text:
(a) (1) Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age.

(2) It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal.

(3) For purposes of this section, “behavioral health treatment” or “BHT” means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan.

(b) The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred:

(1) The department receives all necessary federal approvals to obtain federal funds for the service.

(2) The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year.

(3) The department consults with stakeholders.

(c) The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders.

(d) (1) The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services.

(2) The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria:

(A) They were enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016.

(B) They were deemed to be institutionalized in order to establish eligibility under the terms of the waiver.

(C) They have not been found eligible under any other federally funded Medi-Cal criteria without a spend down of excess income.

(D) They have received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5.

(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.

(f) For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.

(g) The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request.

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

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 145. (AB 118) Effective July 10, 2023.)

article: 4. The Medi-Cal Benefits Program


kind: section

code: WIC

text:
(a) (1) The department shall seek all necessary federal approvals to exercise the option described in Section 1396w-6 of Title 42 of the United States Code, to provide qualifying community-based mobile crisis intervention services to eligible Medi-Cal beneficiaries experiencing a mental health or substance use disorder crisis.

(2) Qualifying community-based mobile crisis intervention services shall be available to eligible Medi-Cal beneficiaries exclusively through a Medi-Cal behavioral health delivery system.

(b) The department shall comply with any federal requirements and conditions for receipt of the increased federal medical assistance percentage described in Section 1396w-6(c) of Title 42 of the United States Code and any associated federal regulations or guidance for qualifying community-based mobile crisis intervention services.

(c) Subject to obtaining the federal approvals described in subdivision (a), the department shall do all of the following:

(1) Establish requirements for the receipt of qualifying community-based mobile crisis intervention services by eligible Medi-Cal beneficiaries experiencing a mental health or substance use disorder crisis, including, but not limited to, utilization controls.

(2) Establish requirements for authorized providers of qualifying community-based mobile crisis intervention services.

(3) Oversee and enforce the requirements and guidelines developed pursuant to this section.

(d) For the purposes of implementing this section, including, but not limited to, providing training and technical assistance, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services.

(e) Subject to federal approval, this section shall be implemented no sooner than January, 1, 2023, and shall be implemented up to the end of the five-year period specified in Section 1396w-6 of Title 42 of the United States Code.

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

(g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action. To the extent practicable, the department shall consult with interested stakeholders when issuing guidance pursuant to this subdivision.

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

(1) “Medi-Cal behavioral health delivery system” has the same meaning as set forth in subdivision (i) of Section 14184.101.

(2) “Qualifying community-based mobile crisis intervention services” has the same meaning as set forth in Section 1396w-6(b) of Title 42 of the United States Code.

history: (History: Added by Stats. 2022, Ch. 47, Sec. 97. (SB 184) Effective June 30, 2022.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 4. The Medi-Cal Benefits Program

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


text:
(a) The department shall file all necessary state plan amendments, as set forth in Section 457.40 of Title 42 of the Code of Federal Regulations, to exercise the health services initiative (HSI) option made available under the Children’s Health Insurance Program (CHIP), established under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et seq.), as that option is described in Section 1397ee(a)(1)(D)(ii) of Title 42 of the United States Code, and as HSI is defined in Section 457.10 of Title 42 of the Code of Federal Regulations, to cover vision services provided to low-income children statewide through a mobile optometric office, as defined in Section 3070.2 of the Business and Professions Code and in accordance with subdivision (g) of Section 14043.15 and with Section 14043.26.

(b) (1) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available. The federal financial participation shall be limited to no more than 3 percent of the total federal dollars available for expenditures not used for Medicaid or health insurance assistance, as described in Section 1397ee(c)(2)(A) of Title 42 of the United States Code.

(2) This section shall be implemented by January 1, 2025, or the date that any necessary federal approvals have been obtained, whichever date is later.

(c) (1) The Vision Services CHIP-HSI Special Fund is hereby created in the State Treasury.

(2) All revenues derived pursuant to paragraph (1) of subdivision (d) and federal financial participation provided for in this section shall be deposited in the State Treasury to the credit of the Vision Services CHIP-HSI Special Fund. Moneys in that fund shall be available to cover vision services, as described in subdivision (a), upon appropriation by the Legislature in the annual Budget Act. Commencing with the first fiscal year in which the department requests funds for this purpose and annually thereafter, the department shall report on projected and actual federal and nonfederal resources and expenditures through the budget estimate process.

(d) (1) The department shall seek to fund the implementation of this section, subject to subdivision (c), with funding other than General Fund moneys, including gifts, donations, bequests, or grants of funds from private sources and public agencies, designated for any of the purposes of this section.

(2) This section shall continue to be implemented only if no General Fund moneys are used for this section.

(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of an all-county letter or similar instruction, without taking any further regulatory action, until regulations are adopted.

history: (History: Added by Stats. 2023, Ch. 487, Sec. 2. (SB 502) Effective January 1, 2024.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Reconstructive surgery shall be covered under this chapter, as defined in subdivision (c), when necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require coverage for cosmetic surgery, as defined in subdivision (d).

(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual competent to evaluate the specific clinical issues involved in the care requested.

(c) “Reconstructive surgery” means surgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:

(1) To improve function.

(2) To create a normal appearance, to the extent possible.

(d) “Cosmetic surgery” means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.

(e) In connection with the interpretation of the definition of reconstructive surgery, a proposed surgical procedure may be subject to prior authorization and utilization review that may include, but need not be limited to, denial under any of the following circumstances:

(1) There is another more appropriate surgical procedure that will be approved for the enrollee.

(2) The procedure or procedures offer only a minimal improvement in the appearance of the enrollee, as defined in regulations adopted by the department.

(3) Denial of payment for procedures performed without prior authorization.

(f) This section shall become operative July 1, 1999.

history: (History: Added by Stats. 1998, Ch. 788, Sec. 4. Effective January 1, 1999. Section operative July 1, 1999, by its own provisions.)

article: 4. The Medi-Cal Benefits Program


text:
(a) An orthotist or prosthetist providing services under this chapter shall be required to be certified in orthotics or prosthetics by either the Board for Orthotist Certification or the American Board of Certification in Orthotics and Prosthetics.

(b) This section shall remain in effect only until the date that the director executes a declaration, that shall be retained by the director, stating that the department has adopted regulations requiring an orthotist or prosthetist to be certified in orthotics or prosthetics by either the Board for Orthotist Certification or the American Board of Certification in Orthotics and Prosthetics, as a condition of providing orthotist or prosthetic services under this chapter, and as of that date is repealed.

history: (History: Added by Stats. 1996, Ch. 1009, Sec. 1. Effective January 1, 1997. Repealed conditionally by its own provisions.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding any other provision of law, donor and recipient organ transplant surgeries are covered under the Medi-Cal program when an organ transplant is provided to a beneficiary who is eligible for full-scope benefits under this chapter in a medical facility that meets the requirements of, and is approved by, the department.

(b) Any donor or recipient organ transplant surgeries authorized by the department pursuant to this chapter are subject to utilization controls.

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

(d) This section shall not apply to Section 14133.8.

history: (History: Added by Stats. 2007, Ch. 300, Sec. 3. Effective January 1, 2008.)

article: 4. The Medi-Cal Benefits Program


text:
(a) A Medi-Cal beneficiary shall remain eligible to receive Medi-Cal coverage for antirejection medication for up to two years following an organ transplant, unless during that period the beneficiary becomes eligible for Medicare or private health insurance that would cover the medication.

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

history: (History: Added by Stats. 2010, Ch. 676, Sec. 1. (AB 2352) Effective January 1, 2011.)

article: 4. The Medi-Cal Benefits Program


text:
(a) For purposes of donor and recipient organ transplant surgeries, the department shall establish standards as to both the circumstances and the criteria that the department will use for approving facilities eligible for receiving reimbursement under the Medi-Cal program.

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

history: (History: Added by Stats. 2007, Ch. 300, Sec. 5. Effective January 1, 2008.)

article: 4. The Medi-Cal Benefits Program


text:
(a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.

(b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the provider.

(c) In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.  Nothing in this section or the Telehealth Advancement Act of 2011 shall be construed to conflict with or supersede the provisions of Section 14091.3 of this code or any other existing state laws or regulations related to reimbursement for services provided by a noncontracted provider.

(d) The department shall not require a health care provider to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth.

(e) For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

(f) Nothing in this section shall be interpreted to authorize the department to require the use of telehealth when the health care provider has determined that it is not appropriate.

(g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, provider bulletins, and similar instructions.

history: (History: Amended by Stats. 2011, Ch. 547, Sec. 9. (AB 415) Effective January 1, 2012.)

article: 4. The Medi-Cal Benefits Program


text: The State Department of Health Care Services shall allow psychiatrists to receive fee-for-service Medi-Cal reimbursement for services provided through telehealth in accordance with the Medicaid state plan.

history: (History: Amended by Stats. 2012, Ch. 782, Sec. 13. (AB 1733) Effective January 1, 2013.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The department, in consultation with interested stakeholders, shall develop, as a pilot project, a pediatric palliative care benefit to evaluate whether, and to what extent, such a benefit should be offered under the Medi-Cal program. The pilot project shall be implemented only to the extent that federal financial participation is available.

(b) Beneficiaries eligible to receive the pediatric palliative care benefit shall be under 21 years of age. The department may further limit the population served by the pilot project to a size deemed sufficient to make the evaluation required pursuant to subdivision (a).

(c) Services covered under the pediatric palliative care benefit shall be designed to meet the unique needs of children, and shall include those types of services that are available through the Medi-Cal hospice benefit. The benefit shall also include the following services, regardless of whether those services are covered under the Medi-Cal hospice benefit:

(1) Hospice services that are provided at the same time that curative treatment is available, to the extent that the services are not duplicative.

(2) Hospice services provided to individuals whose conditions may result in death, regardless of the estimated length of the individual’s remaining period of life.

(3) Any other services that the department determines to be appropriate.

(d) The department, in consultation with interested stakeholders, shall determine the medical conditions and prognoses that render a beneficiary eligible for the benefit.

(e) Providers authorized to provide services under the pilot program shall include licensed hospice agencies and home health agencies licensed to provide hospice care, subject to criteria developed by the department for provider participation.

(f) (1) The department shall submit any necessary application to the federal Centers for Medicare and Medicaid Services for a waiver to implement the pilot project described in this section. The department shall determine the form of waiver most appropriate to achieve the purposes of this section. The waiver request shall be included in any waiver application submitted within 12 months after the effective date of this section, or shall be submitted as an independent application within that time period. After federal approval is secured, the department shall implement the waiver within 12 months of the date of approval.

(2) The waiver shall be designed to cover a period of time necessary to evaluate the medical necessity for, and cost-effectiveness of, a pediatric palliative care benefit. The results of the pilot project shall be made available to the Legislature and appropriate policy and fiscal committees to determine the effectiveness of the benefit.

(g) 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 the provisions of this section by means of provider bulletins or similar instructions, without the adoption of regulations. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue a provider bulletin or other similar instruction at least five days prior to issuance.

(h) (1) Nothing in this section shall result in the elimination or reduction of any covered benefits or services under the Medi-Cal program or the California Children’s Services Program.

(2) This section shall not affect an individual’s eligibility to receive, concurrently with the benefit provided for in this section, any services, including home health services, for which the individual would have been eligible in the absence of this section.

history: (History: Added by Stats. 2006, Ch. 330, Sec. 2. Effective January 1, 2007.)

article: 4. The Medi-Cal Benefits Program


text:
(a) In enacting this section, it is the intent of the Legislature that palliative care include, but not be limited to, all of the following:

(1) Specialized medical care and emotional and spiritual support for people with serious advanced illnesses.

(2) Relief of symptoms, pain, and stress of serious illness.

(3) Improvement of quality of life for both the patient and family.

(4) Appropriate care for any age and for any stage of serious illness, along with curative treatment.

(b) The department, in consultation with interested stakeholders, shall establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.

(c) Covered services shall include, but are not limited to, those types of services that are available through the Medi-Cal hospice benefit. These services shall include the following, regardless of whether these services are covered under the Medi-Cal hospice benefit:

(1) Hospice services that are provided at the same time that curative treatment is available, to the extent that the services are not duplicative.

(2) Hospice services provided to individuals whose conditions may result in death, regardless of the estimated length of the individual’s remaining period of life.

(3) Any other services that the department determines to be appropriate.

(d) The department, in consultation with interested stakeholders, shall establish guidance on the medical conditions and prognoses that render a beneficiary eligible for the palliative care services.

(e) Providers authorized to provide services shall include licensed hospice agencies and home health agencies licensed to provide hospice care that are contracted with Medi-Cal managed care plans to provide palliative care services.

(f) The department shall, to the extent practicable, ensure that the delivery of palliative care services under this section is provided in a manner that is cost neutral to the General Fund on an ongoing basis.

(g) 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 the provisions of this section by means of all plan letters or similar instructions, without the adoption of regulations. The department shall notify stakeholders and the fiscal and appropriate policy committees of the Legislature of its intent to issue all plan letters or other similar instructions prior to issuance.

(h) (1) Nothing in this section shall result in the elimination or reduction of any covered benefits or services under the Medi-Cal program.

(2) This section shall not affect an individual’s eligibility to receive, concurrently with the services provided for in this section, any services, including home health services, for which the individual would have been eligible in the absence of this section.

history: (History: Added by Stats. 2014, Ch. 574, Sec. 1. (SB 1004) Effective January 1, 2015.)

article: 4. The Medi-Cal Benefits Program


text:
(a) An individual who is determined to be eligible to receive hospice services prior to 21 years of age may continue to receive hospice services after 21 years of age when certified as eligible by a physician in accordance with section 1905(o) of the Social Security Act (42 U.S.C. Sec. 1396d(o)).

(b) An individual who is determined to be eligible to receive palliative care services prior to 21 years of age may continue to receive medically necessary palliative care services after 21 years of age when determined to be eligible by the recipient’s treating health care provider.

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

history: (History: Added by Stats. 2023, Ch. 814, Sec. 3. (AB 847) Effective January 1, 2024.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) Any rural hospital may request to participate in a two-year pilot project to perform delegated acute inpatient hospital treatment authorization review under the Medi-Cal program.

(2) Any hospital that elects to participate in the pilot project under this section shall enter into an agreement with the department to ensure the appropriateness of the treatments and services that it provides to a Medi-Cal beneficiary.

(3) Any rural hospital that elects to participate in a pilot project pursuant to this section shall remain in the project for not less than one year, unless it is removed by the department pursuant to subdivision (c).

(b) The department shall review, on a random basis, every six months, up to 25 percent of the Medi-Cal beneficiaries treated by each participating hospital. As long as a hospital participates in a pilot project authorized by this section, reviews required by this section shall not interfere with, or delay, the processing of the hospital’s claims for payment. Consistent with subdivision (c), if the department finds that a hospital participating in a pilot project under this section is accumulating a significant overpayment, the department shall notify the provider.

(c) (1) (A) If the department determines, as a result of a review required by subdivision (b), that the hospital has provided treatment that cannot be approved by the department, the department shall take an immediate disallowance that shall require offsets against pending Medi-Cal payments and any direct payment that may be required by the department. The disallowance shall be based on full extrapolation of the sample to the universe of Medi-Cal days covered by the sample period.

(B) In addition to the requirements of subparagraph (A), if the department determines that the hospital has provided treatment that cannot be approved by the department for 3 percent or more of the Medi-Cal beneficiary days, the department shall take corrective action relative to the hospital’s participation in the pilot project. The corrective action shall include at least one of the following actions:

(i) The revocation of the hospital’s participation pursuant to subdivision (a).

(ii) An increased random review process.

(iii) Mandatory educational programs.

(2) After the random review required by subdivision (b), the hospital shall, through the reduction of the regularly scheduled periodic interim payment over a one-year period, pay the state an amount equal to the reimbursement received by the hospital for services for which approval has been denied and extrapolated pursuant to paragraph (1). This paragraph does not preclude any hospital from appealing a determination of the department under Article 5.3 (commencing with Section 14170). However, any issue under appeal shall not delay any disallowance or corrective action taken by the department under paragraph (1) until the appeal is resolved.

(d) The department may reinstate any hospital’s participation revoked pursuant to subdivision (c) if, after a period of three months, the hospital’s requests for a treatment authorization are not denied in 3 percent or more of the Medi-Cal days.

(e) Six months after the conclusion of the first year of the pilot project, the department shall prepare a report with an evaluation of the project and shall submit it to the appropriate committees of the Legislature. The department shall include its determination as to whether the project should be extended, modified, or terminated in the report and the basis for any determinations made by the department.

(f) (1) As part of the pilot project implemented under this section, the department may, subject to federal approval, authorize the reimbursement of a participating rural hospital at a predetermined amount every two weeks or on some other basis determined to be appropriate by the department. Following every six-month period, the department shall immediately begin adjustment of any overpayment or underpayment, based on the amount paid to the provider as compared to the actual amount of claims approved by the department. Any hospital that is selected to participate in the pilot project under this section that elects to be paid for acute inpatient services under this subdivision shall be subject to the payment provisions of this section for the duration of the hospital’s participation in the pilot project.

(2) The amount of reimbursement under paragraph (1) shall be based on the actual claims payment experience for each hospital for the immediately preceding period of six months and rate adjustments made in accordance with existing Medi-Cal reimbursement requirements.

(g) For purposes of this section, “rural hospital” means a small and rural hospital as defined in Section 124840 of the Health and Safety Code.

(h) The scope of the pilot project shall be subject to federal approval and the necessary resources made available from sources other than the General Fund or savings from program efficiencies that may be identified for this purpose.

(i) The department shall implement this section only upon receipt of all appropriate federal waivers.

history: (History: Amended by Stats. 1996, Ch. 1023, Sec. 477. Effective September 29, 1996.)

article: 4. The Medi-Cal Benefits Program


text:
(a) The purchase of identification bracelets for eligible recipients under the Medi-Cal program who have Alzheimer’s Disease or some other cognitive defect, or medication allergies that could be life threatening, shall be a covered benefit under this chapter.

(b) The bracelets shall be purchased from an organization which maintains a 24-hour toll-free telephone number for emergency or medical personnel to make inquiries.

(c) The director shall develop regulations to implement this section.

(d) For purposes of this section “eligible recipients” means those persons who, in addition to qualifying for benefits under this chapter, have been determined by a licensed physician and surgeon to need the benefit authorized by this section.

(e) Benefits shall be provided under this section only to the extent that full federal financial participation is made available.

(f) Benefits shall be provided under this section only when the director determines that two or more organizationally independent providers are available to supply the benefit authorized by this section.

history: (History: Added by Stats. 1989, Ch. 1082, Sec. 2.)

article: 4. The Medi-Cal Benefits Program


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

(1) “Complex needs patient” means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation. “Complex needs patient” includes, but is not limited to, individuals with spinal cord injury, traumatic brain injury, cerebral palsy, muscular dystrophy, spina bifida, osteogenesis imperfecta, arthrogryposis, amyotrophic lateral sclerosis, multiple sclerosis, demyelinating disease, myelopathy, myopathy, progressive muscular atrophy, anterior horn cell disease, post-polio syndrome, cerebellar degeneration, dystonia, Huntington’s disease, spinocerebellar disease, and the types of amputation, paralysis, or paresis that result in significant physical impairment or functional limitation. “Complex needs patient” does not negate the requirement that an individual meet medical necessity requirements under authority rules to qualify for receiving complex rehabilitation technology.

(2) “Complex rehabilitation technology” means items classified within the federal Medicare Program as of January 1, 2021, as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. These items include, but are not limited to, complex rehabilitation manual and power wheelchairs, power seat elevation or power standing components of power wheelchairs, seating and positioning items, other specialized equipment such as adaptive bath equipment, standing frames, gait trainers, and specialized strollers, and related options and accessories.

(3) “Complex rehabilitation technology services” includes the application of enabling systems designed and assembled to meet the needs of a patient experiencing any permanent or long-term loss or abnormality of physical or anatomical structure or function with respect to mobility or other function or need. These services include, but are not limited to, all of the following:

(A) Evaluating the needs of a patient with a disability, including an assessment of the patient for the purpose of ensuring that the proposed equipment is appropriate.

(B) Documenting medical necessity.

(C) Selecting, fitting, customizing, maintaining, assembling, repairing, replacing, picking up and delivering, and testing equipment and parts.

(D) Training the patient who will use the technology or any individual who assists the patient in using the complex rehabilitation technology.

(4) “Qualified health care professional” means an individual who has no financial relationship to the provider of complex rehabilitation technology and is any of the following:

(A) A physical therapist licensed pursuant to Chapter 5.7 (commencing with Section 2600) of Division 2 of the Business and Professions Code.

(B) An occupational therapist licensed pursuant to Chapter 5.6 (commencing with Section 2570) of Division 2 of the Business and Professions Code.

(C) Other licensed health care professional, approved by the department, and who performs specialty evaluations within the professional’s scope of practice.

(5) “Qualified rehabilitation technology professional” means an individual who meets either of the following:

(A) Holds the credential of Assistive Technology Professional (ATP) from the Rehabilitation Engineering and Assistive Technology Society of North America.

(B) Holds the credential of Certified Complex Rehabilitation Technology Supplier (CRTS) from the National Registry of Rehabilitation Technology Suppliers.

(b) A provider of complex rehabilitation technology to a Medi-Cal beneficiary shall comply with all of the following:

(1) Meet the supplier and quality standards established for a durable medical equipment supplier under the federal Medicare Program and be enrolled as a provider in the Medi-Cal program.

(2) Be accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology.

(3) Employ at least one qualified rehabilitation technology professional as a W-2 employee (receiving a W-2 tax form from the provider) for each distribution location.

(4) Have the qualified rehabilitation technology professional physically present for the evaluation, either in person or remotely if necessary, directly involved in determining the specific complex rehabilitation technology appropriate for the patient, and directly involved with, or closely supervise, the final fitting and delivery of the complex rehabilitation technology.

(5) Maintain a reasonable supply of parts, adequate physical facilities, and qualified service or repair technicians, and provide patients with prompt services and repair for all complex rehabilitation technology supplied.

(6) Provide written information at the time of delivery of complex rehabilitation technology regarding how the patient may receive services and repair.

(c) For complex needs patients receiving a complex rehabilitation manual wheelchair, power wheelchair, or seating component, the patient shall be evaluated, either in person or remotely if necessary, by both of the following:

(1) A qualified health care professional.

(2) A qualified rehabilitation technology professional.

(d) A medical provider shall conduct a physical examination of an individual, either in person or remotely if necessary, before prescribing a power wheelchair or scooter for a Medi-Cal beneficiary. The medical provider shall complete a certificate of medical necessity that documents the medical condition that necessitates the power wheelchair or scooter, and verifies that the patient is capable of using the wheelchair or scooter safely.

(e) The department may adopt utilization controls, including a specialty evaluation by a qualified health care professional, as defined in paragraph (4) of subdivision (a). The department may adopt any other additional utilization controls for complex rehabilitation technology, as appropriate.

(f) The department shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.

history: (History: Amended by Stats. 2025, Ch. 243, Sec. 22. (SB 862) Effective January 1, 2026.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding subdivision (ab) of Section 14132, effective May 1, 2014, purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products pursuant to Section 14105.8 and utilization controls pursuant to Section 14105.395.

(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of a provider bulletin or similar instruction, without taking regulatory action.

(c) This section shall only be implemented to the extent permitted by federal law.

(d) The department shall seek approval for federal financial participation and coverage of the service specified in subdivision (a) under the Medi-Cal program.

history: (History: Added by Stats. 2013, Ch. 23, Sec. 63. (AB 82) Effective June 27, 2013.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are covered benefits for beneficiaries 21 years of age or older under this chapter:

(1) One dental prophylaxis cleaning per year.

(2) One initial dental examination by a dentist.

(b) The following are covered benefits for beneficiaries under 21 years of age under this chapter:

(1) Two dental prophylaxis cleanings per year.

(2) Two periodic dental examinations per year.

(c) For persons 21 years of age or older, laboratory-processed crowns on posterior teeth are a covered benefit when medically necessary to restore a posterior tooth back to normal function based on the criteria specified in the Medi-Cal Dental Manual of Criteria.

(d) Any prefabricated crown made from ADA-approved materials may be used on posterior teeth and may be reimbursed as a stainless steel crown.

(e) Covered dental benefits and accompanying criteria for receipt of those dental benefits under the Medi-Cal program shall be identified in the Medi-Cal Dental Manual of Criteria. Notwithstanding subdivision (h) of Section 14132, the department shall evaluate all covered dental benefits, including those listed in this section and in the Medi-Cal Dental Manual of Criteria, for evidence-based practices consistent with the American Academy of Pediatric Dentistry and the American Dental Association guidelines.

(f) (1) Except as provided in paragraph (2), the department shall require pretreatment radiograph documentation on posttreatment claims to establish the medical necessity for dental restorations. The pretreatment documentation required under this subdivision is intended to reduce fraudulent claims for unnecessary dental fillings. In order to avoid any undue barriers to accessing dental care, the department shall stipulate that the pretreatment radiograph documentation for posttreatment claims will be required only when there are four or more dental fillings being completed in any 12-month period.

(2) For any beneficiary who is under four years of age, or who, regardless of age, has a developmental disability, as defined in subdivision (a) of Section 4512, radiographs or photographs that indicate decay on any tooth surface shall be considered sufficient documentation to establish the medical necessity for treatment provided.

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

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

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 102. (SB 184) Effective June 30, 2022.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding subdivision (h) of Section 14132, effective May 1, 2014, or the effective date of any necessary federal approvals as required by subdivision (d), all of the following are covered benefits for persons 21 years of age or older, subject to utilization controls and medically necessary services:

(1) Examinations, radiographs/photographic images, prophylaxis, and fluoride treatments.

(2) Amalgam and composite restorations.

(3) Stainless steel, resin, and resin window crowns.

(4) Anterior root canal therapy.

(5) Complete dentures, including immediate dentures.

(6) Complete denture adjustments, repairs, and relines.

(7) Emergency procedures are also covered in the above categories of service.

(b) This section shall only be implemented to the extent permitted by federal law.

(c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of a provider bulletin or similar instruction, without taking regulatory action.

(d) The department shall seek approval for federal financial participation and coverage of services specified in subdivision (a) under the Medi-Cal program.

history: (History: Added by Stats. 2013, Ch. 23, Sec. 64. (AB 82) Effective June 27, 2013.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Subject to the availability of funding, the department shall conduct a dental outreach and education program for Medi-Cal beneficiaries. The program shall inform Medi-Cal beneficiaries of the availability of dental care and provide information regarding recommended frequencies for regular and preventive dental care, how to obtain Medi-Cal dental care, how to avoid inappropriate care or fraudulent providers, and how to obtain assistance in getting care or resolving problems with dental care.

(b) The program shall particularly target underserved populations and parents of young and adolescent children, and it shall include the following components:

(1) Incorporation of dental themes and information in ongoing outreach and advertising efforts, including those for Medi-Cal and the Healthy Families program.

(2) Education and outreach materials for inclusion in mailings to beneficiaries.

(3) Education and consumer protection materials for display and distribution at sites providing Medi-Cal dental care, clinics, and other health care facilities and sites.

(c) The department shall consult with dental professional groups and experts, community organizations, advertising and media experts, and other parties, as the department deems appropriate, in order to develop and structure the program in an effective and efficient manner.

history: (History: Added by Stats. 2000, Ch. 93, Sec. 94. Effective July 7, 2000.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Notwithstanding subdivision (a) of Section 4512, or any other provision of this chapter or Chapter 8 (commencing with Section 14200), services provided on or after July 1, 2000, by facilities defined in subdivisions (e) and (h) of Section 1250 of the Health and Safety Code that are otherwise covered services under this chapter shall be reimbursed by the Medi-Cal program when provided to a Medi-Cal beneficiary that has a developmental disability as defined in Section 6001(8) of Title 42 of the United States Code or is a person with a related condition as defined in Section 435.1009 of Title 42 of the Code of Federal Regulations, provided that the Medi-Cal beneficiary was residing in a licensed intermediate care facility/developmentally disabled-habilitative or a licensed intermediate care facility/developmentally disabled-nursing on July 1, 2000, but only for as long as the beneficiary continues, from that date, to reside in a licensed intermediate care facility/developmentally disabled-habilitative or a licensed intermediate care facility/developmentally disabled-nursing.

(b) Nothing in subdivision (a) shall eliminate, for purposes of reimbursement under this section, the requirements and time limits set forth in Section 14115, or any regulations adopted thereunder.

(c) The department shall seek further financial participation, and shall seek federal approval of a state plan amendment if necessary under Section 440.150 of Title 42 of the Code of Federal Regulations, for services provided pursuant to subdivision (a). If federal financial participation is not made available for the services, the services nonetheless shall be reimbursed from the General Fund.

history: (History: Added by Stats. 2000, Ch. 804, Sec. 1. Effective September 28, 2000.)

article: 4. The Medi-Cal Benefits Program


text: It is the intent of the Legislature that if services meeting the conditions of subdivision (a) of Section 14132.92 have been provided to a Medi-Cal beneficiary during the time period of June 15, 1998, to July 2, 2000, and notwithstanding Section 14115, a bill for these services is submitted on behalf of each beneficiary receiving these services postmarked to the department on or before April 30, 2001, the services shall be reimbursed by the General Fund. However, the department shall seek federal financial participation and shall seek federal approval of a state plan amendment if necessary under Section 440.150 of Title 42 of the Code of Federal Regulations, for these services provided during that period. If federal financial participation is not made available for that period, the services nonetheless shall be reimbursed from the General Fund.

history: (History: Added by Stats. 2000, Ch. 804, Sec. 2. Effective September 28, 2000.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Subject to approval by the Centers for Medicare and Medicaid Services of a medicaid state plan amendment electing the Programs of All-Inclusive Care for the Elderly (PACE) as a state medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the Medi-Cal program, subject to utilization controls and eligibility criteria that require that the beneficiary be certifiable for nursing facility services based on Medi-Cal criteria.

(b) Covered services under the PACE benefit of the Medi-Cal program include those set forth in 42 C.F.R. 460.92.

history: (History: Added by Stats. 2003, Ch. 112, Sec. 1. Effective January 1, 2004.)

article: 4. The Medi-Cal Benefits Program


text:
(a) Personal care services, when provided to a categorically needy person as defined in Section 14050.1 is a covered benefit to the extent federal financial participation is available if these services are:

(1) Provided in the beneficiary’s home and other locations as may be authorized by the director subject to federal approval.

(2) Authorized by county social services staff in accordance with a plan of treatment.

(3) Provided by a qualified person.

(4) Provided to a beneficiary who has a chronic, disabling condition that causes functional impairment that is expected to last at least 12 consecutive months or that is expected to result in death within 12 months and who is unable to remain safely at home without the services described in this section.

(b) The department shall seek federal approval of a state plan amendment necessary to include personal care as a Medicaid service pursuant to subdivision (f) of Section 440.170 of Title 42 of the Code of Federal Regulations. For any persons who meet the criteria specified in subdivision (a) or (p), but for whom federal financial participation is not available for a service or services under this section, eligibility for the service or services shall be determined according to the waiver authorized pursuant to Section 14132.951. If federal financial participation for the service or services is not available under this section or Section 14132.951, eligibility for the service or services shall be determined pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

(c) Subdivision (a) shall not be implemented unless the department has obtained federal approval of the state plan amendment described in subdivision (b), and the Department of Finance has determined, and has informed the department in writing, that the implementation of this section will not result in additional costs to the state relative to state appropriation for in-home supportive services under Article 7 (commencing with Section 12300) of Chapter 3, in the 1992–93 fiscal year.

(d) (1) For purposes of this section, personal care services shall mean all of the following:

(A) Assistance with ambulation.

(B) Bathing, oral hygiene and grooming.

(C) Dressing.

(D) Care and assistance with prosthetic devices.

(E) Bowel, bladder, and menstrual care.

(F) Skin care.

(G) Repositioning, range of motion exercises, and transfers.

(H) Feeding and assurance of adequate fluid intake.

(I) Respiration.

(J) Paramedical services.

(K) Assistance with self-administration of medications.

(2) Ancillary services including meal preparation and cleanup, routine laundry, shopping for food and other necessities, and domestic services may also be provided as long as these ancillary services are subordinate to personal care services. Ancillary services may not be provided separately from the basic personal care services.

(e) (1) (A) After consulting with the State Department of Social Services, the department shall adopt emergency regulations to establish the amount, scope, and duration of personal care services available to persons described in subdivision (a) in the fiscal year whenever the department determines that General Fund expenditures for personal care services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, are expected to exceed the General Fund appropriation and the federal appropriation under Title XX of the federal Social Security Act provided for the 1992–93 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1992, as adjusted for caseload growth or as increased in the Budget Act or appropriated by statute. At least 30 days prior to filing these regulations with the Secretary of State, the department shall give notice of the expected content of these regulations to the fiscal committees of both houses of the Legislature.

(B) In establishing the amount, scope, and duration of personal care services, the department shall ensure that General Fund expenditures for personal care services provided for under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, do not exceed the General Fund appropriation and the federal appropriation under Title XX of the federal Social Security Act provided for the 1992–93 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1992, as adjusted for caseload growth or as increased in the Budget Act or appropriated by statute.

(C) For purposes of this subdivision, “caseload growth” means an adjustment factor determined by the department based on (1) growth in the number of persons eligible for benefits under Chapter 3 (commencing with Section 12000) on the basis of their disability, (2) the average increase in the number of hours in the program established pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1988–89 to 1992–93 fiscal years, inclusive, due to the level of impairment, and (3) any increase in program costs that is required by an increase in the mandatory minimum wage.

(2) In establishing the amount, scope, and duration of personal care services pursuant to this subdivision, the department may define and take into account, among other things:

(A) The extent to which the particular personal care services are essential or nonessential.

(B) Standards establishing the medical necessity of the services to be provided.

(C) Utilization controls.

(D) A minimum number of hours of personal care services that must first be assessed as needed as a condition of receiving personal care services pursuant to this section.

The level of personal care services shall be established so as to avoid, to the extent feasible within budgetary constraints, medical out-of-home placements.

(3) To the extent that General Fund expenditures for services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1992–93 fiscal year, adjusted for caseload growth, exceed General Fund expenditures for services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in any fiscal year, the excess of these funds shall be expended for any purpose as directed in the Budget Act or as otherwise statutorily disbursed by the Legislature.

(f) Services pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program. A provider of personal care services shall be qualified to provide the service and shall be a person other than a member of the family. For purposes of this section, a family member means a parent of a minor child or a spouse.

(g) The maximum number of hours available under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3, Section 14132.951, and this section, combined, shall be 283 hours per month.

(h) Personal care services shall not be provided to residents of facilities licensed by the department, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the Community Care Licensing Division of the State Department of Social Services.

(i) Subject to any limitations that may be imposed pursuant to subdivision (e), determination of need and authorization for services shall be performed in accordance with Article 7 (commencing with Section 12300) of Chapter 3.

(j) (1) To the extent permitted by federal law, reimbursement rates for personal care services shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3, plus any increase provided in the annual Budget Act for personal care services rates or included in a county budget pursuant to paragraph (2).

(2) (A) The department shall establish a provider reimbursement rate methodology to determine payment rates for the individual provider mode of service that does all of the following:

(i) Is consistent with the functions and duties of entities created pursuant to Section 12301.6.

(ii) Makes any additional expenditure of state general funds subject to appropriation in the annual Budget Act.

(iii) Permits county-only funds to draw down federal financial participation consistent with federal law.

(B) This ratesetting method shall be in effect in time for any rate increases to be included in the annual Budget Act.

(C) The department may, in establishing the ratesetting method required by subparagraph (A), do both of the following:

(i) Deem the market rate for like work in each county, as determined by the Employment Development Department, to be the cap for increases in payment rates for individual practitioner services.

(ii) Provide for consideration of county input concerning the rate necessary to ensure access to services in that county.

(D) If an increase in individual practitioner rates is included in the annual Budget Act, the state-county sharing ratio shall be as established in Section 12306. If the annual Budget Act does not include an increase in individual practitioner rates, a county may use county-only funds to meet federal financial participation requirements consistent with federal law.

(3) (A) By November 1, 1993, the department shall submit a state plan amendment to the federal Health Care Financing Administration to implement this subdivision. To the extent that any element or requirement of this subdivision is not approved, the department shall submit a request to the federal Health Care Financing Administration for any waivers as would be necessary to implement this subdivision.

(B) The provider reimbursement ratesetting methodology authorized by the amendments to this subdivision in the 1993–94 Regular Session of the Legislature shall not be operative until all necessary federal approvals have been obtained.

(k) (1) The State Department of Social Services shall, by September 1, 1993, notify the following persons that they are eligible to participate in the personal care services program:

(A) Persons eligible for services pursuant to the Pickle Amendment, as adopted October 28, 1976.

(B) Persons eligible for services pursuant to subsection (c) of Section 1383c of Title 42 of the United States Code.

(2) The State Department of Social Services shall, by September 1, 1993, notify persons to whom paragraph (1) applies and who receive advance payment for in-home supportive services that they will qualify for services under this section without a spend down of excess income if they elect to accept payment for services on an arrears rather than an advance payment basis.

(l) An individual who is eligible for services subject to the maximum amount specified in subdivision (b) of Section 12303.4 shall be given the option of hiring their own provider.

(m) The county welfare department shall inform in writing any individual who is potentially eligible for services under this section of their right to the services.

(n) It is the intent of the Legislature that this entire section be an inseparable whole and that no part of it be severable. If any portion of this section is found to be invalid, as determined by a final judgment of a court of competent jurisdiction, this section shall become inoperative.

(o) Paragraphs (2) and (3) of subdivision (a) shall be implemented so as to conform to federal law authorizing their implementation.

(p) (1) Personal care services shall be provided as a covered benefit to a medically needy aged, blind, or disabled person, as defined in subdivision (a) of Section 14051, to the same extent and under the same requirements as they are provided under subdivision (a) of this section to a categorically needy, aged, blind, or disabled person, as defined in subdivision (a) of Section 14050.1, and to the extent that federal financial participation is available.

(2) The department shall seek federal approval of a state plan amendment necessary to include personal care services described in paragraph (1) as a Medicaid service pursuant to subdivision (f) of Section 440.170 of Title 42 of the Code of Federal Regulations.

(3) In the event that the Department of Finance determines that expenditures of both General Fund moneys for personal care services provided under this subdivision to medically needy aged, blind, or disabled persons together with expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for all aged, blind, and disabled persons receiving in-home supportive services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, in the 2000–01 fiscal year or in any subsequent fiscal year, are expected to exceed the General Fund appropriation and the federal appropriation received under Title XX of the federal Social Security Act for expenditures for all aged, blind, and disabled persons receiving in-home supportive services provided in the 1999–2000 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1998, as adjusted for caseload growth or as changed in the Budget Act or by statute or regulation, then this subdivision shall cease to be operative on the first day of the month that begins after the expiration of a period of 30 days subsequent to a notification in writing by the Director of the Department of Finance to the chairperson of the committee in each house that considers appropriations, the chairpersons of the committees and the appropriate subcommittees in each house that consider the State Budget, and the Chairperson of the Joint Legislative Budget Committee.

(4) Solely for purposes of paragraph (3), caseload growth means an adjustment factor determined by the department based on:

(A) Growth in the number of persons eligible for benefits under Chapter 3 (commencing with Section 12000) on the basis of their disability.

(B) The average increase in the number of hours in the program established pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1994–95 to 1998–99 fiscal years, inclusive, due to the level of impairment.

(C) Any increase in program cost that is required by an increase in hourly costs pursuant to the Budget Act or statute.

(5) In the event of a final judicial determination by any court of appellate jurisdiction or a final determination by the Administrator of the federal Centers for Medicare and Medicaid Services that personal care services must be provided to any medically needy person who is not aged, blind, or disabled, then this subdivision shall cease to be operative on the first day of the first month that begins after the expiration of a period of 30 days subsequent to a notification in writing by the Director of Finance to the chairperson of the committee in each house that considers appropriations, the chairpersons of the committees and the appropriate subcommittees in each house that consider the State Budget, and the Chairperson of the Joint Legislative Budget Committee.

(6) If this subdivision ceases to be operative, all aged, blind, and disabled persons who would have been eligible to receive services under this section shall be immediately eligible for services under the IHSS Plus waiver authorized pursuant to Section 14132.951, if otherwise eligible, upon this section becoming inoperative. If this section becomes inoperative and a person is ineligible for the IHSS Plus waiver, then eligibility shall be determined under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 146. (AB 118) Effective July 10, 2023.)

article: 4. The Medi-Cal Benefits Program


text: Medi-Cal personal care services provider rates established as provided in the state plan under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code, by an in-home supportive services public authority established pursuant to paragraph (2) of subdivision (a) and paragraph (4) of subdivision (b) of Section 12301.6 shall be reviewed by the county in which the in-home supportive services public authority operates, to determine that the rates are consistent with the county budget and that the county will be able to fund any increase in its share of costs, prior to the submission of the rates to the department. Certification of the county’s ability to fund any increase in rates shall accompany the submission of rates to the department.

history: (History: Added by Stats. 1995, Ch. 307, Sec. 17. Effective August 3, 1995.)

article: 4. The Medi-Cal Benefits Program


text:
(a) (1) For purposes of this section, “waiver personal care services” means personal care services authorized by the department for persons who are eligible for either nursing or model nursing facility waiver services.

(2) Waiver personal care services shall satisfy all of the following criteria:

(A) The services shall be defined in the nursing and model nursing facility waivers.

(B) The services shall differ in scope from services that may be authorized under Section 14132.95 or 14132.952.

(C) The services shall not replace any hours of services authorized or that may be authorized under Section 14132.95 or 14132.952.

(b) An individual may receive waiver personal care services if all of the following conditions are met:

(1) The individual has been approved by the department to receive services in accordance with a waiver approved under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) for persons who would otherwise require care in a nursing facility.

(2) The individual has doctor’s orders that specify that he or she requires waiver personal care services in order to remain in his or her own home.

(3) The individual chooses, either personally or through a substitute decisionmaker who is recognized under state law for purposes of giving consent for medical treatment, to receive waiver personal care services, as well as medically necessary skilled nursing services, in order to remain in his or her own home.

(4) The waiver personal care services and all other waiver services for the individual do not result in costs that exceed the fiscal limit established under the waiver.

(c) The department shall notify the administrator of the In-Home Supportive Services program in the county of residence of any individual who meets all requirements of subdivision (b) and has been authorized by the department to receive waiver personal care services. The county of residence shall then do the following:

(1) Inform the department of the services that the individual is authorized to receive under Section 14132.95 or 14132.952 at the time he or she becomes eligible for waiver personal care services.

(2) Determine the individual’s eligibility for services under Section 14132.95 or 14132.952 if he or she is not currently authorized to receive those services and if he or she has not been previously determined eligible for those services.

(3) Implement the department’s authorization for waiver personal care services for the individual at the quantity and scope authorized by the department.

(d) (1) Waiver personal care services approved by the department for individuals who meet the requirements of subdivision (b) may be provided in either of the following ways, or a combination of both:

(A) By a licensed and certified home health agency participating in the Medi-Cal program.

(B) By one or more providers of personal care services under Article 7 (commencing with Section 12300) of Chapter 3 and subdivision (d) of Section 14132.95, when the individual elects, in writing, to utilize these service providers.

(2) The department shall approve waiver personal care services for individuals who meet the requirements of subdivision (b) only when the department finds that the individual’s receipt of waiver personal care services is necessary in order to enable the individual to be maintained safely in his or her own home and community.

(3) When waiver personal care services are provided by a licensed and certified home health agency, the home health agency shall receive payment in the manner by which it would receive payment for any other service approved by the department.

(4) (A) When waiver personal care services are provided by one or more providers of personal care services under Article 7 (commencing with Section 12300) of Chapter 3 and subdivision (d) of Section 14132.95, the providers shall receive payment on a schedule and in a manner by which providers of personal care services receive payment. The State Department of Social Services shall commence making payments for waiver personal care services when its payment system has been modified to accommodate those payments. A county is not obligated to administer waiver personal care services until the State Department of Social Services payment system has been modified to accommodate those payments. However, any county or public authority or nonprofit consortium that administers the In-Home Supportive Services and personal care services programs may pay providers for the delivery of waiver personal care services if it chooses to do so. In that case, the county, public authority, or nonprofit consortium shall be reimbursed by the department for the waiver personal care services authorized by the department and provided to an individual upon submittal of documentation as required by the waiver, and in accordance with the requirements of the department.

(B) For purposes of subparagraph (A) and to the extent the department obtains any federal approvals it deems necessary to implement this subparagraph, “payment” includes wages and benefits. Payments provided pursuant to subparagraph (A) shall be available for service dates on or after the effective date specified in the applicable federal approval obtained by the department and only after the Case Management Information and Payroll System (CMIPS) system has been modified to accommodate these payments, or on July 1, 2019, whichever is sooner.

(e) Waiver personal care services shall not be included as alternative resources in a county’s determination of the amount of services an individual may receive under Section 14132.95 or 14132.952.

(f) Any administrative costs to the State Department of Social Services, a county, or a public authority or nonprofit consortium associated with implementing this section shall be considered administrative costs under the waiver and shall be reimbursed by the department.

(g) Two hundred fifty thousand dollars ($250,000) is appropriated from the General Fund to the State Department of Social Services for the 1998–99 fiscal year for the purpose of making changes to the case management, information, and payrolling system that are necessary for the implementation of this section.

(h) This section shall not be implemented until the department has obtained federal approval of any necessary amendments to the existing nursing facility and model nursing facility waivers and the state plan under Title 19 of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.). Any amendments to the existing nursing facility and model nursing facility waivers and the state plan which are deemed to be necessary by the director shall be submitted to the federal Health Care Financing Administration by April 1, 1999.

(i) The department shall implement this section only to the extent that its implementation results in fiscal neutrality, as required under the terms of the waivers.

history: (History: Amended by Stats. 2018, Ch. 35, Sec. 33. (AB 1811) Effective June 27, 2018.)

article: 4. The Medi-Cal Benefits Program


text:
(a) For a beneficiary diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer or for any other qualifying clinical trial, as defined by Section 1396d(gg)(2) of Title 42 of the United States Code, the Medi-Cal program shall provide coverage for all routine patient care costs related to the clinical trial if the beneficiary’s treating physician, who is providing covered health care services to the beneficiary under the Medi-Cal program, recommends participation in the clinical trial after determining that participation in the clinical trial has a meaningful potential to benefit the beneficiary. For purposes of this section, a clinical trial’s endpoints shall not be defined exclusively to test toxicity, but shall have a therapeutic intent.

(b) (1) In accordance with Section 1396d(gg)(1) of Title 42 of the United States Code, “routine patient care costs” means the costs associated with the provision of health care services, including drugs, items, devices, and services that would otherwise be covered under the Medi-Cal program if those drugs, items, devices, and services were not provided in connection with an approved clinical trial program, including:

(A) Health care services typically provided absent a clinical trial.

(B) Health care services required solely for the provision of the investigational drug, item, device, or service.

(C) Health care services required for the clinically appropriate monitoring of the investigational item or service.

(D) Health care services provided for the prevention of complications arising from the provision of the investigational drug, item, device, or service.

(E) Health care services needed for the reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or treatment of the complications.

(2) For purposes of this section, “routine patient care costs” does not include the costs associated with the provision of any of the following:

(A) Drugs or devices that have not been approved by the federal Food and Drug Administration and that are associated with the clinical trial.

(B) Services other than health care services, such as travel, housing, companion expenses, and other nonclinical expenses, that a beneficiary may require as a result of the treatment being provided for purposes of the clinical trial, except as required under the Medicaid Program (42 U.S.C. Sec. 1396a et seq.).

(C) Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient.

(D) Health care items or services that, except for the fact that they are being provided in a clinical trial, are not otherwise covered by the Medi-Cal program.

(E) Health care services customarily provided by the research sponsors free of charge for any beneficiary in the trial.

(c) The treatment shall be provided in a qualifying clinical trial, which means a clinical trial, in any clinical phase of development, that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition and is described in Section 1396d(gg)(2)(A) of Title 42 of the United States Code.

(d) This section does not prohibit the Medi-Cal program from restricting coverage for clinical trials to participating hospitals and physicians in California unless the protocol for the clinical trial is not provided for at a California hospital or by a California physician.

(e) The provision of services when required by this section shall not, in itself, give rise to liability on the part of the Medi-Cal program.

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

(g) The amendments made to this section by the act that added this subdivision shall become effective on July 1, 2022.

history: (History: Amended by Stats. 2022, Ch. 47, Sec. 103. (SB 184) Effective June 30, 2022.)

article: 4. The Medi-Cal Benefits Program


text:
(a) For the purposes of this section, “facility residents” means individuals who are currently residing in a nursing facility and whose care is paid for by Medi-Cal either with or without a long-term care patient liability. The term “facility residents” also includes individuals who are hospitalized and who are or will be waiting for transfer to a nursing facility.

(b) For those patients who are in acute care hospitals and who are pending placement in a nursing facility, the department shall expedite the processing of waiver applications in order to divert hospital discharges from nursing facilities into the community.

(c) The Nursing Facility/Acute Hospital Transition and Diversion Waiver shall include the following services:

(1) One-time community transition services as defined and allowed by the federal Centers for Medicare and Medicaid Services, including, but not limited to, security deposits that are required to obtain a lease on an apartment or home, essential furnishings, and moving expenses required to occupy and use a community domicile, set-up fees, or deposits for utility or service access, including, but not limited to, telephone, electricity, and heating, and health and safety assurances, including, but not limited to, pest eradication, allergen control, or one-time cleaning prior to occupancy. These costs shall not exceed five thousand dollars ($5,000).

(2) Habilitation services, as defined in Section 1915(c)(5) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)(5)), and in attachment 3-d to the July 25, 2003, State Medicaid Directors Letter re Olmstead Update No. 3, to mean services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home- and community-based settings.

(d) (1) (A) Notwithstanding paragraphs (1) and (2) of subdivision (d) of Section 12300.4, the department shall grant an exemption, as described in paragraph (2), to a provider of an applicant or participant of the Nursing Facility/Acute Hospital Transition and Diversion Waiver or the In-Home Operations Waiver, or their successors, who was enrolled in either waiver on January 31, 2016, and whose medical or behavioral needs require that the services to the applicant or participant be provided by the requested provider, if any of the following circumstances exists:

(i) The provider lives in the same home as the waiver applicant or participant, even if the provider is not a family member.

(ii) The provider currently provides care to the waiver participant, and has done so for two or more years continuously.

(iii) The waiver applicant or participant is unable to find a local caregiver who speaks the same language as the applicant or participant, resulting in the applicant or participant being unable to direct their own care.

(B) For a waiver participant who enrolls in either waiver after January 31, 2016, the department shall grant a provider an exemption from the workweek requirements described in paragraphs (1) and (2) of subdivision (d) of Section 12300.4 on a case-by-case basis pursuant to paragraph (5).

(2) A provider of in-home supportive services or waiver personal care services who is granted an exemption pursuant to paragraph (1) may work up to a total of 12 hours per day, and up to 360 hours per month combined for the in-home supportive services and waiver personal care services that they provide, not to exceed each waiver participant’s monthly authorized hours.

(3) On a one-time basis upon implementation of this paragraph, the department shall mail an informational notice and an exemption request form to all providers who may be eligible for an exemption pursuant to this subdivision and to the waiver participants to whom the providers provide services.

(4) At the time of initial application, and at least annually, the department shall inform all waiver applicants or participants whose providers may be eligible for an exemption pursuant to this subdivision and their providers about the exemptions and the application process.

(5) (A) The department shall review the requests for consideration for an exemption described in subparagraph (B) of paragraph (1) pursuant to a process developed by the department with input from stakeholders. The department shall consider whether the waiver applicant or participant meets the criteria described in subparagraph (A) of paragraph (1) in making its determination.

(B) Within 30 days of receiving an application for an exemption described in subparagraph (B) of paragraph (1) from a provider and from a waiver applicant or participant on behalf of a provider, the department shall mail a written notification letter to the provider and the waiver applicant or participant for whom the provider provides services of its approval or denial of the exemption. If the department denies the exemption, the department shall also explain in the notification letter the reason for the denial. The department shall use a standardized notification letter, developed by the department in consultation with stakeholders, for purposes of providing the notification letter that is required by this subparagraph.

(6) The department shall record the number of requests for exemptions that are received and the number of requests approved or denied. These numbers shall be posted no later than every three months on the department’s internet website.

(e) The department shall implement this section only to the extent it can demonstrate fiscal neutrality within the overall department budget, and federal fiscal neutrality as required under the terms of the federal waiver, and only if the department has obtained the necessary approvals and receives federal financial participation from the federal Centers for Medicare and Medicaid Services.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 147. (AB 118) Effective July 10, 2023.)

article: 4. The Medi-Cal Benefits Program