text:
(a) (1) Except as otherwise authorized pursuant to this chapter, the director shall enter into contracts, under this chapter and Chapter 8 (commencing with Section 14200), with managed care plans licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), for the provision of medical benefits to all persons who are eligible to receive medical benefits under publicly supported programs. The director may also amend existing Medi-Cal managed care contracts to include the provision of medical benefits to persons who are eligible to receive medical benefits under publicly supported programs. Contracts may be on an exclusive or nonexclusive basis.

(2) Prior to issuing a new request for proposal or entering into new contracts pursuant to paragraph (1), the director shall provide an opportunity for interested stakeholders to provide input to inform the development of contract provisions.

(b) Contractors pursuant to this article and participating providers acting pursuant to subcontracts with those contractors, shall agree to hold harmless the beneficiaries of the publicly supported programs if the contract between the sponsoring government agency and the contractor does not ensure sufficient funding to cover program benefits.

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

(d) (1) Any managed care contractor serving children with conditions eligible under the CCS program shall report expenditures and savings separately for CCS-covered services and CCS-eligible children.

(2) If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be separate actuarially sound rates for CCS-eligible children.

(3) Notwithstanding paragraph (2), a managed care pilot project may, if approval is obtained from the State CCS program director, utilize an alternative rate structure for CCS-eligible children.

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

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

(g) Any managed care contract that will affect the delivery of care to CCS-eligible children shall be approved by the state CCS program director prior to execution. The state CCS program shall continue to be responsible for selection of CCS-paneled providers and monitoring of contractors to see that CCS state standards are maintained.

history: (History: Amended by Stats. 2023, Ch. 266, Sec. 2. (AB 614) Effective January 1, 2024.)

article: 2.97. Managed Care Plan Contracts


kind: section

code: WIC

text:
(a) When a managed care contractor that is authorized to provide California Children’s Services (CCS) covered services pursuant to subdivision (a) of Section 14094.3 or Article 2.985 (commencing with Section 14094.4) expands a managed care plan’s CCS coverage area to other counties, the contractor shall comply with CCS program standards including, but not limited to, referral of newborns to the appropriate neonatal intensive care level, referral of children requiring pediatric intensive care to CCS-approved pediatric intensive care units, and referral of children with CCS eligible conditions to CCS-approved inpatient facilities and special care centers in accordance with subdivision (c) of Section 14093.05.

(b) The managed care contractor shall comply with CCS program medical eligibility regulations. Questions regarding interpretation of state CCS medical eligibility regulations, or disagreements between the county CCS program and the managed care contractor regarding interpretation of those regulations, shall be resolved by the local CCS program, in consultation with the state CCS program. The resolution determined by the CCS program shall be communicated in writing to the managed care contractor.

(c) In following the treatment plan developed in accordance with CCS program requirements, the managed care contractor shall ensure the timely referral of children with special health care needs to CCS-paneled providers who are board-certified in both pediatrics and in the appropriate pediatric subspecialty.

(d) The managed care contractor shall report expenditures and savings separately for CCS covered services and CCS eligible children, in accordance with paragraph (1) of subdivision (d) of Section 14093.05.

(e) All children who are enrolled with a managed care contractor who are seeking CCS program benefits shall retain all rights to CCS program appeals and fair hearings of denials of medical eligibility or of service authorizations. Information regarding the number, nature, and disposition of appeals and fair hearings shall be part of an annual report to the Legislature on managed care contractor compliance with CCS standards, regulations, and procedures. This report shall be made available to the public.

(f) The department, in consultation with stakeholder groups, shall develop unique pediatric plan performance standards and measurements, including, but not limited to, the health outcomes of children with special health care needs.

history: (History: Amended by Stats. 2016, Ch. 625, Sec. 4. (SB 586) Effective January 1, 2017.)

division: 9. PUBLIC SOCIAL SERVICES

chapter: 7. Basic Health Care

article: 2.97. Managed Care Plan Contracts

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


text:
For purposes of this article the following definitions apply:

(a) “Foster child” means any child who has been taken into custody or placed by a juvenile court pursuant to Article 6 (commencing with Section 300) of Chapter 2 of Part 1 of Division 2 or Section 601 or 602.

(b) “Medi-Cal managed care plan” means any person or entity that has entered into a contract with the director pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.9 (commencing with Section 14088), or Article 2.91 (commencing with Section 14089) of this chapter or pursuant to Article 1 (commencing with Section 14200) of Chapter 8.

(c) “Out-of-county placement” means any foster care placement in which the child has been placed outside of the county with the responsibility for the care and placement of the child.

history: (History: Added by Stats. 1997, Ch. 294, Sec. 65. Effective August 18, 1997.)

article: 2.97. Managed Care Plan Contracts


text: Sections 1371 and 1371.35 of the Health and Safety Code apply to Medi-Cal managed care plan contracts entered into with the State Department of Health Care Services pursuant to this chapter or Chapter 8 (commencing with Section 14200).

history: (History: Added by Stats. 2024, Ch. 763, Sec. 10. (AB 3275) Effective January 1, 2025.)

article: 2.97. Managed Care Plan Contracts


text:
(a) No child in foster care shall be required to enroll in a Medi-Cal managed care plan. A foster child may be voluntarily enrolled in a Medi-Cal managed care plan only when the county child welfare agency with responsibility for the care and placement of the child, in consultation with the child’s foster caregiver, determines that it is in the best interest of the child to do so and the department determines that enrollment is available to the child.

(b) Whenever a foster child is placed in an out-of-county placement, the county child welfare agency with responsibility for the care and placement of the child shall determine, in consultation with the child’s foster caregiver, if the child should remain in, or has enrolled in, a Medi-Cal managed care plan in the county where the child will be placed or in the county with responsibility for the care and placement of the child, as long as the department determines that enrollment is available for the child.

(c) The State Department of Health Services shall establish for Medi-Cal managed care plans urgent disenrollment procedures that provide for disenrollment of foster children in out-of-county placements within two working days of receipt by the department’s enrollment contractor, or the department, if the department has no enrollment contractor, of a request for disenrollment made by the child welfare services agency, the foster caregiver, or other person authorized to make medical decisions on behalf of the foster child.

(d) Medi-Cal managed care plans shall process and pay appropriately documented claims submitted by out-of-plan providers for services provided to foster children in out-of-county placements while they are Medi-Cal members of the plan. This section shall not be construed to prevent a plan from requiring prior authorization for nonemergency services consistent with the plan’s established policies and procedures.

history: (History: Added by Stats. 1997, Ch. 294, Sec. 66. Effective August 18, 1997.)

article: 2.97. Managed Care Plan Contracts


text:
(a) Whenever a foster child enrolled in a county organized health system, established pursuant to Article 2.8 (commencing with Section 14087.5), is placed in an out-of-county placement, the county child welfare agency or probation department with responsibility for the care and placement of the child shall determine, in consultation with the child’s foster caregiver, whether the child should remain enrolled in that county organized health system. The determination shall be made no later than one working day after the out-of-county placement begins.

(b) If it is determined, pursuant to subdivision (a) or at any later date, that a foster child should be disenrolled from a county organized health system due to an out-of-county placement, the county child welfare agency or probation department with responsibility for the care and placement of the child shall request that the child be disenrolled from the county organized health system. The request shall be made to the entity designated by the State Department of Health Care Services to receive requests for disenrollment or to the department, if the department has no designee, no later than one working day after either of the following occurs:

(1) The out-of-county placement begins.

(2) It is determined that a child who initially remained enrolled in the county organized health system following the out-of-county placement, pursuant to subdivision (a), should subsequently be disenrolled.

(c) The State Department of Health Care Services shall, in consultation with other agencies and organizations interested in health care access for foster children, establish for county organized health systems urgent disenrollment procedures that provide for disenrollment of foster children in out-of-county placements within two working days of receipt by the department’s designee or by the department, if the department has no designee, of a request for disenrollment made by the county child welfare services agency, the county probation department, the foster caregiver, or any other person authorized to make medical decisions on behalf of the foster child.

(d) The department shall issue all-county letters or similar instructions to implement subdivision (c) no later than January 1, 2009, and thereafter shall adopt any necessary implementing regulations.

history: (History: Added by Stats. 2007, Ch. 467, Sec. 2. Effective January 1, 2008.)

article: 2.97. Managed Care Plan Contracts


text: For purposes of this article “CCS” means California Children’s Services.

history: (History: Added by Stats. 1994, Ch. 917, Sec. 2. Effective September 28, 1994.)

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.98. California Children’s Services Program and Medi-Cal Managed Care Contracts


text:
(a) The director shall investigate and to the extent feasible require any managed care contractor serving children with conditions eligible under the CCS program, to maintain and follow standards of care established by the program, including use of paneled providers and CCS approved special care centers and to follow treatment plans approved by the program, including specified services and providers of services. If there are insufficient paneled providers willing to enter into contracts with the managed care contractor, the program shall seek to establish new paneled providers willing to contract. If a paneled provider cannot be found, the managed care contractor shall seek program approval to use a specific nonpaneled provider with appropriate qualifications.

(b) The director shall investigate and to the extent feasible require any managed care contractor serving children with conditions eligible under the CCS program, to report expenditures and savings separately for CCS covered services and CCS eligible children.

(c) (1) If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be a separate actuarially sound rate for CCS eligible children.

(2) Notwithstanding paragraph (1), a managed care pilot project may, if approval is obtained from the state CCS program director, utilize an alternative rate structure for CCS eligible children.

article: 2.98. California Children’s Services Program and Medi-Cal Managed Care Contracts


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

(b) (1) In Whole Child Model counties authorized pursuant to Article 2.985 (commencing with Section 14094.4), in order to ensure that CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the department for both services covered and not covered by the managed care contract.

(2) In counties not listed in Section 14094.5, in order to ensure that CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the department and local CCS program agencies for both services covered and not covered by the managed care contract.

history: (History: Amended by Stats. 2016, Ch. 625, Sec. 5. (SB 586) Effective January 1, 2017.)


text:
(a) Notwithstanding this article or Section 14093.05 or 14094.1, CCS covered services shall not be incorporated into any Medi-Cal managed care contract entered into after August 1, 1994, pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.9 (commencing with Section 14088), Article 2.91 (commencing with Section 14089), Article 2.95 (commencing with Section 14092); or either Article 1 (commencing with Section 14200), or Article 7 (commencing with Section 14490) of Chapter 8, until January 1, 2022, and until the evaluation required pursuant to Section 14094.18 has been completed, except for contracts entered into pursuant to the Whole Child Model program, as described in Article 2.985 (commencing with Section 14094.4), or for county organized health systems or Regional Health Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa.

(b) Notwithstanding any other provision of this chapter, providers serving children under the CCS program who are enrolled with a Medi-Cal managed care contractor but who are not enrolled in a pilot project pursuant to subdivision (c) shall continue to submit billing for CCS covered services on a fee-for-service basis until CCS covered services are incorporated into the Medi-Cal managed care contracts described in subdivision (a).

(c) (1) The department may authorize a pilot project in Solano County in which reimbursement for conditions eligible under the CCS program may be reimbursed on a capitated basis pursuant to Section 14093.05, and provided all CCS program’s guidelines, standards, and regulations are adhered to, and the CCS program’s case management is utilized.

(2) During the time period described in subdivision (a), the department may approve, implement, and evaluate limited pilot projects under the CCS program to test alternative managed care models tailored to the special health care needs of children under the CCS program. The pilot projects may include, but need not be limited to, coverage of different geographic areas, focusing on certain subpopulations, and the employment of different payment and incentive models. Pilot project proposals from CCS program-approved providers shall be given preference. All pilot projects shall utilize CCS program-approved standards and providers pursuant to Section 14094.1.

(d) For purposes of this section, CCS covered services include all program benefits administered by the program specified in Section 123840 of the Health and Safety Code regardless of the funding source.

(e) This section shall not be construed to exclude or restrict CCS-eligible children from enrollment with a managed care contractor, or from receiving from the managed care contractor with which they are enrolled primary and other health care unrelated to the treatment of the CCS-eligible condition.

history: (History: Amended by Stats. 2016, Ch. 625, Sec. 6. (SB 586) Effective January 1, 2017.)


text:
For the purposes of this article, the following definitions shall apply:

(a) “CCS provider” means any of the following:

(1) A medical provider that is paneled by the CCS program to treat a CCS-eligible condition pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.

(2) A licensed acute care hospital approved by the CCS program to treat a CCS-eligible condition.

(3) A special care center approved by the CCS program to treat a CCS-eligible condition.

(b) “County organized health system” or “COHS” means:

(1) A county organized health system contracting with the department to provide Medi-Cal services to beneficiaries pursuant to Article 2.8 (commencing with Section 14087.5).

(2) A regional health authority.

(c) “Medi-Cal managed care plan” means a COHS, or, commencing no sooner than January 1, 2024, an alternate health care service plan contracted with the department pursuant to Section 14197.11 in any county described in Section 14094.5.

history: (History: Amended by Stats. 2022, Ch. 73, Sec. 1. (AB 2724) Effective January 1, 2023.)

article: 2.985. Whole Child Model Program

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.985. Whole Child Model Program


text:
(a) No sooner than July 1, 2017, the department may establish a Whole Child Model program for Medi-Cal eligible CCS children and youth enrolled in a managed care plan served by a county organized health system or Regional Health Authority, or commencing no sooner than January 1, 2024, an alternate health care service plan contracted with the department pursuant to Section 14197.11, in the following counties: Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Trinity, and Yolo.

(b) No sooner than January 1, 2025, the department may establish a Whole Child Model program for Medi-Cal eligible CCS children and youth enrolled in a managed care plan served by a county organized health system or Regional Health Authority in the following counties: Butte, Colusa, Glenn, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Yuba, Mariposa, and San Benito.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 128. (AB 118) Effective July 10, 2023.)

article: 2.985. Whole Child Model Program


text:
The goals for the Whole Child Model program for children and youth under 21 years of age who meet the eligibility requirements of Section 123805 of the Health and Safety Code and are enrolled in a managed care plan under a county organized health system or Regional Health Authority, or an alternate health care service plan contracted with the department pursuant to Section 14197.11, shall include all of the following:

(a) Improving the coordination of primary and preventive services with specialty care services, medical therapy units, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term services and supports (LTSS), regional center services, and home- and community-based services using a child and youth and family-centered approach.

(b) Maintaining or exceeding CCS program standards and specialty care access, including access to appropriate subspecialties.

(c) Providing for the continuity of child and youth access to expert, CCS dedicated case management and care coordination, provider referrals, and service authorizations.

(d) Improving the transition of youth from CCS to adult Medi-Cal managed systems of care through better coordination of medical and nonmedical services and supports and improved access to appropriate adult providers for youth who age out of CCS.

(e) Identifying, tracking, and evaluating the transition of children and youth from CCS to the Whole Child Model program to inform future CCS program improvements.

history: (History: Amended by Stats. 2022, Ch. 73, Sec. 3. (AB 2724) Effective January 1, 2023.)

article: 2.985. Whole Child Model Program


text:
(a) No sooner than July 1, 2017, the department may implement the Whole Child Model program established under this section, pursuant to the criteria described in this article. The director shall provide notice to the Legislature, the federal Centers for Medicare and Medicaid Services, counties, CCS providers, and CCS families when each managed care plan, including a transition plan with the county CCS program, has been reviewed and certified as ready to enroll children based on the criteria described in this article.

(b) The department shall do all of the following:

(1) Develop specific CCS program monitoring and oversight standards for managed care plans that are subject to this article, including access monitoring, quality measures, and ongoing public data reporting. No later than January 1, 2025, the department shall, at minimum, do all of the following:

(A) Annually provide an analysis on its internet website regarding trends on CCS enrollment for Whole Child Model counties and non-Whole Child Model counties, in a way that enables a comparison of trends between the two categories of CCS counties.

(B) Develop utilization and quality measures, to be reported on an annual basis in a form and manner specified by the department, that relate specifically to CCS specialty care and report such measures for both Whole Child Model counties and non-Whole Child Model counties. When developing measures, the department shall consider both of the following:

(i) Recommendations of the CCS Redesign Performance Measure Quality Subcommittee established by the department as part of the CCS Advisory Group pursuant to subdivision (c) of Section 14097.17.

(ii) Available data regarding the percentage of children with CCS eligible conditions who receive an annual special care center visit.

(C) Require, as part of its monitoring and oversight responsibilities, any Whole Child Model plan, as applicable, that is subject to one or more findings in its most recent annual medical audit pertaining to access or quality of care in the CCS program to implement quality improvement strategies that are specifically targeted to the CCS population, as determined by the department.

(2) Establish a stakeholder process pursuant to Section 14094.17.

(3) Consult with the statewide stakeholder advisory group established pursuant to Section 14094.17 to develop and implement robust monitoring processes to ensure that managed care plans are in compliance with all of the provisions of this section. The department shall monitor managed care plan compliance with the provisions of this section on at least an annual basis and post CCS-specific monitoring dashboards on its internet website on at least an annual basis.

(c) (1) In order to aid the transition of CCS services into Medi-Cal managed care plans participating in the Whole Child Model program, commencing January 1, 2017, and continuing through the completion of the transition of CCS enrollees into the Whole Child Model program, the department shall begin requesting and collecting from Medi-Cal managed care plans information about each health plan’s provider network, including, but not limited to, the contracting primary care, specialty care providers, and hospital facilities contracting with the Medi-Cal managed care plan.

(2) The department shall analyze the existing Medi-Cal managed care delivery system network and the CCS fee-for-service provider networks to determine the overlap of the provider networks in each county and shall furnish this information to the Medi-Cal managed care plan.

(d) A managed care plan shall not be approved to participate in the Whole Child Model program unless all of the following conditions have been satisfied:

(1) The managed care plan has obtained written approval from the director.

(2) The department has obtained any necessary federal approvals.

(3) The Medi-Cal managed care plan has established a local stakeholder process with the meaningful engagement of a diverse group of families that represent a range of conditions, disabilities, and demographics, and local providers, including, but not limited to, the parent centers, such as family resource centers, family empowerment centers, and parent training and information centers, that support families in the affected county.

(4) The director has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, but not limited to, the requirements set forth in subdivision (b) of Section 14087.48, subdivisions (b) to (f), inclusive, of Section 14093.05, and all of the following:

(A) That the managed care contractor has demonstrated the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions, including primary care physicians, pediatric specialists and subspecialists, professional, allied, and medical supportive personnel, licensed acute care hospitals, and special care centers.

(B) That the Medi-Cal managed care plan has established and maintains an updated and accessible listing of providers and their specialties and subspecialties and makes it available to CCS-eligible children and youth and their parents or guardians, at a minimum by telephone, written material, and internet website.

(C) That the Medi-Cal managed care plan has entered into an agreement with the county CCS program or the state, or both, for the transition of CCS care coordination and service authorization and how the plan will work with the CCS program to ensure continuity and consistency of CCS program expertise for that role, in accordance with this section.

(e) A Medi-Cal managed care plan, prior to implementation of the Whole Child Model program, shall review historical CCS fee-for-service utilization data for CCS-eligible children and youth upon transition of CCS services to managed care plans so that the managed care plans are better able to assist CCS-eligible children and youth and prioritize assessment and care planning.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 129. (AB 118) Effective July 10, 2023.)

article: 2.985. Whole Child Model Program


text:
(a) The department shall develop a memorandum of understanding template, which shall be utilized by participating counties and health plans, and which shall include, but not be limited to, the standards relating to the local administration of, and minimum services to be provided by, counties and Medi-Cal managed care plans in the administration of the Whole Child Model program. The department shall consult with counties and Medi-Cal managed care plans in the development of the Whole Child Model program memorandum of understanding template.

(b) The department shall provide written notice to the county agency, as designated in Section 123850 of the Health and Safety Code, of the calculation for determining the administrative allocation to the county CCS program by means of county information notice. The department shall consult with the Whole Child Model program counties in determining the calculation for determining the administrative allocation.

history: (History: Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 2017.)

article: 2.985. Whole Child Model Program


text:
(a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall establish an assessment process that, at a minimum, does all of the following:

(1) Assesses each CCS child’s or youth’s risk level and needs by performing a risk assessment process using means such as telephonic or in-person communication, review of utilization and claims processing data, or by other means as determined by the department.

(2) Assesses, in accordance with the transition agreement with the county CCS program, the health care needs of CCS-eligible children and youth and coordinates their CCS specialty services, Medi-Cal primary care services and mild to moderate mental health services, specialty mental health as appropriate through the county specialty mental health plan, and Drug Medi-Cal services as appropriate through county substance use disorder program, and regional center services across all settings, including coordination of necessary services within and, when necessary, outside of the managed care plan’s provider network.

(3) Follows timeframes for reassessment of risk and, if necessary, circumstances or conditions that require redetermination of risk level, which shall be set by the department.

(b) The risk assessment process shall be performed in accordance with all applicable federal and state laws.

article: 2.985. Whole Child Model Program


text:
A Medi-Cal managed care plan participating in the Whole Child Model program shall meet all of the following requirements:

(a) Ensure that each CCS-eligible child or youth receives case management, care coordination, provider referral, and service authorization services from an employee or contractor of the plan who has knowledge of, and receives adequate training on, the CCS program, and who has clinical experience with the CCS population, or clinical experience with pediatric patients with complex medical conditions. In addition, the plan shall ensure that a CCS-eligible child has a primary point of contact who shall be responsible for the child’s care coordination.

(b) Work with the state or county CCS program, as appropriate, to ensure that, at a minimum, and in addition to other statutory and contractual requirements, care coordination and care management activities do all of the following:

(1) Reflect a CCS child or youth family-centered, outcome-based approach to care planning.

(2) Ensure families have access to ongoing information, education, and support so that they understand the care plan for their child or youth and their role in the individual care process, the benefits of mental health services, what self-determination means, and what services might be available.

(3) Adhere to the CCS child’s or youth’s or the CCS child’s or youth’s family’s determination about the appropriate involvement of their medical providers and caregivers, according to the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).

(4) Include individual care plans for CCS-eligible children and youth based on the results of the risk assessment process with a particular focus on CCS specialty care.

(5) Consider behavioral health needs of CCS-eligible children and youth and coordinate those services as part of the CCS child’s or youth’s individual care plan, when appropriate, and facilitate a CCS child’s or youth’s ability to access appropriate community resources and other agencies, including referrals, as necessary and appropriate, for behavioral services, such as specialty mental health services and substance use disorder services.

(6) Ensure that children and youth and their families have appropriate access to transportation and other support services necessary to receive treatment.

(c) Incorporate all of the following into the CCS child’s or youth’s plan of care:

(1) Access for families so that families know where to go for ongoing information, education, and support in order that they understand the goals, treatment plan, and course of care for their child or youth and their role in the process, what it means to have primary or specialty care for their child or youth, when it is time to call a specialist, primary, urgent care, or emergency room, what an interdisciplinary team is, and what the community resources are.

(2) A primary or specialty care physician who is the primary clinician for the CCS-eligible child or youth and who provides core clinical management functions.

(3) Care management and care coordination for the CCS-eligible child or youth across the health care system, including transitions among levels of care and interdisciplinary care teams.

(4) Provision of information about qualified professionals, community resources, or other agencies for services or items outside the scope of responsibility of the managed care plan.

(d) Use clinical data to identify CCS-eligible children or youth at the care site with chronic illness or other significant health issues.

(e) Arrange for timely preventive, acute, and chronic illness treatment of CCS-eligible children or youth in the appropriate setting.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 130. (AB 118) Effective July 10, 2023.)

article: 2.985. Whole Child Model Program


text:
A Medi-Cal managed care plan serving children and youth with CCS-eligible conditions under the CCS program shall do all of the following:

(a) Coordinate with each regional center operating within the plan’s service area to assist CCS-eligible children and youth with developmental disabilities and their families in understanding and accessing services and act as a central point of contact for questions related to health care access and care concerns, and problem resolution.

(b) Coordinate with the local CCS Medical Therapy Unit (MTU) to ensure appropriate access to MTU services. The Medi-Cal managed care plan shall enter into a memorandum of understanding or similar agreement with the county regarding coordination of MTU services and other non-MTU services provided by the plan.

(c) Ensure that families have access to ongoing information, education, and support so they understand the care plan, course of treatment, and expected outcomes for their child or youth, the assessment process, what it means, their role in the process, and what services their child or youth may be eligible for.

(d) Facilitate communication among a CCS child’s or youth’s health care and personal care providers, including in-home supportive services and behavioral health providers, when appropriate, with the CCS-eligible child or youth, parent, or guardian.

(e) Facilitate timely access to primary care, specialty care, pharmacy, and other health services provided by CCS providers and facilities with clinical expertise in treating the enrollee’s specific CCS condition that are needed by the CCS child or youth, including referrals to address any physical or cognitive disabilities.

(f) Provide information for families about managed care processes and how to navigate a health plan, including their rights to appeal any service denials, and how to request continuity of care for pharmacy, specialized durable medical equipment, and health care providers pursuant to Section 14094.13.

(g) Establish a mechanism to provide information on how to access local family resource centers or family empowerment centers.

(h) Provide that communication to, and services for, the CCS-eligible children or youth and their families are available in alternative formats that are culturally, linguistically, and physically appropriate through means, including, but not limited to, assistive listening systems, sign language interpreters, captioning, written communication, plain language, and written translations in the applicable Medi-Cal threshold languages.

(i) Provide that materials are available and provided to inform CCS children and youth and their families of procedures for obtaining CCS specialty services and Medi-Cal primary care and mental health benefits, including grievance and appeals procedures that are offered by the managed care plan or are available through the Medi-Cal program.

(j) Identify and track children and youth with CCS-eligible conditions for the duration of the child’s or youth’s participation in the Whole Child Model program and for children and youth who age into adult Medi-Cal systems and who continue to be enrolled in the same Medi-Cal managed care plan for at least three years into adulthood, to the extent feasible.

(k) (1) Comply with Medi-Cal due process requirements and provide timely processes for accepting and acting upon complaints and grievances, including procedures for appealing decisions regarding coverage or benefits. The grievance process shall comply with Section 14450 of this code, and Sections 1368 and 1368.01 of the Health and Safety Code and applicable federal law and regulations.

(2) Upon denial, denial of reauthorization, or termination of services, a notice of action shall be sent to the CCS-eligible child or youth, or person legally authorized to act on behalf of the child or youth. The notice of action shall include information about the option to file a Medi-Cal appeal and Medi-Cal due process rights.

(l) Comply with Section 1383.15 of the Health and Safety Code by allowing a child or youth or the parent or guardian of a child or youth to receive a second opinion from an appropriately qualified health care professional.

(m) Support the established referral pathways in the non-Whole Child Model counties, including, but not limited to, identifying children who may be eligible for the CCS program through internal reports, provider directed referrals, or direct referrals from the Medi-Cal managed care plan.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 131. (AB 118) Effective July 10, 2023.)

article: 2.985. Whole Child Model Program


text:
(a) Each Medi-Cal managed care plan shall establish and maintain a process by which a CCS-eligible child or youth may maintain access to CCS providers that the child or youth has an existing relationship with for treatment of the child’s or youth’s CCS condition for up to 12 months, under the following conditions:

(1) The CCS-eligible child or youth has seen the out-of-network CCS provider for a nonemergency visit at least once during the 12 months immediately preceding the date the Medi-Cal managed care plan assumed responsibility for the child’s or youth’s CCS care under the Whole Child Model program.

(2) The CCS provider accepts the health plan’s rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher, unless the CCS provider enters into an agreement on an alternative payment methodology mutually agreed to by the CCS provider and the Medi-Cal managed care plan.

(3) The managed care plan confirms that the provider meets applicable CCS standards and has no disqualifying quality of care issues.

(4) The CCS provider provides treatment information to the Medi-Cal managed care plan, to the extent authorized by the state and federal patient privacy provisions.

(b) Each Medi-Cal managed care plan shall establish and maintain a process by which a CCS-eligible child or youth may maintain access to specialized or customized durable medical equipment providers for up to 12 months under the conditions in paragraph (2):

(1) For the purposes of this subdivision, “specialized or customized durable medical equipment” means durable medical equipment that meets all of the following criteria:

(A) Is uniquely constructed from raw materials or substantially modified from the base material solely for the full-time use of the specific beneficiary according to a physician’s description and orders.

(B) Is made to order or adapted to meet the specific needs of the beneficiary.

(C) Is uniquely constructed, adapted, or modified to permanently preclude the use of the equipment by another individual, and is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes.

(2) (A) The CCS-eligible child or youth has an ongoing relationship with a durable medical equipment provider who has previously provided specialized or customized equipment, such as power wheelchairs, repairs, and replacement parts; prosthetic limbs; customized orthotic devices; and individualized assistive technology. This does not include generally available or noncustomized durable medical equipment.

(B) The durable medical equipment provider shall accept the health plan’s rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher, unless the durable medical equipment provider enters into an agreement on an alternative payment methodology mutually agreed upon by the durable medical equipment provider and the Medi-Cal managed care plan.

(C) The durable medical equipment provider provides information to the Medi-Cal managed care plan as requested by the plan, to the extent authorized by state and federal patient privacy provisions.

(3) The department may extend the continuity of care duration period described in this subdivision for specialized or customized durable medical equipment that is under warranty as specified by the department.

(c) A managed care plan, at its discretion, may extend the continuity of care period beyond the length of time specified in subdivisions (a) and (b).

(d) (1) Each Medi-Cal managed care plan participating in the Whole Child Model program shall comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code and Section 14185 of this code.

(2) Each Medi-Cal managed care plan shall permit a CCS-eligible child or youth transitioned into the Whole Child Model program to continue use of any currently prescribed prescription drug that is part of a prescribed therapy for the enrollee’s CCS-eligible condition or conditions immediately prior to the date of enrollment, whether or not the prescription drug is covered by the plan, until the Medi-Cal managed care plan and the child’s or youth’s prescribing CCS provider has completed an assessment of the child or youth, created a treatment plan, and agrees with the Medi-Cal managed care plan that the particular prescription drug is no longer medically necessary, or the prescription drug is no longer prescribed by the enrollee’s CCS provider.

(e) Each Medi-Cal managed care plan participating in the Whole Child Model program shall ensure that children and youth are provided expert case management, care coordination, service authorization, and provider referral services. Each plan shall meet this requirement by, at the request of the child, youth, or his or her parent or guardian, allowing the child or youth to continue to receive case management and care coordination from his or her public health nurse. This election shall be made within 90 days of the transition of CCS services into the Medi-Cal managed care plan. A plan shall meet this requirement by either or both of the following:

(1) By entering into a memorandum of understanding with the county for case management and care coordination services to the child.

(2) By entering into a memorandum of understanding with the county for case management, care coordination, provider referral, and service authorization to all or some Whole Child Model program participants.

(f) At least 60 days before the transition of CCS services to the Medi-Cal managed care plan, a written notice shall be provided to all CCS children and youth whose CCS care will become the responsibility of the plan explaining their right to continue receiving case management and care coordination services pursuant to subdivision (e), including a written explanation of the process for that election. A reminder notification shall be sent 30 days prior to the start of the transition.

(g) In the event the county public health nurse leaves the CCS program or is no longer available to provide the services requested under this section, the Medi-Cal managed care plan shall transition the care coordination and case management of a child or youth to an employee or contractor of the plan who has received adequate training on the CCS program and who has clinical experience with the CCS population or pediatric patients with complex medical conditions.

(h) The department may waive the requirement of subdivision (e) if the Medi-Cal managed care plan demonstrates that it cannot meet the requirement because it would result in substantially increased program costs compared to the existing CCS program allocation as provided by the department through the annual Budget Act. The department shall confirm the information provided by the Medi-Cal managed care plan and meet with the county, affected labor organizations, and the plan in an attempt to reach a mutually agreeable contracting arrangement that fulfills the requirements of this section while also ensuring that the arrangement is not in excess of the current county program allocation.

(i) (1) A family or caregiver of a child or youth may appeal the continuity of care limitation in subdivision (a) to the director or his or her designee. When determining whether or not to grant the appeal, the director or his or her designee shall consider all of the following:

(A) Whether the noncontracting CCS provider has any relevant clinical experience or unique expertise that available contracting CCS providers do not have.

(B) If the noncontracting CCS provider is a special care center, whether or not any of the available contracting CCS providers is a special care center of the same type.

(C) The length of the ongoing relationship between the CCS provider and the child or youth.

(D) The proximity of the noncontracting CCS provider to the child’s or youth’s home as compared to the proximity of the contracting CCS provider being put forth by the plan.

(2) The opinion of the director or his or her designee shall be final and binding upon the plan.

(j) This section shall not preclude the right of the CCS child or youth to appeal or be eligible for a fair hearing regarding the extension of a continuity of care period.

(k) Each Medi-Cal managed care plan participating in the Whole Child Model program shall notify the CCS child or youth, in writing, 60 days prior to the end of his or her authorized continuity of care period. The notice shall explain the right to petition the plan for an extension of the continuity of care period, the criteria the plan will use to evaluate the petition, and the appeals process if the plan denies the petition.

article: 2.985. Whole Child Model Program


text:
(a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall provide a mechanism for a CCS-eligible child’s and youth’s parent or caregiver to request a specialist or clinic as a primary care provider.

(b) A CCS specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of CCS-eligible conditions of the CCS child or youth.

article: 2.985. Whole Child Model Program


text:
A Medi-Cal managed care plan shall meet all of the following requirements:

(a) Use all current and applicable CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices in developing criteria for use by the plan’s chief medical officer or the equivalent and other care management staff.

(b) In cases in which applicable CCS clinical guidelines do not exist, use evidence-based guidelines or treatment protocols that are medically appropriate given the child’s CCS-eligible condition.

(c) Utilize only CCS providers to treat CCS conditions in any circumstance in which the child’s CCS-eligible condition requires treatment from the provider types in paragraph (1), (2), or (3) of subdivision (a) of Section 14094.4, except a plan may use an out-of-state provider if an in-state CCS provider does not possess the clinical expertise to appropriately treat the CCS condition of the child or youth.

(d) Utilize a provider dispute resolution process that meets the standards established under Section 1371.38 of the Health and Safety Code.

article: 2.985. Whole Child Model Program


text:
(a) The department shall pay any managed care plan participating in the Whole Child Model program a separate, actuarially sound rate specifically for CCS children and youth, to the extent that an actuarially sound rate can be developed for the managed care plan’s CCS population. When contracting with managed care plans, the department may allow the use of risk corridors or other methods to appropriately mitigate a plan’s risk for this population. If services are already established in the rate of a Medi-Cal managed care plan prior to January 1, 2016, the department shall not be required to create a separate rate for the Whole Child Model program.

(b) Medi-Cal managed care plans shall pay physician and surgeon provider services at rates that are equal to or exceed the applicable CCS fee-for-service rates, unless the physician and surgeon enters into an agreement on an alternative payment methodology mutually agreed to by the physician and surgeon and the Medi-Cal managed care plan

article: 2.985. Whole Child Model Program


text:
(a) A Medi-Cal managed care plan participating in the Whole Child Model program shall create and maintain a clinical advisory committee, composed of the managed care contractor’s chief medical officer or the equivalent, the county CCS medical director, and at least four CCS-paneled providers, to advise on clinical issues relating to CCS conditions, including treatment authorization guidelines, and serve as clinical advisers on other clinical issues relating to CCS conditions.

(b) (1) A Medi-Cal managed care plan participating in the Whole Child Model program shall establish a family advisory group for CCS families.

(2) Family representatives who serve on this advisory group may receive a reasonable per diem payment to enable in-person participation in the advisory group. A plan may conduct family advisory group meetings by teleconference or through other similar electronic means to facilitate family participation in this advisory group.

(3) A representative of this local group shall be invited to serve on the department’s statewide stakeholder advisory group established pursuant to subdivision (c).

(c) (1) The department shall establish a statewide Whole Child Model program stakeholder advisory group, or modify an existing Whole Child Model program stakeholder advisory group, composed of representatives of CCS providers, county CCS program administrators, health plans, family resource centers, regional centers, recognized exclusive representatives of CCS county providers, CCS case managers, CCS medical therapy units, and representatives from family advisory groups established pursuant to subdivision (b). Participation on the statewide stakeholder advisory group shall be voluntary, and members shall be ineligible for travel or other per diem payments.

(2) The department shall consult with the stakeholder advisory group on the implementation of the Whole Child Model program and shall consider the recommendations of the stakeholder advisory group in developing the monitoring processes and outcome measures by which the plans participating in the Whole Child Model program shall be monitored and evaluated.

(3) The statewide Whole Child Model program stakeholder advisory group, as established under this section, shall terminate on December 31, 2026.

history: (History: Amended by Stats. 2023, Ch. 42, Sec. 132. (AB 118) Effective July 10, 2023.)

article: 2.985. Whole Child Model Program


text:
(a) (1) The department shall contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess Medi-Cal managed care plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the Whole Child Model program, including access to primary and specialty care, and youth transitions from Whole Child Model program to adult Medi-Cal coverage.

(2) The department shall provide a report on the results of this evaluation required pursuant to this section to the Legislature by January 1, 2021, or three years from the date when all counties described in Section 14094.5 are fully operational under the Whole Child Model program pursuant to this article, whichever is later. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code.

(b) The evaluation required by this section, at a minimum, shall evaluate the performance of the plans participating in the Whole Child Model program as compared to the performance of the CCS program prior to the implementation of the Whole Child Model program in those same counties. The evaluation shall evaluate whether the inclusion of CCS services in a managed care delivery system improves access to care, quality of care, and the patient experience by analyzing all of the following, and when possible, disaggregating the results, based on the child’s or youth’s race, ethnicity, and primary language spoken at home:

(1) Access to specialty and primary care, and in particular, utilization of CCS-paneled providers.

(2) The type and location of CCS services and the extent to which CCS services are provided in-network compared to out of network.

(3) Utilization rates of inpatient admissions, outpatient services, durable medical equipment, behavioral health services, home health, pharmacy, and other ancillary services.

(4) Patient and family satisfaction.

(5) Appeals and grievances, including the number of petitions to the plan to extend the continuity of care period for durable medical equipment and CCS providers, the results of those appeals, whether any subsequent appeals were made to the department, and the results of those appeals to the department.

(6) Authorization of CCS-eligible services.

(7) Network and provider participation, including participation of pediatricians, pediatric specialists, and pediatric subspecialists, by specialty and subspecialty.

(8) The ability of a child or youth who ages out of CCS and remains in the same Medi-Cal managed care plan to retain his or her existing providers, to the extent possible or known.

(c) The evaluation required by this section shall also evaluate managed care plans participating in the Whole Child Model program as compared to the CCS program in counties where CCS services are not incorporated into managed care, and collect appropriate data to evaluate all of the following:

(1) The rate of new CCS enrollment in each county.

(2) The percentage of CCS-eligible children and youth with a diagnosis requiring a referral to a CCS special care center who have been seen by a CCS special care center.

(3) The percentage of CCS children and youth discharged from a hospital who had at least one followup contact or visit within 28 days after discharge.

(4) Appeals and grievances.

(d) The department shall consult with stakeholders, including, but not limited to, the Whole Child Model program stakeholder advisory group, regarding the scope and structure of the review.

history: (History: Amended by Stats. 2017, Ch. 511, Sec. 23. (AB 1688) Effective January 1, 2018.)

article: 2.985. Whole Child Model Program


text: This article is not intended, and shall not be interpreted, to permit any reduction in benefits or eligibility levels under the CCS program.

article: 2.985. Whole Child Model Program


text:
(a) 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 regulatory action, shall implement, interpret, or make specific this article, Article 2.97 (commencing with Section 14093), Article 2.98 (commencing with Section 14094), and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, CCS numbered letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By January 1, 2023, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2018, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.

(b) The director may enter into exclusive or nonexclusive contracts on a bid, nonbid, or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this article. 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, and shall be exempt from the review and approval of any division of the Department of General Services.

history: (History: Amended by Stats. 2021, Ch. 181, Sec. 2. (AB 1585) Effective January 1, 2022.)

article: 2.985. Whole Child Model Program


text: This article shall not be construed to exclude or restrict the specialty of neonatology from reimbursement under the California Children’s Services (CCS) program, subject to the program’s existing or applicable prior authorization requirements or utilization review. Neonatology shall be included in the CCS program.

article: 2.985. Whole Child Model Program


text:
(a) For any entity or program that seeks to contract with the department to provide, or arrange for the provision of, managed health care services, disease management, or other health services contracted for on a basis other than fee-for-service, the department may consider, but shall not be limited to considering, all of the following:

(1) Whether the applicant is of reputable and responsible character. The department may consider any available information that the applicant has demonstrated a pattern and practice of violations of state or federal laws and regulations.

(2) Whether the applicant has the ability to provide, or arrange for the provision of, health care benefits or services. The department may consider evidence that may include all of the following:

(A) Any prior history of providing, or arranging for the provision of, health care services or benefits in this state, the applicant’s history of substantial compliance with the requirements imposed under that license, and applicable federal laws, regulations, and requirements.

(B) Any prior history in this state or any other state, of providing, or arranging for the provision of, health care services or benefits authorized to receive Medicare Program reimbursement or Medicaid Program reimbursement, the applicant’s history of substantial compliance with that state’s requirements, and applicable federal laws, regulations, and requirements.

(C) Any prior history of providing, or arranging for the provision of, health services as a licensed health professional or an individual or entity contracting with a health care service plan or insurer, and the applicant’s history of substantial compliance with state requirements, and applicable federal law, regulations, and requirements.

(b) The department may also require the entity described in subdivision (a) to furnish other information or documents for the proper administration and enforcement of the licensing laws.

(c) For purposes of paragraph (1) of subdivision (a), “applicant” shall include the applicant’s management company, any affiliate of the applicant, and any controlling person, officer, director, or other person occupying a principal management or supervisory position for the applicant, its management company, or an affiliate of the applicant.

(d) Nothing in this section shall be construed to restrict or limit the department in any way from considering any other factor required by law, or determined by the department to be necessary for consideration, prior to entering into a contract for the provision of managed health care services.

history: (History: Added by Stats. 2006, Ch. 758, Sec. 5. Effective January 1, 2007.)

article: 2.99. Provider Contract Considerations

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 2.99. Provider Contract Considerations


text: The administration of this chapter shall be carried out by the same agents as are authorized by the several boards of supervisors to administer the public assistance programs.

history: (History: Repealed and added by Stats. 1965, 2nd Ex. Sess., Ch. 4.)

article: 3. Administration

path: 9. PUBLIC SOCIAL SERVICES > 7. Basic Health Care > 3. Administration


text: For purposes of administering this chapter and Chapter 8 (commencing with Section 14200) of this part, the director shall have those powers and duties necessary to conform to requirements for securing approval of a state plan under the provisions of the applicable federal law, and the department shall be the single state agency for purposes of Title XIX of the federal Social Security Act.

history: (History: Amended by Stats. 1978, Ch. 429.)

article: 3. Administration


text:
(a) Except as provided in subdivision (i), all types of information, whether written or oral, concerning a person, made or kept by any public officer or agency in connection with the administration of any provision of this chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520) and for which a grant-in-aid is received by this state from the United States government pursuant to Title XIX of the Social Security Act shall be confidential, and shall not be open to examination other than for purposes directly connected with the administration of the Medi-Cal program. However, in the context of a petition for the appointment of a conservator for a person with respect to whom this information is made or kept, and in the context of a criminal prosecution for a violation of Section 368 of Penal Code with respect to such a person, all of the following shall apply:

A public officer or employee of any such agency may answer truthfully, at any proceeding related to the petition or prosecution, when asked if he or she is aware of information that he or she believes is related to the legal mental capacity of that aid recipient or the need for a conservatorship for that aid recipient. If the officer or employee states that he or she is aware of this information, the court may order the officer or employee to testify about his or her observations and to disclose any relevant agency records if the court has an other independent reason to believe that the officer or employee has information that would facilitate the resolution of the matter.

(b) Except as provided in this section, and to the extent permitted by federal law or regulation, all information about applicants and recipients as provided for in subdivision (a) to be safeguarded includes, but is not limited to, names and addresses, medical services provided, social and economic conditions or circumstances, agency evaluation of personal information, and medical data, including diagnosis and past history of disease or disability.

(c) Purposes directly connected with the administration of the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520) encompass those administrative activities and responsibilities in which the department and its agents are required to engage to insure effective program operations. These activities include, but are not limited to: establishing eligibility and methods of reimbursement; determining the amount of medical assistance; providing services for recipients; conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the Medi-Cal program; and conducting or assisting a legislative investigation or audit related to the administration of the Medi-Cal program.

(d) Any officer, agent, or employee of the department or of any public agency shall provide the Joint Legislative Audit Committee and the State Auditor with any and all the information described in subdivision (b) within a reasonable period of time as determined by the committee in consultation with the department, after receipt of a request from the committee approved by a majority of the members of the committee. The Joint Legislative Audit Committee and the State Auditor may use that information only for the purpose of investigating or auditing the administration of the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520), and shall not use that information for commercial or political purposes. In any case where disclosure of information is authorized by this section, the Joint Legislative Audit Committee or the State Auditor shall not disclose the identity of any applicant or recipient, except in the case of a criminal or civil proceeding conducted in connection with the administration of the Medi-Cal program.

(e) The access to information provided in subdivision (d) shall be permitted only to the extent and under the conditions provided by federal law and regulations governing the release of such information.

(f) The department may make rules and regulations governing the custody, use, and preservation of all records, papers, files, and communications pertaining to the administration of the laws relating to the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520). The rules and regulations shall be binding on all departments, officials, and employees of the state, or of any political subdivision of the state and may provide for giving information to or exchanging information with agencies, public, or political subdivisions of the state, and may provide for giving information to or exchanging information with agencies, public or private, which are engaged in planning, providing, or securing such services for or in behalf of recipients or applicants; and for making case records available for research purposes, provided that that research will not result in the disclosure of the identity of applicants for or recipients of those services.

(g) Upon request, the department shall release to the negotiator established pursuant to Article 2.6 (commencing with Section 14081) all computer tapes and any modifications thereto, including paid claims, connected with the administration of the Medi-Cal program which are in the possession or under the control of the department, including tapes prepared prior to the effective date of this section.

To ensure compliance with federal law and regulations, the department shall make the minimum necessary modifications to its computer tapes prior to releasing the tapes to the negotiator in order to assure the confidentiality of the identity of all applicants for, or recipients of, those services. The department shall not make any modifications to paid claims tapes that affect information regarding beneficiaries’ aid categories or counties of origin.

(h) Any person who knowingly releases or possesses confidential information concerning persons who have applied for or who have been granted any form of Medi-Cal benefits or benefits under Chapter 8 (commencing with Section 14200) or Chapter 8.7 (commencing with Section 14520) for which state or federal funds are made available in violation of this section is guilty of a misdemeanor.

(i) (1) To the extent federal funds are made available from the United States Department of Agriculture, the department may do both of the following:

(A) To the extent permitted by federal law, exercise its option under Section 1396a(a)(7)(B) of Title 42 of the United States Code, in coordination with the State Department of Education, to exchange the information necessary to perform direct verification of the eligibility of children for free or reduced price meals.

(B) To the extent permitted by federal law, in coordination with the State Department of Education, exchange the information necessary to perform direct certification for enrolling children to receive free or reduced price meals.

(2) To the extent permitted by state and federal law, the department and the State Department of Education may review the data only for the purposes of improving the effectiveness of the data matches made pursuant to Sections 49561 and 49562 of the Education Code.

history: (History: Amended by Stats. 2008, Ch. 673, Sec. 4. Effective January 1, 2009.)

article: 3. Administration


text:
(a) The State Department of Health Care Services shall post on its Internet Web site all submitted state plan amendments and all federal waiver applications and requests for new waivers, waiver amendments, and waiver renewals and extensions, within 10 business days from the date the department submits these documents for approval to the federal Centers for Medicare and Medicaid Services (CMS).

(b) The department shall post on its Internet Web site final approval or denial letters and accompanying documents for all submitted state plan amendments and federal waiver applications and requests within 10 business days from the date the department receives notification of final approval or denial from CMS.

(c) If the department notifies CMS of the withdrawal of a submitted state plan amendment or federal waiver application or request, as described in subdivisions (a) and (b), the department shall post on its Internet Web site the withdrawal notification within 10 business days from the date the department notifies CMS of the withdrawal.

(d) Unless already posted on the Internet Web site pursuant to subdivisions (a) to (c), inclusive, the department shall post on its Internet Web site all pending submitted state plan amendments and federal waiver applications and requests, that the department submitted to CMS in 2009 and every year thereafter.

history: (History: Added by Stats. 2013, Ch. 23, Sec. 56. (AB 82) Effective June 27, 2013.)

article: 3. Administration


text:
(a) The department shall prepare and submit Medi-Cal program assumptions and estimates to the Department of Finance. The purpose of the assumptions and estimates shall be to clearly identify changes within the Medi-Cal program which have policy or fiscal implications, and to produce reliable forecasts of Medi-Cal expenditures.

(b) (1) Beginning with the estimates for the 2024–25 fiscal year, Medi-Cal program assumptions and estimates shall be organized by and correspond to Budget Act or Budget Bill item numbers, separately identifying expenditures for all of the following:

(A) Purchase of medical care and services.

(B) County and other local assistance administration.

(C) Rate increases.

(2) Estimates and assumptions shall indicate state and federal, as well as total, funds expended.

(c) The department shall submit, by September 10 and March 1 of each year, to the Department of Finance for its approval, all assumptions underlying all Medi-Cal program estimates. The Department of Finance shall approve or modify, in writing, the assumptions underlying all estimates within 15 working days of their receipt. If the Department of Finance does not so approve or modify the assumptions by that date, the assumptions, as presented by the department, shall be deemed to be approved by the Department of Finance as of that date.

(d) The department shall submit an estimate of Medi-Cal program expenditures to the Department of Finance by November 1 and April 20 of each year. All approved estimates and supporting data provided by the department or developed independently by the Department of Finance, shall be made available to the legislative fiscal committees following approval by the Department of Finance. However, departmental estimates with supporting data shall be forwarded to the legislative fiscal committees on or about January 10 and May 15 of each year in the event this information has not been released earlier.

(e) Each Medi-Cal assumption shall contain a clear narrative description of the statutory, regulatory, or policy change, or other change, that has occurred or will occur which affects Medi-Cal program expenditures or which is of policy importance. Each assumption shall include a cost estimate which contains relevant workload, caseload, unit cost and other data or information needed to support the estimate.

(f) The assumptions related to purchase of medical care and services shall include a section with a nontechnical description of the major variables used to produce a base projection. This section shall further contain an estimate of the fiscal impact of the use of these variables. The estimates related to purchase of medical care and services shall include current and budget year base projections of eligibles, users, expenditures and cost per user by quarter with sufficient past actual data to permit evaluation of the projections. The projections shall be prepared by service category and aid category.

(g) Assumptions or estimates related to Medi-Cal county and other local assistance administration costs shall contain a narrative description of how the forecast was prepared. The estimates shall compare past actual and projected workload and expenditures in a format which will permit evaluation of forecasts. Unallocated funds and funds for special projects or special problems shall be separately identified.

(h) The estimates shall compare budgeted to implemented rate increases for the current year. The comparisons shall be by provider category and shall compare budgeted to implemented increases in terms of percentage increases, date of implementation, and revised estimated cost.

(i) This section shall become operative on July 1, 2023.

history: (History: Repealed (in Sec. 133) and added by Stats. 2023, Ch. 42, Sec. 134. (AB 118) Effective July 10, 2023. Operative July 1, 2023, by its own provisions.)

article: 3. Administration


text: The department, in cooperation with the Controller, shall establish a method of providing to the Controller, periodically, updated information regarding changes in the roster of Medi-Cal providers.

history: (History: Added by Stats. 1991, Ch. 560, Sec. 1.)

article: 3. Administration


text:
(a) Any Medi-Cal provider of incontinence supplies or medical supplies, or both, shall provide, to the department, a bond, or other security satisfactory to the department, of not less than twenty-five thousand dollars ($25,000), pursuant to regulations adopted by the department.

(b) (1) After three years of continuous operation as a provider of incontinence supplies or medical supplies, or both, a Medi-Cal provider may apply to the department for an exemption from the requirements of subdivision (a).

(2) The department shall adopt regulations establishing conditions for the approval or denial of applications for exemption pursuant to paragraph (1).

(c) For purposes of this section, “incontinence supplies” and “medical supplies” mean items prescribed by a licensed practitioner to meet medical needs of the patient, and which are eligible for reimbursement pursuant to this chapter.

(d) Subdivisions (a), (b), and (c) do not apply to individuals who are licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.

history: (History: Amended by Stats. 1998, Ch. 310, Sec. 81. Effective August 19, 1998.)

article: 3. Administration


text:
(a) For purposes of this section, “provider of home health agency services” means a home health agency that is licensed by the department under Section 1726 of the Health and Safety Code that meets the requirements for the medicaid program under Subpart A (commencing with Sec. 441.10) of Part 441 of Title 42 of the Code of Federal Regulations, as amended, that meets the requirements for the Medicare program under Part 484 (commencing with Sec. 481.1) and Part 489 (commencing with Sec. 489.1) of Title 42 of the Code of Federal Regulations, as amended, and that is enrolled as a provider in the Medi-Cal program. In the event of inconsistent requirements between the medicaid and Medicare programs, medicaid requirements shall take precedence.

(b) Within 90 days after the effective date of a final federal regulation requiring that a provider of home health agency services must acquire a surety bond in order to participate in the medicaid or Medicare program, each provider of home health agency services shall obtain, and thereafter maintain, a surety bond meeting the requirements of the final federal regulation, as amended, as a condition of participation in the Medi-Cal program.

(c) Any entity that has applied to become a provider of home health agency services less than 90 days prior to the date that the final federal regulation described in subdivision (b) becomes effective shall submit a surety bond within 90 days of the effective date of the regulation.

(d) Failure of a provider of home health agency services to obtain and maintain a surety bond as required in this section shall result in denial or recoupment of Medi-Cal reimbursement for services provided during the period for which a surety bond should have been in effect.

(e) Failure of a provider of home health agency services to obtain and maintain a surety bond as required in this section shall result in automatic termination of the provider’s participation in the Medi-Cal program.

history: (History: Added by Stats. 1998, Ch. 310, Sec. 82. Effective August 19, 1998.)

article: 3. Administration


text:
(a) For purposes of this section, “provider of durable medical equipment” means any person or entity that furnishes medical equipment and medical supplies, meets state and local laws applicable to the furnishing of medical equipment and medical supplies, and that is enrolled as a provider in the Medi-Cal program.

(b) Within 90 days after the effective date of a final federal regulation requiring that a provider of durable medical equipment must acquire a surety bond in order to participate in the medicaid or Medicare program, each provider of durable medical equipment shall obtain, and thereafter maintain, a surety bond meeting the requirements of the final federal regulation, as amended, as a condition of participation in the Medi-Cal program.

(c) Any person or entity that has applied to become a provider of durable medical equipment less than 90 days prior to the date that the final federal regulation described in subdivision (b) becomes effective shall submit a surety bond within 90 days of the effective date of the regulation.

(d) Failure of a provider of durable medical equipment to obtain and maintain a surety bond as required in this section shall result in denial or recoupment of Medi-Cal reimbursement for services provided during the period for which a surety bond should have been in effect.

(e) Failure of a provider of durable medical equipment to obtain and maintain a surety bond as required in this section shall result in automatic termination of the provider’s participation in the Medi-Cal program.

(f) Subdivisions (a), (b), (c), (d), and (e) do not apply to individuals who are licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.

history: (History: Added by Stats. 1998, Ch. 310, Sec. 83. Effective August 19, 1998.)

article: 3. Administration


text:
(a) Each year, by no later than January 10 and concurrently with the release of the May Revision, the State Department of Health Care Services shall provide to the fiscal committees of the Legislature supplemental fiscal information for the Medi-Cal Specialty Mental Health Services Program. This supplemental fiscal information shall include service-type descriptions, children’s and adults’ caseload and fiscal forecast by service type, a detailed explanation of changes to these forecasts, fiscal charts containing children’s and adults’ claim costs and unduplicated client counts, and summary fiscal charts with current-year and budget-year proposals.

(b) For purposes of making the information described in subdivision (a) available to the public, the department shall post this information on its Internet Web site.

history: (History: Added by Stats. 2013, Ch. 23, Sec. 57. (AB 82) Effective June 27, 2013.)

article: 3. Administration


text:
(a) Each year, by no later than January 10 and concurrently with the release of the May Revision, the State Department of Health Care Services shall provide to the fiscal committees of the Legislature supplemental fiscal information for the Drug Medi-Cal Program. This supplemental fiscal information shall include adult, minor-consent, child, and perinatal unique client counts and summary fiscal charts with current-year and budget-year proposals.

(b) For purposes of making the information described in subdivision (a) available to the public, the department shall post this information on its Internet Web site.

history: (History: Added by Stats. 2013, Ch. 23, Sec. 58. (AB 82) Effective June 27, 2013.)

article: 3. Administration


text:
(a) (1) Each provider and each applicant, as defined in Section 14043.1, when applying for enrollment and continued enrollment, shall provide, to the department, a bond, or other security satisfactory to the department, of an amount determined by the department, pursuant to regulations adopted by the department.

(2) The department, in determining the amount of bond or security required by paragraph (1), shall base the determination on the level of estimated billings, and shall not be less than twenty-five thousand dollars ($25,000).

(3) This subdivision shall become operative only if the director executes a declaration, that shall be retained by the director, stating that the surety bonds described in this paragraph are commercially offered throughout the state and by more than one vendor.

(b) (1) After three years of continuous operation as a provider, a Medi-Cal provider may apply to the department for an exemption from the requirements of subdivision (a).

(2) The department shall adopt regulations establishing conditions for the approval or denial of applications for exemption pursuant to paragraph (1).

(c) The department shall establish a mechanism to track rates of participation among providers who are subject to the requirement of subdivision (a) to determine if the requirement is a deterrent to Medi-Cal program participation among provider applicants.

(d) Subdivisions (a) and (b) shall not apply to natural persons licensed or certified pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, or to any clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code, or exempt from licensure under subdivision (c) of Section 1206 of the Health and Safety Code, to any health facility licensed under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, or to any provider that is operated by a city, county, school district, county office of education, or state special school, or any professional corporation practicing pursuant to the Moscone-Knox Professional Corporation Act provided for pursuant to Part 4 (commencing with Section 13400) of Division 3 of Title 1 of the Corporations Code.

(e) Nothing in this section shall relieve an applicant or provider of durable medical equipment or home health agency services from complying with subdivisions (a) and (b) of Sections 14100.8 and 14100.9, as applicable.

history: (History: Amended by Stats. 2000, Ch. 322, Sec. 26. Effective January 1, 2001.)

article: 3. Administration


text: The director may contract with other state agencies for services in connection with the administration of this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part.

article: 3. Administration


text: The department shall enter into an agreement with the Secretary of Health, Education and Welfare under which such secretary will determine eligibility for Medi-Cal in the case of aged, blind or disabled persons under this state’s medical assistance plan approved under Title XIX of the Social Security Act. The state shall pay the Secretary of Health, Education and Welfare an amount equal to one-half of the cost of carrying out the agreement, but in computing such cost with respect to individuals eligible for benefits under Title XVI of the Social Security Act, such payment shall include only those costs which are additional to the costs incurred in carrying out such title.

history: (History: Added by Stats. 1976, Ch. 504.)

article: 3. Administration


text: The department and the State Department of Social Services shall provide to the other any information necessary for the performance of such department’s duties under this chapter.

history: (History: Amended by Stats. 1977, Ch. 1252.)

article: 3. Administration


text: The Workers’ Compensation Appeals Board and the department shall exchange information and cooperate to assure that health services provided by Medi-Cal which are reimbursable by Workers’ Compensation are identified, and that Workers’ Compensation reimburses the department for those services.

history: (History: Added by Stats. 1981, Ch. 102, Sec. 115. Effective June 28, 1981.)

article: 3. Administration


text:
(a) If any program under the Medi-Cal program that provides full-scope Medi-Cal benefits to an applicable individual is not statutorily specified in Section 5000A of the Internal Revenue Code (26 U.S.C. 5000A), nor designated as minimum essential coverage in federal regulations, such as Section 1.5000A-2 of Title 26 of the Code of Federal Regulations, then the department shall apply to the United States Secretary of Health and Human Services for the program to be recognized as minimum essential coverage. Any recognition of minimum essential coverage obtained by the department pursuant to this subdivision shall apply in accordance with the federal approvals received and shall be effective on the first day of the month following the receipt of federal approval unless an earlier effective date is provided in the applicable federal approval.

(b) If the requirement to maintain minimum essential coverage under Section 5000A of the Internal Revenue Code (26 U.S.C. 5000A) is repealed and no similar provision that would cause Medi-Cal beneficiaries to incur a tax penalty for the failure to maintain minimum essential coverage is implemented, this section shall become inoperative, and shall be repealed the following January 1.

(c) For purposes of this section, “applicable individual” shall have the same meaning as that term is defined in Section 5000A(d) of the Internal Revenue Code (26 U.S.C. 5000A(d)).

history: (History: Repealed and added by Stats. 2017, Ch. 52, Sec. 25. (SB 97) Effective July 10, 2017. Conditionally inoperative, by its own provisions. Repealed on January 1 following inoperative date, by its own provisions.)

article: 3. Administration


text:
(a) The department shall, in collaboration with the Exchange, the counties, consumer advocates, and the Statewide Automated Welfare System consortia, develop and prepare one or more reports that shall be issued on at least a biannual basis and shall be made publicly available within 90 days following the end of each reporting period, for the purpose of informing the California Health and Human Services Agency, the Exchange, the Legislature, and the public about the enrollment process for all insurance affordability programs. The data within the reports shall be aggregated and calculated on at least a quarterly basis. The reports shall comply with federal reporting requirements and shall, at a minimum, include the following information, to be derived from, as appropriate depending on the data element, CalHEERS, MEDS, or the Statewide Automated Welfare System:

(1) For applications received for insurance affordability programs through any venue, all of the following:

(A) The number of applications received through each venue.

(B) The number of applicants included on those applications.

(C) Applicant demographics, including, but not limited to, gender, age, race, ethnicity, and primary language.

(D) The disposition of applications, including all of the following:

(i) The number of eligibility determinations that resulted in an approval for coverage.

(ii) The program or programs for which the individuals in clause (i) were determined eligible.

(iii) The number of applications that were denied for any coverage and the reason or reasons for the denials.

(E) The number of days for eligibility determinations to be completed.

(2) With regard to health plan selection, all of the following:

(A) The health plans that are selected by applicants enrolled in an insurance affordability program, reported by the program.

(B) The number of Medi-Cal enrollees who do not select a health plan but are defaulted into a plan.

(3) For annual redeterminations conducted for beneficiaries, all of the following:

(A) The number of redeterminations processed.

(B) The number of redeterminations that resulted in continued eligibility for the same insurance affordability program.

(C) The number of redeterminations that resulted in a change in eligibility to a different insurance affordability program.

(D) The number of redeterminations that resulted in a finding of ineligibility for any program and the reason or reasons for the findings of ineligibility.

(E) The number of days for redeterminations to be completed.

(4) With regard to disenrollments not related to a redetermination of eligibility, all of the following:

(A) The number of beneficiary disenrollments.

(B) The reasons for the disenrollments.

(C) The number of disenrollments that are caused by an individual disenrolling from one insurance affordability program and enrolling into another.

(5) The number of applications for insurance affordability programs that were filed with the help of an assister or navigator.

(6) The total number of grievances and appeals filed by applicants and enrollees regarding eligibility for insurance affordability programs, the basis for the grievance, and the outcomes of the appeals.

(b) The department shall collect the information necessary for these reports and develop these reports using data obtained from the Statewide Automated Welfare System, CalHEERS, MEDS, and any other appropriate state information management systems.

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

(1) “CalHEERS” means the California Healthcare Eligibility, Enrollment, and Retention System developed under Section 15926.

(2) “Exchange” means the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code.

(3) “Statewide Automated Welfare System” means the system developed pursuant to Section 10823.

(4) “MEDS” means the Medi-Cal Eligibility Data System that is maintained by the department.

history: (History: Amended by Stats. 2017, Ch. 511, Sec. 24. (AB 1688) Effective January 1, 2018.)

article: 3. Administration


text:
(a) The implementation of the optional expansion of Medi-Cal benefits to adults who meet the eligibility requirements of Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), shall be contingent upon the following:

(1) If the federal medical assistance percentage payable to the state under the ACA for the optional expansion of Medi-Cal benefits to adults is reduced below 90 percent, that reduction shall be addressed in a timely manner through the annual state budget or legislative process. Upon receiving notification of any reduction in federal assistance pursuant to this paragraph, the Director of Finance shall immediately notify the Chairpersons of the Senate and Assembly Health Committees and the Chairperson of the Joint Legislative Budget Committee.

(2) If, prior to January 1, 2018, the federal medical assistance percentage payable to the state under the ACA for the optional expansion of Medi-Cal benefits to adults is reduced to 70 percent or less, the implementation of any provision in this chapter authorizing the optional expansion of Medi-Cal benefits to adults shall cease 12 months after the effective date of the federal law or other action reducing the federal medical assistance percentage.

(b) For purposes of this section, “ACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148) as originally enacted and as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments.

history: (History: Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 26. (SB 1 1x) Effective September 30, 2013.)

article: 3. Administration


text:
Whenever the director determines that the services or products of a provider cost the program in excess of reasonable value received, the provider shall thereafter be disqualified from participation in the program. The disqualification shall not become effective until an opportunity for a public hearing has been granted.

The department shall conduct a continuing review of reimbursements to all hospitals participating in the program in order to determine if any reimbursements are in excess of reasonable value received.

history: (History: Amended by Stats. 2001, Ch. 745, Sec. 249. Effective October 12, 2001.)

article: 3. Administration


text: The director, with the advice of the Medicaid Advisory Committee required by federal law or regulation, shall determine which of the health care and related remedial or preventive services are elective. The director and the committee shall consult with representatives of providers of such services before making a determination.

history: (History: Amended by Stats. 1982, Ch. 328, Sec. 22. Effective June 30, 1982.)

article: 3. Administration


text:
(a) A noncontract hospital that is in a closed health facility planning area is not eligible to receive reimbursement for services provided to a Medi-Cal beneficiary, unless either of the following apply:

(1) The noncontract hospital provides necessary emergency services to a Medi-Cal beneficiary who is in a life threatening or emergency situation, but cannot be sufficiently stabilized in order to facilitate transport to a contracting hospital.

(2) The noncontract hospital is a facility location of a nonprofit hospital that is an affiliate of a nonprofit health care service plan, the facility location is approved in accordance with the standards of the California Children’s Services (CCS) program, and the hospital is providing medically necessary services for treatment of the CCS-eligible condition of a patient when all of the following apply:

(A) The patient is eligible for services under the California Children’s Services Act (Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code) as well as the Medi-Cal program.

(B) The patient is a member of the health care services plan for other health care services not related to the CCS condition.

(C) The services for treatment of the CCS-eligible patient are authorized by the CCS program.

(b) A noncontract hospital in a closed health facility planning area that provides necessary emergency services to a Medi-Cal beneficiary who is in a life threatening or emergency situation, but cannot be sufficiently stabilized in order to facilitate transport to a contracting hospital, may only be reimbursed for those necessary emergency services when it obtains an approved treatment authorization request.

(c) Any treatment authorization request submitted for any service classified as a necessary emergency service, which would have been subject to prior authorization had it not been so classified, shall be supported by the attending physician’s statement that does all of the following:

(1) Describes in detail the nature of the emergency or life threatening situation, including relevant clinical information about the patient’s condition.

(2) States why the patient could not be sufficiently stabilized for transport to a contracting hospital and why the necessary emergency services rendered were considered to be immediately required. A mere statement that an emergency existed is not sufficient. The treatment authorization request shall be comprehensive enough to support a finding that an emergency or a life threatening situation existed.

(3) Contains the signature of the attending physician who had direct knowledge of the emergency described in the statement.

(d) For the purposes of this section, “necessary emergency services” are limited to those health services medically necessary for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which, if not immediately diagnosed and treated, could lead to significant disability or death.

(e) For the purposes of this section, a “noncontract hospital” means a hospital that has not contracted with the department pursuant to Article 2.6 (commencing with Section 14081) for the provision of inpatient services to Medi-Cal beneficiaries.

(f) Nothing in this section shall be construed as limiting reimbursement for medically necessary care following stabilization, in the event that a contract hospital does not accept transfer of the patient or pending the transfer to a contract hospital.

history: (History: Amended by Stats. 2007, Ch. 418, Sec. 1. Effective October 10, 2007.)

article: 3. Administration