text:
(a) It is necessary that a special commission be established in San Bernardino County in order to meet the problems of the delivery of publicly assisted medical care in the county and to demonstrate ways of promoting quality care and cost efficiency. Because there is no general law under which such a commission could be formed, the adoption of a special act and the formation of a special commission is required.

(b) The Board of Supervisors of San Bernardino County may, by ordinance, establish a commission to negotiate the exclusive contract specified in Section 14087.5 and to arrange for the provision of health care services provided pursuant to this chapter, and to enter into contracts for the provision of health care services to subscribers in the Healthy Families Program. If the board of supervisors elects to enact this ordinance, all rights, powers, duties, privileges, and immunities vested in a county by this article shall be vested in the county commission. Any reference in this article to “county” shall mean the commission established pursuant to this section.

(c) It is the intent of the Legislature that if such a commission is formed, the County of San Bernardino shall, with respect to its medical facilities and programs, occupy no greater or lesser status than any other health care provider in negotiating with the commission for contracts to provide health care services.

(d) The enabling ordinance shall specify the membership of the county commission, the qualifications for individual members, the manner of appointment, selection, or removal of commissioners, and how long they shall serve, and any other matters as the board of supervisors deems necessary or convenient for the conduct of the county commission’s activities. The commission so established shall be considered an entity separate from the county, shall file the statement required by Section 53051 of the Government Code, and shall have, in addition to the rights, powers, duties, privileges, and immunities previously conferred, the power to acquire, possess, and dispose of real or personal property, as may be necessary for the performance of its functions, to employ personnel and contract for services required to meet its obligations, and to sue or be sued. Any obligations of the commission, statutory, contractual, or otherwise, shall be the obligations solely of the commission and shall not be the obligations of the county or of the state unless expressly provided for in a contract between the commission and the county or state.

(e) Upon creation, the commission may borrow from the county, and the county may lend the commission funds, or issue revenue anticipation notes to obtain those funds necessary to commence operations.

(f) In the event the commission may no longer function for the purposes for which established, at such time as the commission’s then existing obligations have been satisfied or the commission’s assets have been exhausted, the board of supervisors may by ordinance terminate the commission.

(g) Prior to the termination of the commission, the board of supervisors shall notify the State Department of Health Services of its intent to terminate the commission. The department shall conduct an audit of the commission’s records within 30 days of notification to determine the liabilities and assets of the commission. The department shall report its findings to the board within 10 days of completion of the audit. The board 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 present the plan to the department within 30 days upon receipt of these findings.

(h) Upon termination of the commission by the board, the County of San Bernardino shall manage any remaining assets of the commission until superseded by a department approved plan. Any liabilities of the commission shall not become obligations of the county upon either the termination of the commission or the liquidation or disposition of the commission’s remaining assets.

(i) Any assets of the commission shall be disposed of pursuant to provisions contained in the contract entered into between the state and the commission pursuant to this article.

history: (History: Amended by Stats. 1997, Ch. 625, Sec. 6. Effective October 3, 1997.)

article: 2.8. County Health Systems


kind: section

code: WIC

text:
(a) It is necessary that a special commission be established in Ventura County in order to meet the problems of the delivery of publicly assisted medical care in the county and to demonstrate ways of promoting quality care and cost efficiency. Because there is no general law under which such a commission could be formed, the adoption of a special act and the formation of a special commission is required.

(b) The Board of Supervisors of Ventura County may, by ordinance, establish a commission to negotiate the exclusive contract specified in Section 14087.5 and to arrange for the provision of health care services provided pursuant to this chapter, and to enter into contracts for the provision of health care services to subscribers in the Healthy Families Program. If the board of supervisors elects to enact this ordinance, all rights, powers, duties, privileges, and immunities vested in a county by this article shall be vested in the county commission. Any reference in this article to “county” shall mean the commission established pursuant to this section.

(c) The enabling ordinance shall specify the membership of the county commission, the qualifications for individual members, the manner of appointment, selection, or removal of commissioners, and how long they shall serve, and any other matters as the board of supervisors deems necessary or convenient for the conduct of the county commission’s activities. The commission so established shall be considered an entity separate from the county, shall file the statement required by Section 53051 of the Government Code, and shall have, in addition to the rights, powers, duties, privileges, and immunities previously conferred, the power to acquire, possess, and dispose of real or personal property, as may be necessary for the performance of its functions, to employ personnel and contract for services required to meet its obligations, and to sue or be sued. Any obligations of the commission, statutory, contractual, or otherwise, shall be the obligations solely of the commission and shall not be the obligations of the county or of the state.

(d) Upon creation, the commission may borrow from the county and the county may lend the commission funds, or issue revenue anticipation notes to obtain those funds necessary to commence operations.

(e) In the event the commission may no longer function for the purposes for which established, at such time as the commission’s then existing obligations have been satisfied or the commission’s assets have been exhausted, the board of supervisors may by ordinance terminate the commission.

(f) Prior to the termination of the commission, the board of supervisors shall notify the State Department of Health Services of its intent to terminate the commission. The department shall conduct an audit of the commission’s records within 30 days of notification to determine the liabilities and assets of the commission. The department shall report its findings to the board within 10 days of completion of the audit. The board 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 present the plan to the department within 30 days upon receipt of these findings.

(g) Any assets of the commission shall be disposed of pursuant to provisions contained in the contract entered into between the state and the commission pursuant to this article.

(h) It is the intent of the Legislature that if such a commission is formed, the County of Ventura shall, with respect to its medical facilities and programs, occupy no greater or lesser status than any other health care provider in negotiating with the commission for contracts to provide health care services.

(i) Upon termination of the commission by the board, the County of Ventura shall manage any assets of the commission until superseded by a department approved plan. Any liabilities of the commission shall not become obligations of the county upon either the termination of the commission or the liquidation or disposition of the commission’s remaining assets.

history: (History: Amended by Stats. 1997, Ch. 625, Sec. 7. Effective October 3, 1997.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 2.8. County Health Systems

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.8. County Health Systems


text:
(a) Any county or counties may establish a special commission in order to meet the problems of the delivery of publicly assisted medical care in the county or counties and to demonstrate ways of promoting quality care and cost efficiency.

(b) (1) A county board of supervisors may, by ordinance, establish a commission to negotiate the exclusive contract specified in Section 14087.5 and to arrange for the provision of health care services provided pursuant to this chapter. The boards of supervisors of more than one county may also establish a single commission with the authority to negotiate an exclusive contract and to arrange for the provision of services in those counties. If a board of supervisors elects to enact this ordinance, all rights, powers, duties, privileges, and immunities vested in a county by this article shall be vested in the county commission. Any reference in this article to “county” shall mean a commission established pursuant to this section.

(2) A commission operating pursuant to this section may also enter into contracts for the provision of health care services to persons who are eligible to receive medical benefits under any publicly supported program, if the commission and participating providers acting pursuant to subcontracts with the commission agree to hold harmless the beneficiaries of the publicly supported programs if the contract between the sponsoring government agency and the commission does not ensure sufficient funding to cover program costs. The commission shall not use any payments or reserves from the Medi-Cal program for this purpose.

(3) In addition to the authority specified in paragraph (1), the board of supervisors may, by ordinance, authorize the commission established pursuant to this section to provide health care delivery systems for any or all of the following persons:

(A) Persons who are eligible to receive medical benefits under both Title 18 of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.) and Title 19 of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).

(B) Persons who are eligible to receive medical benefits under Title 18 of the federal Social Security Act (42 U.S.C. Sec. 1395).

(C) Other individuals or groups in the service area, including, but not limited to, public agencies, private businesses, and uninsured or indigent persons. The commission shall not use any payment or reserve from the Medi-Cal program for purposes of this subparagraph.

(4) Nothing in this section shall prohibit a commission established pursuant to this section from providing services pursuant to subparagraph (C) of paragraph (3) in counties other than the commission’s county if the commission is approved by the Department of Managed Health Care to provide services in those counties. The commission shall not use any payment or reserve from the Medi-Cal program for purposes of this paragraph.

(5) For purposes of providing services to persons described in subparagraph (A) or (B) of paragraph (3), if the commission seeks a contract with the federal Centers for Medicare and Medicaid Services to provide Medicare services as a Medicare Advantage program, the commission shall first obtain a license under the Knox-Keene Health Care Service Plan Act (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).

(6) With respect to the provision of services for persons described in subparagraph (A) or (B) of paragraph (3), the commission shall conform to applicable state licensing and freedom of choice requirements as directed by the federal Centers for Medicare and Medicaid Services.

(7) Any material, provided to a person described in subparagraph (A) or (B) of paragraph (3) who is dually eligible to receive medical benefits under both the Medi-Cal program and the Medicare Program, regarding the enrollment or availability of enrollment in Medicare services established by the commission shall include notice of all of the following information in the following format:

(A) Medi-Cal eligibility will not be lost or otherwise affected if the person does not enroll in the plan for Medicare benefits.

(B) The person is not required to enroll in the Medicare plan to be eligible for Medicare benefits.

(C) The person may have other choices for Medicare coverage and for further assistance may contact the federal Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE or www.Medicare.gov.

(D) The notice shall be in plain language, prominently displayed, and translated into any language other than English that the commission is required to use in communicating with Medi-Cal beneficiaries.

(c) It is the intent of the Legislature that if a county forms a commission pursuant to this section, the county shall, with respect to its medical facilities and programs occupy no greater or lesser status than any other health care provider in negotiating with the commission for contracts to provide health care services.

(d) The enabling ordinance shall specify the membership of the county commission, the qualifications for individual members, the manner of appointment, selection, or removal of commissioners, and how long they shall serve, and any other matters as a board of supervisors deems necessary or convenient for the conduct of the county commission’s activities. A commission so established shall be considered an entity separate from the county or counties, shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code, and shall file the statement required by Section 53051 of the Government Code. The commission shall have in addition to the rights, powers, duties, privileges, and immunities previously conferred, the power to acquire, possess, and dispose of real or personal property, as may be necessary for the performance of its functions, to employ personnel and contract for services required to meet its obligations, to sue or be sued, and to enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. Any obligations of a commission, statutory, contractual, or otherwise, shall be the obligations solely of the commission and shall not be the obligations of the county or of the state.

(e) Upon creation, a commission may borrow from the county or counties, and the county or counties may lend the commission funds, or issue revenue anticipation notes to obtain those funds necessary to commence operations.

(f) In the event a commission may no longer function for the purposes for which it was established, at the time that the commission’s then existing obligations have been satisfied or the commission’s assets have been exhausted, the board or boards of supervisors may by ordinance terminate the commission.

(g) Prior to the termination of a commission, the board or boards of supervisors shall notify the State Department of Health Care Services of its intent to terminate the commission. The department shall conduct an audit of the commission’s records within 30 days of the notification to determine the liabilities and assets of the commission. The department shall report its findings to the board or boards within 10 days of completion of the audit. The board or boards 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 present the plan to the department within 30 days upon receipt of these findings.

(h) Upon termination of a commission by the board or boards, the county or counties shall manage any remaining assets of the commission until superseded by a department approved plan. Any liabilities of the commission shall not become obligations of the county or counties upon either the termination of the commission or the liquidation or disposition of the commission’s remaining assets.

(i) Any assets of a commission shall be disposed of pursuant to provisions contained in the contract entered into between the state and the commission pursuant to this article.

(j) Nothing in this section shall be construed to supersede Section 14093.06 or 14094.3.

history: (History: Amended by Stats. 2007, Ch. 483, Sec. 51. Effective January 1, 2008.)

article: 2.8. County Health Systems


text:
(a) The department shall enter into contracts with counties under this article, and shall be bound by the rates, terms, and conditions negotiated by the negotiator.

(b) In implementing this article, the department may enter into contracts for the provision of essential administrative and other services.

(c) 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 the Public Contract Code.

history: (History: Amended by Stats. 1998, Ch. 834, Sec. 4. Effective January 1, 1999.)

article: 2.8. County Health Systems


text:
(a) The Health Facilities Financing Authority may, pursuant to Chapter 7.2 (commencing with Section 15430) of Division 3 of Title 2 of the Government Code, grant up to four hundred thousand dollars ($400,000) to each participating county to match other moneys, including loans, received by the county if needed for the costs of developmental activities approved by the department and the California Medical Assistance Commission.

(b) Funds may be provided to the county agencies selected as contractors under this article to assist in the design, development and installation of necessary program components. The award of these funds shall be based on criteria established by the department.

history: (History: Amended by Stats. 1991, Ch. 95, Sec. 6. Effective June 30, 1991.)

article: 2.8. County Health Systems


text:
Notwithstanding any provision of law, a member of a commission authorized by Section 14087.51 or 14087.54, or a member of any advisory committee to the commission, shall not be deemed to be interested in a contract entered into by the commission within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all of the following apply:

(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 services under the commission’s program.

(c) (1) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the member was appointed to represent.

(2) If the contract does not contain substantially the same terms and conditions, the member shall recuse himself or herself from making, participating in making, or in any way attempting to use his or her official position to influence the making of, a decision on the contract.

(d) The member does not influence or attempt to influence the commission or another member of the commission to enter into the contract in which the member is interested.

(e) The member discloses the interest to the commission and abstains from voting on the contract.

(f) The commission notes the member’s disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for the purpose without counting the vote of the interested member.

history: (History: Amended by Stats. 2002, Ch. 262, Sec. 1. Effective August 26, 2002.)

article: 2.8. County Health Systems


text:
(a) Notwithstanding any other provision of law, those records of a special commission formed pursuant to this article that reveal the commission’s rates of payment for health care services or the commission’s deliberative processes, discussions, communications, or any other portion of the negotiations with providers of health care services for rates of payment, shall not be required to be disclosed pursuant to the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. However, three years after a contract or contract amendment has been executed, the portion of the contract or contract amendment relating to the rates of payment shall be open to inspection under Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code.

(b) Notwithstanding the California Public Records Act, or Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of, and Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of, the Government Code, or any other provision of state or local law requiring disclosure of public records, those health care peer review and quality assessment records of a special commission authorized by this article, or a committee thereof, shall not be subject to disclosure. These records and proceedings of any such commission or committee and individual members of the commission or committee thereof shall be afforded all immunities, privileges, and protections available to “peer review bodies” as defined under Section 805 of the Business and Professions Code, including the protections of Section 1157 of the Evidence Code.

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 443. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)

article: 2.8. County Health Systems


text:
(a) (1) Notwithstanding subdivision (d) of Section 14087.54, governance of the commission in the County of Orange established pursuant to Section 14087.54, known as the Orange County Health Authority, shall be vested in a governing body consisting of 10 members: 9 voting members and 1 nonvoting member. The nonvoting member shall be the Director of the Orange County Health Care Agency. The nine voting members shall be nominated by the Orange County Health Care Agency and appointed by a majority vote of the Board of Supervisors of the County of Orange and shall consist of the following:

(A) Two members shall each be a member of the Board of Supervisors of the County of Orange, with one additional member of the Board of Supervisors of the County of Orange to serve as an alternate.

(B) One member shall be a current or former hospital administrator.

(C) One member shall be a representative of a community clinic, which may include, but is not limited to, a representative of a federally qualified health center, as defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code.

(D) One member shall be a member of the public who is a legal resident of the County of Orange.

(E) One member shall be a practicing licensed medical provider who is not an owner or officer, or a member of the board of directors, of a contracted independent physician’s association or provider network.

(F) One member shall be a current CalOptima member or a family member of a current CalOptima member.

(G) One member shall be an accounting or public finance professional, or an attorney who is an active member of the State Bar.

(H) One member shall be a practicing licensed physician who is a representative of a contracted independent physician’s association or provider network.

(2) For purposes of identifying qualified individuals to be considered as members of the governing body, the Board of Supervisors of the County of Orange shall consult with stakeholders in the County of Orange, including, but not limited to, providers who serve CalOptima members, consumers, and advocates.

(b) Each member of the governing body shall reside in, or be employed in, the County of Orange and shall be generally representative of the diverse backgrounds, interests, and demography of persons residing in the County of Orange. Each member of the governing body shall have a commitment to a health care system that seeks to improve access to high-quality health care for persons served by the commission and that in fact delivers high-quality care and is financially viable. Each member shall possess the requisite skills and knowledge necessary to design and operate a quality publicly assisted health care delivery system.

(c) (1) Members of the governing body of the commission shall serve four-year terms, except for those members who are members of the Board of Supervisors of the County of Orange who shall serve a one-year term.

(2) A member of the governing body described in any of subparagraphs (B) to (H), inclusive, of paragraph (1) of subdivision (a) shall serve no more than two consecutive terms. An individual who served a one-year term on the governing body as described in paragraph (1) may not be appointed to serve a four-year term under any of subparagraphs (B) to (H), inclusive, of paragraph (1) of subdivision (a) within 12 months of the expiration of their one-year term. The limitations set forth in this paragraph apply only to service for consecutive terms. No other limitation on the number of terms a person may serve is intended.

(3) A member of the governing body of the commission may be removed from the governing body by a vote in favor of that removal of at least two-thirds of the full membership of the Board of Supervisors of the County of Orange.

(d) The governing body of the commission, subject to a two-thirds vote of the full membership, may increase the number of public members, or the number of members who are current CalOptima members or family members of current CalOptima members who may serve as a member of the governing body, subject to an affirmative vote by a majority of the Board of Supervisors of the County of Orange, provided, however, that a change in the composition of the governing body under this subdivision shall not result in the elimination of any member described in paragraph (1) of subdivision (a).

(e) Each member of the governing body shall have the responsibility and duty to follow the requirements of applicable federal and state laws and regulations, including Section 1090 of the Government Code, the applicable provisions of Sections 87100 to 87500, inclusive, of the Government Code, and Section 14047.6 of this code, to serve the public interest of the members of CalOptima, and to ensure the operational well-being and fiscal solvency of the Orange County Health Authority. Members of the governing body shall further strive to improve health care quality, promote prevention and wellness, ensure the provision of cost-effective health and behavioral health care services, reduce health disparities, address the needs of Medi-Cal members who are affected by homelessness and housing instability, improve quality outcomes, and manage the risk and needs of Medi-Cal beneficiaries through whole-person care approaches and addressing social determinants of health. The Orange County Health Authority shall work to earn the public’s trust through its commitment to accountability, responsiveness, transparency, reliability, and cooperation.

(f) A member of the governing body who has a financial interest, within the meaning of Section 87100 of the Government Code, in a decision before the governing body shall, upon identifying a conflict of interest or a potential conflict of interest and immediately prior to the consideration of the matter, do all of the following:

(1) Publicly identify the financial interest that gives rise to the conflict of interest or potential conflict of interest in detail sufficient to be understood by the public, except that disclosure of the exact street address of a residence is not required.

(2) Recuse the member’s own self from discussing and voting on the matter.

(3) Leave the room until after the discussion, vote, and any other disposition of the matter is concluded, unless the matter has been placed on the portion of the agenda reserved for uncontested matters.

(4) Notwithstanding paragraph (3), the member may speak on the issue during the time that the general public speaks on the issue.

(g) (1) A member of the governing body shall not, for a period of one year after leaving office, act as an agent or attorney for, or otherwise represent, for compensation, any other person, by making any formal or informal appearance before, or by making any oral or written communication to, the commission, or any committee, subcommittee, or present member of the commission, or any officer or employee of the commission, if the appearance or communication is made for the purpose of influencing administrative action or influencing any action or proceeding involving the issuance, amendment, awarding, or revocation of a permit, license, grant, or contract, or the sale or purchase of goods or property.

(2) In addition to paragraph (1), a member of the governing body described in subparagraphs (A) and (G) of paragraph (1) of subdivision (a) shall not, for a period of one year after leaving office, serve as an employee, agent, or attorney, or otherwise represent, for compensation, the Orange County Health Authority or any other entity that received an expenditure of Medi-Cal funds from the Orange County Health Authority during the prior five years. This paragraph does not apply to expenditures of Medi-Cal funds from the Orange County Health Authority for routine administrative expenses for reimbursement for travel, continuing education costs, routine office expenses, and other ongoing routine administrative expenses. This paragraph does not prevent any member from returning to or continuing the role that they held when they were appointed to the governing body.

history: (History: Amended by Stats. 2022, Ch. 430, Sec. 1. (AB 498) Effective January 1, 2023.)

article: 2.8. County Health Systems


text:
(a) The counties contracting pursuant to subdivision (a) of Section 14087.5 may arrange for the delivery of Medi-Cal services to Medi-Cal beneficiaries, except that the counties may exclude all of the following:

(1) Long-term care services rendered by nursing facilities or all categories of intermediate care facilities for the developmentally disabled.

(2) Dental services.

(3) Services in any federal or state hospital.

(4) Home- or community-based care waivered services.

(b) Exclusion of these services shall be subject to the approval of the department and the California Medical Assistance Commission.

history: (History: Amended by Stats. 1990, Ch. 1329, Sec. 16. Effective September 26, 1990.)

article: 2.8. County Health Systems


text: Counties contracting with the department pursuant to this article shall be exempt from the provisions of 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: Added by Stats. 1982, Ch. 1594, Sec. 48. Effective September 30, 1982.)

article: 2.8. County Health Systems


text:
The following definitions shall apply for purposes of this article:

(a) “County” means the County of Los Angeles.

(b) “Board of supervisors” means the Board of Supervisors of the County of Los Angeles.

(c) “Commission” means the separate public agency established by the board of supervisors to operate a local initiative for health care in the county.

(d) “Local initiative” means the health plan or plans and other health care programs owned or operated by the commission established under this article, and operated pursuant to the strategic plan.

(e) “Medi-Cal managed care programs” means all those components of the Medi-Cal program that involve the restriction of access for Medi-Cal patients to particular providers or health plans and that involve managed care principles, including, but not limited to, programs such as those described in Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Chapter 8 (commencing with Section 14200), including pilot programs under Article 7 (commencing with Section 14490) thereof.

(f) “Health care consumer” means a Medi-Cal beneficiary or any other person eligible to receive health care services under the local initiative, including parents, legal guardians, or conservators of Medi-Cal beneficiaries and people who will receive health care services under the local initiative.

(g) “Health care consumer advocate” means an individual who, whether in a paid or unpaid capacity, represents the interests of Medi-Cal beneficiaries or people who will receive health care under the local initiative.

(h) “Strategic plan” means the report issued on March 31, 1993, by the State Department of Health Services, entitled “The State Department of Health Services’ Plan for Expanding Medi-Cal Managed Care: Protecting Vulnerable Populations” or the report, as subsequently revised or amended.

history: (History: Amended by Stats. 2004, Ch. 454, Sec. 1. Effective January 1, 2005.)

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


text: The commission shall be deemed to be a public agency that is a local unit of government for purposes of all grant programs and other funding and loan guarantee programs.

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

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


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 the following counties that currently receive Medi-Cal services on a fee-for-service basis: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Imperial, Inyo, Lake, Lassen, Mariposa, Modoc, Nevada, Mono, Placer, Plumas, San Benito, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba.

(b) The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis with one or more managed health care plans to provide a comprehensive program of managed health care plan services to Medi-Cal recipients residing in the counties described in subdivision (a). The director shall give special consideration to managed health care plans that meet all of the following:

(1) Have demonstrated experience in effectively serving Medi-Cal beneficiaries, including diverse populations.

(2) Have demonstrated experience in effectively partnering with public and traditional safety net health care providers.

(3) Have demonstrated experience in working with local stakeholders, including consumers, providers, advocates, and county officials, in plan oversight and in delivery of care.

(4) Have the lowest administrative costs.

(5) Show support from local county officials as demonstrated by an action of the county board of supervisors.

(6) Show recent successful experience with expansion of managed care to a rural area.

(7) Offer a quality improvement program for primary care providers.

(c) Contracts entered into or amended pursuant to this section shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code.

(d) The managed health care plans that the department contracts with under this article shall comply with the requirements of Section 14087.48 and meet all of the following:

(1) Have Medi-Cal managed health care plan contract experience, or evidence of the ability to meet these contracting requirements.

(2) Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), if applicable.

(3) Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department and the federal Centers for Medicare and Medicaid Services.

(e) The managed health care plans that the department contracts with under this article shall provide Medi-Cal beneficiaries with information about enrollment rights and options, plan benefits and rules, and care plan elements so that beneficiaries have the ability to make informed choices. This information shall be delivered in a format and language accessible to beneficiaries. The managed health care plans shall provide access to providers in compliance with applicable state and federal laws, including, but not limited to, physical accessibility and the provision of health plan information in alternative formats.

(f) The department shall conduct a stakeholder process including relevant stakeholders to ensure that beneficiaries, health care providers, and managed health care plans have an opportunity to provide input into the delivery model for these counties and to help ensure smooth care transitions for beneficiaries.

(g) Enrollment in a Medi-Cal managed health care plan or plans under this article shall be mandatory in order to receive services under Medi-Cal, except as otherwise provided by law.

(h) Each beneficiary or eligible applicant shall be informed that the beneficiary or applicant may choose to continue an established patient-provider relationship if the person’s treating provider is a primary care provider or clinic contracting with the managed health care plan, has the available capacity, and agrees to continue to treat that beneficiary or eligible applicant. The managed health care plans shall comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code.

(i) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and amend regulations and orders adopted by the department by means of plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until the time regulations are adopted. It is the intent of the Legislature that the department have temporary authority as necessary to implement program changes until completion of the regulatory process.

(2) The department shall adopt emergency regulations no later than July 1, 2014. The department may readopt any emergency regulation authorized by this section that is the same as or substantially equivalent to an emergency regulation previously adopted pursuant to this section. The initial adoption of emergency regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. Initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law.

(3) The initial emergency regulations and the one readoption of emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and each shall remain in effect for no more than 180 days, by which time final regulations may be adopted.

(j) The cost of any 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.

(k) The department shall have exclusive authority to set the rates, terms, and conditions of managed health care plan contracts and contract amendments under this article. The director may include in the contract a provision for quality assurance withholding from the plan payment, to be paid only if quality measures identified in the plan contract are met.

(l) The department shall provide the fiscal and appropriate policy committees of the Legislature with quarterly updates, commencing January 1, 2014, and ending January 1, 2016, regarding the expansion of Medi-Cal managed care into the new counties authorized pursuant to this section. These updates shall include, but not be limited to, continuity of care requests, grievance and appeal rates, and utilization reports for the new counties.

(m) The department shall seek all necessary federal approvals to allow for federal financial participation in expenditures under this article. This article shall not be implemented until all necessary federal approvals have been obtained.

(n) This section shall be implemented only to the extent federal financial participation or funding is available.

(o) 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 applies to contracts that reveal the department’s rates of payment for health care services, the rates themselves, and rate manuals.

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

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

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

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

history: (History: Amended by Stats. 2021, Ch. 615, Sec. 444. (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 > 2.82. Managed Health Care Expansion into Rural Counties


text: For administrative costs incurred after January 1, 2004, the director may recover any administrative costs incurred by a health plan authorized by this article deemed excessive pursuant to Section 1300.78 of Title 28 of the California Code of Regulations. Health plans that compensate their subcontractors on a capitated basis shall comply with Section 1300.78 of Title 28 of the California Code of Regulations, regarding administrative costs, considering the combined administrative cost for the Medi-Cal business of the health plan and its capitated subcontractors, that are Knox-Keene licensed health care service plans. The recovery of excess administrative cost shall be made in accordance with Sections 14087.103 and 14087.105.

history: (History: Added by Stats. 2003, Ch. 230, Sec. 60. Effective August 11, 2003.)

article: 2.6. Selective Provider Contracts

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.6. Selective Provider Contracts


text: The department shall notify the health plan of the director’s decision to seek recovery of excess administrative costs pursuant to Section 14087.101 at least 30 days prior to initiating the recovery process. The department may recover excess administrative costs immediately after the 30-day notification period, if the health plan does not file an appeal. A health plan may dispute or appeal the director’s decision in accordance with the disputes section of the health plan’s contract with the department for services under this article. If a health plan elects to dispute or appeal the director’s decision, the director may recover any administrative costs deemed excessive, but only after the health plan has had the opportunity to exhaust all appeal procedures provided for in the disputes section of the health plan’s contract with the department.

history: (History: Added by Stats. 2003, Ch. 230, Sec. 61. Effective August 11, 2003.)

article: 2.6. Selective Provider Contracts


text: When it has been determined that the director may recover any administrative costs deemed excessive pursuant to Section 14087.103, the director may recover any excess administrative costs through an offset against any amount currently due to the health plan under this chapter. The director may also recover any administrative costs deemed excessive by means of a repayment agreement executed between that health plan and the director, and by any other means available at law.

history: (History: Added by Stats. 2003, Ch. 230, Sec. 62. Effective August 11, 2003.)

article: 2.6. Selective Provider Contracts


text: When entering into contracts with health care service plans that provide comprehensive dental benefits to Medi-Cal beneficiaries on an at-risk basis, the department may require that the health care service plans pay for the costs of the administrative and regulatory oversight required to monitor the contract compliance terms of the agreement with the department.

history: (History: Added by Stats. 1999, Ch. 146, Sec. 43. Effective July 22, 1999.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.7. Contracts for Medi-Cal Services and Case Management


text:
(a) In areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3 and where the department is contracting with a prepaid health plan that is contracting with, governed, owned or operated by a county board of supervisors, a county special commission or county health authority authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96, a Medi-Cal or California Work Opportunity and Responsibility for Kids (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.

(b) The managed care options information described in subdivision (a) shall include the following elements:

(1) 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 care health 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 any changes in the health care plan’s 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 of the local initiative and commercial plan provider networks, including, but not limited to, the name, address, and telephone number of each primary care provider and hospital, 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 Los Angeles County pursuant to this article, and in Sacramento County (Geographic Managed Care Model) pursuant to Article 2.91 (commencing with Section 14089). The content, form, and the geographic areas used in the personalized provider directories 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.

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

(3) Each beneficiary or eligible applicant shall be informed that if he or she fails to make a choice, he or she shall be assigned to, and enrolled in, a prepaid health plan.

(c) No later than 30 days following the date a Medi-Cal or CalWORKs beneficiary or applicant is determined eligible for Medi-Cal, the beneficiary shall indicate his or her choice, in writing, from among the available prepaid health plans in the region and his or her choice of primary care provider or clinic contracting with the selected prepaid health plan. Notwithstanding the 30-day deadline set forth in this subdivision, if a beneficiary requests a directory for the entire service area within 30 days of receiving an enrollment form, the deadline for choosing a plan shall be extended an additional 30 days from the date of the request.

(d) At the time the beneficiary or eligible applicant selects a prepaid health plan, the department shall, when applicable, encourage the beneficiary or eligible applicant to also indicate, in writing, his or her choice of primary care provider or clinic contracting with the selected prepaid health plan.

(e) In areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3, and where the department is contracting with a prepaid health plan that is contracting with, governed, owned or operated by a county board of supervisors, a county special commission or county health authority authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96, a Medi-Cal or CalWORKs beneficiary who does not make a choice of managed care plans, shall be assigned to and enrolled in an appropriate Medi-Cal prepaid health plan providing service within the area in which the beneficiary resides.

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

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

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

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

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

(A) The maximum distances a beneficiary is required to travel to obtain primary care services from the managed care plan, in which the beneficiary is enrolled.

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

(C) The conditions under which a managed care plan shall provide nonmedical transportation to a primary care service site.

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

(j) To the extent possible, the arrangements for carrying out subdivision (e) shall provide for the equitable distribution of Medi-Cal beneficiaries among participating prepaid health plans, or managed care plans.

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

history: (History: Amended by Stats. 2012, Ch. 728, Sec. 200. (SB 71) Effective January 1, 2013.)

article: 2.7. Contracts for Medi-Cal Services and Case Management


text:
(a) In lieu of establishing the special commission authorized by Section 14087.31, the county may, itself, negotiate with the department the contract specified in Section 14087.3 and arrange for the provision of health care services provided pursuant to this chapter. If the county elects to exercise this option, subdivisions (p), (q), (t), (u), (v), (w), (x), and (z), of Section 14087.31 shall apply with equal force and effect to the County of Tulare, its board of supervisors and its members, and any advisory commission and its members appointed by the board of supervisors to assist with the provision of health care services provided pursuant to this section.

(b) The Tulare County Board of Supervisors shall establish and maintain an advisory commission. The advisory commission shall have a membership that includes beneficiaries, representatives of the community clinics, representatives of hospitals, and physicians. Physician membership shall be nominated by the Tulare County Medical Society.

history: (History: Added by Stats. 1996, Ch. 1017, Sec. 2. Effective January 1, 1997.)


text:
(a) The department shall require, as a condition of obtaining a contract with the department, that a local initiative, as defined in subdivision (w) of Section 53810 of Title 22 of the California Code of Regulations, offer a subcontract to an entity defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code providing services as defined in Section 1396d(a)(2)(C) of Title 42 of the United States Code and operating in the service area covered by the local initiative’s contract with the department. These entities are also known as federally qualified health centers.

(b) Except as otherwise provided in this section, managed care subcontracts offered to a federally qualified health center or a rural health clinic, as defined in Section 1396d(l)(1) of Title 42 of the United States Code, by a local initiative, county organized health system, as defined in Section 12693.05 of the Insurance Code, commercial plan, as defined in subdivision (i) of Section 53810 of Title 22 of the California Code of Regulations, or a health plan contracting with a geographic managed care program, as defined in subdivision (g) of Section 53902 of Title 22 of the California Code of Regulations, shall be on the same terms and conditions offered to other subcontractors providing a similar scope of service. A beneficiary, subscriber, or enrollee of a program or plan who affirmatively selects, or is assigned by default to, a federally qualified health center or rural health clinic under the terms of a contract between a plan, government program, or a subcontractor of a plan or program, and a federally qualified health center or rural health clinic, shall be assigned directly to the federally qualified health center or rural health clinic, and not to an individual provider performing services on behalf of the federally qualified health center or rural health clinic.

(c) The department shall provide incentives in the competitive application process described in paragraph (1) of subdivision (b) of Section 53800 of Title 22 of the California Code of Regulations, to encourage potential commercial plans as defined in subdivision (i) of Section 53810 of Title 22 of the California Code of Regulations to offer subcontracts to these federally qualified health centers.

(d) Reimbursement to federally qualified health centers and rural health centers for services provided pursuant to a subcontract with a local initiative, a commercial plan, geographic managed care program health plan, or a county organized health system, shall be paid in a manner that is not less than the level and amount of payment that the plan would make for the same scope of services if the services were furnished by a provider that is not a federally qualified health center or rural health clinic.

(e) (1) The department shall administer a program to ensure that total payments to federally qualified health centers and rural health clinics operating as managed care subcontractors pursuant to subdivision (d) comply with applicable federal law pursuant to Sections 1902(aa) and 1903(m)(2)(A)(ix) of the Social Security Act (42 U.S.C. Secs. 1396a(aa) and 1396b(m)(2)(A)(ix)). Under the department’s program, federally qualified health centers and rural health clinics subcontracting with local initiatives, commercial plans, county organized health systems, and geographic managed care program health plans shall seek supplemental reimbursement from the department through a per visit fee-for-service billing system utilizing the state’s Medi-Cal fee-for-service claims processing system contractor. To carry out this per visit payment process, each federally qualified health system and rural health clinic shall submit to the department for approval a rate differential calculated to reflect the amount necessary to reimburse the federally qualified health center or rural health clinic for the difference between the payment the center or clinic received from the managed care health plan and either the interim rate established by the department based on the center’s or clinic’s reasonable cost or the center’s or clinic’s prospective payment rate. The department shall adjust the computed rate differential as it deems necessary to minimize the difference between the center’s or clinic’s revenue from the plan and the center’s or clinic’s cost-based reimbursement or the center’s or clinic’s prospective payment rate.

(2) In addition, to the extent feasible, within six months of the end of the center’s or clinic’s fiscal year, the department shall perform an annual reconciliation to reasonable cost, and make payments to, or obtain a recovery from, the center or clinic.

(f) In calculating the capitation rates to be paid to local initiatives, commercial plans, geographic managed care program health plans, and county organized health systems, the department shall not include the additional dollar amount applicable to cost-based reimbursement that would otherwise be paid, absent cost-based reimbursement, to federally qualified health centers and rural health clinics in the Medi-Cal fee-for-service program.

(g) On or before September 30, 2002, the director shall conduct a study of the actual and projected impact of the transition from a cost-based reimbursement system to a prospective payment system for federally qualified health centers and rural health clinics. In conducting the study, the director shall evaluate the extent to which the prospective payment system stimulates expansion of services, including new facilities to expand capacity of the centers, and the extent to which actual and estimated prospective payment rates of federally qualified health centers and rural health clinics for the first five years of the prospective payment system are reflective of the cost of providing services to Medi-Cal beneficiaries. Clinics may submit cost reporting information to the department to provide data for the study.

(h) The department shall approve all contracts between federally qualified health centers or rural health clinics and a local initiative, commercial plan, geographic managed care program health plan, or county organized health system in order to ensure compliance with this section.

(i) This section shall not preclude the department from establishing pilot programs pursuant to Section 14087.329.

history: (History: Amended by Stats. 2017, Ch. 561, Sec. 281. (AB 1516) Effective January 1, 2018.)


text:
(a) The department may establish, for local initiative and for commercial plans, that are providing services to Medi-Cal beneficiaries under a two-plan model contract with the department, not more than two pilot programs for the establishment of reimbursement methodologies. The reimbursement methodologies shall not be limited to those provided in Section 14087.325. The pilot programs may be implemented by amendment to the contract between the department and the local initiative or commercial plan. The department may select the pilot program county or counties on a nonbid basis. The selected counties shall include one county with a sizable number of entities defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code. The department shall review each pilot program annually. Following the review, and notwithstanding any determination made pursuant to subdivision (d), the department shall terminate a pilot program established under this section and shall delete amendments made to the contract implementing the pilot program if the department determines that the pilot program creates any additional cost to the General Fund. The department may also terminate a pilot program based upon criteria specified in the department’s contract establishing the pilot program. The department shall provide the local initiative and commercial plan with notice of the department’s decision to terminate the pilot program for this reason at least 90 days prior to the termination date of the pilot program and deletion of the contract amendments.

(b) Each local initiative and commercial plan participating in a pilot program under this section shall make available to the department any and all financial, membership, utilization, and other information reasonably required by the department to conduct the annual review described in subdivision (a). The information may include, but is not limited to, the financial or other records of participating providers. The amendment to the contract between the local initiative or commercial plan and the department establishing the pilot program shall specify a reasonable timeframe in which the commercial plan or local initiative shall furnish records to the department pursuant to the request of the department.

(c) In assessing whether the pilot program creates any additional cost to the General Fund, as described in subdivision (a), the department shall specifically consider all of the following factors, and may consider additional factors:

(1) Increases in the number of Medi-Cal beneficiaries assigned by the plan to cost-based primary care providers. To enable the department to evaluate these factors, the department may include in the contract amendments establishing the pilot program a requirement that contractors shall periodically report data regarding the number of plan members assigned to each cost-based primary care provider in the plan’s network.

(2) Expansions in the services provided by providers entitled to cost-based reimbursement under the Medi-Cal program.

(3) Medi-Cal caseload or plan membership growth.

(4) Inflation or other reasonable costs of provider operations.

(5) The necessity for a plan to assign plan members to specific primary care providers to meet all of the following requirements:

(A) Medi-Cal contract requirements for access to care.

(B) Unique Medi-Cal member cultural and linguistic needs.

(C) Unique member needs for age-appropriate, gender-appropriate, or pregnancy care requirements.

(d) The pilot program shall be deemed to be successful if the alternative reimbursement methodologies tested result in no additional cost to the General Fund as described in subdivision (c), and the local initiatives, commercial plans, and federally qualified health centers participating in the pilot program agree to accept full financial risk for the scope of services provided by the federally qualified health centers during the final year of the pilot program.

history: (History: Added by Stats. 1997, Ch. 649, Sec. 1. Effective January 1, 1998.)


text:
(a) The following definitions apply for purposes of this section:

(1) “Board” means the Board of Supervisors of the County of Sacramento.

(2) “County” means the County of Sacramento.

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

(4) “Health authority” means a separate public entity established by the board that meets the requirements of state and federal law and criteria established by the department and engages in activities authorized by this section.

(b) The Legislature finds and declares that it is necessary that a health authority be established in the county to meet the problems of delivery of publicly assisted medical care in the county and to demonstrate ways of promoting timely access, quality care, and cost efficiency.

(c) A health authority established by the board, consistent with Section 14087.38, may do all of the following:

(1) Designate a number of Knox-Keene licensed health plans for purposes of the department’s Medi-Cal managed care plan procurement under Section 14089 for the County of Sacramento as specified under subdivision (d), until the health authority implements a county-sponsored local initiative health plan as authorized by Section 14087.38 as described in paragraph (3).

(2) Meet with health plans that operate as Medi-Cal managed care plans in the county pursuant to Section 14089 to review and discuss strategies for improving quality, cost, and access of Medi-Cal services in the county, until the health authority implements any activity described in paragraph (3).

(3) (A) Consistent with Section 14087.38, and upon approval of the health authority and the board, pursue either of the following activities:

(i) Seek and obtain Knox-Keene health plan licensure in order to serve as the county-sponsored local initiative to contract with the department to arrange for the provision of health care services to qualifying individuals, as authorized by Section 14087.3.

(ii) Negotiate and enter into a contract with a Knox-Keene licensed health plan to be the designated county-sponsored local initiative health plan for the purpose of contracting with the department for the provision of health care services to qualifying individuals as authorized by Section 14087.3.

(B) Upon the implementation of any activity described in subparagraph (A), the county may continue to administer its stakeholder advisory committee, as described under Section 14089.07.

(d) (1) For purposes of the designation of health plans pursuant to paragraph (1) of subdivision (c), prior to procurement under Section 14089, the health authority shall meet with any health plans intending to contract with the department as Medi-Cal managed care plans in the county. Any health plan intending to contract with the department as a Medi-Cal managed care plan in the county, and intending to submit a proposal to the department in a procurement process, shall first be required to meet with the health authority.

(2) Subsequent to meeting with all interested health plans, the health authority shall designate to the department at least two Knox-Keene licensed health plans for the department’s approval based on the criteria described in paragraph (3).

(3) Any criteria used by the health authority to determine the designation of health plans pursuant to paragraph (1) of subdivision (c) shall not conflict with requirements for Medi-Cal managed care plans established by the department, the Department of Managed Health Care, the federal Medicaid program, or state law, and shall conform with any guidance issued by the department pursuant to paragraph (7). Designation requirements imposed by the health authority shall further the department’s goals and requirements for procurement under Section 14089 including, but not limited to, increased quality, access, network adequacy, reduction of health disparities, and integration of behavioral and oral health within the delivery of health care services in the Medi-Cal program.

(4) Notwithstanding any designation by the health authority, only health plans approved by the department as meeting plan procurement requirements determined by the department shall be eligible to contract with the department as Medi-Cal managed care plans in the county. Designation by the health authority provides the health plan only with the opportunity to compete in the procurement process under Section 14089 and does not guarantee the award of a Medi-Cal managed care plan contract with the department.

(5) If the health authority does not designate at least two health plans that receive approval from the department, the department shall determine other health plans to contract with as Medi-Cal managed care plans to ensure there are at least two Medi-Cal managed care plans in Sacramento County.

(6) Designation of health plans by the health authority shall continue for the term of the Medi-Cal contract, unless the department determines that the criteria for designation specified in paragraph (3) is no longer met.

(7) 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 subdivision by means of letters or other similar instructions, without taking any further regulatory action. This may include, but need not be limited to, guidance to the health authority with respect to the requisite criteria and timing for the designation of health plans pursuant to this subdivision.

history: (History: Added by Stats. 2021, Ch. 446, Sec. 1. (SB 226) Effective January 1, 2022.)


text:
Governance of the commission shall be vested in a governing body consisting of 13 members, each of whom shall have a fiduciary duty to act in the best interest of the commission and the local initiative, nominated by the following entities, and appointed by the board of supervisors:

(a) Four members shall be nominated by the board of supervisors to represent the County of Los Angeles. No more than one member nominated by the board of supervisors shall be a member of the board of supervisors and each remaining member nominated by the board of supervisors shall possess experience as a health care administrator or as a health care provider.

(b) One member shall be a representative of private hospitals that have Medi-Cal disproportionate share status, or if that status no longer exists, that serve an equivalent patient population, who shall be nominated by the Hospital Association of Southern California.

(c) One member shall be a representative of private hospitals that do not have Medi-Cal disproportionate share status, who shall be nominated by the Hospital Association of Southern California.

(d) One member shall be a representative of free and community clinics, who shall be nominated by the Community Clinics Association of Los Angeles County.

(e) One member shall be a representative of federally qualified health centers, who shall be nominated by the Community Clinics Association of Los Angeles County, or if that status no longer exists, an equivalent group of health centers.

(f) One member shall be a physician representative, who shall be nominated by the Los Angeles County Medical Association, in consultation with other physician associations within the county.

(g) One member shall be a representative of Knox–Keene licensed prepaid health plans, who shall be nominated by the California Association of Health Plans.

(h) One member shall represent health care consumers, and at the time of being nominated, shall be a health care consumer. The initial nominee shall be nominated by the working group on the role of the consumer for the first nominee, and thereafter, by a process determined by the community advisory committee under which only health care consumers may nominate and vote for appointees.

(i) One member shall be a health care consumer advocate, who shall represent health care consumers. The initial nominee shall be nominated by the working group on the role of the consumer for the first nominee, and thereafter, by a process determined by the community advisory committee under which only health care consumers may nominate and vote for appointees.

(j) One member shall be a children’s health care provider representative, who shall be nominated by the Children’s Planning Council as the coordinating entity for organizations and agencies providing direct services to, or advocacy for, children and families within the county.

history: (History: Amended by Stats. 2004, Ch. 454, Sec. 2. Effective January 1, 2005.)


text: Members of the governing body shall either reside, be employed, or provide services in the geographic area served by the local initiative. Nominees shall be appointed to the governing body by the board of supervisors. The board of supervisors shall not deny appointment to a nominee described in subdivisions (b) to (j), inclusive, of Section 14087.961 without specific cause as set forth in Section 14087.964.


text:
(a) The governing body of the commission shall establish rules for its proceedings. There shall be at least six meetings per year.

(b) (1) Each governing body member shall be entitled to one hundred dollars ($100) remuneration from commission funds for each governing body meeting attended, and may receive similar remuneration for attending meetings of committees of the governing body, except that the total remuneration for each governing body member for all meetings shall not exceed the sum of four hundred dollars ($400) per month, plus actual expenses incurred in attending these meetings at rates payable to county officers and employees.

(2) The per meeting rate and monthly limit of one hundred dollars ($100) and four hundred dollars ($400), respectively, may be increased by the governing body, subject to approval by the board of supervisors.


text:
A member of the governing body shall be removed from office if a majority of the members present and voting find that one or more of the following causes for removal exists:

(a) The member neither lives in, nor is employed in, the geographic area served by the local initiative.

(b) The member has been convicted of a crime involving corruption or any felony.

(c) The member has failed to attend three consecutive governing body meetings or a majority of the meetings in the most recent calendar year.

(d) The member has failed to discharge legal obligations as a member of a public agency.

(e) A request for removal has been submitted by the appropriate nominating entity in accordance with Section 14087.9645.


text:
(a) A request for removal under Section 14087.9645 shall be adopted by the nominating entity in the same manner as the nomination was adopted and shall be confirmed by a written request for removal delivered to the governing body, setting forth the grounds for removal.

(b) A removal under subdivision (a) shall be effective upon action by the governing body, that shall be taken at the first meeting following receipt of the written request.

(c) The nominating entity shall be legally responsible for improper removals.

(d) A nominating entity that requests removal of a governing body member shall nominate a successor within 60 days after the effective date of the removal.


text:
(a) The governing body for each geographic region served by the local initiative shall establish a regional community advisory committee to ensure community involvement.

(b) Each regional community advisory committee shall have no more than 35 members, a majority of whom shall be consumers and consumer advocates, but may also include providers.

(c) (1) The chairpersons of the regional community advisory committees shall comprise an executive community advisory committee.

(2) It is the intent of the Legislature that a majority of the executive community advisory committee shall be consumers and consumer advocates, plus two at-large members.

(d) The executive community advisory committee shall make recommendations, and shall report on its activities, to the governing body and shall be able to place matters of the governing body’s agenda for consideration.

history: (History: Amended by Stats. 2004, Ch. 454, Sec. 4. Effective January 1, 2005.)


text: To the full extent permitted by federal law, the department and the commission may enter into contracts to provide or arrange for health care services for any or all persons who are eligible to receive benefits under the Medi-Cal program. The contracts may be on an exclusive or nonexclusive basis, and shall include payment provisions on any basis negotiated between the department and the commission. In addition, health plans or programs operated by the commission as part of the local initiative may also include, but are not limited to, individuals covered under Title 18 of the Social Security Act (Subchapter 18 (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code), individuals employed by public agencies and private businesses, and uninsured or indigent patients.


text: Notwithstanding any other provision of law, the county shall not be liable for any damages or losses, whether financial or in any other form, that may result from the reliance of any person, entity, or agency on the actions or omissions of, or the findings made by, the auditor-controller under this section.


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

(1) The board of supervisors or the governing body appointed the member to represent the interests of the county, physicians, health care practitioners, hospitals, pharmacies, other health care organizations, consumers, or consumer advocates. For purposes of this section, each group whose interests are described in this paragraph shall be referred to as a stakeholder.

(2) The contract or the contract as amended authorizes individuals or organizations in the same stakeholder group that the member was appointed to represent to provide services under the local initiative.

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

(4) The contract or the contract as amended does not specifically authorize the member or the member’s organization, as defined in paragraph (1) of subdivision (e), to provide services under the local initiative.

(b) If paragraphs (1) to (3), inclusive, of subdivision (a) are satisfied but the contract or the contract as amended would specifically authorize the member or the member’s organization to provide services under the local initiative, the contract approved by the governing body of the commission shall be deemed to comply with Section 1090 of the Government Code if the member abstains from voting on the contract or amendment to the contract, the member discloses the interest to the governing body or the advisory panel, whichever is applicable, the governing body or advisory panel notes the disclosure and the abstention in its official records, the member does not influence or attempt to influence the governing body, the advisory panel, or any member of the governing body or advisory panel to enter into the particular contract or the contract as amended, and the governing body or advisory panel authorizes the contract or amendment to the contract in good faith only by a vote of its membership sufficient for the purpose without counting the vote of the member.

(c) Notwithstanding any other provision of law, income from a contractor under the local initiative to a member or to a member’s organization, as defined in paragraph (1) of subdivision (e), which is unrelated income, as defined in paragraph (2) of subdivision (e), shall not cause the member of the governing body of the commission or the member of the advisory panel to the governing body to be deemed to be interested in the contract or amendment to the contract for purposes of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code, if the contract or the contract as amended contains substantially the same terms and conditions as contracts entered into with other contractors in the same stakeholder group that is the source of the unrelated income.

(d) If the particular contract or the contract as amended does not contain substantially the same terms and conditions as contracts entered into with other contractors in the same stakeholder group that is the source of the unrelated income, the contract approved by the governing body of the commission shall be deemed to comply with Section 1090 of the Government Code if the member abstains from voting on the contract or amendment to the contract, the member discloses the interest to the governing body or the advisory panel, whichever is applicable, the governing body or advisory panel notes the disclosure and abstention in its official records, the member does not influence or attempt to influence the governing body to enter into the particular contract or the contract as amended, and the governing body or advisory panel authorizes the contract or amendment to the contract in good faith only by a vote of its membership sufficient for that purpose without counting the vote of the member.

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

(1) “Member’s organization” means an entity for which the member serves as an employee, officer, board member, or consultant, or in which the member has any other financial interest for purposes of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code.

(2) “Unrelated income” means income that is not related to, or is not for providing services under, the local initiative.

history: (History: Amended by Stats. 2004, Ch. 454, Sec. 5. Effective January 1, 2005.)


text:
(a) Contracts under this article between the department and the commission 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.

(b) It is the intent of the Legislature that the county shall, with respect to its medical facilities and programs, occupy no greater or lesser status than any other health care provider in negotiating with the commission for contracts to provide health care services.


text: Neither the commission nor its local initiative shall be considered to be an agency, division, department, or instrumentality of the county, and neither the commission nor its local initiative shall be subject to the personnel, procurement, or other operational rules of the county.


text:
(a) The board of supervisors may, by ordinance, resolution, or other action, establish a commission in order to meet the problems of delivery of publicly assisted medical care in the county and demonstrate ways of promoting quality care and cost efficiency. The health care services provided by the commission shall include, but are not limited to, services covered under this chapter provided on a coordinated managed care basis. The commission shall operate the local initiative that provides or arranges for the delivery of health care services in all or part of the geographic area of the county, in a manner that is consistent with managed care principles, techniques, and practices directed at ensuring cost-effective and adequate access to quality care, without discrimination on the basis of medical condition, diagnosis, or illness, in an amount, duration, and scope that is sufficient to reasonably achieve its purpose for enrollees in the local initiative. If the board of supervisors establishes a commission, all rights, powers, duties, privileges, and immunities vested in the county pursuant to the contract with the department under this article shall be vested in the commission.

(b) (1) The commission shall be considered a public entity that is a local unit of government and that is separate from the county, shall file the statement required by Section 53051 of the Government Code, and shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code. The commission, members of the commission, and employees of the commission shall be protected by the immunities applicable to public entities and public employees governed by Part 2 (commencing with Section 814) of Division 3.6 of Title 1 of the Government Code, except as provided by other statutes or regulations that apply expressly to the commission.

(2) The commission shall have all power necessary and appropriate to do all of the following:

(A) Operate programs involving health care services, including, but not limited to, the power to own and operate one or more health plans.

(B) To enter into agreements with any public or private entity or entities to provide or arrange for health care services on a capitated or noncapitated basis.

(C) To acquire, possess, and dispose of real or personal property.

(D) To employ personnel and contract for services required to meet its obligations.

(E) To sue or be sued.

(F) To enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code.

(3) The commission may enter into contracts with public and private health care providers to provide health care and related services to individuals enrolled in any health plan or health program operated as part of the local initiative.

(c) Nothing in this section shall be construed to authorize the commission to operate any health care program other than the local initiative described in the strategic plan as it currently exists or as it may be amended by the department.

history: (History: Amended by Stats. 2004, Ch. 228, Sec. 12.7. Effective August 16, 2004.)


text:
(a) The composition of the 13-member governing body of the commission, as prescribed in Section 14087.961, shall be subject to alteration upon a two-thirds vote of the full membership of the governing body, if the action is also concurred in by an affirmative vote of at least four members of the board of supervisors; provided, however, no change in the composition of the governing board shall result in the elimination of representation by the county, private physicians, hospitals, and other providers, clinics, or consumers and consumer advocates.

(b) Notwithstanding subdivision (a), no governing body member shall be removed except as provided in Section 14087.964.


text:
(a) Members of the governing body of the commission shall serve four-year terms.

(b) Individuals shall be limited to serving on the governing body for two consecutive four-year terms or a maximum of 10 years.

history: (History: Amended by Stats. 2004, Ch. 454, Sec. 3. Effective January 1, 2005.)


text:
(a) A majority of the members of the governing body shall constitute a quorum for the transaction of business, and all official acts of the governing body shall require the affirmative vote of a majority of the members present and voting.

(b) No official act shall be approved with less than the affirmative vote of four members of the governing body, unless the number of members prohibited from voting because of conflicts of interest precludes adequate participation in the vote.


text:
A member of the governing body may be removed at the request of the entity that nominated the member. The entity that nominated a member may request removal of that member for any of the following reasons:

(a) Any of the causes listed in Section 14087.964.

(b) The member no longer meets the qualifications for office or the criteria applied by the nominating entity in selecting the member as its nominee.


text:
(a) The governing body shall establish a technical advisory committee to provide technical expertise to the governing body.

(b) Members of the committee shall include a medical school representative, an epidemiologist, a pharmacist, a representative of a nursing association, a home health care representative, a long-term care provider, a mental health care provider, a medical rehabilitation provider, and an expert on health care quality, or, in the alternative, other persons with health care expertise.

(c) The technical advisory committee shall meet on a regular basis, and shall make recommendations and reports to the governing body.

history: (History: Amended by Stats. 2001, Ch. 528, Sec. 1. Effective January 1, 2002.)


text:
(a) The governing body shall establish a children’s health consultant advisory committee to provide to the governing body expertise on child, adolescent, and maternal health issues.

(b) Members of the committee shall include representatives of government health departments and school districts in the geographic area served by the local initiative, as well as medical professionals with background in pediatrics and obstetric care, or, in the alternative, other persons with health care expertise.

(c) The children’s health consultant advisory committee shall meet on a regular basis, and shall make recommendations and reports to the governing body.

history: (History: Added by Stats. 2001, Ch. 528, Sec. 2. Effective January 1, 2002.)


text:
(a) The commission may borrow or receive funds from any person or entity as necessary to cover development costs and other actual or projected obligations of the local initiative.

(b) The county may lend funds to the commission upon such terms as the board of supervisors may establish.

(c) Notwithstanding any other provision of law, both the county and the commission shall be eligible to receive funding under subdivision (p) of Section 14163, and the local initiative shall be considered for all purposes to satisfy the requirements of subdivision (p) of Section 14163.

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


text:
(a) The auditor-controller of the county, at those intervals the auditor-controller deems appropriate, but no less frequently than annually, shall conduct a review of the fiscal condition of the commission, report the findings to the commission and the board of supervisors, and provide a copy of the findings to any public agency upon request.

(b) At the county auditor-controller’s discretion, other operational or financial audits of the commission may be conducted.

(c) Upon the written request of the county auditor-controller, the commission shall provide full access to all commission records and documents as necessary to allow the county auditor-controller to perform the activities authorized by this section.


text:
(a) Notwithstanding any other provision of law, any obligation of the commission and its local initiative, statutory, contractual, or otherwise, shall be an obligation solely of the commission and shall not be an obligation of the county or of the state. Except as otherwise provided in this article, neither the county nor the state shall be liable for any act or omission of the commission.

(b) Except as agreed to by contract with the county, no liability of the commission shall become an obligation of the county upon either termination of the commission and its local initiative or the liquidation or disposition of the commission’s remaining assets.

(c) All claims for money damages against the commission shall be governed by Part 3 (commencing with Section 900) and Part 4 (commencing with Section 940) of Division 3.6 of Title 1 of the Government Code, except as otherwise provided by other statutes or regulations that expressly apply to the commission.


text: The department, if at no state General Fund expense, may take all appropriate steps, in cooperation with the county and the commission, to obtain approval for a demonstration or pilot project under applicable federal laws, including, but not limited to, Section 1315 of Title 42 of the United States Code, in connection with the local initiative in the county. The project may include Medi-Cal coverage for enrollees in the local initiative who otherwise would not be covered under the Medi-Cal program. The project shall not be used to curtail existing rights with respect to eligibility and services for the Medi-Cal population, nor to obtain federal waivers of the payment provisions applicable to federally qualified health centers or noninstitutional providers under paragraphs (10), (13), (30), and (37) of subsection (a) of Section 1396a of Title 42 of the United States Code.


text: In any transfer of functions from county employees to the commission, the commission shall continue to recognize the employee organization that represented the employees performing those functions at the time of the transfer of duties. The commission shall also be bound by the terms of any memorandum of understanding that is in effect as of the date of the transfer of functions for the duration thereof, or until replaced by a subsequent memorandum of understanding.