuance is necessary to permit presentation of an adequate defense. The temporary suspension order shall remain in effect until the hearing is completed and the department has made a final determination on the merits. However, the temporary suspension order shall be deemed vacated if the director fails to make a final determination on the merits within 60 days after the original hearing has been completed.

(6) A contractor may request a hearing in connection with any sanctions applied pursuant to this section, other than those contained in a temporary suspension order, within 15 working days after the notice of the effective date of the sanctions has been given pursuant to paragraph (3), by sending a letter so stating to the address specified in the notice. The department shall stay implementation of the sanction upon receipt of the request for a hearing. Implementation of the sanction shall remain stayed until the effective date of the final decision of the department.

(7) Except as otherwise provided herein, all hearings to review the imposition of sanctions, including temporary suspension orders, shall be held pursuant to the procedures set forth in Section 100171 of the Health and Safety Code.

(e) The department may collect civil penalties imposed pursuant to this section by withholding the amount of the penalty from capitation payments owed by the department to the contractor.

history: (History: Amended by Stats. 1997, Ch. 220, Sec. 35. Effective August 4, 1997.)


text:
(a) The department may conduct onsite reviews of a provider or facility that has agreed with the primary care case management contractor or a potential contractor to provide services to beneficiaries enrolled with the contractor. These reviews may be for purposes such as evaluating the capabilities of potential contractors, monitoring quality of care, investigating complaints, and ensuring contractor compliance with the terms of the contract entered into pursuant to this article.

(b) Prior to adding a provider or facility to an existing network of providers and facilities, the primary care case management contractor shall submit a complete prequalification package to the department. The department shall provide to the contractor written acknowledgment that the package is complete within 10 working days.

(c) (1) If the provider or facility proposed for addition to the contractor’s existing network is currently enrolled in the Medi-Cal program, the provider or facility may begin treating beneficiaries enrolled with the contractor immediately upon the contractor’s receipt of the acknowledgment required by subdivision (b), subject to paragraph (2) and subdivision (d).

(2) Whenever warranted, the department may rescind the privilege provided for in paragraph (1) by advance notification to the contractor, pending the onsite review required by subdivision (d). Notification shall be in writing and describe the conditions that support the rescission of the privilege.

(d) (1) The department shall conduct an onsite review of the provider or facility within a reasonable period of time after receipt of the package, which shall be not more than 60 days after receipt of the package, unless there are extenuating circumstances.

(2) The department shall notify the contractor in writing of the department’s final decision on the request to add the provider or facility to the contractor’s existing network within 10 working days of the date of the review.

(e) In the conduct of the onsite review of the provider or facility, the department shall not condition approval of the site on adherence by the provider or facility to requirements that are not contained in any statute, regulation, or commonly accepted community standard of medical practice that directly applies to the category of provider or facility being inspected. This subdivision does not, however, relieve the contractor of any obligations under the contract entered into pursuant to this article.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 56. Effective August 24, 2007.)


text:
(a) The department may enter into primary care case management contracts with primary care providers that serve persons infected with human immunodeficiency virus (HIV). Except as otherwise provided in this section, contracts made pursuant to this section shall be subject to all the requirements of this article and regulations of the department.

(b) Primary care providers contracted with pursuant to this section may provide services exclusively to Medi-Cal eligible persons infected with HIV.

(c) Capitation payment rates for primary care providers under this section shall be calculated based on the equivalent fee-for-service costs of providing care to HIV infected patients rather than on the equivalent fee-for-service cost of providing care to all Medi-Cal patients.

history: (History: Added by Stats. 1992, Ch. 34, Sec. 1. Effective April 20, 1992.)


text:
(a) The purpose of this article is to provide a comprehensive program of managed health care plan services to Medi-Cal recipients residing in clearly defined geographical areas. It is, further, the purpose of this article to create maximum accessibility to health care services by permitting Medi-Cal recipients the option of choosing from among two or more managed health care plans or fee-for-service managed case arrangements, including, but not limited to, health maintenance organizations, prepaid health plans, and primary care case management plans. Independent practice associations, health insurance carriers, private foundations, and university medical centers systems, not-for-profit clinics, and other primary care providers, may be offered as choices to Medi-Cal recipients under this article if they are organized and operated as managed care plans, for the provision of preventive managed health care plan services.

(b) The department may seek proposals and then shall enter into contracts based on relative costs, extent of coverage offered, quality of health services to be provided, financial stability of the health care plan or carrier, recipient access to services, cost-containment strategies, peer and community participation in quality control, emphasis on preventive and managed health care services and the ability of the health plan to meet all requirements for both of the following:

(1) Certification, where legally required, by the Director of the Department of Managed Health Care and the Insurance Commissioner.

(2) Compliance with all of the following:

(A) The health plan shall satisfy all applicable state and federal legal requirements for participation as a Medi-Cal managed care contractor.

(B) The health plan shall meet any standards established by the department for the implementation of this article.

(C) The health plan receives the approval of the department to participate in the pilot project under this article.

(c) (1) (A) The proposals shall be for the provision of preventive and managed health care services to specified eligible populations on a capitated, prepaid, or postpayment basis.

(B) Enrollment in a Medi-Cal managed health care plan under this article shall be voluntary for beneficiaries eligible for the federal Supplemental Security Income for the Aged, Blind, and Disabled Program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of Title 42 of the United States Code).

(2) The cost of each program established under this section shall not exceed the total amount that the department estimates it would pay for all services and requirements within the same geographic area under the fee-for-service Medi-Cal program.

(d) (1) An eligible beneficiary shall be entitled to enroll in any health care plan contracted for pursuant to this article that is in effect for the geographic area in which the beneficiary resides. The department shall make available to recipients information summarizing the benefits and limitations of each health care plan available pursuant to this section in the geographic area in which the recipient resides. A Medi-Cal or CalWORKs applicant or beneficiary shall be informed of the health care options available regarding methods of receiving Medi-Cal benefits. The county shall ensure that each beneficiary is informed of these options and informed that a health care options presentation is available.

(2) No later than 30 days following the date a Medi-Cal or CalWORKs recipient is informed of the health care options described in paragraph (1), the recipient shall indicate the recipient’s choice, in writing, of one of the available health care plans and the recipient’s choice of primary care provider or clinic contracting with the selected health care plan. Notwithstanding the 30-day deadline set forth in this paragraph, if a beneficiary requests a directory for the entire service area within 30 days of the date of receiving an enrollment form, the deadline for choosing a plan shall be extended an additional 30 days from the date of that request.

(3) The health care options information described in this subdivision shall include the following elements:

(A) Each beneficiary or eligible applicant shall be provided, at a minimum, with the name, address, telephone number, and specialty, if any, of each primary care provider, by specialty or clinic participating in each managed health care plan option through a personalized provider directory for that beneficiary or applicant. This information shall be presented under the geographic area designations by the name of the primary care provider and clinic, and shall be updated based on information electronically provided monthly by the health care plans to the department, setting forth changes in the health care plan provider network. The geographic areas shall be based on the applicant’s residence address, the minor applicant’s school address, the applicant’s work address, or any other factor deemed appropriate by the department, in consultation with health plan representatives, legislative staff, and consumer stakeholders. In addition, directories of the entire service area, including, but not limited to, the name, address, and telephone number of each primary care provider and hospital, of all Geographic Managed Care health plan provider networks shall be made available to beneficiaries or applicants who request them from the health care options contractor. Each personalized provider directory shall include information regarding the availability of a directory of the entire service area, provide telephone numbers for the beneficiary to request a directory of the entire service area, and include a postage-paid mail card to send for a directory of the entire service area. The personalized provider directory shall be implemented as a pilot project in Sacramento County pursuant to this article, and in Los Angeles County (Two-Plan Model) pursuant to Article 2.7 (commencing with Section 14087.305). The content, form, and geographic areas used shall be determined by the department in consultation with a workgroup to include health plan representatives, legislative staff, and consumer stakeholders, with an emphasis on the inclusion of stakeholders from Los Angeles and Sacramento Counties. The personalized provider directories may include a section for each health plan. Prior to implementation of the pilot project, the department, in consultation with consumer stakeholders, legislative staff, and health plans, shall determine the parameters, methodology, and evaluation process of the pilot project. The pilot project shall thereafter be in effect for a minimum of two years. Following two years of operation as a pilot project in two counties, the department, in consultation with consumer stakeholders, legislative staff, and health plans, shall determine whether to implement personalized provider directories as a permanent program statewide. If necessary, the pilot project shall continue beyond the initial two-year period until this determination is made. This pilot project shall only be implemented to the extent that it is budget neutral to the department.

(B) Each beneficiary or eligible applicant shall be informed that the beneficiary or applicant may choose to continue an established patient-provider relationship in a managed care option, if the treating provider is a primary care provider or clinic contracting with any of the health plans available and has the available capacity and agrees to continue to treat that beneficiary or eligible applicant.

(C) Each beneficiary or eligible applicant shall be informed that if the beneficiary or applicant fails to make a choice, the beneficiary or applicant shall be assigned to, and enrolled in, a health care plan.

(4) At the time the beneficiary or eligible applicant selects a health care plan, the department shall, when applicable, encourage the beneficiary or eligible applicant to also indicate, in writing, that person’s choice of primary care provider or clinic contracting with the selected health care plan.

(5) Commencing with the implementation of a geographic managed care project in a designated county, a Medi-Cal or CalWORKs beneficiary who does not make a choice of health care plans in accordance with paragraph (2), shall be assigned to and enrolled in an appropriate health care plan providing service within the area in which the beneficiary resides.

(6) If a beneficiary or eligible applicant does not choose a primary care provider or clinic, or does not select a primary care provider who is available, the health care plan selected by or assigned to the beneficiary shall ensure that the beneficiary selects a primary care provider or clinic within 30 days after enrollment or is assigned to a primary care provider within 40 days after enrollment.

(7) A Medi-Cal or CalWORKs beneficiary dissatisfied with the primary care provider or health care plan shall be allowed to select or be assigned to another primary care provider within the same health care plan. In addition, the beneficiary shall be allowed to select or be assigned to another health care plan contracted for pursuant to this article that is in effect for the geographic area in which the beneficiary resides in accordance with Section 1903(m)(2)(F)(ii) of the Social Security Act.

(8) The department or its contractor shall notify a health care plan when it has been selected by or assigned to a beneficiary. The health care plan that has been selected or assigned by a beneficiary shall notify the primary care provider that has been selected or assigned. The health care plan shall also notify the beneficiary of the health care plan and primary care provider selected or assigned.

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

(e) A participating county may include within the plan or plans providing coverage pursuant to this section, employees of county government, and others who reside in the geographic area and who depend upon county funds for all or part of their health care costs.

(f) Funds may be provided to prospective contractors to assist in the design, development, and installation of appropriate programs. The award of these funds shall be based on criteria established by the department.

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

(h) Notwithstanding any other provision of law, on and after the effective date of the act adding this subdivision, the department shall have exclusive authority to set the rates, terms, and conditions of geographic managed care contracts and contract amendments under this article. As of that date, all references to this article to the negotiator or to the California Medical Assistance Commission shall be deemed to mean the department.

(i) Notwithstanding Section 7926.220 of the Government Code, a contract or contract amendments executed by both parties after the effective date of the act adding this subdivision shall be considered a public record for purposes of the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code) and shall be disclosed upon request. This subdivision includes contracts that reveal the department’s rates of payment for health care services, the rates themselves, and rate manuals.

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 445. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.91. Geographic Managed Care Pilot Project


text: In accordance with procedures required by Section 14408, all marketing activities shall require prior approval of the department.

history: (History: Added by Stats. 1984, Ch. 1509, Sec. 2.)

article: 2.91. Geographic Managed Care Pilot Project


text: In accordance with procedures required by Chapter 8 (commencing with Section 14200), each contract with a capitated health system shall provide for a grievance procedure under which Medi-Cal beneficiaries may submit their grievances. The department shall establish standards for these procedures to include appeals to an entity other than the capitated health system.

history: (History: Added by Stats. 1984, Ch. 1509, Sec. 3.)


text: The department shall not contract with insurance carriers, organized health systems, or provider organizations, that employ or subcontract with plans that employ providers under suspension from the Medicare or Medi-Cal program.

history: (History: Added by Stats. 1984, Ch. 1509, Sec. 4.)


text: The department may consult with the Department of Insurance or the Department of Managed Health Care, and shall consult with the Division of Medi-Cal Fraud and Elder Abuse within the Office of the Attorney General, the appropriate licensing boards, and the laboratory field services unit of the department, for the purposes of determining the qualifications, performance capability, and financial stability of prospective contractors.

history: (History: Amended by Stats. 2021, Ch. 554, Sec. 10. (SB 823) Effective January 1, 2022.)


text:
(a) (1) The department may implement a multiplan project in the County of San Diego, upon approval of the Board of Supervisors of the County of San Diego, for the provision of benefits under this chapter to eligible Medi-Cal recipients. The multiplan project implemented in the County of San Diego pursuant to this section shall provide diagnostic, therapeutic, and preventive services provided under the Medi-Cal program, and additional benefits including, but not limited to, medical-related transportation, comprehensive patient management, and referral to other support services.

(2) The County of San Diego shall be eligible to receive funds transferred pursuant to paragraph (1) of subdivision (p) of Section 14163 for the development and implementation of this section. These funds in the amount allocated by the department for the County of San Diego shall be paid by the department upon the enactment of this section to the County of San Diego to reimburse a portion of the costs of the development of the project. To the full extent permitted by state and federal law, these funds shall be distributed by the department for expenditure by the County of San Diego in a manner that qualifies for federal financial participation under the Medicaid program and the department shall expedite the payment of the federal funds to the County of San Diego. The department shall seek additional state, federal, and other funds to pay for costs that are incurred by the County of San Diego to develop the multiplan project in excess of the payment required by this section, and the department shall assist the county in obtaining the additional funds.

(b) (1) The County of San Diego may establish an advisory board composed of consumer representatives and health care professionals’ representatives. The board shall advise the Health and Human Services Agency of the County of San Diego and review and comment on all aspects of the implementation of the multiplan project. The advisory board shall advise on the implementation of the state Medi-Cal policy as it pertains to Medi-Cal managed care plans in the County of San Diego. Each supervisor of the board of supervisors shall appoint at least one member to the advisory board with each supervisor to appoint an equal number of members from their district. The advisory board shall vote on all pilot project policies and issues that are submitted to the board of supervisors.

(2) Notwithstanding any other law, a member of the advisory board established pursuant to this section shall not be deemed to be interested in a contract entered into by the department within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if the member is a Medi-Cal recipient or if all of the following apply:

(A) The member was appointed to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations.

(B) The contract authorizes the member or the organization the member represents to provide Medi-Cal services under the multiplan project.

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

(D) The member does not influence or attempt to influence the advisory board or another member of the advisory board to recommend that the department enter into the contract in which the member is interested.

(E) The member discloses the interest to the advisory board and abstains from voting on any recommendation on the contract.

(F) The advisory board notes the member’s disclosure and abstention in its official records.

(3) Members of the advisory board shall not be paid compensation for activities relating to their duties as members, but members who are Medi-Cal recipients shall be reimbursed an appropriate amount by the County of San Diego for their travel and child care expenses incurred in performing their duties under this section. Members of the advisory board who are Medi-Cal recipients may also be reimbursed by the County of San Diego for their time in performing their duties under this section, at the discretion of the county.

(c) At the discretion of the department, the County of San Diego, the department, or other appropriate entities may perform any of the following in a manner that accomplishes the integration of the intake of eligible beneficiaries to the project, the assessment of beneficiary individual and family needs and circumstances, and the timely referral of beneficiaries to health care and other services to respond to their individual and family needs:

(1) Determine the eligibility of Medi-Cal applicants and recipients in a manner and environment that is accessible to the recipients and applicants.

(2) Perform enrollment activities in a manner that ensures that recipients be given the opportunity to select the provider of their choice in a manner and environment that is accessible to the recipients.

(3) The department may negotiate and amend its contract with the county to provide for specified quality improvement activities, and may require each of the health plans to participate in those activities. The department shall also participate in the county’s quality improvement activities.

(d) Notwithstanding Section 14089 or any other provision of law, the County of San Diego, when contracting with the department pursuant to this section or Section 14089, shall not be liable for damages for injury to persons or property arising out of the actions or inactions of the department, the department’s other contractors, or providers of health care or other services, or Medi-Cal recipients. This section shall not relieve the County of San Diego from liability arising out of its actions or inactions.

(e) The County of San Diego, when contracting with the department pursuant to Section 14089 or this section, shall have no legal duty to provide health care or other services to Medi-Cal recipients, and shall have no financial responsibility for the department’s other contractors or providers of health care or other services, except to the extent specifically set forth in contracts between the department and the county.

(f) Notwithstanding Section 14089.6, the department may terminate any existing managed care contract with either a prepaid health plan or a primary care case management plan for services in the County of San Diego in accordance with the terms and conditions set forth in the existing contract, at any time that the department determines that termination is in the best interest of the state. The department shall notify an existing prepaid health plan at least 90 days prior to termination. The department shall notify a primary care case management plan at least 30 days prior to termination.

(g) All contracts entered into by the department and the County of San Diego pursuant to Section 14089 or this section shall not be for the benefit of any third party, and no third-party beneficiary relationship shall be established between the county and any other party, except as may be specifically set forth in contracts between the department and the County of San Diego.

(h) (1) For purposes of this section, “multiplan project” means a program authorized by this section in which a number of Knox-Keene licensed health plans designated by the county and approved by the department shall be the only Medi-Cal managed care health plans authorized to operate within the County of San Diego, with the exception of special projects approved by the department.

(2) Designated health plans shall include, but not be limited to, health plans sponsored by traditional Medi-Cal physicians, neighborhood health centers, community clinics, health systems, including hospitals and other providers, or a combination thereof.

(3) Participating health plans shall first be designated by the county for approval by the department. Health plans approved by the department shall be eligible to contract with the department. Designation by the county and approval by the department provides the health plan only with the opportunity to compete for a contract and does not guarantee a contract with the state.

(4) Designation requirements imposed by the county shall not conflict with the requirements imposed by the department, the federal Medicaid program, and the Medi-Cal program, and may not impose stricter requirements, without the department’s approval, than those imposed by the department, the federal Medicaid program, and the Medi-Cal program.

(5) Designation of health plans by the county will continue for the term of the Medi-Cal contract.

(i) Nothing in this section relieves the county of duties or liabilities imposed by Part 5 (commencing with Section 17000) or that it has assumed through contract with entities other than the department.

(j) Indian health facilities in the County of San Diego may contract directly with the department as Medi-Cal fee-for-service case management providers apart from the geographic managed care program or may participate in the network of one or more of the geographic managed care plans. Indian health service facilities that contract with the department as fee-for-service case management providers may enroll Medi-Cal recipients, including, but not limited to, recipients who are in any of the geographic managed care mandatory enrollment aid codes.

history: (History: Amended by Stats. 2024, Ch. 134, Sec. 1. (SB 1257) Effective January 1, 2025.)


text:
(a) The department or its authorized agents shall conduct periodic audits or review, including onsite audits or review, to monitor compliance with Article 4 (commencing with Section 14400) of Chapter 8 with regard to any contract made pursuant to this article. These reviews may be conducted with or without notice and may include assistance by the Attorney General if requested.

(b) The department may terminate a contract, in whole or in part, when the director determines that this action is necessary to protect the health of the beneficiaries or the funds appropriated to carry out the Medi-Cal program.

history: (History: Added by Stats. 1984, Ch. 1509, Sec. 6.)


text: Current prepaid health plan and primary care case management contracts entered into by the department pursuant to Chapter 7 (commencing with Section 14088) and Chapter 8 (commencing with Section 14200) shall not be terminated solely due to the implementation of this article in areas served by prepaid health plans and primary care case management contractors. Upon expiration of these contracts, the department shall enter into good faith negotiations for one renewal of these contracts. These plans may continue to serve their Medi-Cal enrollees and to enroll new beneficiaries. Upon expiration or final termination of these renewal contracts and subject to compliance with all applicable requirements prepaid health plan and primary care case management contractors in the areas shall be allowed the opportunity to participate as new contractors under this article.

history: (History: Amended by Stats. 1991, Ch. 95, Sec. 9. Effective June 30, 1991.)


text:
(a) The Sacramento County Department of Health and Human Services may establish a stakeholder advisory committee to provide input on the delivery of health care services provided in the county pursuant to this article, Section 14182, and Part 3.6 (commencing with Section 15909). The advisory committee shall include, but not be limited to, Medi-Cal beneficiaries, patient representatives, health care providers, and representatives of Medi-Cal managed care health plans.

(b) The advisory committee may submit written input to the State Department of Health Care Services regarding policies that improve coordination with traditional and safety net providers, enhance the capacity of the county’s health care delivery system, and improve health care services and health outcomes.

(c) The advisory committee may request, in writing, and receive final reports submitted to the department by any managed care health plan operating in Sacramento County as long as the report is not exempt from disclosure pursuant to Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code, or any other contractual, statutory, or legal exemption, or privilege. The advisory committee may review and provide written comments to the department on these reports, that may include issues such as evaluation of access, quality, and consumer protections.

(d) No state General Fund moneys shall be used to fund advisory committee costs, nor to fund any related administrative costs incurred by the county.

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 446. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)


text:
(a) The department may adopt emergency regulations to implement this article in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The initial adoption of emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and the first readoption of those regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations and each shall remain in effect for no more than 180 days.

(b) All regulations adopted pursuant to this section prior to the repeal and addition of this section by the act adding this section shall remain in full force and effect unless they are repealed or amended by the department in accordance with the Administrative Procedure Act.

history: (History: Repealed and added by Stats. 2001, Ch. 171, Sec. 41. Effective August 10, 2001.)


text:
(a) Sacramento County may establish a stakeholder advisory committee to provide input on the delivery of oral health and dental care services, including prevention and education services, dental managed care, and fee-for-service Denti-Cal. The advisory committee shall include, but not be limited to, local nonprofit organizations, representatives from the First Five Sacramento Commission, representatives and members of the local dental society, local health and human services representatives, representatives of Medi-Cal dental managed care plans, Medi-Cal enrollees, and other interested individuals. The advisory committee may meet on a monthly basis.

(b) The advisory committee may submit written input to the State Department of Health Care Services or the Sacramento County Board of Supervisors, as applicable, regarding policies that improve the delivery of oral health and dental services in Sacramento under the Medi-Cal program or county-administered health care system.

(c) The State Department of Health Care Services shall meet periodically, but at least on a quarterly basis, with the advisory committee to facilitate communication, dissemination of information, and improvements in the provision of oral health and dental care services under the Medi-Cal program in the County of Sacramento. The dissemination of information shall include data reported from performance measures and benchmarks used by the department.

(d) The advisory committee may meet periodically, but at least twice annually, with the Sacramento County Department of Health and Human Services advisory committee established pursuant to Section 14089.07.

(e) No state General Fund moneys shall be used to fund advisory committee costs or to fund any related administrative costs incurred by the county.

history: (History: Added by Stats. 2012, Ch. 23, Sec. 79. (AB 1467) Effective June 27, 2012.)


text:
(a) In order to achieve maximum cost savings, the Legislature finds and declares that an expedited contract process for contracts under this article is necessary.

(b) Contracts under this article shall be on a nonbid basis, and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

history: (History: Amended by Stats. 1998, Ch. 834, Sec. 8. Effective January 1, 1999.)


text:
(a) It is the intent of the Legislature to improve access to oral health and dental care services provided to Medi-Cal beneficiaries enrolled in dental health managed care plans in the Counties of Sacramento and Los Angeles through implementation of performance contracting to ensure dental health plans meet quality criteria and timely access to dental care, as contained in Section 14459.6, and implementation of a beneficiary dental exception process for Medi-Cal beneficiaries in the County of Sacramento to access dental care through fee-for-service Denti-Cal when applicable.

(b) (1) The Director of Health Care Services shall exercise his or her authority under Section 14131.15 to establish a beneficiary dental exception (BDE) process, as described in paragraph (2), for Medi-Cal beneficiaries mandatorily enrolled in dental health plans in the County of Sacramento. The BDE process shall be implemented no later than July 1, 2012, and shall be in effect for as long as mandatory enrollment for dental care is in effect in the County of Sacramento. The department shall consult with the advisory committee established pursuant to Section 14089.08 regarding potential modifications to the BDE process. For purposes of emergency access to dental care issues, the department shall establish specific processes under the BDE to accommodate for these issues.

(2) The BDE shall be available to Medi-Cal dental managed care beneficiaries in the County of Sacramento who are unable to secure access to services through their managed care plan, in accordance with applicable contractual timeframes and in accordance with 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). The BDE shall allow a beneficiary to opt-out of Medi-Cal dental managed care and move into fee-for-service Denti-Cal where the beneficiary may select his or her own dental provider on an ongoing basis. The beneficiary shall remain in fee-for-service Denti-Cal until the time he or she chooses to opt in to a dental managed care arrangement.

(3) Beneficiaries shall be notified of the BDE option, which shall include the process for access to emergency visits, through a letter from the department detailing the process, directions on how to fill out the BDE form, and where to access the BDE form. A hard copy of the BDE form shall accompany the letter from the department. The BDE form, directions on how to fill out the BDE form, and a description of the process shall also be posted on the department’s Internet Web site for easy access by beneficiaries and the public. The department shall also notify and inform dental managed care plans of the BDE process and its operation.

(4) Upon receipt of the BDE form, the department shall have no more than three business days to contact the beneficiary. The department shall, within five business days from the date of contact with the beneficiary, work with the beneficiary and the dental plan to schedule an appointment within the applicable contractual timeframes and in accordance with 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).

(A) If an appointment is not available, the department shall approve and process the BDE and move the beneficiary into fee-for-service Denti-Cal.

(B) If an appointment is available, the beneficiary shall receive from the department a followup telephone call after the appointment to assess how the visit went and to determine if there is a need for any additional followup.

(5) Based on the followup as identified in subparagraph (B) of paragraph (4), to the extent no additional access issues to contractually required services are identified, the BDE shall be closed and the beneficiary shall remain in the selected dental plan.

(c) The department shall take all necessary steps to implement the BDE process as described in this section and shall, monthly, publicly report on the department’s Internet Web site the number of individuals requesting the BDE and the specific outcome of each request, including, but not limited to, summary data on the types of visits subject to the BDE process, the services provided, description of timely access to care, the delivery system in which services were provided, beneficiary satisfaction, and the department’s perspective of the outcome. The information provided on the department’s Internet Web site shall be deidentified in accordance with the Health Insurance Portability and Availability Act of 1996 (HIPAA), including Section 164.514 of Title 45 of the Code of Federal Regulations, and shall not contain any personally indentifiable information according 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).

(d) The department shall consult with stakeholders in the development of the BDE form and related materials.

history: (History: Added by Stats. 2012, Ch. 23, Sec. 80. (AB 1467) Effective June 27, 2012.)


text:
(a) Nursing facility services necessary for the treatment of illness or injury are covered subject to the provisions of this section:

(b) Nursing facility services are covered only after prior authorization has been obtained from the designated Medi-Cal consultant for the field office area in which the nursing facility is located. The authorization request shall be initiated by the facility and shall be signed by the attending physician. Nursing facility services may be authorized either for a distinct-part nursing facility (a facility that is a distinct part of an acute care hospital), or for a freestanding nursing facility (a facility that is not part of an acute care hospital).

(1) Distinct-part nursing facility care at the distinct-part nursing facility reimbursement rate for any Medi-Cal patient determined to need long-term nursing care shall be authorized when any one of the following conditions is met:

(A) There is no freestanding nursing facility within 15 miles, which shall be defined as 30 minutes at 30 miles per hour, from the established residential address of that patient prior to admission to nursing care and the distinct-part nursing facility is within a shorter actual travel time than the closest freestanding nursing facility able and willing to admit the patient.

(B) There is a freestanding nursing facility within 15 miles, as defined in subparagraph (A) from the established residential address of the patient before admission to nursing care, but after reasonable placement efforts, no such facility is able and willing to accept the patient, and the distinct-part nursing facility is within a shorter travel time than the closest freestanding nursing facility able and willing to admit the patient, within the 25-day placement period.

(C) There is no freestanding nursing facility within 30 minutes actual travel time from the established residential address of the immediate family member, such as the spouse, parent, child, or sibling of the patient, who certifies that he or she is the family member who will be most frequently visiting and helping with the personal needs of the patient, or if there is such a freestanding nursing facility, there is none able and willing, after reasonable placement efforts, to accept the patient, and the distinct-part nursing facility is within a shorter travel time than the closest freestanding nursing facility. In this case, the distinct-part nursing facility shall submit with the treatment authorization request a signed statement from the immediate family member certifying that he or she is the person who will be most frequently visiting and seeing to the personal needs of the patient. The signed statement of the family member shall contain an explanation of the relationship to the patient, the residential address used in calculating the distance to the distinct-part nursing facility, and the mode of transportation to be used. A copy of this certification shall be kept in the patient’s file at the distinct-part nursing facility.

(D) The immediate family member who will be most frequently visiting and seeing to the personal needs of the patient cannot, because of established health reasons, travel to a freestanding nursing facility that is able and willing to admit the patient and that is within 30 minutes actual travel time, but he or she is able to travel to the distinct-part nursing facility. The certification so stating, and signed by that family member, shall be submitted with the treatment authorization request. A copy of this certification shall be kept in the patient’s file at the distinct-part nursing facility.

(E) The patient has a spouse residing in the same distinct-part nursing facility.

(F) The patient is currently, as of the time approval is sought, residing in the distinct-part nursing facility and has been continuously residing in that facility for at least 120 consecutive days, and payment has been made or approved during the 120 consecutive days by Medicare, other health insurance, or by Medi-Cal at a distinct-part nursing facility rate. For patients who have met this requirement and are later hospitalized, a treatment authorization request at the distinct-part nursing facility rate shall be reinstated if the patient returns to the same distinct-part nursing facility during the seven-day bed-hold period specified in Section 1599.79 of the Health and Safety Code. Otherwise, to reside in a distinct-part nursing facility, the patient shall meet one of the conditions set forth unless the patient’s attending physician documents in the medical record that discharge to a freestanding nursing facility would cause physical or psychological harm to the patient.

(2) “Actual travel time” means the amount of time it would usually take the immediate family member to travel between two specific points by means of whatever transport would be available to him or her, taking into account actual road and weather conditions.

(3) “Reasonable placement efforts” means that during the 25-day time period beginning with the date that approval for the Medi-Cal distinct-part nursing facility rate is first sought, the facility shall do all of the following:

(A) Contact on a daily basis, not including Saturdays, Sundays, or holidays, Medi-Cal-certified freestanding nursing facilities within the applicable mileage or travel time, to determine whether each such freestanding nursing facility is able and willing to admit the patient. In meeting this requirement, facilities shall contact only those freestanding nursing facilities that they, in good faith, believe may be able and willing to admit this patient, taking into account previous contacts. Further attempts at placement calls will be waived by the department. Freestanding nursing facilities within the applicable mileage or travel time are those within the appropriate travel time plus any freestanding nursing facility within a shorter actual travel time than the distinct-part nursing facility from the appropriate residential address such as the patient’s or the immediate family member’s.

(B) Document that the facility contacted a person responsible for admission decisions during each required contact, the date and time of each contact with a freestanding nursing facility, the name and title of each person contacted, the reason given for the freestanding nursing facility not being able or willing to admit the patient on the day contacted, and the date, if any, when the freestanding nursing facility would be able and willing to accept the patient. Contacts may be made by telephone or facsimile transmission.

(C) Submit the documentation specified in subparagraph (B) to the Medi-Cal field office at the conclusion of the 25-day placement effort period.

(4) Upon submission of documentation that reasonable placement efforts requirement were met, the distinct-part nursing facility rate or acute administrative days shall be approved as follows:

(A) Hospitals seeking to place a patient into their own distinct-part nursing facilities shall be approved for acute administrative days for a patient determined to need long-term nursing facility care, who remains in an acute care bed during the placement period. If a contacted freestanding nursing facility was able and willing to admit the patient during the 25-day period, the hospital’s treatment authorization request shall be subsequently authorized for approval of acute administrative days until the date that the freestanding nursing facility is able to accept the patient.

At the completion of the reasonable placement effort period, if no freestanding nursing facility is able and willing to take the patient, the hospital’s treatment authorization request shall be authorized for approval for acute administrative days for days of care during the reasonable placement period. The hospital, in order to comply with this subparagraph, shall complete the 25-day placement period if there is a freestanding nursing facility within the applicable mileage or travel time willing to take the patient, but due to occupancy, is unable to accept transfer on the days it was contacted. If, however, there is a freestanding nursing facility within the applicable mileage or travel time, but the freestanding nursing facility is not able or willing to admit the patient at the time of the placement effort or in the future, the length of placement time required shall vary and may be shorter than 25 days. If documentation establishes that no freestanding nursing facility within the applicable mileage or travel time, is, or will ever be, able or willing to admit the patient, further placement efforts shall not be required. The distinct-part nursing facility rate of reimbursement shall be approved upon the patient’s admission to the distinct-part nursing facility if reasonable placement efforts requirement has been met and no freestanding nursing facility within the applicable mileage or travel time standard was able and willing to accept the patient.

(B) When a patient is either admitted to a distinct-part nursing facility from an acute hospital, nonacute facility, or community setting, or was a distinct-part nursing facility resident whose care has been, but is no longer being, paid by another payment source, a treatment authorization request shall be approved at the distinct-part nursing facility rate for a patient who has been admitted and determined to need long-term nursing facility placement when the reasonable placement efforts requirement has been met. If a contacted freestanding nursing facility is able and willing to admit the patient during the 25-day period, the distinct-part nursing facility treatment authorization request shall be subsequently authorized for approval at the distinct-part nursing facility rate until the date that the freestanding nursing facility is able to accept the patient. If the basis on which the final distinct-part nursing facility approval is sought is the lack of any freestanding nursing facility able and willing to take the patient after reasonable placement efforts, this approval shall not be given until after the completion of the reasonable placement period, but may be given for days of care during that period. The criteria for shortening the reasonable placement period to less than 25 days shall apply. Notwithstanding the general requirement that skilled nursing care must receive prior authorization, when a distinct-part nursing facility admits a patient during the time it is making reasonable placement efforts, authorization of the distinct-part nursing facility rate may be given postadmission.

However, no days of care shall be authorized for any period prior to the receipt of the treatment authorization request from the facility, unless retroactive authorization may be given.

(C) When a patient spends some of the placement period in the hospital and some of that time in a distinct-part nursing facility, acute administrative days shall be authorized for the hospital days and the distinct-part nursing facility rate for the distinct-part nursing facility days, subject to the provisions of this paragraph.

(5) Reasonable placement efforts, as defined in paragraph (3), shall be conducted for all patients in need of long-term nursing care who are seeking admission to a distinct-part nursing facility pursuant to paragraph (1) of subdivision (a) of Section 51335 of Title 22 of the California Code of Regulations. Patients requiring nursing care for postsurgical rehabilitative or therapy services shall not be subject to the reasonable placement efforts required for admission to a distinct-part nursing facility but they shall be subject to all other Medi-Cal criteria for these admissions. A patient, who is a resident of a distinct-part nursing facility and who has been hospitalized for more than the seven-day bed-hold period, may be readmitted to the distinct-part nursing facility without meeting the reasonable placement efforts requirement for admission, if the attending physician documents that discharge to a freestanding nursing facility will result in physical or psychological harm.

(6) If a distinct-part nursing facility desires of its own volition to admit a patient needing nursing care at the freestanding nursing facility rate, the department shall approve a treatment authorization request submitted for approval at that rate. Distinct-part nursing facilities shall be enrolled in the Medi-Cal program as a freestanding nursing facility provider for that purpose, in addition to being otherwise enrolled in the Medi-Cal program. A distinct-part nursing facility objecting to the freestanding nursing facility rate in any other circumstance, such as when it has not accepted the rate of its own volition, shall not be deemed to have waived its rights to administrative appeal and further review.

(7) With respect to acute care hospitals that are licensed for distinct-part nursing beds, and determined by the State Department of Health Services to provide special services to a unique population, the department shall enact and enforce no regulation, field office instruction, or preadmission screening criteria that restricts a Medi-Cal beneficiary’s freedom to seek admission to a nursing facility or unit that is a distinct part of an acute care hospital on terms or conditions different from those governing admission to a long-term care facility.

(c) The department may waive the requirements of this section if it can be demonstrated that both of the following apply:

(1) Access to care is compromised for a specific patient population.

(2) The facility can demonstrate an increase in acute administrative days that are attributable to unsuccessful placement efforts.

history: (History: Amended by Stats. 2007, Ch. 188, Sec. 60. Effective August 24, 2007.)

article: 2.92. Health Benefits Study

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.92. Health Benefits Study


text: It is the purpose of this article to ensure that the Medi-Cal program is operated in the most cost-effective and efficient manner possible by assuring that beneficiaries have early and ongoing access to identified sources of quality primary care who have agreed to accept Medi-Cal patients. In so doing, it is intended to optimally realize the quality of care and health care financing benefits demonstrated by the experience of successful commercial managed care plans when patients affiliate with a single, specified primary care provider and management of patient care is placed within the control of the responsible primary care provider.

history: (History: Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

article: 2.95. Primary Care Provider Enrollment

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.95. Primary Care Provider Enrollment


text: The department shall seek all federal waivers necessary to allow federal financial participation in expenditures under this article.

article: 2.95. Primary Care Provider Enrollment


text: The director may establish policy and procedures that assure that outpatient physician’s services, and any other Medi-Cal services the director may designate, provided by a source other than the primary care provider with whom a beneficiary is enrolled under this article, shall not be covered under the Medi-Cal program unless they are provided on an emergency basis or authorized by the responsible primary care provider.

article: 2.95. Primary Care Provider Enrollment


text: In implementing this article, the director has discretion to extend administrative or reimbursement flexibilities to participating primary care providers.

article: 2.95. Primary Care Provider Enrollment


text: For purposes of this article “primary care provider” is defined as set forth in paragraph (1) of subdivision (a) of Section 14088.

article: 2.95. Primary Care Provider Enrollment


text:
The director shall investigate and may to the extent feasible require that:

(a) Primary care providers specify their capacity to accept Medi-Cal Patients and obtain a primary care provider project code under which fee-for-service Medi-Cal beneficiaries may enroll with the provider as their exclusive primary care source.

(b) Each primary care provider accept and enroll fee-for-service beneficiaries up to the provider’s specified capacity.

(c) Any managed care contractor serving children with conditions eligible under the California Children’s Services program shall maintain and follow standards of care established by the program, including use of paneled providers and CCS approved special care centers and shall follow treatment plans approved by the program, including specified services and providers of services. If there are insufficient paneled providers willing to enter into contracts with the managed care contractor, the program shall seek to establish new paneled providers willing to contract. If a paneled provider cannot be found, the managed care contractor shall seek program approval to use a specific nonpaneled provider with appropriate qualifications.

(d) Any managed care contractor serving children with conditions eligible under the CCS program shall report expenditures and savings separately for CCS covered services and CCS eligible children. If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be a separate actuarially sound rate for CCS-eligible children.

(e) This article is not intended to and shall not be interpreted to permit any reduction in benefits or eligibility levels under the CCS program. Any medically necessary service not available under the managed care contracts authorized under this article shall remain the responsibility of the state and county.

(f) To assure CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the state and local CCS program agencies for both services covered and not covered by the managed care contract.

(g) Beneficiaries enroll with or are assigned to a primary care provider who will be the exclusive source of fee-for-service primary care for the beneficiary. However, enrollment under this article shall be subordinated to any legal requirement that a beneficiary enroll in a Medi-Cal managed care plan contracting under this chapter or (Chapter 8 (commencing with Section 14200)).

article: 2.95. Primary Care Provider Enrollment


text: In areas where a Medi-Cal beneficiary has the opportunity to enroll in a Medi-Cal managed care plan or to enroll with a primary care provider under this article, the director may require a beneficiary who is certified pursuant to subdivision (c) of Section 14016.5 that he or she has an established relationship with a provider, to enroll in a managed care plan, a pilot project, or a primary care provider under this article, if the beneficiary relies on care provided by hospital emergency departments for nonemergency care.

article: 2.95. Primary Care Provider Enrollment


text: To the extent that this article proves to be effective in reducing the cost of uncoordinated primary care delivered in the hospital emergency room or the costs of duplicative, unnecessary, or avoidable services, program savings may be shared with primary care providers who enroll beneficiaries under this article.

history: (History: Amended by Stats. 2006, Ch. 538, Sec. 704. Effective January 1, 2007.)

article: 2.95. Primary Care Provider Enrollment


text: The purpose of this article is to ensure quality of care and to provide increased access to health care services in the most cost-effective and efficient manner possible, to persons who are eligible to receive medical benefits under publicly supported programs other than Medi-Cal.

history: (History: Added by Stats. 1992, Ch. 722, Sec. 86. Effective September 15, 1992.)

article: 2.97. Managed Care Plan Contracts

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.97. Managed Care Plan Contracts