Welfare and Institutions Code — Part 11 | WIC — United States — California law | Esheria

Welfare and Institutions Code

Part 11 of 35 · provisions 2,001–2,200

This section says the act is to be known as the Welfare and Institutions Code.

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The Department of the Youth Authority may establish, maintain, or help develop regional centers for counties’ alternative placement options. When a California law mentions “Whittier State School,” it must be read as referring to Fred C. Nelles School for Boys. This section defines “Youth Authority,” “authority,” “the authority,” and “board” for this chapter. This provision states the purpose of the division: to provide protection, care, and assistance to people in need, and to promote welfare through prompt, humane aid and services without discrimination. This section states the purposes of public social services funded by state grants-in-aid to counties.

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Provisions of Welfare and Institutions Code

Showing 200 of 6,925

  1. 14132.01.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Certain licensed clinics must bill Medi-Cal and Family PACT for covered drugs and supplies at the lesser of cost or usual charge, with specific reimbursement limits and a notice requirement for non-340B drugs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.01. (a) Notwithstanding any other provision of law, a community clinic or free clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or an intermittent clinic operating pursuant to subdivision (h) of Section 1206 of the Health and Safety Code, that has a valid license pursuant to Article 13 (commencing with Section 4180) of Chapter 9 of Division 2 of the Business and Professions Code shall bill and be reimbursed, as described in this section, for drugs and supplies covered under the Medi-Cal program and Family PACT Waiver Program. (b) (1) A clinic described in subdivision (a) shall bill the Medi-Cal program and Family PACT Waiver Program for drugs and supplies covered under those programs at the lesser of cost or the clinic’s usual charge made to the general public. (2) For purposes of this section, “cost” means an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed twelve dollars ($12) per billing unit as identified in either the Family PACT Policies, Procedures, and Billing Instructions Manual, or the Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient clinic billing for drugs and supplies, as applicable. For purposes of this section, “cost” for a take-home drug that is dispensed for use by the patient within a specific timeframe of five or less days from the date medically indicated means actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed seventeen dollars ($17) per prescription. Reimbursement shall be at the lesser of the amount billed or the Medi-Cal reimbursement rate, and shall not exceed the net cost of these drugs or supplies when provided by retail pharmacies under the Medi-Cal program. (c) A clinic described in subdivision (a) that furnishes services free of charge, or at a nominal charge, as defined in subsection (a) of Section 413.13 of Title 42 of the Code of Federal Regulations, or that can demonstrate to the department, upon request, that it serves primarily low-income patients, and its customary practice is to charge patients on the basis of their ability to pay, shall not be subject to reimbursement reductions based on its usual charge to the general public. (d) Federally qualified health centers and rural health clinics that are clinics as described in subdivision (a) may bill and be reimbursed as described in this section, upon electing to be reimbursed for pharmaceutical goods and services on a fee-for-service basis, as permitted by subdivision (k) of Section 14132.100. (e) A clinic that otherwise meets the qualifications set forth in subdivision (a), that is eligible to, but that has elected not to, utilize drugs purchased under the 340B Discount Drug Program for its Medi-Cal patients, shall provide notification to the Health Resources and Services Administration’s Office of Pharmacy Affairs that it is utilizing non-340B drugs for its Medi-Cal patients in the manner and to the extent required by federal law. (Amended by Stats. 2005, Ch. 503, Sec. 1. Effective January 1, 2006.)
  2. 14132.02.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must seek federal approval, may seek related waivers, and must adopt regulations and provide semiannual status reports; coverage of long-term services and supports is limited to eligible individuals who meet Medi-Cal asset requirements when federal approval is obtained.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.02. (a) The department shall seek approval from the United States Secretary of Health and Human Services to provide individuals made eligible pursuant to Section 14005.60 with the alternative benefit package option authorized by Section 1396u-7(b)(1)(D) of Title 42 of the United States Code. Effective January 1, 2014, the alternative benefit package shall provide the same schedule of benefits provided to full-scope Medi-Cal beneficiaries qualifying under the modified adjusted gross income standard pursuant to Section 1396a(e)(14) of Title 42 of the United States Code, except coverage of long-term services and supports shall be excluded unless otherwise required by Section 1396u-7(a)(2) of Title 42 of the United States Code or made available pursuant to subdivision (b). The alternative benefit package shall also include any benefits otherwise required by Section 1396u-7 of Title 42 of the United States Code and any regulations or guidance issued pursuant to that section. (b) Notwithstanding Section 14005.64, and only to the extent federal approval is obtained, the department shall provide coverage for long-term services and supports to only those individuals who meet the asset requirements imposed under the Medi-Cal program for receipt of the services. (c) For purposes of this section, long-term services and supports include nursing facility services, a level of care in any institution equivalent to nursing facility services, home- and community-based services furnished under the state plan or a waiver under Section 1315 or 1396n of Title 42 of the United States Code, home health services as described in Section 1396d(a)(7) of Title 42 of the United States Code, and personal care services described in Section 1396d(a)(24) of Title 42 of the United States Code. (d) The department may seek approval of any necessary state plan amendments or waivers to implement this section. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time any necessary regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, 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. (f) This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained. (Amended (as added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 28) by Stats. 2013, Ch. 442, Sec. 13. (SB 28) Effective January 1, 2014.)
  3. 14132.025.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal covers emergency services and care, and Medi-Cal managed care plans must cover and reimburse those services for enrolled beneficiaries, subject to a stated exclusion.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.025. (a) Notwithstanding any other law, emergency services and care necessary for the treatment of an emergency medical condition, as defined in subdivision (b) of Section 1317.1 of the Health and Safety Code, are a covered benefit. For purposes of this section, “emergency services and care” has the same meaning as defined in Section 438.114 of Title 42 of the Code of Federal Regulations and paragraph (1) of, and subparagraph (A) of paragraph (2) of, subdivision (a) of Section 1317.1 of the Health and Safety Code. (b) For a beneficiary with a psychiatric emergency medical condition, as defined in subdivision (k) of Section 1317.1 of the Health and Safety Code, emergency services and care necessary to relieve or eliminate that condition are covered, regardless of whether the beneficiary is voluntary, or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (Part 1 (commencing with Section 5000) of Division 5 of the Welfare and Institutions Code). (c) (1) A Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, shall be responsible for covering, and reimbursing providers furnishing, the emergency services and care described in subdivisions (a) and (b), and any poststabilization care services required under Section 438.114 of Title 42 of the Code of Federal Regulations, for its enrolled Medi-Cal beneficiaries, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care. (2) This subdivision does not limit or reduce the scope of covered emergency services and care described in subdivisions (a) and (b) for Medi-Cal fee-for-service beneficiaries. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-plan letters, information notices, plan or provider bulletins, or similar instructions until the department can promulgate any necessary regulations. (e) For purposes of this section, emergency services and care includes emergency room professional services and facility charges for emergency room visits. (f) This section shall be implemented in a manner consistent with federal law and only to the extent federal financial participation is available and not otherwise jeopardized. (g) The Legislature finds and declares that this section is intended to clarify, and not expand, the scope of Medi-Cal covered benefits. (Added by Stats. 2024, Ch. 632, Sec. 6. (AB 1316) Effective January 1, 2025.)
  4. 14132.03.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section lists certain services as covered Medi-Cal benefits and limits some behavioral health treatment services to people receiving them through federally approved waivers or state plan amendments. The department may also seek approval for state plan amendments.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.03. (a) The following shall be covered Medi-Cal benefits effective January 1, 2014: (1) Mental health services included in the essential health benefits package adopted by the state pursuant to Section 1367.005 of the Health and Safety Code and Section 10112.27 of the Insurance Code and approved by the United States Secretary of Health and Human Services under Section 18022 of Title 42 of the United States Code. To the extent behavioral health treatment services are considered mental health services pursuant to the essential health benefits package, these services shall only be provided to individuals who receive services through federally approved waivers or state plan amendments pursuant to the Lanterman Developmental Disability Services Act, at Division 4.5 (commencing with Section 4500). (2) Substance use disorder services included in the essential health benefits package adopted by the state pursuant to Section 1367.005 of the Health and Safety Code and Section 10112.27 of the Insurance Code and approved by the United States Secretary of Health and Human Services under Section 18022 of Title 42 of the United States Code. (b) The department may seek approval of any necessary state plan amendments to implement this section. (c) This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained. (Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 29. (SB 1 1x) Effective September 30, 2013.)
  5. 14132.05.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must give the Legislature’s fiscal and appropriate policy committees a copy of its submission to the federal Health Care Financing Administration about any completed evaluation of the Family PACT federal waiver.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.05. The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of their submittal to the federal Health Care Financing Administration pertaining to any evaluation completed regarding the Family PACT federal waiver required by subdivision (aa) of Section 14132. (Added by Stats. 2000, Ch. 93, Sec. 90. Effective July 7, 2000.)
  6. 14132.06.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section treats certain local educational agency services as covered Medi-Cal benefits, sets billing and enrollment rules, and requires claim-pursuit and accounting steps by the department and local educational agencies.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.06. (a) Services specified in this section that are provided by a local educational agency are covered Medi-Cal benefits, to the extent federal financial participation is available, and subject to utilization controls and standards adopted by the department, and consistent with Medi-Cal requirements for physician prescription, order, and supervision. (b) Any provider enrolled on or after January 1, 1993, to provide services pursuant to this section may bill for those services provided on or after January 1, 1993. (c) This section shall not be interpreted to expand the current category of professional health care practitioners permitted to directly bill the Medi-Cal program. (d) This section is not intended to increase the scope of practice of any health professional providing services under this section or Medi-Cal requirements for physician prescription, order, and supervision. (e) (1) For the purposes of this section, the local educational agency, as a condition of enrollment to provide services under this section, shall be considered the provider of services. A local educational agency provider, as a condition of enrollment to provide services under this section, shall enter into, and maintain, a contract with the department in accordance with guidelines contained in regulations adopted by the director and published in Title 22 of the California Code of Regulations. (2) Notwithstanding paragraph (1), a local educational agency providing services pursuant to this section shall utilize current safety net and traditional health care providers, when those providers are accessible to specific schoolsites identified by the local educational agency to participate in this program, rather than adding duplicate capacity. (f) For the purposes of this section, covered services may include all of the following local educational agency services: (1) Health and mental health evaluations and health and mental health education. (2) Medical transportation. (A) The following provisions shall not apply to medical transportation eligible to be billed under this section: (i) Section 51323(a)(2)(A) of Title 22 of the California Code of Regulations. (ii) Section 51323(a)(3)(B) of Title 22 of the California Code of Regulations. (iii) For students whose medical or physical condition does not require the use of a gurney, Section 51231.1(f) of Title 22 of the California Code of Regulations. (iv) For students whose medical or physical condition does not require the use of a wheelchair, Section 51231.2(e) of Title 22 of the California Code of Regulations. (B) (i) Subparagraph (A) shall become inoperative on January 1, 2018, or on the date the director executes a declaration stating that the regulations implementing subparagraph (A) and Section 14115.8 have been updated, whichever is later. (ii) The department shall post the declaration executed under clause (i) on its Internet Web site and transmit a copy of the declaration to the Assembly Committee on Budget and the Senate Committee on Budget and Fiscal Review and the LEA Ad Hoc Workgroup. (iii) If subparagraph (A) becomes inoperative on January 1, 2018, subparagraph (A) and this subparagraph shall be inoperative on January 1, 2018, unless a later enacted statute enacted before that date, deletes or extends that date. (iv) If subparagraph (A) becomes inoperative on the date the director executes a declaration as described in clause (i), subparagraph (A) and this subparagraph shall be inoperative on the January 1 immediately following the date subparagraph (A) becomes inoperative, unless a later enacted statute enacted before that date, deletes or extends that date. (3) Nursing services. (4) Occupational therapy. (5) Physical therapy. (6) Physician services. (7) Mental health and counseling services. (8) School health aide services. (9) Speech pathology services. These services may be provided by either of the following: (A) A licensed speech pathologist. (B) A credentialed speech-language pathologist, to the extent authorized by Chapter 5.3 (commencing with Section 2530) of Division 2 of the Business and Professions Code. (10) Audiology services. (11) Targeted case management services for children regardless of whether the child has an individualized education plan (IEP) or an individualized family service plan (IFSP). (g) Local educational agencies may, but need not, provide any or all of the services specified in subdivision (f). (h) For the purposes of this section, “local educational agency” means the governing body of any school district or community college district, the county office of education, a charter school, a state special school, a California State University campus, or a University of California campus. (i) Notwithstanding any other law, a community college district, a California State University campus, or a University of California campus, consistent with the requirements of this section, may bill for services provided to any student, regardless of age, who is a Medi-Cal recipient. (j) No later than July 1, 2013, and every year thereafter, the department shall make publicly accessible an annual accounting of all funds collected by the department from federal Medicaid payments allocable to local educational agencies, including, but not limited to, the funds withheld pursuant to subdivision (g) of Section 14115.8. The accounting shall detail amounts withheld from federal Medicaid payments to each participating local educational agency for that year. One-time costs for the development of this accounting shall not exceed two hundred fifty thousand dollars ($250,000). (k) (1) If the requirements in paragraphs (2) and (4) are satisfied, the department shall seek federal financial participation for covered services that are provided by a local educational agency pursuant to subdivision (a) to a child who is an eligible Medi-Cal beneficiary, regardless of either of the following: (A) Whether the child has an IEP or an IFSP. (B) Whether those same services are provided at no charge to the beneficiary or to the community at large. (2) The local educational agency shall take all reasonable measures to ascertain and pursue claims for payment of covered services specified in this section against legally liable third parties pursuant to Section 1902(a)(25) of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(25)). (3) If a legally liable third party receives a claim submitted by a local educational agency pursuant to paragraph (2), the legally liable third party shall either reimburse the claim or issue a notice of denial of noncoverage of services or benefits. If there is no response to a claim submitted to a legally liable third party by a local educational agency within 45 days, the local educational agency may bill the Medi-Cal program pursuant to subdivision (b). The local educational agency shall retain a copy of the claim submitted to the legally liable third party for a period of three years. (4) This subdivision shall not be implemented until the department obtains any necessary federal approvals. (Amended by Stats. 2016, Ch. 86, Sec. 320. (SB 1171) Effective January 1, 2017.)
  7. 14132.07.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    A Medi-Cal managed care plan may not limit a beneficiary’s choice of qualified family-planning provider and must reimburse an out-of-plan or out-of-network qualified provider at the applicable fee-for-service rate.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.07. (a) A Medi-Cal managed care plan shall not restrict the choice of the qualified provider from whom a beneficiary enrolled in the managed care plan may receive family planning services covered by the Medi-Cal program pursuant to subdivision (n) of Section 14132. (b) The following definitions shall apply for purposes of this section: (1) “Medi-Cal managed care plan” means an applicable organization or entity that contracts with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following: (A) Article 2.7 (commencing with Section 14087.3). (B) Article 2.8 (commencing with Section 14087.5). (C) Article 2.81 (commencing with Section 14087.96). (D) Article 2.82 (commencing with Section 14087.98). (E) Article 2.91 (commencing with Section 14089). (F) Chapter 8 (commencing with Section 14200). (2) “Qualified provider” means a provider that is licensed to furnish family planning services, is an enrolled Medi-Cal provider, and is willing to furnish family planning services to an enrollee. A qualified provider may be an out-of-plan or out-of-network provider. (c) A Medi-Cal managed care plan shall reimburse an out-of-plan or out-of-network qualified provider at the applicable fee-for-service rate. (d) If federal approval is required to implement this section, the section shall be implemented only to the extent that federal approval is obtained. (Added by Stats. 2017, Ch. 572, Sec. 3. (SB 743) Effective January 1, 2018.)
  8. 14132.09.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Biomarker testing is a covered Medi-Cal benefit, with limits and exceptions, and the department can issue instructions to implement it.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.09. (a) By July 1, 2024, biomarker testing, as specified in this section, is a covered benefit, subject to utilization controls and medical necessity requirements, as described in Section 14059.5. Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a Medi-Cal beneficiary’s disease or condition to guide treatment decisions. Coverage shall include biomarker tests that meet any of the following: (1) A labeled indication for a test that has been approved or cleared by the United States Food and Drug Administration (FDA) or is an indicated test for an FDA-approved drug. (2) A national coverage determination made by the federal Centers for Medicare and Medicaid Services, to the extent allowed under the Medicaid program. (3) A local coverage determination made by a Medicare Administrative Contractor for California. (4) Evidence-based clinical practice guidelines, supported by peer-reviewed literature and peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff. (5) Standards set by the National Academy of Medicine. (b) (1) This section does not preclude any obligation on a Medi-Cal managed care plan subject to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, including any obligations under Section 1363.5 of the Health and Safety Code. (2) This section does not require coverage of biomarker testing for screening purposes unless otherwise required by this chapter. (3) The department shall direct, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, that biomarker testing is to be provided in a manner that limits disruptions in care. (c) Restricted or denied use of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is subject to grievance and appeal processes under state and federal law. (d) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained. (e) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action. (2) An all-county letter, plan letter, plan or provider bulletin, or similar instructions promulgated pursuant to paragraph (1) shall be based at a minimum on evidence-based clinical practice guidelines. (f) For purposes of this section, the following definitions apply: (1) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. A biomarker includes, but is not limited to, gene mutations or protein expression. (2) “Biomarker testing” is the analysis of an individual’s tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker testing includes, but is not limited to, single-analyte tests, multiplex panel tests, and whole genome sequencing. (g) This section is subject to the provisions of Section 1367.665 of the Health and Safety Code as amended by Chapter 605 of the Statutes of 2021 for a Medi-Cal beneficiary with advanced or metastatic stage III or IV cancer covered by a Medi-Cal managed care plan. (Added by Stats. 2023, Ch. 401, Sec. 3. (SB 496) Effective January 1, 2024.)
  9. 14132.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section defines “surgical center” and says the director must set payment rates for services provided by surgical centers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.1. As used in this chapter “surgical center” means a surgical clinic that is licensed under Section 1203 of the Health and Safety Code. Pursuant to Section 14105, the director shall establish the rates of payment for services provided by surgical centers. (Amended by Stats. 1982, Ch. 328, Sec. 36. Effective June 30, 1982.)
  10. 14132.10.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Pediatric day health care is a covered Medi-Cal benefit, but only under department-set terms and limits, with several cost and authorization restrictions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.10. (a) (1) Pediatric day health care provided by a health facility licensed under paragraph (11) of subdivision (a) of Section 1250.1 of the Health and Safety Code is a covered benefit under this chapter subject to terms, conditions, and utilization controls developed by the department. Pediatric day health care does not include inpatient long-term care or family respite care. (2) Pediatric day health care services may be provided at any time of the day and on any day of the week, so long as the total number of authorized hours is not exceeded. Pediatric day health care services may be covered for up to 23 hours per calendar day. (b) The department shall publish emergency regulations for pediatric day health care services by October 1, 1997. These regulations shall reimburse providers at a rate that shall be determined by the department, consistent with efficiency, economy, and quality of care until a new rate is determined on the basis of a cost study conducted by the department. (c) Coverage for pediatric day health care services shall be available only to the extent that no additional net program costs are incurred. (d) The department shall not approve a request for authorization of pediatric day health care when the beneficiary for whom the authorization is requested is an inpatient in a licensed health care facility. (e) The department shall not approve a request for authorization of pediatric day health care if the department determines that the total cost incurred by the Medi-Cal program for providing pediatric day health care services and all other medically necessary services to the individual beneficiary is greater than the total cost incurred by the Medi-Cal program in providing medically equivalent services at the beneficiary’s otherwise appropriate level of institutional or home care. (f) Coverage for pediatric day health care services shall be available only to the extent that federal financial participation in the cost of providing these services is available pursuant to a federally approved state plan amendment including those services as a Medi-Cal program benefit. (Amended by Stats. 2019, Ch. 64, Sec. 1. (AB 781) Effective January 1, 2020.)
  11. 14132.101.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    A federally qualified health center or rural health clinic must file a scope-of-service change request within 150 days after the start of the relevant fiscal year, and certain federally qualified health centers are treated as timely if they meet Section 14132.102(c).

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.101. (a) Notwithstanding paragraphs (4) and (5) of subdivision (e) of Section 14132.100, a scope-of-service change request, whether mandatory or permissive, shall be timely when filed within 150 days following the beginning of the federally qualified health center’s or rural health clinic’s fiscal year following the year in which the change occurred. (b) Notwithstanding subdivision (a), and notwithstanding subdivision (e) of Section 14132.100, a federally qualified health center described in Section 14132.102 shall be deemed to have filed a scope-of-service change in a timely manner upon compliance with the requirements set forth in subdivision (c) of Section 14132.102. (Added by Stats. 2005, Ch. 548, Sec. 1. Effective January 1, 2006.)
  12. 14132.102.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Certain Los Angeles cost-based FQHCs must move to PPS rates when the waiver ends, and the department must process and finalize scope-of-service rate adjustments and federal approval steps.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.102. (a) With the exception of clinics and hospital outpatient departments that are subject to Section 14105.24, federally qualified health centers (FQHCs) that are receiving cost-based reimbursement under the terms of the Los Angeles County 1115 Waiver Demonstration Project on June 30, 2005, shall be required to transition to a prospective payment system (PPS) rate upon expiration of that waiver. These FQHCs shall be referred to in this section as “Los Angeles cost-based FQHCs.” (b) For visits occurring on or after July 1, 2005, Los Angeles cost-based FQHCs shall receive a PPS rate equivalent to the following: (1) FQHC sites that were in existence during the FQHC’s 2000 fiscal year shall be permitted to elect their 2000 per-visit rates or the average of the 1999 and 2000 per-visit rates as reported on the cost reports submitted for those fiscal years adjusted as described in subdivision (c). (2) FQHC sites that were first qualified as an FQHC after the site’s 2000 fiscal year shall receive a base rate equivalent to the first full fiscal year rate, as audited on the cost report submitted for that fiscal year and adjusted as described in subdivision (c). (3) Sites that were first qualified as an FQHC after the site’s 2000 fiscal year, and that have not yet filed a cost report for their first full fiscal year shall have a rate set in accordance with subdivision (i) of Section 14132.100 and adjusted as described in subdivision (c). (c) The base rates described in this section shall be adjusted in the manner described in subdivision (d), paragraphs (1), (2), (3), and (7) of subdivision (e), and subdivision (f) of Section 14132.100. (d) For Los Angeles cost-based FQHCs, as defined in subdivision (a), no new cost reports shall be required in order to claim scope-of-service changes occurring in fiscal years prior to July 1, 2005. Only the following information shall be required by the department: (1) A description of the events triggering any applicable rate changes in the form of Worksheet 1 of the Change in Scope-of-Service Request form developed for fiscal years 2004 and thereafter, modified to identify the applicable fiscal year in which the scope change occurred. (2) The two worksheets to the Change in Scope-of-Service Request form summarizing the health center’s health care practitioners and services for the applicable fiscal year or years. (e) Change in Scope-of-Service Request forms for changes occurring prior to July 1, 2005, shall be filed with the department no later than July 1, 2006, and shall be deemed to have been filed only when both the Medi-Cal cost report for the applicable period and the referenced Change in Scope-of-Service Request form worksheets have been filed with the department. The date of filing shall be the date on which either the Medi-Cal cost report or the referenced Change in Scope-of-Service Request forms are received by the department, whichever is later. (f) Notwithstanding Section 14132.107, the department shall calculate a tentative scope-of-service rate adjustment based on 80 percent of the difference in the “as reported” scope-of-service per visit cost. This adjustment shall occur no later than 150 days after receipt of the Medi-Cal cost report and the referenced Change in Scope-of-Service Request forms. Within 12 months after receipt of request forms, the department shall complete its FQHC fiscal year audit of the Medi-Cal cost report and associated Change in Scope-of-Service Request and final rate adjustment pursuant to that audit. The final rate adjustment will be retroactive to July 1, 2005. Nothing in this subdivision shall be construed to extend the time period for review and finalization of cost reports as set forth in Section 14170. (g) The department shall, by no later than March 30, 2006, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section. (h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and only to the extent that all necessary federal approvals are obtained and there is an appropriation for the purposes of implementing this section, the department may implement this section without taking any regulatory action and by means of a provider bulletin or similar instructions. (Added by Stats. 2005, Ch. 548, Sec. 2. Effective January 1, 2006.)
  13. 14132.107.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must finalize certain reimbursement claims within 150 days of receipt and pay them within 30 days after finalization. Disputed payments follow Section 14171. Scope changes going forward must be finalized within 90 days of receipt and paid within 30 days after finalization.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.107. Claims for reimbursement under subdivision (e) of Section 14132.100 shall be finalized by the department within 150 days of receipt of the claims for reimbursement. These claims for reimbursement shall be paid within 30 days of being finalized by the department. However, the payment of those amounts that are disputed shall be subject to the requirements, timeframes, and procedures specified in Section 14171. Scope changes going forward shall be finalized within 90 days of receipt and paid within 30 days of being finalized by the department. (Added by Stats. 2004, Ch. 228, Sec. 21. Effective August 16, 2004.)
  14. 14132.108.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    A specified rate-adjustment request will count as timely if it is filed within 90 days after the end of a stated 150-day timeframe.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.108. Notwithstanding any other provision of law, requests for rate adjustments for scope-of-service rate changes under paragraph (4) of subdivision (e) of Section 14132.100 for an FQHC’s or RHC’s fiscal year ending in 2004 shall be deemed to have been filed in a timely manner so long as it is filed within 90 days following the end of the 150-day timeframe applicable to scope-of-service changes occurring from January 1, 2001, to the end of an FQHC’s or RHC’s 2003 fiscal year, as specified in paragraph (6) of subdivision (e) of Section 14132.100. (Added by Stats. 2004, Ch. 228, Sec. 22. Effective August 16, 2004.)
  15. 14132.11.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Starting July 1, 2024, pharmacogenomic testing is a covered Medi-Cal benefit, subject to utilization controls and evidence-based clinical practice guidelines.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.11. (a) Commencing on July 1, 2024, pharmacogenomic testing shall be a covered benefit under the Medi-Cal program, subject to utilization controls and evidence-based clinical practice guidelines. (b) “Pharmacogenomic testing” means laboratory genetic testing that includes, but is not limited to, a panel test, to identify how a person’s genetics may impact the efficacy, toxicity, and safety of medications. (c) This section shall be implemented only to the extent that any necessary federal approvals have been obtained and federal financial participation is available and not otherwise jeopardized. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action. (Added by Stats. 2023, Ch. 329, Sec. 2. (AB 425) Effective January 1, 2024.)
  16. 14132.13.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Certain Medi-Cal services are covered benefits, and the department must set reimbursement rates for them.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.13. (a) Services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program are covered benefits under the Medi-Cal program. (b) The department shall develop rates of reimbursement for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program in consultation with community paramedicine programs, triage to alternate destination programs, and mobile integrated health programs. (c) This section shall be implemented only to the extent that the department obtains any necessary federal waivers or other federal approvals and that federal financial participation is available and not otherwise jeopardized. (d) Implementation of this section shall be subject to an appropriation made by the Legislature for the purpose of this section. (e) For purposes of this section, the following definitions apply: (1) “Community paramedicine program” means a program defined in Section 1815 of the Health and Safety Code. (2) “Mobile integrated health program” means a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the emergency medical services system. (3) “Triage to alternate destination program” means a program defined in Section 1819 of the Health and Safety Code. (Added by Stats. 2024, Ch. 884, Sec. 3. (SB 1180) Effective January 1, 2025.)
  17. 14132.14.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal covers FDA-approved menopause treatments subject to medical necessity, and the department must set up a reimbursement policy for menopause care services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.14. (a) Federal Food and Drug Administration-approved treatments for menopausal symptoms are covered benefits under the Medi-Cal program, subject to medical necessity. These include all of the following: (1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss. (2) Low-dose antidepressants. (3) Anticonvulsants. (4) Medications to prevent or treat osteoporosis. (5) Nonhormonal medications for vasomotor-related symptoms. (b) The department shall establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall consider current clinical care recommendations from the Menopause Society or other nationally recognized professional association, and shall identify billing codes for services commonly used to treat symptoms resulting from menopause. (c) Coverage pursuant to this subdivision shall be provided without discrimination on the basis of gender expression or identity. (d) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action. (f) This section shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized. (Added by Stats. 2026, Ch. 27, Sec. 86. (SB 164) Effective June 29, 2026.)
  18. 14132.15.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section defines “rehabilitation services” for use in Section 14132(p).

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.15. For purposes of subdivision (p) of Section 14132, “rehabilitation services” means services intended to assist physically or cognitively impaired persons to achieve or regain their maximum functional potential for mobility, self-care, and independent living. (Added by Stats. 1985, Ch. 1360, Sec. 2.)
  19. 14132.16.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Mammography for screening or diagnostic purposes must be covered under this chapter when referred by a patient’s physician, starting on or after January 1, 1988, to the extent federal law requires or allows.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.16. Mammography for screening or diagnostic purposes upon the referral of a patient’s physician shall be covered under this chapter on or after January 1, 1988, to the extent required or permitted by federal law. (Added by Stats. 1987, Ch. 550, Sec. 4.)
  20. 14132.17.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Annual cervical cancer tests for screening or diagnostic purposes are a covered Medi-Cal benefit when referred by a patient’s physician, to the extent federal law requires or allows.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.17. Annual cervical cancer tests for screening or diagnostic purposes, upon the referral of a patient’s physician, is a covered benefit under this chapter, on or after January 1, 1991, to the extent required or permitted by federal law. (Added by Stats. 1990, Ch. 1279, Sec. 4.)
  21. 14132.171.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must reimburse Medi-Cal providers for annual cognitive health assessments for eligible older beneficiaries, and it may implement the section through plan letters or similar instructions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.171. (a) (1) An annual cognitive health assessment for Medi-Cal beneficiaries who are 65 years of age or older is a covered benefit if they are otherwise ineligible for a similar assessment as part of an annual wellness visit under the Medicare Program. Subject to paragraph (3), the department shall provide reimbursement to a Medi-Cal provider who renders this service. (2) The payment for the cognitive health assessment developed pursuant to paragraph (1) shall only be available upon appropriation by the Legislature for these purposes. (3) (A) A Medi-Cal provider shall only be eligible to receive the payment for the benefit specified in paragraph (1) if the provider conducts the cognitive health assessment using validated tools, as recommended by the department. (B) (i) The department shall determine the cognitive health assessment validated tools, as described in subparagraph (A), in consultation with the State Department of Public Health’s Alzheimer’s Disease Program (Article 4 (commencing with Section 125275) of Chapter 2 of Part 5 of Division 106 of the Health and Safety Code), that program’s 10 California Alzheimer’s Disease Centers, representatives of primary care physician specialties, including, but not limited to, family medicine, and the Alzheimer’s Disease and Related Disorders Advisory Committee of the California Health and Human Services Agency (Chapter 3.1 (commencing with Section 1568.15) of Division 2 of the Health and Safety Code). (ii) With respect to the validated tools, the department shall select multiple tools. To improve overall accessibility of these tools and minimize access barriers, at least one of those tools shall not carry any restrictions on copyright or trademark. (b) An annual cognitive health assessment shall identify signs of Alzheimer’s disease or dementia, consistent with the standards for detecting cognitive impairment under the federal Centers for Medicare and Medicaid Services and the recommendations by the American Academy of Neurology. (c) By January 1, 2024, the department shall do both of the following: (1) Consolidate and analyze the data on the administration of the cognitive health assessment in the Medi-Cal managed care and fee-for-service delivery systems. (2) Post information on the utilization of, and payment for, this benefit on its internet website. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section, in whole or in part, by means of all-plan letters, provider bulletins, or similar instructions, without taking any further regulatory action. (e) This section shall be implemented only to the extent any necessary federal approvals are obtained and federal financial participation is available. (Amended by Stats. 2025, Ch. 21, Sec. 105. (AB 116) Effective June 30, 2025.)
  22. 14132.18.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section makes community supported living arrangement services a covered Medi-Cal benefit if federal funding is available, and requires the department to apply for approval, seek waivers, and set program standards.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.18. (a) Community supported living arrangement services approved by the United States Department of Health and Human Services in accordance with Section 1396v of Title 42 of the United States Code is a covered benefit under this chapter to the extent that federal financial participation is available for those services and shall be subject to the terms, conditions, and duration of any waiver obtained from the Secretary of the United States Department of Health and Human Services. (b) (1) The department, in consultation with the State Department of Developmental Services, shall submit an application to the secretary for approval to provide community supported living arrangement services and seek any federal waivers necessary to implement this subdivision. (2) State matching funds for the federal medicaid funding shall come out of purchase of services funds of the regional centers, established pursuant to Article 1 (commencing with Section 4620) of Chapter 5 of Division 4.5 and it is the intent of the Legislature that no new funds from the General Fund shall be appropriated for this purpose. (c) The department, in consultation with the State Department of Developmental Services, shall establish and maintain program standards for quality assurance and minimum protection to protect the health, safety, and welfare of individuals receiving community supported living arrangement services and as otherwise necessary to implement this section. (d) In order to facilitate the design and development of community supported living arrangement services; program regulations implementing, interpreting, or making specific the provisions of subdivision (a) shall not be subject to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. This subdivision shall become inoperative on January 1, 1997. (e) If the provision of community supported living arrangements as a covered benefit under this chapter receive federal approval, the department shall collect patient-specific cost data and compare the costs of providing community supported living arrangements under this chapter with the costs experienced prior to the provision of community supported living arrangements as a covered benefit under this chapter. (f) This section shall cease to be operative if the Director of Health Services determines (1) California’s application for federal funds under the community supported living arrangements medicaid state plan option is not accepted; (2) California’s application for renewal of funding for community supported living arrangements is not accepted during the course of the grant; (3) federal funding for community supported living arrangements ceases to be available; or (4) California determines that it no longer chooses to participate in the community supported living arrangements medicaid state plan option. (Added by Stats. 1991, Ch. 735, Sec. 6. Conditionally inoperative by its own provisions.)
  23. 14132.19.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must convene and later identify an advisory working group on childhood trauma screening protocols, and the group must review the protocols periodically.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.19. (a) (1) The department, in consultation with the State Department of Social Services, county mental health experts, managed care plan experts, behavioral health experts, child welfare experts, and stakeholders, shall convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit, consistent with existing law and this section. The advisory working group shall consider both of the following: (A) Existing screening tools used in the Medi-Cal program, including, but not limited to, the Staying Healthy Assessment developed by the department, the United States Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics Bright Futures periodicity schedule and anticipatory guidance. (B) The efficacy and appropriateness of the types of providers authorized to administer screenings. (2) The department shall convene the advisory working group by May 1, 2018. The advisory working group shall report its findings and recommendations, as well as any appropriations necessary to implement those recommendations, to the department and to the Legislature’s budget subcommittees on health and human services no later than May 1, 2019. The advisory working group shall be disbanded on December 31, 2019. (3) Findings or recommendations of the advisory working group that cannot be implemented without a subsequent appropriation by the Legislature, as determined by the department, shall not be implemented until the appropriation is made. (4) On or before May 1, 2019, the department shall identify an existing advisory working group to periodically review and consider the protocols for the screening of trauma in children consistent with subparagraphs (A) and (B) of paragraph (1). The group created pursuant to this section may, as part of its work, recommend to the department an existing group appropriate to conduct this review. The advisory working group identified by department shall review and consider the protocols for the screening of trauma in children at least once every five years, or upon the request of the department. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. (c) This section shall be implemented only if and to the extent that federal financial participation under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.) is not jeopardized and all necessary federal approvals have been obtained. (d) “Trauma,” as used in this section, means the result of an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. (Added by Stats. 2017, Ch. 700, Sec. 1. (AB 340) Effective January 1, 2018.)
  24. 14132.195.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Medi-Cal managed care plans must make sure contracted providers follow the required developmental screening schedule and use approved screening tools correctly.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.195. (a) Consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit pursuant to subdivision (v) of Section 14132 shall include developmental screening services for individuals zero to three years of age, inclusive. (b) Medi-Cal managed care plans shall ensure, and monitor compliance with, both of the following: (1) Developmental screening services provided by providers who contract with Medi-Cal managed care plans comply with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures Guidelines and Recommendations for Preventive Pediatric Health Care, as established by the American Academy of Pediatrics, and by any future updates to this material. (2) Developmental screening tools administered by providers who contract with Medi-Cal managed care plans are administered in their entirety, and in adherence to, the specific tools’ recommended guidelines. (c) This section does not limit or restrict the scope of the EPSDT benefit, as required to be provided to eligible Medi-Cal beneficiaries under 21 years of age pursuant to Section 1396d(r) of Title 42 of the United States Code. (d) This section does not limit or restrict blood lead screenings required under Chapter 5 (commencing with Section 105275) of Part 5 of Division 103 of the Health and Safety Code. (Added by Stats. 2019, Ch. 387, Sec. 2. (AB 1004) Effective January 1, 2020.)
  25. 14132.20.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must establish and seek approval for a Medi-Cal program for continuous skilled nursing care for persons with developmental disabilities, subject to waiver or State Plan requirements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.20. (a) The department shall establish a program to provide continuous skilled nursing care to persons with developmental disabilities as a benefit of the Medi-Cal program, when those services are provided in accordance with an approved federal waiver or Medi-Cal State Plan amendment meeting the requirements of subdivision (b). “Continuous skilled nursing care” means medically necessary care provided by, or under the supervision of, a registered nurse within his or her scope of practice, seven days a week, 24 hours per day, in a facility participating in the program. Continuous skilled nursing care shall include a minimum of eight hours per day provided by or under the direct supervision of a registered nurse. Each facility providing continuous skilled nursing care in the program shall have a minimum of one registered nurse or one licensed vocational nurse awake and in the facility at all times when a consumer is present. (b) The department shall submit to the federal Centers for Medicare and Medicaid Services, a request, developed in consultation with the State Department of Public Health, the State Department of Developmental Services, and the Association of Regional Center Agencies, to provide continuous skilled nursing care services under a federal waiver pursuant to Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) or pursuant to a Medi-Cal State Plan amendment. (c) (1) The program shall provide continuous skilled nursing care to persons with developmental disabilities in the least restrictive home-like setting. (2) Participation in the program shall be restricted to facilities that meet all eligibility requirements. The facilities shall be approved by the department, in consultation with the State Department of Public Health, the State Department of Developmental Services, and the appropriate regional center agencies, and shall meet the requirements of subdivision (f). (d) Under the program established by this section, a person with developmental disabilities shall be eligible to receive continuous skilled nursing care if all of the following conditions are met: (1) The person with developmental disabilities meets the criteria specified in the federal waiver or the Medi-Cal State Plan amendment. (2) The person with developmental disabilities resides in a facility that meets the provider participation criteria as specified in the federal waiver or the Medi-Cal State Plan amendment. (3) The continuous skilled nursing care services are provided in accordance with the federal waiver or the Medi-Cal State Plan amendment. (e) The services provided to persons with developmental disabilities under the program, pursuant to Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)), shall not result in costs that exceed the fiscal limit established in the federal waiver. (f) A facility seeking to participate in the program shall provide care for persons with developmental disabilities who require the availability of continuous skilled nursing care in accordance with the terms of the federal waiver or the Medi-Cal State Plan amendment. During participation in the program, the facility shall comply with all the terms and conditions of the federal waiver or the Medi-Cal State Plan amendment. (g) In implementing this article, the department may enter into contracts for the provision of essential administration and other services. Contracts entered into under this section may be on a noncompetitive bid basis and shall be exempt from the requirements of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (h) This section shall not become operative unless and until the federal Centers for Medicare and Medicaid Services approve a federal waiver pursuant to Section 1915(c) of the Social Security Act (42 U.S.C. Sec. 1396n(c)) or approve a Medi-Cal State Plan amendment to implement the program authorized by this section. If the federal Centers for Medicare and Medicaid Services provide the aforementioned approval, the Director of Health Care Services shall execute a declaration stating that this approval has been granted. The director shall retain the declaration and this section shall become operative on the date that the director executes a declaration pursuant to this subdivision. (Added by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 44. Effective July 28, 2009. Conditionally operative as provided in subd. (h).)
  26. 14132.21.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must assess whether to apply for a Medicaid State Plan amendment to provide targeted case management for certain pregnant women and new mothers affected by substance use.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.21. The department shall assess the feasibility of applying to the federal Health Care Financing Administration for a Medicaid State Plan amendment to provide targeted case management to pregnant substance-abusing women and women who have given birth to a drug-exposed or alcohol-exposed infant. These women may be identified through self-referral, family planning or health clinics, public or private hospitals, drug treatment programs, the Medi-Cal program, or other public assistance or health treatment programs. Women eligible for services under the targeted case management program would be provided the following case management services: (a) Intake and service needs assessment of women currently receiving Medi-Cal benefits. (b) Development of a coordinated health and treatment plan for the eligible woman and her infant, listing needed services. (c) Case management services to assist with gaining access to needed medical, social, educational, and other services. (d) Referral to any of the following programs that are listed in the woman’s health and treatment plan: (1) Child Health and Disability Prevention Program. (2) Supplementary Food Program for Women, Infants, and Children (WIC). (3) Drug abuse treatment and detoxification programs. (4) In-home support services to enhance the woman’s utilization of drug treatment programs, and prenatal and perinatal care services. (5) Transportation to health and drug treatment services. (6) Crisis assistance to address health and drug treatment needs. (7) Other case management services authorized by the federal Health Care Financing Administration. (Amended by Stats. 2013, Ch. 22, Sec. 103. (AB 75) Effective June 27, 2013. Operative July 1, 2013, by Sec. 110 of Ch. 22.)
  27. 14132.22.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section limits the listed dental restorative materials, allows a provider to recommend a different material after consulting the beneficiary, and allows the provider to claim the amalgam reimbursement rate when a different material is used.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.22. (a) For purposes of this section, dental restorative materials are limited to composite resin, glass ionomer cement, resin ionomer cement, and amalgam, as described on the Dental Board of California’s dental materials factsheet. (b) A provider of services that includes the provision of dental restorative materials to a beneficiary under this chapter may recommend, after consultation with the beneficiary, a dental restorative material other than the covered benefit of amalgam. (c) A provider may claim and receive the reimbursement rate for an amalgam restoration when using a different dental restorative material. (Amended by Stats. 2004, Ch. 183, Sec. 386. Effective January 1, 2005.)
  28. 14132.23.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Medi-Cal-covered active and retentive orthodontic treatment is reimbursed quarterly, subject to utilization controls, and the retentive phase stops being covered under paragraph (1) once the department implements the specified dental procedures code.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.23. (a) (1) Except as set forth in paragraph (2), and notwithstanding any other provision of law or regulation, the active and retentive phases of orthodontic treatment covered under the Medi-Cal program shall be reimbursed on a quarterly basis, as determined by dividing the sum of the authorized treatment allowances by the estimated number of three-month periods that the patient’s treatment will require, subject to the department’s utilization controls. (2) The retentive phase of orthodontic treatment shall be reimbursed pursuant to paragraph (1) only until the department implements the Code on Dental Procedures and Nomenclature, as published by the American Dental Association in its Current Dental Terminology manual, at which time paragraph (1) shall not apply to retentive phase orthodontic services that are covered under the Medi-Cal program. (b) This section shall become operative on July 1, 2008. (Added by Stats. 2007, Ch. 494, Sec. 1. Effective January 1, 2008. Section operative July 1, 2008, by its own provisions.)
  29. 14132.25.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must establish and administer a subacute care program, set reimbursement rates, and create eligibility and utilization criteria.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.25. (a) On or before July 1, 1983, the State Department of Health Care Services shall establish a subacute care program in health facilities in order to more effectively use the limited Medi-Cal dollars available while at the same time ensuring needed services for these patients. The subacute care program shall be available to patients in health facilities who meet subacute care criteria. Subacute care may be provided by any facility designated by the director as meeting the subacute care criteria that has an approved provider participation agreement with the department. (b) The department shall develop a rate of reimbursement for this subacute care program. Reimbursement rates shall be determined in accordance with methodology developed by the department, specified in regulation, and may include the following: (1) All-inclusive per diem rates. (2) Individual patient-specific rates according to the needs of the individual subacute care patient. (3) Other rates subject to negotiation with the health facility. (c) Reimbursement at subacute care rates, as specified in subdivision (b), shall only be implemented if funds are available for this purpose pursuant to the annual Budget Act. (d) The department may negotiate and execute an agreement with any health facility that meets the standards for providing subacute care. An agreement may be negotiated or established between the health facility and the department for subacute care based on individual patient assessment. The department shall establish level of care criteria and appropriate utilization controls for patients eligible for the subacute care program. (e) For the purposes of this section, pediatric subacute services are the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. (f) Medical necessity for pediatric subacute care services shall be substantiated in any one of the following ways: (1) A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day. (2) Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen as needed, and dependence on one of the five treatment procedures listed in subparagraphs (B) to (F), inclusive: (A) Dependence on intermittent suctioning at least every eight hours and room air mist and oxygen as needed. (B) Dependence on continuous intravenous therapy, including administration of a therapeutic agent necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of more than one agent, via a peripheral or central line, without continuous infusion. (C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours. (D) Dependence on tube feeding by means of a nasogastric or gastrostomy tube. (E) Dependence on other medical technologies required continuously, which, in the opinion of the attending physician and the Medi-Cal consultant, require the services of a professional nurse. (F) Dependence on biphasic positive airway pressure at least six hours a day, including assessment or intervention every three hours and lacking either cognitive or physical ability of the patient to protect his or her airway. (3) Dependence on total parenteral nutrition or other intravenous nutritional support, and dependence on one of the treatment procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2). (4) Dependence on skilled nursing care in the administration of any three of the six treatment procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2). (5) Dependence on biphasic positive airway pressure or continuous positive airway pressure at least six hours a day, including assessment or intervention every three hours and lacking either cognitive or physical ability of the patient to protect his or her airway and dependence on one of the five treatment procedures specified in subparagraphs (A) to (E), inclusive, of paragraph (2). (g) The medical necessity determination outlined in subdivision (f) is intended solely for the evaluation of a patient who is potentially eligible and meets the criteria to be transferred from an acute care setting to a subacute level of care. (Amended by Stats. 2011, Ch. 294, Sec. 2. (AB 667) Effective January 1, 2012.)
  30. 14132.26.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must create and run a Medi-Cal assisted living waiver program, work with specified partners, evaluate it, limit initial participation, and avoid implementing it if it would add costs to Medi-Cal.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.26. (a) The department shall develop a program that requires a waiver of federal law to test the efficacy of providing an assisted living benefit to beneficiaries under the Medi-Cal program. Assisted living benefits shall include, but are not limited to, the care and supervision activities specified in Section 1569.2 of the Health and Safety Code and Section 87101 of Title 22 of the California Code of Regulations, and other health-related services. The program developed pursuant to this section shall be known as the waiver program for purposes of this section. The department shall submit any necessary waiver applications or modifications to the medicaid state plan to the Health Care Financing Administration to implement the waiver program, and shall implement the waiver program only to the extent federal financial participation is available. (b) The department shall develop the waiver program in conjunction with other state departments, consumers, consumer advocates, housing and service providers, and experts in the fields of gerontology, geriatric health, nursing services, and independent living. (c) The assisted living benefit shall be designed to provide eligible individuals with a range of services that enable them to remain in the least restrictive and most homelike environment while receiving the medical and personal care necessary to protect their health and well-being. Benefits provided pursuant to this waiver program shall include only those not otherwise available under the state plan, and may include, but are not limited to, medicine management, coordination with a primary health care provider, and case management. (d) (1) Eligible individuals shall be those who are eligible for the Medi-Cal program and are determined by the department to be eligible for placement in a nursing facility, as defined under subdivisions (c) and (d) of Section 1250 of the Health and Safety Code. Eligibility shall be based on an assessment of an individual’s ability to perform functional and instrumental activities of daily living, as well as the individual’s medical diagnosis and prognosis, and other criteria, including other Medi-Cal services that the beneficiary is receiving, as specified in the waiver. (2) An eligible individual shall participate in the waiver program only if he or she is fully informed of the program and the nature of the assisted living benefit and indicates in writing his or her choice to participate. (e) (1) The waiver program shall test the effectiveness of providing a Medi-Cal assisted living benefit through two service delivery approaches, as specified in paragraphs (2) and (3). (2) Under the first model, an assisted living benefit shall be provided to residents of licensed residential care facilities. Facility participation in the program shall be determined by the department in conjunction with the State Department of Social Services and in accordance with the criteria for participation specified in the waiver. Under this model the facility operator shall be responsible for the provision of services allowed under the benefit, either directly or through contracts with other provider agencies, as permitted and specified in the waiver. During participation in the waiver program, residential care facilities shall comply with all terms and conditions of the waiver. The department and the State Department of Social Services, may, as determined necessary and appropriate, waive provisions contained in Division 2 (commencing with Section 1200) of the Health and Safety Code, subdivision (h) of Section 14132.95, and Title 22 of the California Code of Regulations for facilities providing services to waiver program participants. (3) Under the second model, an assisted living benefit shall be provided to residents in publicly funded senior and disabled housing projects. Under this model an independent agency, pursuant to a contract with the department, shall be responsible for the provision of case management and other services to eligible individuals, as specified in the waiver. (f) The department shall evaluate the effectiveness of the waiver program. (1) The evaluation shall include, but not be limited to, participant satisfaction, health, and safety, the quality of life of the participant receiving the assisted living benefit, and demonstration of the cost neutrality of the waiver program as specified in federal guidelines. (2) The evaluation shall estimate the projected savings, if any, in the budgets of state and local governments if the program was expanded statewide. (3) The evaluation shall be submitted to the appropriate policy and fiscal committees of the Legislature on or before January 1, 2003. (g) The department shall limit the number of participants in the waiver program during the initial three years of its operation to a number that will be statistically significant for purposes of the program evaluation and that meets any requirements of the federal Health Care Financing Administration, including a request to waive statewide implementation requirements for the waiver program during the initial years of evaluation. (h) In implementing this section, the department may enter into contracts for the provision of essential administrative and other services. Contracts entered into under this section may be on a noncompetitive bid basis, and shall be exempt from the requirements of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (i) The department shall not implement the waiver program specified in subdivision (a) if the benefits provided pursuant to the waiver program will result in additional costs to the Medi-Cal program. (j) The waiver program shall be developed and implemented only to the extent that funds are appropriated or otherwise available for that purpose. (Amended by Stats. 2002, Ch. 1161, Sec. 84. Effective September 30, 2002.)
  31. 14132.27.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must seek federal waiver approval, implement the Disease Management Waiver only if federal financial participation is available, and follow limits on services, eligibility, evaluation, funding, and participant numbers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.27. (a) (1) The department shall apply for a waiver of federal law pursuant to Section 1396n of Title 42 of the United States Code to test the efficacy of providing a disease management benefit to beneficiaries under the Medi-Cal program. A disease management benefit shall include, but not be limited to, the use of evidence-based practice guidelines, supporting adherence to care plans, and providing patient education, monitoring, and healthy lifestyle changes. (2) The waiver developed pursuant to this section shall be known as the Disease Management Waiver. The department shall submit any necessary waiver applications or modifications to the Medicaid State Plan to the federal Centers for Medicare and Medicaid Services to implement the Disease Management Waiver, and shall implement the waiver only to the extent federal financial participation is available. (b) The Disease Management Waiver shall be designed to provide eligible individuals with a range of services that enable them to remain in the least restrictive and most homelike environment while receiving the medical care necessary to protect their health and well-being. Services provided pursuant to this waiver program shall include only those not otherwise available under the state plan, and may include, but are not limited to, medication management, coordination with a primary care provider, use of evidence-based practice guidelines, supporting adherence to a plan of care, patient education, communication and collaboration among providers, and process and outcome measures. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waiver. (c) Eligibility for the Disease Management Waiver shall be limited to those persons who are eligible for the Medi-Cal program as aged, blind, and disabled persons or those persons over 21 years of age who are not enrolled in a Medi-Cal managed care plan, or eligible for the federal Medicare program, and who are determined by the department to be at risk of, or diagnosed with, select chronic diseases, including, but not limited to, advanced atherosclerotic disease syndromes, congestive heart failure, and diabetes. Eligibility shall be based on the individual’s medical diagnosis and prognosis, and other criteria, as specified in the waiver. (d) The Disease Management Waiver shall test the effectiveness of providing a Medi-Cal disease management benefit. The department shall evaluate the effectiveness of the Disease Management Waiver. (1) The evaluation shall include, but not be limited to, participant satisfaction, health and safety, the quality of life of the participant receiving the disease management benefit, and demonstration of the cost neutrality of the Disease Management Waiver as specified in federal guidelines. (2) The evaluation shall estimate the projected savings, if any, in the budgets of state and local governments if the Disease Management Waiver was expanded statewide. (3) The evaluation shall be submitted to the appropriate policy and fiscal committees of the Legislature on or before January 1, 2008. (e) The department shall limit the number of participants in the Disease Management Waiver during the initial three years of its operation to a number that will be statistically significant for purposes of the waiver evaluation and that meets any requirements of the federal government, including a request to waive statewide implementation requirements for the waiver during the initial years of evaluation. (f) In undertaking this Disease Management Waiver, the director may enter into contracts for the purpose of directly providing Disease Management Waiver services. (g) The department shall seek all federal waivers necessary to allow for federal financial participation under this section. (h) The Disease Management Waiver shall be developed and implemented only to the extent that funds are appropriated or otherwise available for that purpose. (i) The department shall not implement this section if any of the following apply: (1) The department’s application for federal funds under the Disease Management Waiver is not accepted. (2) Federal funding for the waiver ceases to be available. (Added by Stats. 2003, Ch. 230, Sec. 71. Effective August 11, 2003.)
  32. 14132.28.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    If the department ends or does not renew a subacute care services provider contract, it must give the health facility 30 days’ notice and then provide transfer guidance. The facility must keep providing subacute services and follow staffing and transfer laws, with payment rules that change depending on compliance and whether the contract has ended.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.28. (a) If the department decides to terminate or not renew a health facility’s subacute care services provider contract, the department shall notify the health facility 30 days before the termination or nonrenewal becomes effective. (b) (1) Once the department has notified the health facility pursuant to subdivision (a), the department shall provide guidance to the health facility regarding expectations for the transfer of patients. The guidance shall consider the need to minimize trauma of a patient due to transfer, and shall ensure, prior to any transfer or discharge, that the facility has complied with the transfer and discharge requirements of Section 1336.2 of the Health and Safety Code, subsection (a) of Section 483.12 of Title 42 of the Code of Federal Regulations, and any other state and federal laws applicable to the transfer and discharge of patients of a nursing facility, as defined in subdivision (k) of Section 1250 of the Health and Safety Code. The department’s Medi-Cal division shall coordinate with the department’s Licensing and Certification Division in developing the guidance for the protection of patients’ transfer rights. (2) Prior to any transfer, the health facility shall continue to provide the subacute level of services required by a patient and shall comply with state laws governing subacute staffing levels. The health facility shall continue to be paid commensurate with that subacute level of service. If the health facility fails to comply with applicable state laws regarding subacute staffing levels, the facility shall be paid at the facility’s Medi-Cal nursing facility rate. (3) Any health facility that has a subacute services provider contract that has been terminated or has not been renewed may not be reimbursed commensurate with the subacute level of service for patients admitted after the contract is terminated or not renewed, unless and until the facility obtains a new subacute services provider contract. The facility may be reimbursed commensurate with the subacute level of service where the patient returns to the facility during the bed-hold period. Where the patient returns to the facility following the bed-hold period, the facility shall be reimbursed at the facility’s Medi-Cal nursing facility rate. (Added by Stats. 2003, Ch. 443, Sec. 1. Effective January 1, 2004.)
  33. 14132.29.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    A health facility with a subacute services provider contract must follow this section’s patient transfer and discharge rules and give patients and their representatives written appeal notice.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.29. (a) A health facility that has a subacute services provider contract with the department under this chapter shall comply with the patient transfer and discharge requirements of this section. (b) Before patients are transferred due to any change in the status of the license or operation of the facility, including the termination of the subacute services provider contract by the department, the facility shall comply with the transfer and discharge requirements of Section 1336.2 of the Health and Safety Code, subsection (a) of Section 483.12 of Title 42 of the Code of Federal Regulations, and any other state and federal laws applicable to the transfer and discharge of patients of a nursing facility, as defined in subdivision (k) of Section 1250 of the Health and Safety Code. (c) All of the rights and procedures that apply to the appeal of the transfer or discharge of a nursing facility patient pursuant to the sections cited in subdivision (b) shall apply to an appeal pursuant to this subdivision. The facility shall ensure that each patient and patient’s representative is notified of this right to appeal. The notification shall be in writing and shall be communicated in a language and manner that is understood by the patient or patient’s representative. (Added by Stats. 2003, Ch. 443, Sec. 2. Effective January 1, 2004.)
  34. 14132.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Medi-Cal reimbursement is barred for certain general acute care hospital services unless the hospital first gets the required permit or supplemental service approval.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.3. In addition to any other criteria as provided in subdivision (p) of Section 14132, no reimbursement shall be made pursuant to this chapter for any service in a general acute care hospital for which a special permit or a supplemental service approval is required pursuant to Section 1256.1 of the Health and Safety Code unless that general acute care hospital has first obtained a special permit or a supplemental service approval from the State Department of Health Services. (Added by Stats. 1982, Ch. 421, Sec. 2.)
  35. 14132.34.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Human milk and human milk derivatives supplied by a mothers’ milk bank are covered services under this chapter.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.34. (a) Human milk and human milk derivatives supplied by a mothers’ milk bank for human consumption are a covered service under this chapter. (b) For purposes of this section, “mothers’ milk bank” means any person, firm, or corporation which engages in the not-for-profit procurement, processing, storage, distribution, or use of human milk, contributed by volunteer donors, in compliance with standards prescribed by the Human Milk Banking Association of North America. (Added by Stats. 1988, Ch. 956, Sec. 3. Effective September 19, 1988.)
  36. 14132.35.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Outpatient rehabilitation services are covered, but the department and Medi-Cal field offices must not discriminate against elderly recipients, and stroke centers must meet certification and licensure requirements to qualify for reimbursement.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.35. (a) Outpatient rehabilitation services are covered under this chapter, subject to utilization controls. (b) The department and the Medi-Cal field offices shall not discriminate against elderly recipients in authorizing services under this section, and shall recognize the importance of rehabilitation services in allowing elderly persons to remain independent and at home. (c) Rehabilitation services may be provided in group settings, including what is referred to as stroke centers which offer programs and group training for adults in therapeutic exercise, activities of daily living, speech remediation, or counseling. (d) In order to be eligible for reimbursement under this section, stroke centers shall be certified as participating providers and meet the rules and regulations of the department. Stroke centers shall meet the requirements for licensure of either adult day health care centers or outpatient rehabilitation clinics. (Added by Stats. 1985, Ch. 1360, Sec. 3.)
  37. 14132.36.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Community health worker services are a covered Medi-Cal benefit, and Medi-Cal managed care plans and the department have outreach, notice, and billing-pathway duties tied to those services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.36. (a) Community health worker services are a covered Medi-Cal benefit. (b) For purposes of this section, the following definitions apply: (1) “Community health worker” means a liaison, link, or intermediary between health and social services and the community to facilitate access to services and to improve the access and cultural competence of service delivery. A community health worker is a frontline health worker either trusted by, or who has a close understanding of, the community served. Community health workers include Promotores, Promotores de Salud, Community Health Representatives, navigators, and other nonlicensed health workers, including violence prevention professionals. A community health worker’s lived experience shall align with and provide a connection to the community being served. (2) “Supervising provider” is an enrolled Medi-Cal provider that is authorized to supervise a community health worker pursuant to the federally approved Medicaid state plan amendment and that ensures that a community health worker meets the qualifications as required by the department. The supervising provider directly or indirectly oversees community health workers and the services that they deliver to Medi-Cal members. (c) A Medi-Cal managed care plan shall engage in outreach and education efforts to enrollees in a form and manner as directed by the department. At a minimum, the department shall require a Medi-Cal managed care plan to provide the following information to an enrollee: (1) A description of the community health worker services benefit, including eligibility and coverage criteria. (2) A list of providers that are authorized to refer an enrollee to community health worker services, and an explanation of how to request a referral. (3) A list of contracted community health worker entities, including community-based organizations, community clinics, local health jurisdictions, licensed providers, clinics, or hospitals available to provide community health worker services, updated at least annually. (4) An email address, internet website, and telephone number for an enrollee to access to request additional information regarding community health worker services. (d) The outreach and education efforts conducted by a Medi-Cal managed care plan pursuant to subdivision (c) shall meet cultural and linguistic appropriateness standards, as determined by the department. (e) The Medi-Cal managed care plan shall notify providers about the community health worker services benefit, as set forth by the department. (f) (1) No later than July 1, 2025, a Medi-Cal managed care plan shall adopt policies and procedures to effectuate a billing pathway for supervising providers, including contracted hospitals, to claim for the provision of community health worker services to enrollees during an emergency department visit and an outpatient followup to an emergency department visit, that are consistent with guidance developed by the department pursuant to paragraph (2). (2) No later than July 1, 2025, the department shall, consistent with subdivision (g), develop guidance on policies and procedures to effectuate a billing pathway for supervising providers, including contracted hospitals, to claim for the provision of community health worker services to Medi-Cal members under the fee-for-service delivery system during an emergency department visit and as an outpatient followup to an emergency department visit. (g) The department shall, through existing and regular stakeholder processes, inform stakeholders about, and accept input from stakeholders on, implementation of the community health worker services benefit. (h) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained. (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of policy letters, provider bulletins, or other similar instructions, without taking any further regulatory action. (Amended by Stats. 2025, Ch. 21, Sec. 102. (AB 116) Effective June 30, 2025.)
  38. 14132.39.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Midwifery services provided by a licensed midwife are covered under this chapter, subject to federal financial participation and utilization controls.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.39. Midwifery services provided by a licensed midwife shall be covered under this chapter, to the extent that federal financial participation is available, and, subject to utilization controls. (Added by Stats. 1993, Ch. 1280, Sec. 6. Effective January 1, 1994.)
  39. 14132.4.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Nurse-midwifery services provided by a certified nurse-midwife must be covered under this chapter, as required by federal law, and are subject to utilization controls.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.4. Nurse-midwifery services provided by a certified nurse-midwife shall be covered under the provisions of this chapter, to the extent required by federal law, subject to utilization controls. (Added by Stats. 1982, Ch. 327, Sec. 229. Effective June 30, 1982.)
  40. 14132.41.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must let certified nurse practitioners bill Medi-Cal independently, and if they do, the department must pay them directly.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.41. (a) Services provided by a certified nurse practitioner shall be covered under this chapter to the extent authorized by federal law, and subject to utilization controls. The department shall permit a certified nurse practitioner to bill Medi-Cal independently for his or her services. If a certified nurse practitioner chooses to bill Medi-Cal independently for his or her services, the department shall make payment directly to the certified nurse practitioner. (b) For purposes of this section, “certified” means nationally board certified in a recognized specialty. (Amended by Stats. 2006, Ch. 719, Sec. 1. Effective January 1, 2007.)
  41. 14132.42.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Medi-Cal inpatient hospital care generally cannot be limited to less than 48 hours after a normal vaginal delivery or less than 96 hours after a caesarean section, unless the stated discharge and follow-up visit conditions are met.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.42. Benefits under this chapter shall not be restricted for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following delivery by caesarean section. However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours following a delivery if both of the following conditions are met: (a) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother. (b) A postdischarge followup visit for the mother and newborn within 48 hours of discharge, when prescribed by the treating physician, is also a covered benefit under this chapter. The visit shall be by a licensed health care provider whose scope of practice includes postpartum care and newborn care. The visit shall include, at a minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments. The treating physician shall disclose to the mother the availability of a postdischarge visit, including an in-home visit, physician office visit, or plan facility visit. The treating physician, in consultation with the mother, shall determine whether the postdischarge visit shall occur at home, the plan’s facility, or the treating physician’s office after assessment of certain factors. These factors shall include, but not be limited to, the transportation needs of the family and environmental and social risks. (Added by Stats. 1998, Ch. 652, Sec. 4. Effective January 1, 1999.)
  42. 14132.44.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section covers targeted case management as a Medi-Cal benefit and sets rules for local agencies, the department, reporting, contracting, claims, and reimbursement.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.44. (a) Targeted case management (TCM), pursuant to Section 1915(g) of the Social Security Act as amended by Public Law 99-272 (42 U.S.C. Sec. 1396n(g)), shall be covered as a benefit, effective January 1, 1995. Nothing in this section shall be construed to require any local governmental agency to implement TCM. (b) A local governmental agency may contract with the department to provide TCM services. The department shall not contract with local education agencies to provide case management services under this section. (c) A local governmental agency may contract with any private or public entity to provide TCM services on its behalf under the conditions specified by the department in regulations. (d) Each local governmental agency that provides TCM services shall have all of the following: (1) Established procedures for performance monitoring. (2) A countywide system to prevent duplication of services and to ensure coordination and continuity of care among providers of case management services provided to beneficiaries who are eligible to receive case management services from two or more programs. (3) A fee mechanism effective January 1, 1995, specific to TCM services provided, which may vary by program. (e) Subject to the requirements of federal law and regulations, a local governmental agency or an entity under contract with a local governmental agency may provide TCM services to one or all of the following groups of Medi-Cal beneficiaries, which shall be defined in regulation: (1) High-risk persons. (2) Persons who have language or other comprehension barriers. (3) Persons on probation. (4) Persons who have exhibited an inability to handle personal, medical, or other affairs. (5) Persons abusing alcohol or drugs, or both. (6) Adults at risk of institutionalization. (7) Adults at risk of abuse or neglect. (f) (1) A local governmental agency that elects to provide TCM services to the groups specified in subdivision (e) shall, for each fiscal year, for the purpose of obtaining federal Medicaid reimbursement, submit an annual cost report as prescribed by the department that certifies all of the following: (A) The expenditure of 100 percent of the costs incurred for the provision of TCM services from the local governmental agency’s general fund or from any other funds allowed under federal law and regulation. (B) The amount of funds expended on allowable TCM services. (C) Its expenditures represent costs that are eligible for federal financial participation. (D) The costs reflected in the annual cost reports used to determine TCM rates are developed in compliance with the definitions contained in the Office of Management and Budget (OMB) Circular A-87. (E) Case management services provided in accordance with Section 1396n(g) of Title 42 of the United States Code will not duplicate case management services provided under any home- and community-based services waiver. (F) Claims for providing case management services pursuant to this section will not duplicate claims made to public agencies or private entities under other program authorities for the same purposes. (G) The requirements of subdivision (d) have been met. (2) The department shall deny any claim if it determines that any certification required by this subdivision is not adequately supported for purposes of federal financial participation. (3) (A) A city that is not a local governmental agency, or any other local public entity that contracts with a local governmental agency pursuant to subdivision (c) and that is located within a county that is a participating local governmental agency pursuant to this section, may submit certification to the local governmental agency of amounts expended for TCM services in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations. (B) A city or other local public entity that submits certification pursuant to this paragraph shall comply with the requirements of paragraph (1), with other requirements applicable to local governmental agencies that the department determines, in regulations, to be applicable, and with all applicable federal requirements. (C) The local governmental agency shall forward the city’s or local public entity’s certification to the department for purposes of claiming federal financial participation. (D) As applicable, the local governmental agency shall obtain and retain appropriate certifications from the expending city or local public entity, together with documentation of the underlying expenditures, as required by the department. (g) Except as otherwise provided in paragraph (3) of subdivision (f), only a local governmental agency may submit TCM service claims to the department for the performance of TCM services. (h) The department, in consultation with local governmental agencies, and consistent with federal regulations, and the State Medicaid Manual of the Department of Health and Human Services, Centers for Medicare and Medicaid Services, shall adopt regulations that define TCM services, establish the standards under which TCM services qualify as a Medi-Cal reimbursable service, prescribe the methodology for determining the rate of reimbursement, and establish a claims submission and processing system and method to certify local expenditures. (i) (1) Notwithstanding any other provision of this section, the state shall be held harmless, in accordance with paragraphs (2) and (3) from any federal audit disallowance and interest resulting from payments made by the federal Medicaid Program as reimbursement for claims for providing TCM services pursuant to this section, for the disallowed claim. (2) To the extent that a federal audit disallowance and interest results from a claim or claims for which any local governmental agency has received reimbursement for TCM services, the department shall recoup from the local governmental agency that submitted that disallowed claim, through offsets or by a direct billing, amounts equal to the amount of the disallowance and interest, in that fiscal year, for the disallowed claim. All subsequent claims submitted to the department applicable to any previously disallowed claim, may be held in abeyance, with no payment made, until the federal disallowance issue is resolved. (3) Notwithstanding paragraphs (1) and (2), to the extent that a federal audit disallowance and interest results from a claim or claims for which the local governmental agency has received reimbursement for TCM services performed by an entity under contract with, and on behalf of, the participating local governmental agency, the department shall be held harmless by that particular local governmental agency for 100 percent of the amount of any such federal audit disallowance and interest, for the disallowed claim. (j) The expenditure of local funds required by this section shall not create, lead to, or expand the health care funding obligations or service obligations for current or future years for each local governmental agency, except as required by this section or as may be required by federal law. (k) Subject to the requirements of federal law and regulations, TCM services are services which assist beneficiaries to gain access to needed medical, social, educational, and other services. Services provided by local governmental agencies, and their subcontractors, shall be defined in regulation, and shall include at least one of the following: (1) Assessment. (2) Plan development. (3) Linkage and consultation. (4) Assistance in accessing services. (5) Periodic review. (6) Crisis assistance planning. (l) As a condition of participation and in consideration of the joint effort of the local governmental agencies and the department in implementing this section and the ongoing need of local governmental agencies to receive technical support from the department, as well as assistance in claims processing and program monitoring, the local governmental agencies shall cover the costs of the administrative activities performed by the department. Each local governmental agency shall annually pay a portion of the total costs of administrative activities performed by the department through a mechanism agreed to by the department and the local governmental agencies, or if no agreement is reached by August 1 of each year, directly to the state. The department shall determine and report the staffing requirements upon which projected costs will be based. Projected costs shall include the anticipated salaries, benefits, and operating expenses necessary to administer targeted case management. (m) For the purposes of this section a “local governmental agency” means a county or chartered city. (n) Nothing in this section or in Section 14132.47 shall be construed to prevent any state agency from providing TCM services or from contracting with others to provide these services. (Amended by Stats. 2008, Ch. 464, Sec. 1. Effective January 1, 2009.)
  43. 14132.45.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Regulations that implement, interpret, or make specific subdivision (z) of Section 14132 are not subject to Government Code Chapter 3.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.45. Regulations implementing, interpreting, or making specific the provisions of subdivision (z) of Section 14132 shall not be subject to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (Added by Stats. 1988, Ch. 1555, Sec. 8.)
  44. 14132.46.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The Director of Health Services may recover the cost of certain targeted case management services from persons or entities that had a contractual or legal duty to pay when the services were provided.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.46. Pursuant to Sections 14024 and 14124.90, the Director of Health Services may recover for the cost of targeted case management services rendered under Section 14132.44 to eligible Medi-Cal beneficiaries, from any person, corporation, or partnership who, at the time services are rendered, has a contractual or legal obligation to pay for the services. (Added by Stats. 1989, Ch. 532, Sec. 1.)
  45. 14132.47.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section lets local agencies and local educational consortia participate in Medi-Cal Administrative Claiming, but only if they meet contract, certification, claim-submission, fee, and compliance requirements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.47. (a) It is the intent of the Legislature to provide local governmental agencies the choice of participating in either or both of the Targeted Case Management (TCM) and Administrative Claiming process programs at their option, subject to the requirements of this section and Section 14132.44. (b) The department may contract with each participating local governmental agency or each local educational consortium to assist with the performance of administrative activities necessary for the proper and efficient administration of the Medi-Cal program, pursuant to Section 1903a of the federal Social Security Act (42 U.S.C. Sec. 1396b(a)), and this activity shall be known as the Administrative Claiming process. (c) (1) Subject to the requirements of paragraph (2) of subdivision (f), as a condition for participation in the Administrative Claiming process, each participating local governmental agency or each local educational consortium shall, for the purpose of claiming federal Medicaid reimbursement, enter into a contract with the department and shall certify to the department the total amount the local governmental agency or each local educational consortium expended on the allowable administrative activities. (2) The department shall deny the claim if it determines that the certification is not adequately supported, or does not otherwise comply with federal requirements, for purposes of claiming federal financial participation. (d) Each participating local governmental agency or local educational consortium may subcontract with private or public entities to assist with the performance of administrative activities necessary for the proper and efficient administration of the Medi-Cal program under the conditions specified by the department in regulations. (e) Each Administrative Claiming process contract shall include a requirement that each participating local governmental agency or each local educational consortium submit a claiming plan in a manner that shall be prescribed by the department in regulations, developed in consultation with local governmental agencies. (f) (1) The department shall require that each participating local governmental agency or each local educational consortium certify to the department both of the following: (A) The expenditure of 100 percent of the cost of performing Administrative Claiming process activities. The funds expended for this purpose shall be from the local governmental agency’s general fund or the general funds of local educational agencies or from any other funds allowed under federal law and regulation. (B) In each fiscal year that its expenditures represent costs that are eligible for federal financial participation for that fiscal year. The department shall deny the claim if it determines that the certification is not adequately supported for purposes of federal financial participation. (2) (A) (i) A city that is not a participating local governmental agency, or any other local public entity, that contracts with a local governmental agency pursuant to subdivision (d) and that is located within a county that is a participating local governmental agency pursuant to this section, may submit certification to the local governmental agency of amounts expended for Administrative Claiming services in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations. (ii) A city or other local public entity that submits certification pursuant to this paragraph shall comply with the requirements of paragraph (1), with other requirements applicable to local governmental agencies that the department determines, in regulations, to be applicable, and with all applicable federal requirements. (iii) The local governmental agency shall forward the city’s or local public entity’s certification to the department for the purposes of claiming federal financial participation. (iv) As applicable, the local governmental agency shall obtain and retain appropriate certifications from the expending city or local public entity, together with documentation of the underlying expenditures, as required by the department. (B) A tribe or tribal organization, as defined in subdivision (n), that is not participating in Administrative Claiming process activities as a local governmental agency, may contract with, and submit to a tribe or tribal organization that is contracting with, the department pursuant to subdivision (b) amounts expended for Administrative Claiming process activities that it is certifying in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations and other applicable federal law and regulations. The tribe or tribal organization receiving the certification shall forward it to the department for purposes of claiming federal financial participation. The certification shall comply with all of the requirements for certification set forth in subparagraph (A). (g) (1) Notwithstanding any other provision of this section, the state shall be held harmless, in accordance with paragraphs (2) and (3), from any federal audit disallowance and interest resulting from payments made to a participating local governmental agency or local educational consortium pursuant to this section, for the disallowed claim. (2) To the extent that a federal audit disallowance and interest results from a claim or claims for which any participating local governmental agency or local educational consortium has received reimbursement for Administrative Claiming process activities, the department shall recoup from the local governmental agency or local educational consortium that submitted the disallowed claim, through offsets or by a direct billing, amounts equal to the amount of the disallowance and interest, in that fiscal year, for the disallowed claim. All subsequent claims submitted to the department applicable to any previously disallowed administrative activity or claim, may be held in abeyance, with no payment made, until the federal disallowance issue is resolved. (3) Notwithstanding paragraph (2), to the extent that a federal audit disallowance and interest results from a claim or claims for which the participating local governmental agency or local educational consortium has received reimbursement for Administrative Claiming process activities performed by an entity under contract with, and on behalf of, the participating local governmental agency or local educational consortium, the department shall be held harmless by that particular participating local governmental agency or local educational consortium for 100 percent of the amount of the federal audit disallowance and interest, for the disallowed claim. (h) The use of local funds required by this section shall not create, lead to, or expand the health care funding obligations or service obligations for current or future years for any participating local governmental agency or local educational consortium, except as required by this section or as may be required by federal law. (i) The department shall deny any claim from a participating local governmental agency or local educational consortium if the department determines that the claim is not adequately supported in accordance with criteria established pursuant to this subdivision and implementing regulations before it forwards the claim for reimbursement to the federal Medicaid Program. In consultation with local governmental agencies and local educational consortia, the department shall adopt regulations that prescribe the requirements for the submission and payment of claims for administrative activities performed by each participating local governmental agency and local educational consortium. (j) Administrative activities shall be those determined by the department to be necessary for the proper and efficient administration of the state’s Medicaid plan and shall be defined in regulation. (k) If the department denies any claim submitted under this section, the affected participating local governmental agency or local educational consortium may, within 30 days after receipt of written notice of the denial, request that the department reconsider its action. The participating local governmental agency or local educational consortium may request a meeting with the director or his or her designee within 30 days to present its concerns to the department after the request is filed. If the director or his or her designee cannot meet, the department shall respond in writing indicating the specific reasons for which the claim is out of compliance to the participating local governmental agency or local educational consortium in response to its appeal. Thereafter, the decision of the director shall be final. (l) To the extent consistent with federal law and regulations, participating local governmental agencies or local educational consortium may claim the actual costs of nonemergency, nonmedical transportation of Medi-Cal eligibles to Medi-Cal covered services, under guidelines established by the department, to the extent that these costs are actually borne by the participating local governmental agency or local educational consortium. A local educational consortium may only claim for nonemergency, nonmedical transportation of Medi-Cal eligibles for Medi-Cal covered services, through the Medi-Cal administrative activities program. Medi-Cal medical transportation services shall be claimed under the local educational agency Medi-Cal billing option, pursuant to Section 14132.06. (m) As a condition of participation in the Administrative Claiming process and in recognition of revenue generated to each participating local governmental agency and each local educational consortium in the Administrative Claiming process, each participating local governmental agency and each local educational consortium shall pay an annual participation fee through a mechanism agreed to by the state and local governmental agencies and local educational consortia, or, if no agreement is reached by August 1 of each year, directly to the state. The participation fee shall be used to cover the cost of administering the Administrative Claiming process, including, but not limited to, claims processing, technical assistance, and monitoring. The department shall determine and report staffing requirements upon which projected costs will be based. The amount of the participation fee shall be based upon the anticipated salaries, benefits, and operating expenses, to administer the Administrative Claiming process and other costs related to that process. (n) (1) For the purposes of this section, “participating local governmental agency” means a county, chartered city, Native American Indian tribe, tribal organization, or subgroup of a Native American Indian tribe or tribal organization, under contract with the department pursuant to subdivision (b). (2) Each participating Native American Indian tribe, tribal organization, or subgroup of a Native American Indian tribe or tribal organization may claim, as a Medi-Cal Administrative Activity, facilitating Medi-Cal applications, which includes, but is not limited to, using the California Healthcare Eligibility, Enrollment, and Retention System. (o) For purposes of this section, “local educational agency” means a local educational agency, as defined in subdivision (h) of Section 14132.06, that participates under the Administrative Claiming process as a subcontractor to the local educational consortium in its service region. (p) (1) For purposes of this section, “local educational consortium” means a local agency that is one of the service regions of the California County Superintendent Educational Services Association. (2) Each local educational consortium shall contract with the department pursuant to paragraph (1) of subdivision (c). (q) (1) Each participating local educational consortium shall be responsible for the local educational agencies in its service region that participate in the Administrative Claiming process. This responsibility includes, but is not limited to, the preparation and submission of all administrative claiming plans, training of local educational agency staff, overseeing the local educational agency time survey process, and the submission of detailed quarterly invoices on behalf of any participating local educational agency. (2) Each participating local educational consortium shall ensure local educational agency compliance with all requirements of the Administrative Claiming process established for local governmental agencies. (3) Ninety days prior to the initial participation in the Administrative Claiming process, each local educational consortium shall notify the department of its intent to participate in the process, and shall identify each local educational agency that will be participating as its subcontractor. (r) (1) Each local educational agency that elects to participate in the Administrative Claiming process shall submit claims through its local educational consortium or through the local governmental agency, but not both. (2) Each local educational agency participating as a subcontractor to a local educational consortium shall comply with all requirements of the Administrative Claiming process established for local governmental agencies. (s) A participating local governmental agency or a local educational consortium may charge an administrative fee to any entity claiming Administrative Claiming through that agency. (t) The department shall continue to administer the Administrative Claiming process in conformity with federal requirements. (u) The department shall provide technical assistance to all participating local governmental agencies and local educational consortia in order to maximize federal financial participation in the Administrative Claiming process. (v) This section shall be applicable to Administrative Claiming process activities performed, and to moneys paid to participating local governmental agencies for those activities in the 1994–95 fiscal year and thereafter, and to local educational consortia in the 1998–99 fiscal year and thereafter. (w) Nothing in this section or Section 14132.44 shall be construed to prevent any state agency from participating in the Administrative Claiming process or from contracting with others to engage in these activities. (Amended by Stats. 2013, Ch. 306, Sec. 1. (AB 1233) Effective September 9, 2013.)
  46. 14132.48.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Targeted case management services are covered as a Medi-Cal benefit for specified populations, subject to utilization controls.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.48. Targeted case management services to which Sections 14132.44 and 14132.47 does not apply, and as specified in Section 1915(g) of the federal Social Security Act, as amended by Public Law 99-272 (42 U.S.C. Section 1396n(g)), shall be covered as a benefit under this chapter, subject to utilization controls, for the following populations: (a) Persons served by regional centers administered by the State Department of Developmental Services. (b) Persons served in other programs administered by the State Department of Developmental Services. (c) Persons receiving services pursuant to Section 14021.3. (d) Persons in programs determined appropriate by the director. (Added by Stats. 1994, Ch. 147, Sec. 27. Effective July 11, 1994.)
  47. 14132.49.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department may cover targeted case management for pregnant and parenting adolescents and their children, but only with available funding and utilization controls, and within stated funding limits.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.49. (a) Upon federal approval of the state plan amendments made pursuant to Section 14021.7 for federal financial assistance, targeted case management, pursuant to subdivision (g) of Section 1396n of Title 42 of the United States Code, is covered as a benefit, subject to the availability of funding through the budget process, and subject to utilization controls, for pregnant and parenting adolescents and their children. (b) In administering subdivision (a), the department shall limit the targeted case management benefit to the amount of General Fund or other public moneys, and federal matching funds made available in the Budget Act or other legislation. (c) The department may redirect General Fund moneys for local assistance for existing adolescent family life programs to the extent necessary to provide state matching funds for implementation of subdivision (a). The amount which may be redirected shall not exceed the amount appropriated for local assistance for the Adolescent Family Life Program. (d) It is the intent of the Legislature that the additional federal matching funds made available by implementation of subdivision (a) be used to expand the Adolescent Family Life Program and not supplant General Fund or other public moneys or federal funds provided for pursuant to Titles V and XIX of the federal Social Security Act (Sec. 701 and following, and Sec. 1396 and following, respectively, of Title 42 of the United States Code). (e) Determinations to continue, expand, or terminate the program shall be based on all of the following: (1) The department’s assessment of the effect of Medi-Cal funding for services on the effectiveness of the Adolescent Family Life Program. (2) A determination of the amount of federal funds received for this service. (3) An assessment of the cost-effectiveness of the services to the General Fund. (4) An estimate of the amount of federal funds that could be received by expanding the project to all adolescent family programs statewide. (f) The department shall submit, not later than June 30, 1993, amendments to the state plan required to implement the amendments made to this section during the 1992 portion of the 1991–92 Regular Session for approval by the Secretary of Health and Human Services. (Amended by Stats. 1992, Ch. 123, Sec. 1. Effective January 1, 1993.)
  48. 14132.55.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    For Medi-Cal reimbursement, speech pathologists and audiologists must be licensed by the named board or a comparable state agency. Licensed speech-language pathologists and audiologists may use certain personnel while completing specified requirements and are reimbursed for those services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.55. For the purposes of reimbursement under the Medi-Cal program, a speech pathologist or audiologist shall be licensed by the Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board or similarly licensed by a comparable agency in the state in which they practice. Licensed speech-language pathologists or licensed audiologists are authorized to utilize and shall be reimbursed for the services of those personnel in the process of completing requirements under the provisions of subdivision (c) of Section 2532.2 of the Business and Professions Code. (Amended by Stats. 2025, Ch. 592, Sec. 47. (SB 861) Effective January 1, 2026.)
  49. 14132.56.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    This section makes behavioral health treatment a Medi-Cal covered service for people under 21 only when required by the federal government, and only when federal funding and approvals are in place.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.56. (a) (1) Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be a covered Medi-Cal service for individuals under 21 years of age. (2) It is the intent of the Legislature that, to the extent the federal government requires BHT to be a covered Medi-Cal service, the department shall seek statutory authority to implement this new benefit in Medi-Cal. (3) For purposes of this section, “behavioral health treatment” or “BHT” means professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and are administered by the department as described in the approved state plan. (b) The department shall implement, or continue to implement, this section only after all of the following occurs or has occurred: (1) The department receives all necessary federal approvals to obtain federal funds for the service. (2) The department seeks an appropriation that would provide the necessary state funding estimated to be required for the applicable fiscal year. (3) The department consults with stakeholders. (c) The department shall develop and define eligibility criteria, provider participation criteria, utilization controls, and delivery system structure for services under this section, subject to limitations allowable under federal law, in consultation with stakeholders. (d) (1) The department, commencing on the effective date of the act that added this subdivision until March 31, 2017, inclusive, may make available to individuals described in paragraph (2) contracted services to assist those individuals with health insurance enrollment, without regard to whether federal funds are available for the contracted services. (2) The contracted services described in paragraph (1) may be provided only to an individual under 21 years of age whom the department identifies as no longer eligible for Medi-Cal solely due to the transition of BHT coverage from the waiver program under Section 1915(c) of the federal Social Security Act to the Medi-Cal state plan in accordance with this section and who meets all of the following criteria: (A) They were enrolled in the home and community-based services waiver for persons with developmental disabilities under Section 1915(c) of the Social Security Act as of January 31, 2016. (B) They were deemed to be institutionalized in order to establish eligibility under the terms of the waiver. (C) They have not been found eligible under any other federally funded Medi-Cal criteria without a spend down of excess income. (D) They have received a BHT service from a regional center for persons with developmental disabilities as provided in Chapter 5 (commencing with Section 4620) of Division 4.5. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning six months after the effective date of this section, the department shall provide semiannual status reports to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted. (f) For the purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this subdivision shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services. (g) The department may seek approval of any necessary state plan amendments or waivers to implement this section. The department shall make any state plan amendments or waiver requests public at least 30 days prior to submitting to the federal Centers for Medicare and Medicaid Services, and the department shall work with stakeholders to address the public comments in the state plan amendment or waiver request. (h) This section shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained. (Amended by Stats. 2023, Ch. 42, Sec. 145. (AB 118) Effective July 10, 2023.)
  50. 14132.57.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must seek federal approval, comply with federal conditions, set service and provider requirements, and oversee the program for qualifying community-based mobile crisis intervention services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.57. (a) (1) The department shall seek all necessary federal approvals to exercise the option described in Section 1396w-6 of Title 42 of the United States Code, to provide qualifying community-based mobile crisis intervention services to eligible Medi-Cal beneficiaries experiencing a mental health or substance use disorder crisis. (2) Qualifying community-based mobile crisis intervention services shall be available to eligible Medi-Cal beneficiaries exclusively through a Medi-Cal behavioral health delivery system. (b) The department shall comply with any federal requirements and conditions for receipt of the increased federal medical assistance percentage described in Section 1396w-6(c) of Title 42 of the United States Code and any associated federal regulations or guidance for qualifying community-based mobile crisis intervention services. (c) Subject to obtaining the federal approvals described in subdivision (a), the department shall do all of the following: (1) Establish requirements for the receipt of qualifying community-based mobile crisis intervention services by eligible Medi-Cal beneficiaries experiencing a mental health or substance use disorder crisis, including, but not limited to, utilization controls. (2) Establish requirements for authorized providers of qualifying community-based mobile crisis intervention services. (3) Oversee and enforce the requirements and guidelines developed pursuant to this section. (d) For the purposes of implementing this section, including, but not limited to, providing training and technical assistance, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services. (e) Subject to federal approval, this section shall be implemented no sooner than January, 1, 2023, and shall be implemented up to the end of the five-year period specified in Section 1396w-6 of Title 42 of the United States Code. (f) This section shall be implemented only to the extent that any necessary federal approvals have been obtained and federal financial participation is available and not otherwise jeopardized. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action. To the extent practicable, the department shall consult with interested stakeholders when issuing guidance pursuant to this subdivision. (h) For purposes of this section, the following definitions apply: (1) “Medi-Cal behavioral health delivery system” has the same meaning as set forth in subdivision (i) of Section 14184.101. (2) “Qualifying community-based mobile crisis intervention services” has the same meaning as set forth in Section 1396w-6(b) of Title 42 of the United States Code. (Added by Stats. 2022, Ch. 47, Sec. 97. (SB 184) Effective June 30, 2022.)
  51. 14132.58.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must file state plan amendments to use a CHIP health services option for statewide vision services for low-income children, subject to federal approval and funding limits.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.58. (a) The department shall file all necessary state plan amendments, as set forth in Section 457.40 of Title 42 of the Code of Federal Regulations, to exercise the health services initiative (HSI) option made available under the Children’s Health Insurance Program (CHIP), established under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et seq.), as that option is described in Section 1397ee(a)(1)(D)(ii) of Title 42 of the United States Code, and as HSI is defined in Section 457.10 of Title 42 of the Code of Federal Regulations, to cover vision services provided to low-income children statewide through a mobile optometric office, as defined in Section 3070.2 of the Business and Professions Code and in accordance with subdivision (g) of Section 14043.15 and with Section 14043.26. (b) (1) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available. The federal financial participation shall be limited to no more than 3 percent of the total federal dollars available for expenditures not used for Medicaid or health insurance assistance, as described in Section 1397ee(c)(2)(A) of Title 42 of the United States Code. (2) This section shall be implemented by January 1, 2025, or the date that any necessary federal approvals have been obtained, whichever date is later. (c) (1) The Vision Services CHIP-HSI Special Fund is hereby created in the State Treasury. (2) All revenues derived pursuant to paragraph (1) of subdivision (d) and federal financial participation provided for in this section shall be deposited in the State Treasury to the credit of the Vision Services CHIP-HSI Special Fund. Moneys in that fund shall be available to cover vision services, as described in subdivision (a), upon appropriation by the Legislature in the annual Budget Act. Commencing with the first fiscal year in which the department requests funds for this purpose and annually thereafter, the department shall report on projected and actual federal and nonfederal resources and expenditures through the budget estimate process. (d) (1) The department shall seek to fund the implementation of this section, subject to subdivision (c), with funding other than General Fund moneys, including gifts, donations, bequests, or grants of funds from private sources and public agencies, designated for any of the purposes of this section. (2) This section shall continue to be implemented only if no General Fund moneys are used for this section. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of an all-county letter or similar instruction, without taking any further regulatory action, until regulations are adopted. (Added by Stats. 2023, Ch. 487, Sec. 2. (SB 502) Effective January 1, 2024.)
  52. 14132.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Certain silicone or comparable external prostheses, prosthetic implants, and reconstructive surgery related to mastectomy must be treated as medically necessary and covered under this chapter.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.6. External prostheses constructed of silicon or other comparable materials, prosthetic implants, and reconstructive surgery incident to mastectomy shall be deemed medically necessary and shall be covered under this chapter. As used in this section, “mastectomy” means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Coverage under this section shall include the provision of initial and subsequent prosthetic devices pursuant to an order of the patient’s physician. (Amended by Stats. 1989, Ch. 1398, Sec. 4. Effective October 2, 1989.)
  53. 14132.62.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Reconstructive surgery is covered when needed for the listed purposes, and only a licensed physician with the relevant clinical competence may deny initial coverage authorization requests.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.62. (a) Reconstructive surgery shall be covered under this chapter, as defined in subdivision (c), when necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require coverage for cosmetic surgery, as defined in subdivision (d). (b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual competent to evaluate the specific clinical issues involved in the care requested. (c) “Reconstructive surgery” means surgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function. (2) To create a normal appearance, to the extent possible. (d) “Cosmetic surgery” means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance. (e) In connection with the interpretation of the definition of reconstructive surgery, a proposed surgical procedure may be subject to prior authorization and utilization review that may include, but need not be limited to, denial under any of the following circumstances: (1) There is another more appropriate surgical procedure that will be approved for the enrollee. (2) The procedure or procedures offer only a minimal improvement in the appearance of the enrollee, as defined in regulations adopted by the department. (3) Denial of payment for procedures performed without prior authorization. (f) This section shall become operative July 1, 1999. (Added by Stats. 1998, Ch. 788, Sec. 4. Effective January 1, 1999. Section operative July 1, 1999, by its own provisions.)
  54. 14132.63.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Orthotists or prosthetists providing services under this chapter must be certified by one of the listed certification boards.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.63. (a) An orthotist or prosthetist providing services under this chapter shall be required to be certified in orthotics or prosthetics by either the Board for Orthotist Certification or the American Board of Certification in Orthotics and Prosthetics. (b) This section shall remain in effect only until the date that the director executes a declaration, that shall be retained by the director, stating that the department has adopted regulations requiring an orthotist or prosthetist to be certified in orthotics or prosthetics by either the Board for Orthotist Certification or the American Board of Certification in Orthotics and Prosthetics, as a condition of providing orthotist or prosthetic services under this chapter, and as of that date is repealed. (Added by Stats. 1996, Ch. 1009, Sec. 1. Effective January 1, 1997. Repealed conditionally by its own provisions.)
  55. 14132.69.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal covers donor and recipient organ transplant surgeries for eligible full-scope beneficiaries when the transplant is provided in a department-approved facility.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.69. (a) Notwithstanding any other provision of law, donor and recipient organ transplant surgeries are covered under the Medi-Cal program when an organ transplant is provided to a beneficiary who is eligible for full-scope benefits under this chapter in a medical facility that meets the requirements of, and is approved by, the department. (b) Any donor or recipient organ transplant surgeries authorized by the department pursuant to this chapter are subject to utilization controls. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or other instructions, without taking any further regulatory action. (d) This section shall not apply to Section 14133.8. (Added by Stats. 2007, Ch. 300, Sec. 3. Effective January 1, 2008.)
  56. 14132.70.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    A Medi-Cal beneficiary may keep coverage for antirejection medication for up to two years after an organ transplant, unless Medicare or private health insurance that covers the medication becomes available.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.70. (a) A Medi-Cal beneficiary shall remain eligible to receive Medi-Cal coverage for antirejection medication for up to two years following an organ transplant, unless during that period the beneficiary becomes eligible for Medicare or private health insurance that would cover the medication. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions, without taking any further regulatory action. (Added by Stats. 2010, Ch. 676, Sec. 1. (AB 2352) Effective January 1, 2011.)
  57. 14132.71.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must set standards for approving Medi-Cal facilities for donor and recipient organ transplant surgeries, and it may carry out that section through letters, bulletins, or other instructions without further regulatory action.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.71. (a) For purposes of donor and recipient organ transplant surgeries, the department shall establish standards as to both the circumstances and the criteria that the department will use for approving facilities eligible for receiving reimbursement under the Medi-Cal program. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or other instructions, without taking any further regulatory action. (Added by Stats. 2007, Ch. 300, Sec. 5. Effective January 1, 2008.)
  58. 14132.72.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal cannot require in-person contact for telehealth services that are appropriately provided by telehealth, and the department cannot make providers document a barrier to an in-person visit or limit the service setting.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.72. (a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply. (b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the provider. (c) In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Nothing in this section or the Telehealth Advancement Act of 2011 shall be construed to conflict with or supersede the provisions of Section 14091.3 of this code or any other existing state laws or regulations related to reimbursement for services provided by a noncontracted provider. (d) The department shall not require a health care provider to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth. (e) For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider. (f) Nothing in this section shall be interpreted to authorize the department to require the use of telehealth when the health care provider has determined that it is not appropriate. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, provider bulletins, and similar instructions. (Amended by Stats. 2011, Ch. 547, Sec. 9. (AB 415) Effective January 1, 2012.)
  59. 14132.723.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    During a state of emergency, certain Medi-Cal telehealth, telephonic, and off-premises services can be reimbursed, and the department may extend the rule to some other fee-for-service providers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.723. (a) (1) Notwithstanding any other law, neither face-to-face contact nor a patient’s physical presence on the premises shall be required for services provided by an enrolled community clinic to a Medi-Cal beneficiary during or immediately following a state of emergency, as described in Section 8628.5 of the Government Code. (2) Notwithstanding any other law, the department may apply paragraph (1) to services provided by another enrolled fee-for-service Medi-Cal provider, clinic, or facility during or immediately following a state of emergency. (b) For purposes of this section, the following terms have the following meanings: (1) (A) “Enrolled community clinic” means a community clinic licensed under subdivision (a) of Section 1204 of the Health and Safety Code, an intermittent clinic exempt from licensure under subdivision (h) of Section 1206 of the Health and Safety Code, a clinic operated by the state or any of its political subdivisions, including, but not limited to, the University of California or a city or county that is exempt from licensure under subdivision (b) of Section 1206 of the Health and Safety Code, a tribal clinic exempt from licensure under subdivision (c) of Section 1206 of the Health and Safety Code, or an outpatient setting conducted, maintained, or operated by a federally recognized Indian tribe, tribal organization, or urban Indian organization, as defined in Section 1603 of Title 25 of the United States Code, that is certified, as applicable, and enrolled in good standing as a Medi-Cal provider or, in the case of an intermittent site, is added to a parent clinic’s provider master file under Section 14043.15. (B) An outpatient setting that operates as a federally qualified health center (FQHC) or a rural health center (RHC) shall qualify as an enrolled community clinic, regardless of its license type or license-exempt status. (2) “Immediately following” means up to 90 calendar days, as deemed appropriate by the department, following the termination of the proclaimed state of emergency, as described in Section 8629 of the Government Code. Under extraordinary circumstances, including, but not limited to, the destruction of an enrolled location, as described in subdivision (a), the department may extend, in its discretion or at the direction of the Governor, the period of time immediately following the termination of a state of emergency beyond 90 calendar days and for as long as is necessary for the health and safety of the public. (3) (A) “Premises” means either of the following, as applicable: (i) A site located within the four walls of the enrolled community clinic, and at the address listed either on the primary care clinic license or in the provider master file. (ii) A site located within the four walls of the enrolled fee-for-service Medi-Cal provider, clinic, or facility, and at the address listed either on its license or in the provider master file. (B) For purposes of an FQHC or RHC, “premises” include a site located outside of the four walls of the FQHC or RHC, and at an address other than the address listed on its license or in the provider master file, but within the boundaries of the proclamation declaring the state of emergency. (4) “Telehealth” has the same meaning as provided in Section 2290.5 of the Business and Professions Code. (5) “Telephonic services” means health services provided via telephone with audio component only. (c) The following services shall be reimbursable when provided by an enrolled community clinic, an enrolled fee-for-service Medi-Cal program provider, clinic, or facility approved by the department pursuant to paragraph (2) of subdivision (a) during or immediately following a state of emergency for any dates of service on or after the date that the department obtains federal approvals and federal matching funds to implement these provisions pursuant to subdivision (f). (1) Telehealth services, including services provided by the enrolled community clinic or approved enrolled provider, clinic, or facility at a distant site location, whether on or off the premises, to a Medi-Cal beneficiary located at an originating site, which includes the beneficiary’s home, temporary shelter, or any other location, if the services are provided somewhere located within the boundaries of the proclamation declaring the state of emergency. (2) Telephonic services. (3) Covered benefit services that are otherwise reimbursable to an FQHC or RHC, but that are provided somewhere off the premises, including, but not limited to, at a temporary shelter, a Medi-Cal beneficiary’s home, or any location other than the premises, but within the boundaries of the proclamation declaring the state of emergency. (d) For purposes of paragraph (1) of subdivision (c), and consistent with Section 14132.72, the department shall ensure its reimbursement policies reflect the intent of the Legislature to authorize reimbursement for telehealth services appropriately provided by an enrolled community clinic, or, if approved by the department pursuant to paragraph (2) of subdivision (a), by an enrolled fee-for-service Medi-Cal provider, clinic, or facility, respectively, during or immediately following a state of emergency. This subdivision does not limit reimbursement for, or coverage of, or reduce access to, services provided through telehealth on or before the enactment of this section. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. (f) This section shall be implemented only to the extent that both of the following occur: (1) The department obtains any federal approvals necessary to implement this section. (2) The department obtains federal matching funds to the extent permitted by federal law. (Added by Stats. 2019, Ch. 829, Sec. 1. (AB 1494) Effective January 1, 2020.)
  60. 14132.724.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must publish guidance for certain Medi-Cal providers by July 1, 2020, and later adopt regulations by January 1, 2024.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.724. (a) On or before July 1, 2020, the department shall issue, and shall publish on its internet website, guidance for enrolled community clinics and other enrolled fee-for-service Medi-Cal providers, clinics, or facilities that are subject to Section 14132.723 in order to facilitate reimbursement for services provided pursuant to Section 14132.723, whether those services are provided at a health facility, a shelter, the Medi-Cal beneficiary’s home, or any other location within the boundaries of the emergency proclamation for the state of emergency, as described in Section 8628.5 of the Government Code. This guidance shall include, at a minimum, all of the following information: (1) Instructions, including examples, describing how enrolled community clinics and other enrolled fee-for-service Medi-Cal providers, clinics, or facilities submit claims for telehealth or telephonic services, as described in Section 14132.723, to Medi-Cal beneficiaries located outside the premises of the enrolled community clinic or other enrolled fee-for-service Medi-Cal provider, clinic, or facility during or immediately following a state of emergency. (2) Direction to Medi-Cal managed care plans on paying any claims submitted in accordance with the guidance issued under this section, including that Medi-Cal managed care plans contracting with the department under the Medi-Cal program are responsible for ensuring their delegated payers comply with all applicable federal and state laws, regulations, contract requirements, and any department-issued guidance related to the provision of services by enrolled community clinics or other providers, clinics, or facilities during or immediately following a state of emergency. (3) (A) Identification of services, provided during or immediately following a state of emergency, that may be provided solely through a telephonic visit, and identification of services that require other forms of telehealth, such as a live, synchronous video interaction, asynchronous store and forward, or an interactive telecommunications system. (B) Identification of telephonic, facsimile, email, or remote patient monitoring devices that may be used and reimbursed as part of a Medi-Cal covered service, including, but not limited to, laboratory, x-ray, or physician services, subject to any required federal approvals or waivers sought under subdivision (d). (4) Policies for ensuring prompt payment of claims submitted by enrolled community clinics or other enrolled fee-for-service Medi-Cal providers, clinics, or facilities for services provided during or immediately following a state of emergency, including, but not limited to, the temporary waiver of documentation requirements and streamlined billing or appeal processes for commonly owned entities. (b) For purposes of this section, the following terms have the following meanings: (1) “Asynchronous store and forward” has the same meaning as provided in Section 2290.5 of the Business and Professions Code. (2) “Immediately following” has the same meaning as provided in Section 14132.723. (3) “Interactive telecommunications system” has the same meaning as provided in Section 410.78 of Title 42 of the Code of Federal Regulations. (4) “Premises” has the same meaning as provided in Section 14132.723. (5) “Telehealth” has the same meaning as provided in Section 2290.5 of the Business and Professions Code. (c) The department shall seek federal approval of any necessary state plan amendments or waivers to implement this section, including, but not limited to, any demonstration program or similar opportunities allowing a telephonic visit to be used as a substitute for other forms of telehealth, such as synchronous video interaction, asynchronous store and forward, or an interactive telecommunications system. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. The department shall adopt regulations by January 1, 2024, 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. (Added by Stats. 2019, Ch. 829, Sec. 2. (AB 1494) Effective January 1, 2020.)
  61. 14132.725.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section sets telehealth rules for Medi-Cal, including definitions, provider communication duties, reimbursement rules, and limits on when new patient relationships may be created through certain virtual modalities.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.725. (a) For purposes of this section, the following definitions apply: (1) “Border community” means border areas adjacent to the State of California where it is customary practice for California residents to use medical resources in adjacent areas outside the state. Under these circumstances, program controls and limitations are the same as for services rendered by health care providers within the state. (2) “Health care provider” has the same meaning as set forth in paragraph (3) of subdivision (a) of Section 2290.5 of the Business and Professions Code, and shall be either enrolled as a Medi-Cal rendering provider, or a nonphysician medical practitioner affiliated with an enrolled Medi-Cal provider group. “Health care provider” also includes any provider type designated by the department pursuant to subparagraph (A) of paragraph (2) of subdivision (b). The enrolled Medi-Cal provider or provider group for which the health care provider renders services via telehealth shall meet all Medi-Cal requirements and shall be located in the state or a border community. (3) “Health care service plan” has the same meaning as set forth in subdivision (f) of Section 1345 of the Health and Safety Code. (4) “Medi-Cal managed care plan” has the same meaning as set forth in subdivision (j) of Section 14184.101. (5) “Network provider” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (6) “Telehealth” has the same meaning as set forth in paragraph (6) of subdivision (a) of Section 2290.5 of the Business and Professions Code. (b) (1) Subject to subdivision (k), in-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed. (2) (A) In implementing this section, the department shall designate and periodically update the covered health care services and provider types, including required licensing and credentialing criteria, as applicable, which may be appropriately delivered via the telehealth modalities described in this subdivision. (B) Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Subject to subdivision (k), utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code. (c) (1) (A) Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. (B) (i) The department may provide specific exceptions to the requirement specified in subparagraph (A), based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance. (ii) In making exceptions to the requirement specified in subparagraph (A), in addition to the provisions in clause (i), the department may also take into consideration the availability of broadband access based on speed standards set by the Federal Communications Commission, pursuant to Section 706 of the Telecommunications Act of 1996 (Pub. L. No. 104-104) or other applicable federal law or regulation. (2) Effective on the date designated by the department pursuant to paragraph (1), a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also maintain and follow protocols to do one of the following: (A) Offer those services via in-person, face-to-face contact. (B) (i) Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care. (ii) Clause (i) does not require a provider to schedule an appointment with a different provider on behalf of a patient. (3) In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services. (4) A health care provider may establish a new patient relationship with a Medi-Cal beneficiary via video synchronous interaction consistent with any requirements imposed by the department. (5) (A) A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, telephonic (audio-only) synchronous interaction, remote patient monitoring, or other virtual communication modalities, except as set forth in paragraph (4) of subdivision (g) of Section 14132.100. (B) Notwithstanding the prohibition in subparagraph (A), the department may provide for specific exceptions to this prohibition, the department may provide for specific exceptions described in clauses (i) and (ii), which shall be developed in consultation with affected stakeholders and published in departmental guidance. (i) Notwithstanding the prohibition in subparagraph (A), a health care provider may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (p) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state law, regulations, and guidance. (ii) Notwithstanding the prohibition in subparagraph (A), a health care provider may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance. (6) Subject to subdivision (k), the department may establish separate fee schedules for applicable health care services delivered via remote patient monitoring or other permissible virtual communication modalities. (7) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities. (d) In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by a health care provider to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider. (1) The provider shall document in the patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received. (2) The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subdivision. (3) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities. (e) (1) The department shall develop, in consultation with affected stakeholders, an informational notice to be distributed to fee-for-service Medi-Cal beneficiaries and for use by Medi-Cal managed care plans in communicating to their enrollees. Information in the notice shall include, but not be limited to, all of the following: (A) The availability of Medi-Cal covered telehealth services. (B) The beneficiary’s right to access all medically necessary covered services through in-person, face-to-face visits, and a provider’s and Medi-Cal managed care plan’s responsibility to offer or arrange for that in-person care, as applicable. (C) An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn by the Medi-Cal beneficiary at any time without affecting their ability to access covered Medi-Cal services in the future. (D) An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted. (E) Notification of the beneficiary’s right to make complaints about the offer of telehealth services in lieu of in-person care or about the quality of care delivered through telehealth. (2) The informational notice shall be translated into threshold languages determined by the department pursuant to subdivision (b) of Section 14029.91 and provided in a format that is culturally and linguistically appropriate. (3) This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities. (f) (1) Subject to subdivision (k), the department shall reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed. (2) Subject to subdivision (k), for applicable health care services appropriately provided by a network provider via video synchronous interaction, audio-only synchronous interaction modality, or asynchronous store and forward, as applicable, to an enrollee of a Medi-Cal managed care plan, the Medi-Cal managed care plan shall reimburse the network provider at payment amounts that are not less than the amounts the network provider would have received if the services were delivered via in-person, face-to-face contact, unless the Medi-Cal managed care plan and network provider mutually agree to reimbursement in different amounts. (g) On or before January 1, 2023, the department shall develop a research and evaluation plan that does all of the following: (1) Proposes strategies to analyze the relationship between telehealth and the following: access to care, access to in-person care, quality of care, and Medi-Cal program costs, utilization, and program integrity. (2) Examines issues using an equity framework that includes stratification by available geographic and demographic factors, including, but not limited to, race, ethnicity, primary language, age, and gender, to understand inequities and disparities in care. (3) Prioritizes research and evaluation questions that directly inform Medi-Cal policy. (h) Applicable health care services provided through asynchronous store and forward, video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities as described in this section shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations. (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, plan letters, provider bulletins, and similar instructions, without taking any further regulatory action. (j) Consistent with the requirements of this section and subject to subdivision (k), a PACE organization approved by the department pursuant to Chapter 8.75 (commencing with Section 14591) may use video telehealth to conduct initial assessments and annual reassessments for eligibility for enrollment in the PACE program. (k) The department shall seek any federal approvals it deems necessary to implement this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (l) This section shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subdivision (k), whichever is later. (m) This section does not apply to health care services provided via telehealth in an FQHC or RHC visit as described in paragraph (4) of subdivision (g) of Section 14132.100. (Amended by Stats. 2023, Ch. 172, Sec. 1. (AB 1241) Effective January 1, 2024. Conditionally operative on or after January 1, 2023, by its own provisions.)
  62. 14132.726.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must start in 2028 and every two years produce a public Medi-Cal telehealth utilization report using Medi-Cal data and other available data sources.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.726. (a) (1) Commencing in 2028 and every two years thereafter, the department shall use Medi-Cal data and other data sources available to the department to produce analyses in a publicly available Medi-Cal telehealth utilization report. (2) The department may include the analyses described in paragraph (1) in each of the department’s Biennial Telehealth Utilization Reports. A report described in paragraph (1) may be an update to the department’s Biennial Telehealth Utilization Report, if the department continues to publish that report since its inception in 2024, or it may be a different applicable report published by the department. (b) The analyses described in subdivision (a) shall address telehealth access and utilization data, including all of the following: (1) Telehealth visits per 100,000 Medi-Cal member months. This information shall be disaggregated by demographics and other metrics, including, but not limited to, age group, race and ethnicity, sex, primary language, county, county size, aid code group, and Medi-Cal managed care plan. (2) Telehealth visits and all outpatient visits. (3) Commonly utilized Current Procedural Terminology (CPT) codes for outpatient telehealth visits. (4) Percentage of Medi-Cal members by number of telehealth claims. (5) Utilization of telehealth by Medi-Cal members with multiple claims with a higher-than-average rate of use. This information shall be disaggregated by demographics and other metrics, including, but not limited to, age group, race and ethnicity, sex, primary language, aid code group, and number and percentage of telehealth utilizers per reporting period. (6) Telehealth visits of specialty mental health services and nonspecialty mental health services. (7) Telehealth visits of outpatient dental services. (8) New patient telehealth claims utilization by modality mix. (9) Established patient telehealth claims utilization by modality mix. (10) Commonly utilized medical outpatient health services delivered via telehealth. (11) Telehealth visits as a percentage of all medical outpatient health services. (c) (1) Wherever possible based on the availability of data, the analyses described in subdivision (a) shall be disaggregated by geographic, demographic, and social determinants of health categories to identify disparities. (2) Social determinants of health categories may be approximated using existing data sources, including the Healthy Places Index or similar indices. (d) In addition to the data elements described in subdivision (b), the department shall identify other data elements, including, but not limited to, data on patient outcomes and population health, for inclusion in future reports to help to identify and address access-to-care issues or provide greater insight into utilization of telehealth modalities. (Added by Stats. 2025, Ch. 437, Sec. 2. (AB 688) Effective January 1, 2026.)
  63. 14132.73.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The State Department of Health Care Services must allow psychiatrists to receive fee-for-service Medi-Cal reimbursement for telehealth services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.73. The State Department of Health Care Services shall allow psychiatrists to receive fee-for-service Medi-Cal reimbursement for services provided through telehealth in accordance with the Medicaid state plan. (Amended by Stats. 2012, Ch. 782, Sec. 13. (AB 1733) Effective January 1, 2013.)
  64. 14132.731.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section requires certain county or department contracts to reimburse eligible Drug-Medi-Cal providers for covered services delivered by video or audio-only synchronous interaction, restricts new patient relationships through some virtual modalities, and lets the department issue exceptions and implementing guidance.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.731. (a) A county that enters into a Drug Medi-Cal Treatment Program contract with the department in accordance with Section 14124.20, or the department if entering into a Drug Medi-Cal Treatment Program contract directly with providers or as otherwise described in Section 14124.21, shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction. (b) A Drug Medi-Cal certified provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other virtual communication modalities, except as set forth in paragraph (4) of subdivision (g) of Section 14132.100. Notwithstanding this prohibition, the department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. (c) Drug Medi-Cal reimbursable services provided through a video synchronous interaction or an audio-only synchronous interaction pursuant to subdivision (a) shall be subject to billing, reimbursement, and utilization management policies imposed by the department. (d) Drug Medi-Cal reimbursable services provided through a video synchronous interaction or an audio-only synchronous interaction shall be provided in compliance with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, Part 2 of Title 42 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations. (e) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available. (f) The department shall adopt regulations by July 1, 2024, to implement this section in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). (g) Notwithstanding the rulemaking provisions of the Administrative Procedure Act, the department may, if it deems it appropriate, implement, interpret, or make specific this section by means of provider bulletins, written guidelines, or similar instructions from the department, until regulations are adopted. (Repealed and added by Stats. 2022, Ch. 47, Sec. 101. (SB 184) Effective June 30, 2022.)
  65. 14132.74.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must create and run a pilot pediatric palliative care benefit for Medi-Cal, subject to federal funding/approval limits and stakeholder consultation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.74. (a) The department, in consultation with interested stakeholders, shall develop, as a pilot project, a pediatric palliative care benefit to evaluate whether, and to what extent, such a benefit should be offered under the Medi-Cal program. The pilot project shall be implemented only to the extent that federal financial participation is available. (b) Beneficiaries eligible to receive the pediatric palliative care benefit shall be under 21 years of age. The department may further limit the population served by the pilot project to a size deemed sufficient to make the evaluation required pursuant to subdivision (a). (c) Services covered under the pediatric palliative care benefit shall be designed to meet the unique needs of children, and shall include those types of services that are available through the Medi-Cal hospice benefit. The benefit shall also include the following services, regardless of whether those services are covered under the Medi-Cal hospice benefit: (1) Hospice services that are provided at the same time that curative treatment is available, to the extent that the services are not duplicative. (2) Hospice services provided to individuals whose conditions may result in death, regardless of the estimated length of the individual’s remaining period of life. (3) Any other services that the department determines to be appropriate. (d) The department, in consultation with interested stakeholders, shall determine the medical conditions and prognoses that render a beneficiary eligible for the benefit. (e) Providers authorized to provide services under the pilot program shall include licensed hospice agencies and home health agencies licensed to provide hospice care, subject to criteria developed by the department for provider participation. (f) (1) The department shall submit any necessary application to the federal Centers for Medicare and Medicaid Services for a waiver to implement the pilot project described in this section. The department shall determine the form of waiver most appropriate to achieve the purposes of this section. The waiver request shall be included in any waiver application submitted within 12 months after the effective date of this section, or shall be submitted as an independent application within that time period. After federal approval is secured, the department shall implement the waiver within 12 months of the date of approval. (2) The waiver shall be designed to cover a period of time necessary to evaluate the medical necessity for, and cost-effectiveness of, a pediatric palliative care benefit. The results of the pilot project shall be made available to the Legislature and appropriate policy and fiscal committees to determine the effectiveness of the benefit. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the provisions of this section by means of provider bulletins or similar instructions, without the adoption of regulations. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue a provider bulletin or other similar instruction at least five days prior to issuance. (h) (1) Nothing in this section shall result in the elimination or reduction of any covered benefits or services under the Medi-Cal program or the California Children’s Services Program. (2) This section shall not affect an individual’s eligibility to receive, concurrently with the benefit provided for in this section, any services, including home health services, for which the individual would have been eligible in the absence of this section. (Added by Stats. 2006, Ch. 330, Sec. 2. Effective January 1, 2007.)
  66. 14132.75.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must set standards, guidance, and technical assistance for palliative care in Medi-Cal managed care, and it may use plan letters instead of regulations.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.75. (a) In enacting this section, it is the intent of the Legislature that palliative care include, but not be limited to, all of the following: (1) Specialized medical care and emotional and spiritual support for people with serious advanced illnesses. (2) Relief of symptoms, pain, and stress of serious illness. (3) Improvement of quality of life for both the patient and family. (4) Appropriate care for any age and for any stage of serious illness, along with curative treatment. (b) The department, in consultation with interested stakeholders, shall establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services. (c) Covered services shall include, but are not limited to, those types of services that are available through the Medi-Cal hospice benefit. These services shall include the following, regardless of whether these services are covered under the Medi-Cal hospice benefit: (1) Hospice services that are provided at the same time that curative treatment is available, to the extent that the services are not duplicative. (2) Hospice services provided to individuals whose conditions may result in death, regardless of the estimated length of the individual’s remaining period of life. (3) Any other services that the department determines to be appropriate. (d) The department, in consultation with interested stakeholders, shall establish guidance on the medical conditions and prognoses that render a beneficiary eligible for the palliative care services. (e) Providers authorized to provide services shall include licensed hospice agencies and home health agencies licensed to provide hospice care that are contracted with Medi-Cal managed care plans to provide palliative care services. (f) The department shall, to the extent practicable, ensure that the delivery of palliative care services under this section is provided in a manner that is cost neutral to the General Fund on an ongoing basis. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the provisions of this section by means of all plan letters or similar instructions, without the adoption of regulations. The department shall notify stakeholders and the fiscal and appropriate policy committees of the Legislature of its intent to issue all plan letters or other similar instructions prior to issuance. (h) (1) Nothing in this section shall result in the elimination or reduction of any covered benefits or services under the Medi-Cal program. (2) This section shall not affect an individual’s eligibility to receive, concurrently with the services provided for in this section, any services, including home health services, for which the individual would have been eligible in the absence of this section. (Added by Stats. 2014, Ch. 574, Sec. 1. (SB 1004) Effective January 1, 2015.)
  67. 14132.755.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Dyadic behavioral health visits must be covered as a Medi-Cal benefit, subject to utilization controls, starting no sooner than July 1, 2022.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.755. (a) Commencing no sooner than July 1, 2022, dyadic behavioral health visits shall be a covered benefit under the Medi-Cal program, subject to utilization controls. (b) The dyadic services benefit is a family- and caregiver-focused model of care intended to address developmental and behavioral health conditions of children as soon as they are identified, and that fosters access to preventive care for children, rates of immunization completion, coordination of care, child social-emotional health and safety, developmentally appropriate parenting, and maternal mental health. Dyadic behavioral health visits are provided for the child and caregiver or parent at medical visits, providing screening for behavioral health problems, interpersonal safety, tobacco and substance misuse and social determinants of health, such as food insecurity and housing instability, and referrals for appropriate followup care. (c) This section shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins, plan letters, information notices, or other similar instructions, without taking any further regulatory action. (Added by Stats. 2021, Ch. 143, Sec. 392. (AB 133) Effective July 27, 2021.)
  68. 14132.76.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Some people eligible for hospice or palliative care before age 21 may keep receiving those services after age 21 if the stated eligibility conditions are met. The department must seek any federal approvals needed to implement the section.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.76. (a) An individual who is determined to be eligible to receive hospice services prior to 21 years of age may continue to receive hospice services after 21 years of age when certified as eligible by a physician in accordance with section 1905(o) of the Social Security Act (42 U.S.C. Sec. 1396d(o)). (b) An individual who is determined to be eligible to receive palliative care services prior to 21 years of age may continue to receive medically necessary palliative care services after 21 years of age when determined to be eligible by the recipient’s treating health care provider. (c) The department shall seek any federal approvals it deems necessary to implement this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized. (Added by Stats. 2023, Ch. 814, Sec. 3. (AB 847) Effective January 1, 2024.)
  69. 14132.765.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Certain prosthetic and orthotic devices under Medi-Cal do not need a treatment authorization request if the cost is within set dollar limits; the department must implement this rule, and the director may later reinstate prior authorization if specific conditions are met.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.765. (a) No treatment authorization request shall be required for the provision of prosthetic devices or for the replacement or repair of prosthetic devices, if the cost does not exceed five hundred dollars ($500). (b) No treatment authorization request shall be required for the provision of orthotic devices or for the replacement or repair of orthotic devices, if the cost does not exceed two hundred fifty dollars ($250). (c) The department shall implement subdivisions (a) and (b) commencing March 1, 1994. (d) Notwithstanding subdivision (c), the department shall implement subdivisions (a) and (b) only if one of the following occurs: (1) The report required by Section 14132.76 contains a conclusion that the pilot demonstration program required by that section was cost-effective. (2) The report required by Section 14132.76 is not submitted to the appropriate committees of the Legislature by December 31, 1993. (d) Notwithstanding subdivisions (a) and (b), the director may reinstate the requirement for prior authorization if the director determines that the elimination of the requirement results in unnecessary utilization, after notice to the Joint Legislative Budget Committee 30 days prior to the reinstatement of the requirement for prior authorization. (Added by Stats. 1993, Ch. 460, Sec. 1. Effective January 1, 1994.)
  70. 14132.77.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Rural hospitals may ask to join a two-year Medi-Cal pilot project, but participating hospitals must sign an agreement, stay in the project for at least one year unless removed, and follow the department’s review and repayment rules.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.77. (a) (1) Any rural hospital may request to participate in a two-year pilot project to perform delegated acute inpatient hospital treatment authorization review under the Medi-Cal program. (2) Any hospital that elects to participate in the pilot project under this section shall enter into an agreement with the department to ensure the appropriateness of the treatments and services that it provides to a Medi-Cal beneficiary. (3) Any rural hospital that elects to participate in a pilot project pursuant to this section shall remain in the project for not less than one year, unless it is removed by the department pursuant to subdivision (c). (b) The department shall review, on a random basis, every six months, up to 25 percent of the Medi-Cal beneficiaries treated by each participating hospital. As long as a hospital participates in a pilot project authorized by this section, reviews required by this section shall not interfere with, or delay, the processing of the hospital’s claims for payment. Consistent with subdivision (c), if the department finds that a hospital participating in a pilot project under this section is accumulating a significant overpayment, the department shall notify the provider. (c) (1) (A) If the department determines, as a result of a review required by subdivision (b), that the hospital has provided treatment that cannot be approved by the department, the department shall take an immediate disallowance that shall require offsets against pending Medi-Cal payments and any direct payment that may be required by the department. The disallowance shall be based on full extrapolation of the sample to the universe of Medi-Cal days covered by the sample period. (B) In addition to the requirements of subparagraph (A), if the department determines that the hospital has provided treatment that cannot be approved by the department for 3 percent or more of the Medi-Cal beneficiary days, the department shall take corrective action relative to the hospital’s participation in the pilot project. The corrective action shall include at least one of the following actions: (i) The revocation of the hospital’s participation pursuant to subdivision (a). (ii) An increased random review process. (iii) Mandatory educational programs. (2) After the random review required by subdivision (b), the hospital shall, through the reduction of the regularly scheduled periodic interim payment over a one-year period, pay the state an amount equal to the reimbursement received by the hospital for services for which approval has been denied and extrapolated pursuant to paragraph (1). This paragraph does not preclude any hospital from appealing a determination of the department under Article 5.3 (commencing with Section 14170). However, any issue under appeal shall not delay any disallowance or corrective action taken by the department under paragraph (1) until the appeal is resolved. (d) The department may reinstate any hospital’s participation revoked pursuant to subdivision (c) if, after a period of three months, the hospital’s requests for a treatment authorization are not denied in 3 percent or more of the Medi-Cal days. (e) Six months after the conclusion of the first year of the pilot project, the department shall prepare a report with an evaluation of the project and shall submit it to the appropriate committees of the Legislature. The department shall include its determination as to whether the project should be extended, modified, or terminated in the report and the basis for any determinations made by the department. (f) (1) As part of the pilot project implemented under this section, the department may, subject to federal approval, authorize the reimbursement of a participating rural hospital at a predetermined amount every two weeks or on some other basis determined to be appropriate by the department. Following every six-month period, the department shall immediately begin adjustment of any overpayment or underpayment, based on the amount paid to the provider as compared to the actual amount of claims approved by the department. Any hospital that is selected to participate in the pilot project under this section that elects to be paid for acute inpatient services under this subdivision shall be subject to the payment provisions of this section for the duration of the hospital’s participation in the pilot project. (2) The amount of reimbursement under paragraph (1) shall be based on the actual claims payment experience for each hospital for the immediately preceding period of six months and rate adjustments made in accordance with existing Medi-Cal reimbursement requirements. (g) For purposes of this section, “rural hospital” means a small and rural hospital as defined in Section 124840 of the Health and Safety Code. (h) The scope of the pilot project shall be subject to federal approval and the necessary resources made available from sources other than the General Fund or savings from program efficiencies that may be identified for this purpose. (i) The department shall implement this section only upon receipt of all appropriate federal waivers. (Amended by Stats. 1996, Ch. 1023, Sec. 477. Effective September 29, 1996.)
  71. 14132.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Covered services must include rehabilitative services for certain stroke and brain-injury patients.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.8. Services covered under this chapter shall include rehabilitative services for the physically or cognitively impaired stroke patient, or a patient who has brain injury for whom the medical prognosis and signs indicate potential for faster or more complete recovery, or maintenance or prevention of degeneration, in a variety of situations, including acute inpatient intensive rehabilitation immediately after the occurrence of stroke or injury, inpatient maintenance for the chronically impaired in a hospital or long-term care facility, outpatient services in a rehabilitation clinic or an adult day health care center, and in-home care or home health agency services for the patient at home. Rehabilitative services for the physically or cognitively impaired patient only for those whom the medical prognosis and signs indicate potential for faster or more complete recovery, or maintenance or prevention of degeneration, shall be considered to fall within the definition of medical necessity, as that term is used in Section 14133.3. For purposes of this section, “brain injury” means clinically evident brain damage resulting directly or indirectly from tumor, trauma, infection, anoxia, or vascular lesions not primarily due to degenerative or aging processes which result in temporary or permanent physical or cognitive deficits. This section shall not negate the department’s utilization review authority under subdivision (a) of Section 14133. (Amended by Stats. 1986, Ch. 258, Sec. 1.)
  72. 14132.81.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Identification bracelets for certain eligible Medi-Cal recipients are a covered benefit, subject to federal funding and provider-availability conditions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.81. (a) The purchase of identification bracelets for eligible recipients under the Medi-Cal program who have Alzheimer’s Disease or some other cognitive defect, or medication allergies that could be life threatening, shall be a covered benefit under this chapter. (b) The bracelets shall be purchased from an organization which maintains a 24-hour toll-free telephone number for emergency or medical personnel to make inquiries. (c) The director shall develop regulations to implement this section. (d) For purposes of this section “eligible recipients” means those persons who, in addition to qualifying for benefits under this chapter, have been determined by a licensed physician and surgeon to need the benefit authorized by this section. (e) Benefits shall be provided under this section only to the extent that full federal financial participation is made available. (f) Benefits shall be provided under this section only when the director determines that two or more organizationally independent providers are available to supply the benefit authorized by this section. (Added by Stats. 1989, Ch. 1082, Sec. 2.)
  73. 14132.85.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section defines key terms for complex rehabilitation technology and requires Medi-Cal providers, medical providers, and patients to meet specific evaluation and documentation rules.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.85. (a) For purposes of this section, the following definitions apply: (1) “Complex needs patient” means an individual with a diagnosis or medical condition that results in significant physical impairment or functional limitation. “Complex needs patient” includes, but is not limited to, individuals with spinal cord injury, traumatic brain injury, cerebral palsy, muscular dystrophy, spina bifida, osteogenesis imperfecta, arthrogryposis, amyotrophic lateral sclerosis, multiple sclerosis, demyelinating disease, myelopathy, myopathy, progressive muscular atrophy, anterior horn cell disease, post-polio syndrome, cerebellar degeneration, dystonia, Huntington’s disease, spinocerebellar disease, and the types of amputation, paralysis, or paresis that result in significant physical impairment or functional limitation. “Complex needs patient” does not negate the requirement that an individual meet medical necessity requirements under authority rules to qualify for receiving complex rehabilitation technology. (2) “Complex rehabilitation technology” means items classified within the federal Medicare Program as of January 1, 2021, as durable medical equipment that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. These items include, but are not limited to, complex rehabilitation manual and power wheelchairs, power seat elevation or power standing components of power wheelchairs, seating and positioning items, other specialized equipment such as adaptive bath equipment, standing frames, gait trainers, and specialized strollers, and related options and accessories. (3) “Complex rehabilitation technology services” includes the application of enabling systems designed and assembled to meet the needs of a patient experiencing any permanent or long-term loss or abnormality of physical or anatomical structure or function with respect to mobility or other function or need. These services include, but are not limited to, all of the following: (A) Evaluating the needs of a patient with a disability, including an assessment of the patient for the purpose of ensuring that the proposed equipment is appropriate. (B) Documenting medical necessity. (C) Selecting, fitting, customizing, maintaining, assembling, repairing, replacing, picking up and delivering, and testing equipment and parts. (D) Training the patient who will use the technology or any individual who assists the patient in using the complex rehabilitation technology. (4) “Qualified health care professional” means an individual who has no financial relationship to the provider of complex rehabilitation technology and is any of the following: (A) A physical therapist licensed pursuant to Chapter 5.7 (commencing with Section 2600) of Division 2 of the Business and Professions Code. (B) An occupational therapist licensed pursuant to Chapter 5.6 (commencing with Section 2570) of Division 2 of the Business and Professions Code. (C) Other licensed health care professional, approved by the department, and who performs specialty evaluations within the professional’s scope of practice. (5) “Qualified rehabilitation technology professional” means an individual who meets either of the following: (A) Holds the credential of Assistive Technology Professional (ATP) from the Rehabilitation Engineering and Assistive Technology Society of North America. (B) Holds the credential of Certified Complex Rehabilitation Technology Supplier (CRTS) from the National Registry of Rehabilitation Technology Suppliers. (b) A provider of complex rehabilitation technology to a Medi-Cal beneficiary shall comply with all of the following: (1) Meet the supplier and quality standards established for a durable medical equipment supplier under the federal Medicare Program and be enrolled as a provider in the Medi-Cal program. (2) Be accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology. (3) Employ at least one qualified rehabilitation technology professional as a W-2 employee (receiving a W-2 tax form from the provider) for each distribution location. (4) Have the qualified rehabilitation technology professional physically present for the evaluation, either in person or remotely if necessary, directly involved in determining the specific complex rehabilitation technology appropriate for the patient, and directly involved with, or closely supervise, the final fitting and delivery of the complex rehabilitation technology. (5) Maintain a reasonable supply of parts, adequate physical facilities, and qualified service or repair technicians, and provide patients with prompt services and repair for all complex rehabilitation technology supplied. (6) Provide written information at the time of delivery of complex rehabilitation technology regarding how the patient may receive services and repair. (c) For complex needs patients receiving a complex rehabilitation manual wheelchair, power wheelchair, or seating component, the patient shall be evaluated, either in person or remotely if necessary, by both of the following: (1) A qualified health care professional. (2) A qualified rehabilitation technology professional. (d) A medical provider shall conduct a physical examination of an individual, either in person or remotely if necessary, before prescribing a power wheelchair or scooter for a Medi-Cal beneficiary. The medical provider shall complete a certificate of medical necessity that documents the medical condition that necessitates the power wheelchair or scooter, and verifies that the patient is capable of using the wheelchair or scooter safely. (e) The department may adopt utilization controls, including a specialty evaluation by a qualified health care professional, as defined in paragraph (4) of subdivision (a). The department may adopt any other additional utilization controls for complex rehabilitation technology, as appropriate. (f) The department shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (Amended by Stats. 2025, Ch. 243, Sec. 22. (SB 862) Effective January 1, 2026.)
  74. 14132.86.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal covers prescribed enteral nutrition products, subject to the Medi-Cal product list and utilization controls.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.86. (a) Notwithstanding subdivision (ab) of Section 14132, effective May 1, 2014, purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products pursuant to Section 14105.8 and utilization controls pursuant to Section 14105.395. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of a provider bulletin or similar instruction, without taking regulatory action. (c) This section shall only be implemented to the extent permitted by federal law. (d) The department shall seek approval for federal financial participation and coverage of the service specified in subdivision (a) under the Medi-Cal program. (Added by Stats. 2013, Ch. 23, Sec. 63. (AB 82) Effective June 27, 2013.)
  75. 14132.88.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section sets covered Medi-Cal dental benefits by age group and requires the department to use radiograph documentation rules for certain posttreatment dental claims.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.88. (a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are covered benefits for beneficiaries 21 years of age or older under this chapter: (1) One dental prophylaxis cleaning per year. (2) One initial dental examination by a dentist. (b) The following are covered benefits for beneficiaries under 21 years of age under this chapter: (1) Two dental prophylaxis cleanings per year. (2) Two periodic dental examinations per year. (c) For persons 21 years of age or older, laboratory-processed crowns on posterior teeth are a covered benefit when medically necessary to restore a posterior tooth back to normal function based on the criteria specified in the Medi-Cal Dental Manual of Criteria. (d) Any prefabricated crown made from ADA-approved materials may be used on posterior teeth and may be reimbursed as a stainless steel crown. (e) Covered dental benefits and accompanying criteria for receipt of those dental benefits under the Medi-Cal program shall be identified in the Medi-Cal Dental Manual of Criteria. Notwithstanding subdivision (h) of Section 14132, the department shall evaluate all covered dental benefits, including those listed in this section and in the Medi-Cal Dental Manual of Criteria, for evidence-based practices consistent with the American Academy of Pediatric Dentistry and the American Dental Association guidelines. (f) (1) Except as provided in paragraph (2), the department shall require pretreatment radiograph documentation on posttreatment claims to establish the medical necessity for dental restorations. The pretreatment documentation required under this subdivision is intended to reduce fraudulent claims for unnecessary dental fillings. In order to avoid any undue barriers to accessing dental care, the department shall stipulate that the pretreatment radiograph documentation for posttreatment claims will be required only when there are four or more dental fillings being completed in any 12-month period. (2) For any beneficiary who is under four years of age, or who, regardless of age, has a developmental disability, as defined in subdivision (a) of Section 4512, radiographs or photographs that indicate decay on any tooth surface shall be considered sufficient documentation to establish the medical necessity for treatment provided. (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins, plan letters, or other similar instructions, without taking regulatory action. (g) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available. (Amended by Stats. 2022, Ch. 47, Sec. 102. (SB 184) Effective June 30, 2022.)
  76. 14132.89.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Certain dental services are covered for Medi-Cal persons age 21 or older, subject to utilization controls and medical necessity.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.89. (a) Notwithstanding subdivision (h) of Section 14132, effective May 1, 2014, or the effective date of any necessary federal approvals as required by subdivision (d), all of the following are covered benefits for persons 21 years of age or older, subject to utilization controls and medically necessary services: (1) Examinations, radiographs/photographic images, prophylaxis, and fluoride treatments. (2) Amalgam and composite restorations. (3) Stainless steel, resin, and resin window crowns. (4) Anterior root canal therapy. (5) Complete dentures, including immediate dentures. (6) Complete denture adjustments, repairs, and relines. (7) Emergency procedures are also covered in the above categories of service. (b) This section shall only be implemented to the extent permitted by federal law. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of a provider bulletin or similar instruction, without taking regulatory action. (d) The department shall seek approval for federal financial participation and coverage of services specified in subdivision (a) under the Medi-Cal program. (Added by Stats. 2013, Ch. 23, Sec. 64. (AB 82) Effective June 27, 2013.)
  77. 14132.9.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Utilization controls under Section 14132(h) may not require an examination by someone who is not licensed as a dentist.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.9. Notwithstanding subdivision (h) of Section 14132, any utilization controls imposed under such subdivision shall not include mandatory examination by any person not licensed as a dentist under the Dental Practice Act. (Added by Stats. 1975, Ch. 958.)
  78. 14132.905.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Day care habilitative services are limited to alcohol- and drug-exposed pregnant women and women in the postpartum period, unless federal law requires otherwise.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.905. (a) Day care habilitative services, pursuant to subdivision (c) of Section 14021, shall be provided only to alcohol- and drug-exposed pregnant women and women in the postpartum period, or as required by federal law. (b) This section shall become operative on July 1, 2013. (Added by Stats. 2013, Ch. 22, Sec. 106. (AB 75) Effective June 27, 2013. Adding action operative July 1, 2013, by Sec. 110 of Ch. 22. Section operative July 1, 2013, by its own provisions.)
  79. 14132.91.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must run a Medi-Cal dental outreach and education program if funding is available.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.91. (a) Subject to the availability of funding, the department shall conduct a dental outreach and education program for Medi-Cal beneficiaries. The program shall inform Medi-Cal beneficiaries of the availability of dental care and provide information regarding recommended frequencies for regular and preventive dental care, how to obtain Medi-Cal dental care, how to avoid inappropriate care or fraudulent providers, and how to obtain assistance in getting care or resolving problems with dental care. (b) The program shall particularly target underserved populations and parents of young and adolescent children, and it shall include the following components: (1) Incorporation of dental themes and information in ongoing outreach and advertising efforts, including those for Medi-Cal and the Healthy Families program. (2) Education and outreach materials for inclusion in mailings to beneficiaries. (3) Education and consumer protection materials for display and distribution at sites providing Medi-Cal dental care, clinics, and other health care facilities and sites. (c) The department shall consult with dental professional groups and experts, community organizations, advertising and media experts, and other parties, as the department deems appropriate, in order to develop and structure the program in an effective and efficient manner. (Added by Stats. 2000, Ch. 93, Sec. 94. Effective July 7, 2000.)
  80. 14132.915.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must create, manage, and publicly report dental fee-for-service performance measures and related program data.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.915. (a) (1) The department shall establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. The performance measures shall be designed to evaluate utilization, access, availability, and effectiveness of preventive care and treatment. (2) Prior to establishing the quality and access criteria described in paragraph (1), the department shall consult with stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties. (3) The performance measures established by the department to monitor the dental fee-for-service program for children shall include, but not be limited to, all of the following: (A) Overall utilization of dental services. (B) For each provider, all of the following: (i) Number of annual dental visits. (ii) Number of annual preventive dental services. (iii) Number of annual dental treatment services. (iv) Number of annual examinations and oral health evaluations. (C) Number of applications of dental sealants and fluoride varnishes. (D) Continuity of care and overall utilization over an extended period of time. (E) All of the following ratios: (i) Sealant to restoration. (ii) Filling to preventive services. (iii) Treatment to caries prevention. (F) No sooner than January 1, 2018, number of beneficiaries requiring general anesthesia to perform procedures. (4) The performance measures established by the department to monitor the dental fee-for-service program for adults shall include, but not be limited to, all of the following: (A) Overall utilization of dental services. (B) For each provider, all of the following: (i) Number of annual dental visits. (ii) Number of annual preventive dental services. (iii) Number of annual dental treatment services. (iv) Number of annual examinations and oral health evaluations. (C) Treatment to caries prevention ratio. (5) The performance measures shall be reported as aggregate numbers and as percentages, if appropriate, using standards that are as equivalent to those used by managed care entities as feasible. Performance measures for the dental fee-for-service program for children shall be reported by age groupings if appropriate. (b) The department shall include the initial list of performance measures in any dental contract entered into between the department and a fee-for-service contractor on or after enactment of this section. (c) To ensure that the dental health needs of Medi-Cal beneficiaries are met, the department shall, when evaluating performance measures for retention on, addition to, or deletion from, the list of performance measures, consider all of the following criteria: (1) Annual and multiyear Medi-Cal dental fee-for-service trended data. (2) Other state and national dental program performance and quality measures. (3) Other state and national performance ratings. (d) On October 1, 2014, for the 2013 calendar year, and on or before October 1, 2016, for the 2015 calendar year, the list of performance measures established by the department along with the data of the dental fee-for-service program performance shall be posted on the department’s Internet Web site. (e) Commencing January 31, 2017, for the 2015–16 fiscal year, and annually on or before January 31 for each preceding fiscal year thereafter, the list of performance measures established by the department along with the data of the dental fee-for-service program shall be posted on the department’s Internet Web site. (f) Commencing April 30, 2017, for the July 2016 to September 2016, inclusive, fiscal quarter, and quarterly thereafter on or before April 30, July 31, October 31, and January 31 for the fiscal quarter ending seven months prior, the data of the dental fee-for-service program performance shall be posted on the department’s Internet Web site. (g) The department may amend or remove performance measures and establish additional performance measures in accordance with all of the following: (1) The department shall consider performance measures established by other states, the federal government, and national organizations developing dental program performance and quality measures. (2) The department shall notify a fee-for-service contractor, at least 30 days prior to the implementation date, of any updates or changes to performance measures. The department shall also post these updates or changes on its Internet Web site at least 30 days prior to implementation in order to maintain transparency to the public. (3) In establishing the performance measures, the department shall consult with stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties. (h) The department shall annually prepare a summary report of the nature and types of complaints and grievances regarding access to, and quality of, dental services, including the outcome. Commencing January 31, 2017, for the prior fiscal year, and annually thereafter, for each preceding fiscal year, this report shall be posted on the department’s Internet Web site. (i) The department shall ensure, to the greatest degree possible, that the categories of data and performance measures selected under this section are consistent with the categories of data and performance measures selected under Section 14459.6. (j) No sooner than July 1, 2019, the department shall annually publish utilization data from the preceding calendar year and post this material on its Internet Web site. The utilization data shall be made publicly available for both the dental fee-for-service and dental managed care programs. The utilization data shall include all of the following information: (1) Number of patients seen on a per-provider basis. (2) Number of annual preventative dental services, dental treatment services, examinations, and oral health evaluations rendered by each provider during each calendar year. (3) Number of beneficiaries who received general anesthesia services. (Amended by Stats. 2016, Ch. 613, Sec. 1. (AB 2207) Effective January 1, 2017.)
  81. 14132.92.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal must reimburse certain covered services for specified beneficiaries in certain intermediate care facilities, and the department must seek additional federal financial participation and approval if needed.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.92. (a) Notwithstanding subdivision (a) of Section 4512, or any other provision of this chapter or Chapter 8 (commencing with Section 14200), services provided on or after July 1, 2000, by facilities defined in subdivisions (e) and (h) of Section 1250 of the Health and Safety Code that are otherwise covered services under this chapter shall be reimbursed by the Medi-Cal program when provided to a Medi-Cal beneficiary that has a developmental disability as defined in Section 6001(8) of Title 42 of the United States Code or is a person with a related condition as defined in Section 435.1009 of Title 42 of the Code of Federal Regulations, provided that the Medi-Cal beneficiary was residing in a licensed intermediate care facility/developmentally disabled-habilitative or a licensed intermediate care facility/developmentally disabled-nursing on July 1, 2000, but only for as long as the beneficiary continues, from that date, to reside in a licensed intermediate care facility/developmentally disabled-habilitative or a licensed intermediate care facility/developmentally disabled-nursing. (b) Nothing in subdivision (a) shall eliminate, for purposes of reimbursement under this section, the requirements and time limits set forth in Section 14115, or any regulations adopted thereunder. (c) The department shall seek further financial participation, and shall seek federal approval of a state plan amendment if necessary under Section 440.150 of Title 42 of the Code of Federal Regulations, for services provided pursuant to subdivision (a). If federal financial participation is not made available for the services, the services nonetheless shall be reimbursed from the General Fund. (Added by Stats. 2000, Ch. 804, Sec. 1. Effective September 28, 2000.)
  82. 14132.925.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Licensed intermediate care facilities must provide selected day treatment and transportation services, reimburse the regional center, and report costs; the department also has federal-approval and reimbursement-related responsibilities.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.925. (a) (1) Notwithstanding any other provision of law or regulation to the contrary, to the extent federal financial participation is available, in furtherance of Section 14105.06 and subdivisions (a) and (c) of Section 14132.92, effective July 1, 2007, a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall be responsible for providing day treatment and transportation services consistent with Section 14105.06 and subdivision (a) of Section 14132.92, that are selected and authorized through the individual program plan process pursuant to Sections 4646 and 4646.5 and applicable regulations, for each beneficiary receiving those services who resides in that licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled. (2) (A) The services described in paragraph (1) shall be arranged by the regional center pursuant to Sections 4646 and 4646.5 and applicable regulations. (B) The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center for the full costs of making the disbursements to day treatment and transportation service providers. (3) Nothing in this section shall authorize the licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled to substitute day treatment or transportation services not selected and authorized through the individual program plan process pursuant to Sections 4646 and 4646.5 and applicable regulations. (b) (1) The State Department of Developmental Services shall be responsible for reimbursing a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled for the costs of reimbursing the regional center for the full cost of making disbursements for day treatment and transportation services, plus a coordination fee which will include an administrative fee and reimbursement for increased costs associated with the quality assurance fee. This payment shall be a supplement to the Medi-Cal payment from the State Department of Health Care Services described in Sections 14105.06 and 14132.92. (2) A licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled may authorize the regional center to invoice the State Department of Developmental Services on its behalf for the services described in subdivision (a). (3) (A) The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center for the full costs of making disbursements for day treatment and transportation services within 30 days of receipt of payment from the State Department of Developmental Services pursuant to instructions from the State Department of Developmental Services. (B) If there is a failure to reimburse the regional center within 30 days of receipt of payment from the State Department of Developmental Services, for all or part of the costs associated with disbursement for day treatment and transportation services, the outstanding amount shall be recovered by any of the following methods: (i) Lump sum payment by the provider. (ii) Offset against current payments due to the provider from the State of California. (iii) A repayment agreement between the provider and the State of California. (c) (1) A licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall report the costs incurred pursuant to subdivision (a) according to instructions from the State Department of Health Care Services. (2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this subdivision by means of a provider bulletin or similar instruction. (d) (1) If the services meeting the conditions of subdivision (a) have been provided to a Medi-Cal beneficiary on or after July 1, 2007, and, notwithstanding Section 14115, a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled may authorize the regional center to invoice the State Department of Developmental Services on its behalf for arranging for the services described in subdivision (a). The licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall reimburse the regional center the full cost of making disbursements for day treatment and transportation services within 30 days of receipt of payment from the State Department of Developmental Services pursuant to instruction from the State Department of Developmental Services. If a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled fails to reimburse the regional center within 30 days of receipt of payment from the State Department of Developmental Services, for all or part of the costs associated with the day treatment and transportation services, the outstanding amount shall be recovered by any of the following methods: (A) Lump sum payment by the provider. (B) Offset against current payments due to the provider from the State of California. (C) A repayment agreement between the provider and the State of California. (2) The department shall seek federal financial participation, including any moneys available pursuant to the American Recovery and Reinvestment Act of 2009 (Public Law 111-5), pursuant to a federally approved state plan amendment authorizing reimbursement for costs incurred pursuant to subdivision (a) for day treatment and transportation services provided on or after July 1, 2007. (3) Upon approval of the state plan amendment, the reimbursement payments made pursuant to this section by the State Department of Developmental Services to a licensed intermediate care facility/developmentally disabled-habilitative, licensed intermediate care facility/developmentally disabled-nursing, or licensed intermediate care facility/developmentally disabled shall be subject to the quality assurance fee imposed upon designated intermediate care facilities pursuant to Article 7.5 (commencing with Section 1324) of Chapter 2 of Division 2 of the Health and Safety Code. (4) If federal financial participation is not made available for day treatment and transportation services provided on or after July 1, 2007, the services nonetheless shall be reimbursed from the General Fund by the State Department of Developmental Services. (e) The State Department of Health Care Services shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this section. The Director of Health Care Services, with the concurrence of the Director of Developmental Services, may alter the methodology specified in this section to the extent necessary to meet the requirements of federal law or regulations or to obtain federal approval. If after seeking federal approval, federal approval is not obtained or federal financial participation is no longer available, this section and Section 4646.55 shall not be implemented or shall become inoperative. (Added by Stats. 2010, Ch. 717, Sec. 157. (SB 853) Effective October 19, 2010. Conditionally inoperative as provided in subd. (e).)
  83. 14132.93.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    For certain Medi-Cal services provided between June 15, 1998 and July 2, 2000, bills submitted by April 30, 2001 are to be reimbursed from the General Fund.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.93. It is the intent of the Legislature that if services meeting the conditions of subdivision (a) of Section 14132.92 have been provided to a Medi-Cal beneficiary during the time period of June 15, 1998, to July 2, 2000, and notwithstanding Section 14115, a bill for these services is submitted on behalf of each beneficiary receiving these services postmarked to the department on or before April 30, 2001, the services shall be reimbursed by the General Fund. However, the department shall seek federal financial participation and shall seek federal approval of a state plan amendment if necessary under Section 440.150 of Title 42 of the Code of Federal Regulations, for these services provided during that period. If federal financial participation is not made available for that period, the services nonetheless shall be reimbursed from the General Fund. (Added by Stats. 2000, Ch. 804, Sec. 2. Effective September 28, 2000.)
  84. 14132.94.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    PACE program services become a Medi-Cal covered benefit only if federal approval is obtained and the beneficiary meets the stated utilization and eligibility criteria.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.94. (a) Subject to approval by the Centers for Medicare and Medicaid Services of a medicaid state plan amendment electing the Programs of All-Inclusive Care for the Elderly (PACE) as a state medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the Medi-Cal program, subject to utilization controls and eligibility criteria that require that the beneficiary be certifiable for nursing facility services based on Medi-Cal criteria. (b) Covered services under the PACE benefit of the Medi-Cal program include those set forth in 42 C.F.R. 460.92. (Added by Stats. 2003, Ch. 112, Sec. 1. Effective January 1, 2004.)
  85. 14132.95.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section treats personal care services as a covered Medi-Cal benefit if stated conditions are met, and it sets rules for approval, administration, provider qualifications, limits, notices, and when the section can operate.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.95. (a) Personal care services, when provided to a categorically needy person as defined in Section 14050.1 is a covered benefit to the extent federal financial participation is available if these services are: (1) Provided in the beneficiary’s home and other locations as may be authorized by the director subject to federal approval. (2) Authorized by county social services staff in accordance with a plan of treatment. (3) Provided by a qualified person. (4) Provided to a beneficiary who has a chronic, disabling condition that causes functional impairment that is expected to last at least 12 consecutive months or that is expected to result in death within 12 months and who is unable to remain safely at home without the services described in this section. (b) The department shall seek federal approval of a state plan amendment necessary to include personal care as a Medicaid service pursuant to subdivision (f) of Section 440.170 of Title 42 of the Code of Federal Regulations. For any persons who meet the criteria specified in subdivision (a) or (p), but for whom federal financial participation is not available for a service or services under this section, eligibility for the service or services shall be determined according to the waiver authorized pursuant to Section 14132.951. If federal financial participation for the service or services is not available under this section or Section 14132.951, eligibility for the service or services shall be determined pursuant to Article 7 (commencing with Section 12300) of Chapter 3. (c) Subdivision (a) shall not be implemented unless the department has obtained federal approval of the state plan amendment described in subdivision (b), and the Department of Finance has determined, and has informed the department in writing, that the implementation of this section will not result in additional costs to the state relative to state appropriation for in-home supportive services under Article 7 (commencing with Section 12300) of Chapter 3, in the 1992–93 fiscal year. (d) (1) For purposes of this section, personal care services shall mean all of the following: (A) Assistance with ambulation. (B) Bathing, oral hygiene and grooming. (C) Dressing. (D) Care and assistance with prosthetic devices. (E) Bowel, bladder, and menstrual care. (F) Skin care. (G) Repositioning, range of motion exercises, and transfers. (H) Feeding and assurance of adequate fluid intake. (I) Respiration. (J) Paramedical services. (K) Assistance with self-administration of medications. (2) Ancillary services including meal preparation and cleanup, routine laundry, shopping for food and other necessities, and domestic services may also be provided as long as these ancillary services are subordinate to personal care services. Ancillary services may not be provided separately from the basic personal care services. (e) (1) (A) After consulting with the State Department of Social Services, the department shall adopt emergency regulations to establish the amount, scope, and duration of personal care services available to persons described in subdivision (a) in the fiscal year whenever the department determines that General Fund expenditures for personal care services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, are expected to exceed the General Fund appropriation and the federal appropriation under Title XX of the federal Social Security Act provided for the 1992–93 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1992, as adjusted for caseload growth or as increased in the Budget Act or appropriated by statute. At least 30 days prior to filing these regulations with the Secretary of State, the department shall give notice of the expected content of these regulations to the fiscal committees of both houses of the Legislature. (B) In establishing the amount, scope, and duration of personal care services, the department shall ensure that General Fund expenditures for personal care services provided for under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, do not exceed the General Fund appropriation and the federal appropriation under Title XX of the federal Social Security Act provided for the 1992–93 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1992, as adjusted for caseload growth or as increased in the Budget Act or appropriated by statute. (C) For purposes of this subdivision, “caseload growth” means an adjustment factor determined by the department based on (1) growth in the number of persons eligible for benefits under Chapter 3 (commencing with Section 12000) on the basis of their disability, (2) the average increase in the number of hours in the program established pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1988–89 to 1992–93 fiscal years, inclusive, due to the level of impairment, and (3) any increase in program costs that is required by an increase in the mandatory minimum wage. (2) In establishing the amount, scope, and duration of personal care services pursuant to this subdivision, the department may define and take into account, among other things: (A) The extent to which the particular personal care services are essential or nonessential. (B) Standards establishing the medical necessity of the services to be provided. (C) Utilization controls. (D) A minimum number of hours of personal care services that must first be assessed as needed as a condition of receiving personal care services pursuant to this section. The level of personal care services shall be established so as to avoid, to the extent feasible within budgetary constraints, medical out-of-home placements. (3) To the extent that General Fund expenditures for services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1992–93 fiscal year, adjusted for caseload growth, exceed General Fund expenditures for services provided under this section and expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in any fiscal year, the excess of these funds shall be expended for any purpose as directed in the Budget Act or as otherwise statutorily disbursed by the Legislature. (f) Services pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program. A provider of personal care services shall be qualified to provide the service and shall be a person other than a member of the family. For purposes of this section, a family member means a parent of a minor child or a spouse. (g) The maximum number of hours available under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3, Section 14132.951, and this section, combined, shall be 283 hours per month. (h) Personal care services shall not be provided to residents of facilities licensed by the department, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the Community Care Licensing Division of the State Department of Social Services. (i) Subject to any limitations that may be imposed pursuant to subdivision (e), determination of need and authorization for services shall be performed in accordance with Article 7 (commencing with Section 12300) of Chapter 3. (j) (1) To the extent permitted by federal law, reimbursement rates for personal care services shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3, plus any increase provided in the annual Budget Act for personal care services rates or included in a county budget pursuant to paragraph (2). (2) (A) The department shall establish a provider reimbursement rate methodology to determine payment rates for the individual provider mode of service that does all of the following: (i) Is consistent with the functions and duties of entities created pursuant to Section 12301.6. (ii) Makes any additional expenditure of state general funds subject to appropriation in the annual Budget Act. (iii) Permits county-only funds to draw down federal financial participation consistent with federal law. (B) This ratesetting method shall be in effect in time for any rate increases to be included in the annual Budget Act. (C) The department may, in establishing the ratesetting method required by subparagraph (A), do both of the following: (i) Deem the market rate for like work in each county, as determined by the Employment Development Department, to be the cap for increases in payment rates for individual practitioner services. (ii) Provide for consideration of county input concerning the rate necessary to ensure access to services in that county. (D) If an increase in individual practitioner rates is included in the annual Budget Act, the state-county sharing ratio shall be as established in Section 12306. If the annual Budget Act does not include an increase in individual practitioner rates, a county may use county-only funds to meet federal financial participation requirements consistent with federal law. (3) (A) By November 1, 1993, the department shall submit a state plan amendment to the federal Health Care Financing Administration to implement this subdivision. To the extent that any element or requirement of this subdivision is not approved, the department shall submit a request to the federal Health Care Financing Administration for any waivers as would be necessary to implement this subdivision. (B) The provider reimbursement ratesetting methodology authorized by the amendments to this subdivision in the 1993–94 Regular Session of the Legislature shall not be operative until all necessary federal approvals have been obtained. (k) (1) The State Department of Social Services shall, by September 1, 1993, notify the following persons that they are eligible to participate in the personal care services program: (A) Persons eligible for services pursuant to the Pickle Amendment, as adopted October 28, 1976. (B) Persons eligible for services pursuant to subsection (c) of Section 1383c of Title 42 of the United States Code. (2) The State Department of Social Services shall, by September 1, 1993, notify persons to whom paragraph (1) applies and who receive advance payment for in-home supportive services that they will qualify for services under this section without a spend down of excess income if they elect to accept payment for services on an arrears rather than an advance payment basis. (l) An individual who is eligible for services subject to the maximum amount specified in subdivision (b) of Section 12303.4 shall be given the option of hiring their own provider. (m) The county welfare department shall inform in writing any individual who is potentially eligible for services under this section of their right to the services. (n) It is the intent of the Legislature that this entire section be an inseparable whole and that no part of it be severable. If any portion of this section is found to be invalid, as determined by a final judgment of a court of competent jurisdiction, this section shall become inoperative. (o) Paragraphs (2) and (3) of subdivision (a) shall be implemented so as to conform to federal law authorizing their implementation. (p) (1) Personal care services shall be provided as a covered benefit to a medically needy aged, blind, or disabled person, as defined in subdivision (a) of Section 14051, to the same extent and under the same requirements as they are provided under subdivision (a) of this section to a categorically needy, aged, blind, or disabled person, as defined in subdivision (a) of Section 14050.1, and to the extent that federal financial participation is available. (2) The department shall seek federal approval of a state plan amendment necessary to include personal care services described in paragraph (1) as a Medicaid service pursuant to subdivision (f) of Section 440.170 of Title 42 of the Code of Federal Regulations. (3) In the event that the Department of Finance determines that expenditures of both General Fund moneys for personal care services provided under this subdivision to medically needy aged, blind, or disabled persons together with expenditures of both General Fund moneys and federal funds received under Title XX of the federal Social Security Act for all aged, blind, and disabled persons receiving in-home supportive services pursuant to Article 7 (commencing with Section 12300) of Chapter 3, in the 2000–01 fiscal year or in any subsequent fiscal year, are expected to exceed the General Fund appropriation and the federal appropriation received under Title XX of the federal Social Security Act for expenditures for all aged, blind, and disabled persons receiving in-home supportive services provided in the 1999–2000 fiscal year pursuant to Article 7 (commencing with Section 12300) of Chapter 3, as it read on June 30, 1998, as adjusted for caseload growth or as changed in the Budget Act or by statute or regulation, then this subdivision shall cease to be operative on the first day of the month that begins after the expiration of a period of 30 days subsequent to a notification in writing by the Director of the Department of Finance to the chairperson of the committee in each house that considers appropriations, the chairpersons of the committees and the appropriate subcommittees in each house that consider the State Budget, and the Chairperson of the Joint Legislative Budget Committee. (4) Solely for purposes of paragraph (3), caseload growth means an adjustment factor determined by the department based on: (A) Growth in the number of persons eligible for benefits under Chapter 3 (commencing with Section 12000) on the basis of their disability. (B) The average increase in the number of hours in the program established pursuant to Article 7 (commencing with Section 12300) of Chapter 3 in the 1994–95 to 1998–99 fiscal years, inclusive, due to the level of impairment. (C) Any increase in program cost that is required by an increase in hourly costs pursuant to the Budget Act or statute. (5) In the event of a final judicial determination by any court of appellate jurisdiction or a final determination by the Administrator of the federal Centers for Medicare and Medicaid Services that personal care services must be provided to any medically needy person who is not aged, blind, or disabled, then this subdivision shall cease to be operative on the first day of the first month that begins after the expiration of a period of 30 days subsequent to a notification in writing by the Director of Finance to the chairperson of the committee in each house that considers appropriations, the chairpersons of the committees and the appropriate subcommittees in each house that consider the State Budget, and the Chairperson of the Joint Legislative Budget Committee. (6) If this subdivision ceases to be operative, all aged, blind, and disabled persons who would have been eligible to receive services under this section shall be immediately eligible for services under the IHSS Plus waiver authorized pursuant to Section 14132.951, if otherwise eligible, upon this section becoming inoperative. If this section becomes inoperative and a person is ineligible for the IHSS Plus waiver, then eligibility shall be determined under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. (Amended by Stats. 2023, Ch. 42, Sec. 146. (AB 118) Effective July 10, 2023.)
  86. 14132.951.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section directs state agencies to seek and implement an IHSS Plus Medicaid waiver, sets limits on who can receive services, and gives the department limited regulatory flexibility.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.951. (a) It is the intent of the Legislature that the State Department of Health Services seek approval of a Medicaid waiver under the federal Social Security Act in order that the services available under Article 7 (commencing with Section 12300) of Chapter 3, known as the In-Home Supportive Services program, may be provided as a Medi-Cal benefit under this chapter, to the extent federal financial participation is available. The waiver shall be known as the “IHSS Plus waiver.” (b) To the extent feasible, the IHSS Plus waiver described in subdivision (a) shall incorporate the eligibility requirements, benefits, and operational requirements of the In-Home Supportive Services program. The director shall have discretion to modify eligibility requirements, benefits, and operational requirements as needed to secure approval of the Medicaid waiver. (c) Upon implementation of the IHSS Plus waiver, and to the extent federal financial participation is available, the services available through the In-Home Supportive Services program shall be furnished as benefits of the Medi-Cal program through the IHSS Plus waiver to persons who meet the eligibility requirements of the IHSS Plus waiver. The benefits shall be limited by the terms and conditions of the IHSS Plus waiver and by the availability of federal financial participation. (d) Upon implementation of the IHSS Plus waiver: (1) A person who is eligible for the IHSS Plus waiver shall no longer be eligible to receive services under the In-Home Supportive Services program to the extent those services are available through the IHSS Plus waiver. (2) A person shall not be eligible to receive services pursuant to the IHSS Plus waiver to the extent those services are available pursuant to Section 14132.95. (e) Services provided pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program. (f) Services shall not be provided to residents of facilities licensed by the department, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the State Department of Social Services. (g) To the extent permitted by federal law, reimbursement rates for services shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. (h) (1) Notwithstanding the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the provisions of this section through all-county welfare director letters or similar publications. Actions taken to implement, interpret, or make specific this section shall not be subject to the Administrative Procedure Act or to the review and approval of the Office of Administrative Law. Upon request of the department, the Office of Administrative Law shall publish the regulations in the California Code of Regulations. All county welfare director letters or similar publications authorized pursuant to this section shall remain in effect for no more than 18 months. (2) The department may also adopt emergency regulations implementing the provisions of this section. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted. The department shall seek input from the entities listed in Section 12305.72 when developing the regulations, all county welfare director letters, or similar publications. (i) In the event of a conflict between the terms of the IHSS Plus waiver and any provision of this part or any regulation, all-county welfare directors letters or similar publications adopted for the purpose of implementing this part, the terms of the waiver shall control to the extent that the services are covered by the waiver. If the department determines that a conflict exists, the department shall issue updated instructions to counties for the purposes of implementing necessary program changes. The department shall post a copy of, or a link to, the instructions on its Web site. (j) (1) Notwithstanding subdivision (b) or any other provision of this section, the department shall not waive or modify the provisions of Section 12301.2, 12301.6, 12302.25, 12306.1, or 12309. (2) Upon receipt of the IHSS Plus waiver, the director shall report to the Legislature on any modifications in benefits or eligibility and operational requirements of the In-Home Supportive Services program required for receipt of the waiver. (Amended by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 45. Effective July 28, 2009.)
  87. 14132.952.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section creates the IHSS Plus option and sets rules for how it is approved, operated, funded, and limited.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.952. (a) The department shall seek approval of an amendment to the Medicaid state plan pursuant to Section 1396n(j) of Title 42 of the United States Code to provide self-directed personal assistance services under the state plan in order that the services available under Article 7 (commencing with Section 12300) of Chapter 3, known as the In-Home Supportive Services (IHSS) program, may be provided as a Medi-Cal benefit under this chapter, to the extent that federal financial participation is available. This program shall be known as the “IHSS Plus option.” (b) To the extent feasible, the IHSS Plus option shall incorporate the eligibility requirements, benefits, and operational requirements of the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. The director shall have the discretion to modify these eligibility requirements, benefits, and operational requirements to the extent necessary to secure federal approval of the Medicaid state plan amendment. (c) The services available through the IHSS Plus waiver pursuant to Section 14132.951 shall be furnished as benefits under the IHSS Plus option to the extent that federal financial participation is available to persons who meet the eligibility requirements of the IHSS Plus option. Upon implementation of the IHSS Plus option, a person who is eligible for services under the IHSS Plus option shall no longer be eligible to receive services under Section 14132.951. (d) Upon implementation of the IHSS Plus option: (1) A person who is eligible for the IHSS Plus option shall not be eligible to receive services under the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3 to the extent those services are available through the IHSS Plus option. (2) A person shall not be eligible to receive services pursuant to the IHSS Plus option to the extent those services are available pursuant to Section 14132.95. (e) Services provided pursuant to this section shall be rendered, under the administrative direction of the State Department of Social Services, in the manner authorized in Article 7 (commencing with Section 12300) of Chapter 3, for the In-Home Supportive Services program. (f) Services shall not be provided to residents of facilities licensed by the State Department of Public Health, and shall not be provided to residents of a community care facility or a residential care facility for the elderly licensed by the State Department of Social Services. (g) To the extent permitted by federal law, reimbursement rates for services under the IHSS Plus option shall be equal to the rates in each county for the same mode of services in the In-Home Supportive Services program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. (h) (1) Notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) the department may implement the provisions of this section through all-county welfare director letters or similar publications. Actions taken to implement, interpret, or make specific this section shall not be subject to the Administrative Procedure Act or to the review and approval of the Office of Administrative Law. Upon request of the department, the Office of Administrative Law shall publish the regulations in the California Code of Regulations. All county welfare director letters or similar publications authorized pursuant to this section shall remain in effect for no more than 18 months. (2) The department may also adopt emergency regulations implementing the provisions of this section. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review and approval by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted. The department shall seek input from the entities listed in Section 12305.72 when developing the regulations, all-county welfare director letters, or similar publications. (i) (1) Notwithstanding subdivision (b) or any other provision of this section, the department shall not waive or modify the provisions of Section 12301.2, 12301.6, 12302.25, 12306.1, or 12309. (2) Upon the federal Centers for Medicare and Medicaid Services’ approval of the Medicaid state plan amendment known as the “IHSS Plus option,” the director shall notify the Legislature of any modifications in benefits or eligibility and operational requirements of the In-Home Supportive Services program required for that Medicaid state plan amendment to become effective. (Added by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 46. Effective July 28, 2009.)
  88. 14132.955.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Personal care services may be provided at a recipient’s workplace if they are already authorized for home use and are needed to help the recipient work.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.955. Personal care services that are provided pursuant to Section 14132.95 shall include services in the recipient’s place of employment if both of the following conditions are met: (a) The personal care services are limited to those that are currently authorized for the recipient in the recipient’s home and those services are to be utilized by the recipient at the recipient’s place of employment to enable the recipient to obtain, retain, or return to, work. Authorized services utilized by the recipient at the recipient’s place of employment shall be services that are relevant and necessary in supporting and maintaining employment. However, work place services shall not be used to supplant any reasonable accommodations required of an employer by the Americans with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) or other legal entitlements or third-party obligations. (b) The provision of personal care services at the recipient’s place of employment shall be authorized only to the extent that the total hours utilized at the work place are within the total personal care services hours authorized for the recipient in the home. Additional personal care services hours may not be authorized in connection with a recipient’s employment. (Added by Stats. 2002, Ch. 1088, Sec. 9. Effective January 1, 2003.)
  89. 14132.956.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must assess whether exercising a federal Medi-Cal option would be cost efficient and, if so, take steps to implement it.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.956. (a) The department shall assess and determine whether it would be cost efficient for the state to exercise the option made available under Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)). When performing this assessment, the department shall collaborate and consult with the State Department of Social Services, the State Department of Developmental Services, the California Department of Aging, and any other state agency that the department believes can assist in its determination whether it would be cost efficient for the state to exercise this option. If the department determines that it would be cost efficient for the state to exercise the federal option, it shall seek a Medi-Cal State Plan amendment to provide home- and community-based attendant services and supports that include assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks pursuant to Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)). (b) If the department determines that it would be cost efficient to exercise the option made available under Section 1915(k) of the federal Social Security Act (42 U.S.C. Sec. 1396n(k)), the department shall establish a development and implementation council that shall include, as a majority of its members, persons with disabilities and elderly individuals, and their representatives. The department shall consult and collaborate with the council when developing and implementing a Medi-Cal State Plan amendment to exercise this option. (c) Services and supports pursuant to this section may be rendered under the administrative direction of other state departments in accordance with the Medi-Cal State Plan amendment and subject to the department’s authority as the designated single state agency for the administration or supervision of the administration of the Medi-Cal program. (d) (1) Notwithstanding the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) the department, and any other state department pursuant to subdivision (c), may implement this section through all-county letters or similar instructions from the director, until regulations are adopted. (2) The department, and any other state department rendering services and supports pursuant to subdivision (c), shall adopt emergency regulations implementing this section within 24 months from the date federal approval pursuant to this section is received. The adoption of regulations implementing this section shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. The emergency regulations authorized by this section shall be exempt from review and approval by the Office of Administrative Law. Any emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 18 months by which time final regulations shall be adopted. (Added by Stats. 2011, Ch. 8, Sec. 36. (SB 72) Effective March 24, 2011.)
  90. 14132.96.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    County review and budget certification are required before certain Medi-Cal personal care services provider rates are submitted to the department.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.96. Medi-Cal personal care services provider rates established as provided in the state plan under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code, by an in-home supportive services public authority established pursuant to paragraph (2) of subdivision (a) and paragraph (4) of subdivision (b) of Section 12301.6 shall be reviewed by the county in which the in-home supportive services public authority operates, to determine that the rates are consistent with the county budget and that the county will be able to fund any increase in its share of costs, prior to the submission of the rates to the department. Certification of the county’s ability to fund any increase in rates shall accompany the submission of rates to the department. (Added by Stats. 1995, Ch. 307, Sec. 17. Effective August 3, 1995.)
  91. 14132.966.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Physician assistant services are covered benefits under this chapter, subject to federal authorization and utilization controls. The department may not impose stricter chart review, countersignature, or similar coverage or payment conditions on supervising physicians than allowed by the referenced rules.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.966. (a) Services provided by a physician assistant are a covered benefit under this chapter to the extent authorized by federal law and subject to utilization controls. (b) Subject to subdivision (a), all services performed by a physician assistant within his or her scope of practice that would be a covered benefit if performed by a physician and surgeon shall be a covered benefit under this chapter. (c) The department shall not impose chart review, countersignature, or other conditions of coverage or payment on a physician and surgeon supervising physician assistants that are more stringent than requirements imposed by Chapter 7.7 (commencing with Section 3500) of Division 2 of the Business and Professions Code or regulations of the Medical Board of California promulgated under that chapter. (Added by Stats. 2007, Ch. 376, Sec. 7. Effective January 1, 2008.)
  92. 14132.968.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section sets Medi-Cal rules for pharmacist services, including a fee schedule, reimbursement at 85% of physician-service fees, enrollment requirements for pharmacists, and department rulemaking/reporting duties.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.968. (a) (1) Pharmacist services are a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services. (2) The department shall establish a fee schedule for the list of pharmacist services. (3) The rate of reimbursement for pharmacist services shall be at 85 percent of the fee schedule for physician services under the Medi-Cal program, except for medication therapy management (MTM) pharmacist services as described in Section 14132.969. (b) (1) The following services are covered pharmacist services that may be provided to a Medi-Cal beneficiary: (A) Furnishing travel medications, as authorized in clause (3) of subparagraph (A) of paragraph (10) of subdivision (a) of Section 4052 of the Business and Professions Code. (B) Furnishing naloxone hydrochloride, as authorized in Section 4052.01 of the Business and Professions Code. (C) Furnishing self-administered hormonal contraception, as authorized in subdivision (a) of Section 4052.3 of the Business and Professions Code. (D) Initiating and administering immunizations, as authorized in Section 4052.8 of the Business and Professions Code. (E) Providing tobacco cessation counseling and furnishing nicotine replacement therapy, as authorized in Section 4052.9 of the Business and Professions Code. (F) Initiating and furnishing preexposure prophylaxis, as authorized in Section 4052.02 of the Business and Professions Code. (G) Initiating and furnishing postexposure prophylaxis, as authorized in Section 4052.03 of the Business and Professions Code. (H) Providing MTM pharmacist services in conjunction with the dispensing of qualified specialty drugs, as described in Section 14132.969. (2) Covered pharmacist services shall be subject to department protocols and utilization controls. (c) A pharmacist shall be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement pursuant to this section. (d) (1) The director shall seek any necessary federal approvals to implement this section. This section shall not be implemented until the necessary federal approvals are obtained and shall be implemented only to the extent that federal financial participation is available. (2) This section neither restricts nor prohibits any services currently provided by pharmacists as authorized by law, including, but not limited to, this chapter, or the Medicaid state plan. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. By July 1, 2021, 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, 2017, 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. (Amended by Stats. 2024, Ch. 1, Sec. 4. (SB 339) Effective February 6, 2024.)
  93. 14132.969.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must set up an MTM reimbursement system for covered pharmacist services tied to qualified specialty drugs, subject to funding and federal approval.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.969. (a) Subject to an annual appropriation for this express purpose, the department shall implement a medication therapy management (MTM) reimbursement methodology for covered pharmacist services related to the dispensing of qualified specialty drugs by an eligible pharmacy contracted with the department pursuant to subdivision (c). MTM reimbursement pursuant to this section is intended to supplement Medi-Cal payments made to eligible pharmacies for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories, as identified by the department pursuant to paragraph (2) of subdivision (b). (b) In implementing this section, the department shall do all of the following: (1) Establish and maintain protocols and utilization controls for covered MTM pharmacist services. (2) Establish and maintain a list of covered specialty drug therapy categories for which MTM pharmacist services reimbursement is available. (3) Establish and maintain rates of reimbursement for covered MTM pharmacist services under contracts with participating pharmacies pursuant to subdivision (c). (4) Establish and maintain the eligibility criteria and conditions for receipt of MTM pharmacist services reimbursement pursuant to this section. (c) (1) MTM pharmacist services reimbursement pursuant to this section shall only be available to a Medi-Cal enrolled pharmacy that enters into an MTM pharmacist services contract with the department. (2) For purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services. (d) (1) This section shall apply to dates of service on or after July 1, 2021, or to dates of service on or after the effective date reflected in any necessary federal approvals obtained by the department pursuant to paragraph (2), whichever is later. (2) The department shall seek any necessary federal approvals to implement this section. (3) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (e) This section neither restricts nor prohibits any services currently provided by pharmacists as authorized by law, including, but not limited to, this chapter, or the Medicaid state plan. (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins or other similar instructions, without taking any further regulatory action. (g) For purposes of this section, the following definitions apply: (1) “Medication therapy management” or “MTM” means a distinct service or group of services, as determined by the department, that are provided by pharmacists to improve health outcomes of beneficiaries who are at risk of treatment failure due to noncompliance, nonadherence, or other factors found to negatively affect drug therapy outcomes. (2) “Specialty drugs” has the same meaning as set forth in paragraph (13) of subdivision (a) of Section 14105.45. (Added by Stats. 2021, Ch. 143, Sec. 395. (AB 133) Effective July 27, 2021.)
  94. 14132.97.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section sets conditions for waiver personal care services, tells the department and counties what they must do, and limits implementation until required federal approval and fiscal neutrality are in place.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.97. (a) (1) For purposes of this section, “waiver personal care services” means personal care services authorized by the department for persons who are eligible for either nursing or model nursing facility waiver services. (2) Waiver personal care services shall satisfy all of the following criteria: (A) The services shall be defined in the nursing and model nursing facility waivers. (B) The services shall differ in scope from services that may be authorized under Section 14132.95 or 14132.952. (C) The services shall not replace any hours of services authorized or that may be authorized under Section 14132.95 or 14132.952. (b) An individual may receive waiver personal care services if all of the following conditions are met: (1) The individual has been approved by the department to receive services in accordance with a waiver approved under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) for persons who would otherwise require care in a nursing facility. (2) The individual has doctor’s orders that specify that he or she requires waiver personal care services in order to remain in his or her own home. (3) The individual chooses, either personally or through a substitute decisionmaker who is recognized under state law for purposes of giving consent for medical treatment, to receive waiver personal care services, as well as medically necessary skilled nursing services, in order to remain in his or her own home. (4) The waiver personal care services and all other waiver services for the individual do not result in costs that exceed the fiscal limit established under the waiver. (c) The department shall notify the administrator of the In-Home Supportive Services program in the county of residence of any individual who meets all requirements of subdivision (b) and has been authorized by the department to receive waiver personal care services. The county of residence shall then do the following: (1) Inform the department of the services that the individual is authorized to receive under Section 14132.95 or 14132.952 at the time he or she becomes eligible for waiver personal care services. (2) Determine the individual’s eligibility for services under Section 14132.95 or 14132.952 if he or she is not currently authorized to receive those services and if he or she has not been previously determined eligible for those services. (3) Implement the department’s authorization for waiver personal care services for the individual at the quantity and scope authorized by the department. (d) (1) Waiver personal care services approved by the department for individuals who meet the requirements of subdivision (b) may be provided in either of the following ways, or a combination of both: (A) By a licensed and certified home health agency participating in the Medi-Cal program. (B) By one or more providers of personal care services under Article 7 (commencing with Section 12300) of Chapter 3 and subdivision (d) of Section 14132.95, when the individual elects, in writing, to utilize these service providers. (2) The department shall approve waiver personal care services for individuals who meet the requirements of subdivision (b) only when the department finds that the individual’s receipt of waiver personal care services is necessary in order to enable the individual to be maintained safely in his or her own home and community. (3) When waiver personal care services are provided by a licensed and certified home health agency, the home health agency shall receive payment in the manner by which it would receive payment for any other service approved by the department. (4) (A) When waiver personal care services are provided by one or more providers of personal care services under Article 7 (commencing with Section 12300) of Chapter 3 and subdivision (d) of Section 14132.95, the providers shall receive payment on a schedule and in a manner by which providers of personal care services receive payment. The State Department of Social Services shall commence making payments for waiver personal care services when its payment system has been modified to accommodate those payments. A county is not obligated to administer waiver personal care services until the State Department of Social Services payment system has been modified to accommodate those payments. However, any county or public authority or nonprofit consortium that administers the In-Home Supportive Services and personal care services programs may pay providers for the delivery of waiver personal care services if it chooses to do so. In that case, the county, public authority, or nonprofit consortium shall be reimbursed by the department for the waiver personal care services authorized by the department and provided to an individual upon submittal of documentation as required by the waiver, and in accordance with the requirements of the department. (B) For purposes of subparagraph (A) and to the extent the department obtains any federal approvals it deems necessary to implement this subparagraph, “payment” includes wages and benefits. Payments provided pursuant to subparagraph (A) shall be available for service dates on or after the effective date specified in the applicable federal approval obtained by the department and only after the Case Management Information and Payroll System (CMIPS) system has been modified to accommodate these payments, or on July 1, 2019, whichever is sooner. (e) Waiver personal care services shall not be included as alternative resources in a county’s determination of the amount of services an individual may receive under Section 14132.95 or 14132.952. (f) Any administrative costs to the State Department of Social Services, a county, or a public authority or nonprofit consortium associated with implementing this section shall be considered administrative costs under the waiver and shall be reimbursed by the department. (g) Two hundred fifty thousand dollars ($250,000) is appropriated from the General Fund to the State Department of Social Services for the 1998–99 fiscal year for the purpose of making changes to the case management, information, and payrolling system that are necessary for the implementation of this section. (h) This section shall not be implemented until the department has obtained federal approval of any necessary amendments to the existing nursing facility and model nursing facility waivers and the state plan under Title 19 of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.). Any amendments to the existing nursing facility and model nursing facility waivers and the state plan which are deemed to be necessary by the director shall be submitted to the federal Health Care Financing Administration by April 1, 1999. (i) The department shall implement this section only to the extent that its implementation results in fiscal neutrality, as required under the terms of the waivers. (Amended by Stats. 2018, Ch. 35, Sec. 33. (AB 1811) Effective June 27, 2018.)
  95. 14132.971.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Certain counties or related public/nonprofit entities are treated as the employer for bargaining purposes, recipients keep hiring and supervision rights, and pay and benefits must match the county IHSS standard when federal approval conditions are met.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.971. (a) The county, or the public authority or nonprofit consortium established pursuant to Section 12301.6, shall be deemed to be the employer to meet and confer in good faith, in accordance with Chapter 10 (commencing with Section 3500) of Division 4 of Title 1 of the Government Code, regarding wages, benefits, and other terms and conditions of employment of individuals providing waiver personal care services pursuant to Section 14132.97. For purposes of this section, bargaining unit placement pursuant to Section 3507.1 of the Government Code, and waiver personal care services, individuals providing waiver personal care services shall be deemed a part of the established bargaining unit of in-home supportive services providers of an employer of record described in Section 12301.6 in the county in which the individual delivers waiver personal care services. (b) Recipients shall retain the right to hire, fire, and supervise the work of any waiver personal care services personnel providing services to them. (c) For service dates on or after the effective date specified in the applicable federal approval obtained by the department pursuant to subdivision (e), wages, benefits, and all other terms and conditions of employment for individuals providing waiver personal care services pursuant to Section 14132.97 shall be equal to the wages, benefits, and other terms and conditions of employment in the respective county for the individual provider mode of services in the In-Home Supportive Services (IHSS) program pursuant to Article 7 (commencing with Section 12300) of Chapter 3. (d) If eligibility for benefits requires a provider to work a threshold number of hours, eligibility shall be determined based on the aggregate number of monthly hours worked between IHSS and waiver personal care services. (e) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized. (Added by Stats. 2018, Ch. 35, Sec. 34. (AB 1811) Effective June 27, 2018.)
  96. 14132.98.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal must cover routine patient care costs for eligible cancer clinical trial participants when the treating physician recommends the trial and sees meaningful potential benefit.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.98. (a) For a beneficiary diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer or for any other qualifying clinical trial, as defined by Section 1396d(gg)(2) of Title 42 of the United States Code, the Medi-Cal program shall provide coverage for all routine patient care costs related to the clinical trial if the beneficiary’s treating physician, who is providing covered health care services to the beneficiary under the Medi-Cal program, recommends participation in the clinical trial after determining that participation in the clinical trial has a meaningful potential to benefit the beneficiary. For purposes of this section, a clinical trial’s endpoints shall not be defined exclusively to test toxicity, but shall have a therapeutic intent. (b) (1) In accordance with Section 1396d(gg)(1) of Title 42 of the United States Code, “routine patient care costs” means the costs associated with the provision of health care services, including drugs, items, devices, and services that would otherwise be covered under the Medi-Cal program if those drugs, items, devices, and services were not provided in connection with an approved clinical trial program, including: (A) Health care services typically provided absent a clinical trial. (B) Health care services required solely for the provision of the investigational drug, item, device, or service. (C) Health care services required for the clinically appropriate monitoring of the investigational item or service. (D) Health care services provided for the prevention of complications arising from the provision of the investigational drug, item, device, or service. (E) Health care services needed for the reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or treatment of the complications. (2) For purposes of this section, “routine patient care costs” does not include the costs associated with the provision of any of the following: (A) Drugs or devices that have not been approved by the federal Food and Drug Administration and that are associated with the clinical trial. (B) Services other than health care services, such as travel, housing, companion expenses, and other nonclinical expenses, that a beneficiary may require as a result of the treatment being provided for purposes of the clinical trial, except as required under the Medicaid Program (42 U.S.C. Sec. 1396a et seq.). (C) Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient. (D) Health care items or services that, except for the fact that they are being provided in a clinical trial, are not otherwise covered by the Medi-Cal program. (E) Health care services customarily provided by the research sponsors free of charge for any beneficiary in the trial. (c) The treatment shall be provided in a qualifying clinical trial, which means a clinical trial, in any clinical phase of development, that is conducted in relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition and is described in Section 1396d(gg)(2)(A) of Title 42 of the United States Code. (d) This section does not prohibit the Medi-Cal program from restricting coverage for clinical trials to participating hospitals and physicians in California unless the protocol for the clinical trial is not provided for at a California hospital or by a California physician. (e) The provision of services when required by this section shall not, in itself, give rise to liability on the part of the Medi-Cal program. (f) This section shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized. (g) The amendments made to this section by the act that added this subdivision shall become effective on July 1, 2022. (Amended by Stats. 2022, Ch. 47, Sec. 103. (SB 184) Effective June 30, 2022.)
  97. 14132.985.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    If federal financial participation is unavailable, the covered service costs must be paid with state-only funds.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.985. For services provided pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, Section 14499.5, or Chapter 1 (commencing with Section 101525) to Chapter 4 (commencing with Section 101825), inclusive, of Part 4 of Division 101 of the Health and Safety Code, the cost for services defined in Section 1370.6 of the Health and Safety Code and Sections 14087.11 and 14132.98 of this code shall be provided by state-only funds if federal financial participation is not available. (Added by renumbering Section 14132.99 (as amended by Stats. 2002, Ch. 664, Sec. 237) by Stats. 2015, Ch. 303, Sec. 615. (AB 731) Effective January 1, 2016.)
  98. 14132.99.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must speed up waiver processing for certain hospital patients, set out services and limits for the waiver, and handle provider exemptions, notices, review, and reporting.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.99. (a) For the purposes of this section, “facility residents” means individuals who are currently residing in a nursing facility and whose care is paid for by Medi-Cal either with or without a long-term care patient liability. The term “facility residents” also includes individuals who are hospitalized and who are or will be waiting for transfer to a nursing facility. (b) For those patients who are in acute care hospitals and who are pending placement in a nursing facility, the department shall expedite the processing of waiver applications in order to divert hospital discharges from nursing facilities into the community. (c) The Nursing Facility/Acute Hospital Transition and Diversion Waiver shall include the following services: (1) One-time community transition services as defined and allowed by the federal Centers for Medicare and Medicaid Services, including, but not limited to, security deposits that are required to obtain a lease on an apartment or home, essential furnishings, and moving expenses required to occupy and use a community domicile, set-up fees, or deposits for utility or service access, including, but not limited to, telephone, electricity, and heating, and health and safety assurances, including, but not limited to, pest eradication, allergen control, or one-time cleaning prior to occupancy. These costs shall not exceed five thousand dollars ($5,000). (2) Habilitation services, as defined in Section 1915(c)(5) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)(5)), and in attachment 3-d to the July 25, 2003, State Medicaid Directors Letter re Olmstead Update No. 3, to mean services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home- and community-based settings. (d) (1) (A) Notwithstanding paragraphs (1) and (2) of subdivision (d) of Section 12300.4, the department shall grant an exemption, as described in paragraph (2), to a provider of an applicant or participant of the Nursing Facility/Acute Hospital Transition and Diversion Waiver or the In-Home Operations Waiver, or their successors, who was enrolled in either waiver on January 31, 2016, and whose medical or behavioral needs require that the services to the applicant or participant be provided by the requested provider, if any of the following circumstances exists: (i) The provider lives in the same home as the waiver applicant or participant, even if the provider is not a family member. (ii) The provider currently provides care to the waiver participant, and has done so for two or more years continuously. (iii) The waiver applicant or participant is unable to find a local caregiver who speaks the same language as the applicant or participant, resulting in the applicant or participant being unable to direct their own care. (B) For a waiver participant who enrolls in either waiver after January 31, 2016, the department shall grant a provider an exemption from the workweek requirements described in paragraphs (1) and (2) of subdivision (d) of Section 12300.4 on a case-by-case basis pursuant to paragraph (5). (2) A provider of in-home supportive services or waiver personal care services who is granted an exemption pursuant to paragraph (1) may work up to a total of 12 hours per day, and up to 360 hours per month combined for the in-home supportive services and waiver personal care services that they provide, not to exceed each waiver participant’s monthly authorized hours. (3) On a one-time basis upon implementation of this paragraph, the department shall mail an informational notice and an exemption request form to all providers who may be eligible for an exemption pursuant to this subdivision and to the waiver participants to whom the providers provide services. (4) At the time of initial application, and at least annually, the department shall inform all waiver applicants or participants whose providers may be eligible for an exemption pursuant to this subdivision and their providers about the exemptions and the application process. (5) (A) The department shall review the requests for consideration for an exemption described in subparagraph (B) of paragraph (1) pursuant to a process developed by the department with input from stakeholders. The department shall consider whether the waiver applicant or participant meets the criteria described in subparagraph (A) of paragraph (1) in making its determination. (B) Within 30 days of receiving an application for an exemption described in subparagraph (B) of paragraph (1) from a provider and from a waiver applicant or participant on behalf of a provider, the department shall mail a written notification letter to the provider and the waiver applicant or participant for whom the provider provides services of its approval or denial of the exemption. If the department denies the exemption, the department shall also explain in the notification letter the reason for the denial. The department shall use a standardized notification letter, developed by the department in consultation with stakeholders, for purposes of providing the notification letter that is required by this subparagraph. (6) The department shall record the number of requests for exemptions that are received and the number of requests approved or denied. These numbers shall be posted no later than every three months on the department’s internet website. (e) The department shall implement this section only to the extent it can demonstrate fiscal neutrality within the overall department budget, and federal fiscal neutrality as required under the terms of the federal waiver, and only if the department has obtained the necessary approvals and receives federal financial participation from the federal Centers for Medicare and Medicaid Services. (Amended by Stats. 2023, Ch. 42, Sec. 147. (AB 118) Effective July 10, 2023.)
  99. 14132.991.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section lets the director manage and renew a Medi-Cal waiver, including contracting with care management organizations, setting enrollment targets, and ending contracts in some cases.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.991. (a) When renewing the Nursing Facility/Acute Hospital Transition and Diversion Waiver, as authorized by subdivision (t) of Section 14132, the director may take the following actions, among others: (1) Contract with one or more organizations, referred to as a care management contractor, qualified to provide or arrange for delivery of care management and waiver services, including, but not limited to, personal needs assessments, and arranging for services available through public and private agencies, including services available under the waiver, for the waiver participants and applicants. The contract with the care management contractor, the care management contract, may require the care management contractor or their subcontractor, or both, to do all of the following, among other things: (A) Provide, arrange for, or subcontract with community-based providers for the provision of, waiver services to waiver participants. (B) Recognize program and service linkages, coordinate service delivery mechanisms and promote prevention of avoidable institutional placement, emergency room visits or inpatient hospital stays, or both, and coordination between health, social, and long-term services and supports by person-centered care planning. (C) Provide or arrange for, care management to each waiver participant to stabilize their health care, and provide access to home- and community-based services, including managing and anticipating episodes of medical crisis in which transitional care management is needed. (D) Carry out the waiver’s person-centered model of care, pursuant to the requirements set forth in Sections 441.720, 441.725, and 441.540 of Title 42 of the Code of Federal Regulations. (E) Submit all information and reports required by the department, including, but not limited to, annual financial statements in the timeframe specified by the department. (F) Pay any providers of waiver services who are not directly employed by or contracted with the care management contractor no less than the rates specified in the waiver or the department’s fee schedule, whichever is less, for the provider type. (G) Bill the department, at the rate established by the state, for all services the care management contractor provides to waiver participants, directly or through a subcontractor or other direct service provider. (H) Comply with the requirements of the waiver, including any other requirements established by the department regarding waiver operations, including, but not limited to, requirements regarding care coordination. These requirements may be set forth in the care management contract, care management manual, all-county letters, plan letters, plan or provider bulletins or policy letters, or similar instructions. (2) Propose that the waiver provide for achievement of annual cost neutrality in the aggregate to allow enrollment and authorization of waiver services based on the medical necessity of the waiver services on a case-by-case basis. (3) Expand the number of waiver slots up to 5,000 additional slots, the director may seek federal approval to amend the waiver to add additional slots or make changes to the waiver model with approval from the Department of Finance. (4) Require care management contractors to enroll at least 60 percent of all total annual enrollments from either of the following: (A) Hospital, nursing facility, or other institutional settings assisting members with transitions back to the home or community, or both, setting. (B) Individuals who had been continuously receiving in home care services, of the type offered under the waiver, under the Early and Periodic Screening, Diagnosis, and Treatment State Plan benefit, California Children Services or Pediatric Palliative Care programs for children, for at least the prior three months but have at the time of transition exceeded the age limit for that benefit. (5) If the director determines that the care management contractor is not fiscally solvent, or is in danger of becoming fiscally insolvent, the director has the option to immediately terminate the contract with the care management contractor. (6) Terminate or refuse to renew, in whole or in part, a care management contract when the director determines that the action is necessary to protect the health of the beneficiaries or funds appropriated to the Medi-Cal program. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, plan or provider bulletins, policy letters, or other similar instructions, without taking regulatory action. (c) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts entered into or amended pursuant to this section shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and shall be exempt from the review or approval of any division of the Department of General Services. (d) The department shall implement this section only to the extent it can demonstrate federal cost neutrality as required under the terms of the waiver, and only to the extent any necessary federal approvals are obtained and federal financial participation is available. (Added by Stats. 2017, Ch. 52, Sec. 49. (SB 97) Effective July 10, 2017.)
  100. 14132.993.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section lets certain military family members keep or regain their place in specified waiver-program waiting lists when they move out of state on official orders and later return, if they meet the stated conditions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.993. (a) This section applies to the Home- and Community-Based Alternatives Waiver (HCBA), the Assisted Living Waiver (ALW), and, to the extent that the dependent child or spouse of an active duty military service member is deemed eligible for the Medi-Cal program, the Home- and Community-Based Services for the Developmentally Disabled (HCBS-DD) 1915(c) waiver programs, pursuant to state law and Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)). (b) (1) If a dependent child or spouse of an active duty military service member is currently included on the waiting list for a waiver program specified in subdivision (a) and transfers out of state with the military service member on official military orders, the dependent child or spouse shall retain their place on the waiting list for the applicable waiver program if the child or spouse subsequently reestablishes residence in this state. The dependent child’s or spouse’s place on the waiting list shall advance as the waiting list advances during the time they are out of the state. (A) In order for the place on the waiting list to be saved after the dependent child or spouse leaves the state, the dependent child or spouse shall notify the department or its designee that they are leaving the state due to the military service member’s transfer orders and that they are requesting to remain on the waiver program’s waiting list. (B) While the dependent child or spouse resides out of state and is in the first place on the waiver program’s waiting list, and has not informed the department or its designee that the military service member has received official military orders to relocate back to the state, waiver applicants with places farther down the waiting list shall continue to be processed for intake into the waiver program without regard to the dependent child’s or spouse’s place on the waiting list. (C) If a dependent child or spouse who is on the waiver program’s waiting list informs the department or its designee that the military service member has received official military orders to return to the state and that the dependent child or spouse would like to enroll in the waiver program, the department or its designee shall take action on the dependent child’s or spouse’s waiver program application in accordance with their place on the waiver program’s waiting list. (2) If a dependent child or spouse of an active duty military service member enrolled in a waiver program specified in subdivision (a) transfers out of state with the military service member on official military orders, and then returns to the state with the military service member on official military orders, the dependent child or spouse shall be reenrolled in the applicable waiver program if there is an open slot in the waiver program, or shall be placed in the first place on the waiver program’s waiting list if there is no open slot in the waiver program, subject to the dependent child or spouse meeting all of the following conditions: (A) The dependent child or spouse reestablishes residence in this state. (B) The dependent child or spouse submits an application for enrollment in the waiver program and is found to be eligible for the applicable waiver program. (i) If no more than three years have passed since the dependent child or spouse left the waiver program, they may apply for reenrollment in the waiver program using an abbreviated waiver program enrollment form developed by the department. (ii) If more than three years have passed since the dependent child or spouse left the waiver program, they shall apply for reenrollment in the waiver program using the standard waiver program enrollment form for that waiver program. (iii) The dependent child or spouse shall follow the regular Medi-Cal eligibility and enrollment processes to obtain Medi-Cal enrollment. (c) An individual applying for a waiver program specified in subdivision (a) who is a dependent child or spouse of an active duty military service member and is residing out of state with that military service member may submit the individual’s application to enroll in that waiver program as soon as the military service member receives official military orders to transfer to this state and before moving to this state. A copy of the order shall be submitted with the application for the Medi-Cal program and the applicable waiver program. The department or its designee may work with the dependent child or spouse, or their family, prior to their actual relocation to the state in order to evaluate the waiver program application with the goal of having medically necessary waiver program services in place as soon as possible when the family relocates to the state. (d) (1) This section is not intended to authorize the provision of services to a dependent child or spouse of an active duty military service member through a waiver program specified in subdivision (a) while the dependent child or spouse is transferred to, and living, out of state with the military service member, or has not yet transferred to this state. Waiver program services provided to a dependent child or spouse under this section shall only be provided upon their establishing residence in this state and enrolling in Medi-Cal and the waiver program. (2) This section is not intended to prevent another individual from receiving services through a waiver program described in subdivision (a) due to lack of space in the applicable waiver program on the sole basis that a dependent child or spouse described in this section is placed on the waiting list for that waiver program while the dependent child or spouse is transferred to, and living, out of state with the military service member, or has not yet transferred to this state. (e) For purposes of this section, “dependent child” means an individual, whether a minor or an adult, who is a dependent of a parent or guardian. (f) (1) This section shall be implemented only to the extent that any necessary federal approvals have been obtained and that federal financial participation is available. (2) The department may seek amendments to the waiver programs specified in subdivision (a), or take other action, as necessary to implement this section. (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of letters or other similar instructions, without taking regulatory action. (Added by Stats. 2019, Ch. 846, Sec. 1. (SB 289) Effective January 1, 2020.)
  101. 14132.994.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    A Medi-Cal managed care plan must cover COVID-19 screening, testing, immunizations, and therapeutics, following the listed statutes, regulations, plan letters, manuals, contracts, and other guidance.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.994. A Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, shall cover COVID-19 screening, testing, immunizations, and therapeutics in accordance with applicable statutes, regulations, all plan letters, the Medi-Cal provider manual, Medi-Cal managed care plan contracts with the department pursuant to this chapter or Chapter 8 (commencing with Section 14200), and other guidance. (Added by Stats. 2025, Ch. 21, Sec. 106. (AB 116) Effective June 30, 2025.)
  102. 14132.995.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal coverage for vaccines and immunizations follows specified federal and professional recommendations, and implementation depends on federal funding and approvals.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14132.995. (a) Notwithstanding any other law, vaccines and immunizations are covered in accordance with a recommendation from the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians or any modification or supplement to that recommendation adopted pursuant to Section 120164 of the Health and Safety Code, with respect to the individual involved. (b) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained. (c) Notwithstanding any other law, the department, without taking any further regulatory action, may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions. (Added by Stats. 2025, Ch. 105, Sec. 61. (AB 144) Effective September 17, 2025.)
  103. 14133.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section limits which utilization controls may be applied to certain Medi-Cal services, including prior authorization, postservice prepayment audit, postservice postpayment audit, service limits, and review under Professional Standards Review Organization agreements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133. Utilization controls that may be applied to the services set forth in Section 14132 which are subject to utilization controls shall be limited to: (a) Prior authorization, which is approval by a department consultant, of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Prior authorization includes authorization for multiple services which are requested and granted on the basis of an extended treatment plan where there is a need for continuity in the treatment of a chronic or extended condition. (b) Postservice prepayment audit, which is review for medical necessity and program coverage after service was rendered but before payment is made. Payment may be withheld or reduced if the service rendered was not a covered benefit, deemed medically unnecessary or inappropriate. Nothing in this subdivision shall supersede the claims processing deadlines provided by Section 14104.3. (c) Postservice postpayment audit, which is review for medical necessity and program coverage after service was rendered and the claim paid. The department may take appropriate steps to recover payments made if subsequent investigation uncovers evidence that the claim should not have been paid. (d) Limitation on number of services, which means certain services may be restricted as to number within a specified time frame. (e) Review of services pursuant to Professional Standards Review Organization agreements entered into in accordance with Section 14104. (Amended by Stats. 1979, Ch. 373.)
  104. 14133.01.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department and its designee may use a sampling methodology for prior authorization, and the department must set and manage several TAR processing requirements, including electronic submission rules and backup submission methods.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.01. (a) Notwithstanding any other law, the director or his or her designee may apply prior authorization by designing a sampling methodology that will result in a generally acceptable audit standard for approval of a treatment authorization request (TAR), or a class of TARs. The director or his or her designee shall determine the applicable sampling methodology based upon health care industry standards and discussions with applicable Medi-Cal providers or their representatives. This sampling methodology shall be implemented by no later than July 1, 2005, and an outline of the methodology shall be provided to the fiscal and policy committees of both houses of the Legislature. It is the intent of the Legislature for the department to review the sampling methodology on an ongoing basis and update the methodology as applicable on a periodic basis in order to keep abreast of health care industry trends and the need to manage an efficient and effective Medi-Cal program. (b) The department shall pursue additional means to improve and streamline the treatment authorization request process including, where applicable, those identified by independent analyses such as the July 2003 report by the California HealthCare Foundation entitled Medi-Cal Treatment Authorizations and Claims Processing: Improving Efficiency and Access to Care, and those identified by Medi-Cal providers. It is the Legislature’s intent that any identified improvements be cost beneficial to the state and to the Medi-Cal program as a whole. (c) (1) By July 1, 2016, or a subsequent date determined by the department, treatment authorization requests, excluding treatment authorization requests submitted by dental providers enrolled in the Medi-Cal Dental program, shall be submitted in an electronic format determined by the department and shall be submitted via the department’s Internet Web site or other electronic means designated by the department. The department may implement this requirement in phases. (2) The department shall consider the capacity of independent sole practitioners, small independent provider-owned clinics, and rural providers to comply with the requirements of this section, and shall implement the electronic submission process in a manner that offers these providers both of the following: (A) Reasonable time to establish the infrastructure necessary for the generation of electronic treatment authorization requests. (B) An opportunity to participate in education and training regarding the generation and submission of electronic treatment authorization requests provided by the department or its agents. (3) The department shall designate an alternate format for submitting requests for authorization of services when the department’s Internet Web site or other electronic means designated in paragraph (1) are unavailable due to a system disruption. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking regulatory action, implement, interpret, or make specific, this section and any applicable waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions. Thereafter, the department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The department shall consult with interested parties and appropriate stakeholders in implementing this section. (Amended by Stats. 2014, Ch. 849, Sec. 3. (SB 1457) Effective January 1, 2015.)
  105. 14133.05.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must review treatment authorization requests only for medical necessity. Providers may appeal an adverse decision, but they must use available administrative remedies before going to court.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.05. (a) Notwithstanding any other provision of law, a request for a treatment authorization received by the department shall be reviewed for medical necessity only. (b) Any claim for a service that is authorized pursuant to a treatment authorization request that qualifies for approval under the requirements established by the department in regulations shall be reduced in accordance with Section 14115. (c) If a provider does not agree with the decision on a treatment authorization request, the provider may appeal the decision pursuant to procedures set forth in regulations adopted by the department. (d) Providers shall comply with the administrative remedies available to them prior to seeking a judicial remedy with respect to a decision of the department on a treatment authorization request. (Added by Stats. 2000, Ch. 93, Sec. 95. Effective July 7, 2000.)
  106. 14133.07.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    A doctor of podiatric medicine is not required to seek prior authorization for podiatric services when a physician and surgeon providing the same services would not have to do so, and must follow the same Medi-Cal billing and service policies as a physician and surgeon.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.07. (a) A doctor of podiatric medicine shall not be required to submit prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician and surgeon providing the same services would not be required to submit prior authorization to the department. (b) A doctor of podiatric medicine acting within their scope of practice and providing services pursuant to subdivision (a) is subject to the same Medi-Cal billing and services policies as required for a physician and surgeon, including, but not limited to, a maximum numerical service limitation in any one calendar month. (Repealed and added by Stats. 2019, Ch. 433, Sec. 2. (AB 678) Effective January 1, 2020.)
  107. 14133.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director must decide which utilization controls apply to specific services, and those controls must be reasonably related to their purpose. Prior authorization is not required for the first two covered services or the first two drug prescriptions each month if formulary conditions are met, and the director may modify or remove prior authorization for low-cost items under $100, with notice and findings required to reinstate it.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.1. (a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any specific service or group of services which are subject to utilization controls. Each utilization control shall be reasonably related to the purpose for which it is imposed. (b) Except as provided in Sections 14103.6 and 14133.15, neither prior authorization nor the limitation specified in subdivision (d) of Section 14133 shall be required for the first two services per month which are included among the services listed in subdivision (a) of Section 14132, or for the first two drug prescriptions purchased during any one month, provided that the prescription drugs are included in the Medi-Cal Drug Formulary and the prescription otherwise conforms to applicable formulary requirements. (c) The director shall, after a determination of cost benefit, modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment which costs less than one hundred dollars ($100), except for prescribed drugs, provided that the requirement of prior authorization for treatment, supplies, or equipment may be reinstituted upon a finding by the department that the elimination of the requirement has resulted in unnecessary utilization, and upon notice to the Joint Legislative Budget Committee 30 days prior to the reinstitution of the requirement of prior authorization. Modification of the utilization controls may include establishing prior authorization review thresholds at levels other than one hundred dollars ($100) if indicated by the cost-benefit analysis. (Amended by Stats. 1986, Ch. 775, Sec. 1.)
  108. 14133.10.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director may create a Medi-Cal case management program and contract for related expertise; the department may do daily reviews and must seek needed federal waivers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.10. (a) Where it is expected to be cost-effective, the director may, in conducting Medi-Cal acute care inpatient hospital utilization control, establish a program of aggressive case management of elective, nonemergency acute care hospital admissions for the purpose of reducing both the numbers and duration of acute care hospital stays by Medi-Cal beneficiaries. (b) In conducting the case management program, the department may, conduct daily reviews to determine the need for additional days of inpatient care. (c) In undertaking this case management program, the director may enter into contracts, on a bid or nonbid basis, for the purposes of obtaining the necessary expertise to train and educate utilization control staff in case management concepts, principles and techniques, identify and recommend cost-effective therapies, services and technology as alternatives to elective acute care hospitalization or to directly provide the case management and diversion services. (d) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts under this article may be on a nonbid basis, and shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. Contracts shall have no force and effect unless approved by the Department of Finance. (e) The department shall seek all federal waivers necessary to allow for federal financial participation under this section. (Added by Stats. 1992, Ch. 722, Sec. 122. Effective September 15, 1992.)
  109. 14133.12.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director must apply utilization controls to certain continuous skilled nursing care services, and the department must monitor them and consult with specified agencies.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.12. (a) The director shall apply utilization controls to continuous skilled nursing care services provided pursuant to the pilot program established under Section 14495.10, including, but not limited to, prior authorization and monitoring by the department. Prior authorization shall ensure that continuous skilled nursing care services are medically necessary, and that the provision of continuous skilled nursing care will avoid a transfer to, or placement at, a higher level of service. Monitoring shall be conducted by the department including, but not limited to, evaluation of quality of life, health, safety, and well-being of the beneficiary, and quality, efficiency, and cost effectiveness of the continuous skilled nursing care services. The department shall consult with the State Department of Developmental Services and regional centers to design monitoring efforts. (b) Payment of the reimbursement rates established pursuant to Section 14110.55 shall be subject to all billing criteria of the Medi-Cal program and the utilization controls set forth in this section. (c) This section shall become operative only if the federal waiver identified under Section 14495.10 is approved by the federal Health Care Financing Administration. The director shall maintain a record of the satisfaction of this condition. (Added by Stats. 1999, Ch. 845, Sec. 2. Effective January 1, 2000. Conditionally operative by its own provisions.)
  110. 14133.14.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must use specified criteria to choose providers for prior authorization for noninvasive testing, and those providers must have access to the existing prior authorization appeals process for denial of services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.14. The criteria that the department shall use to identify providers to be placed on prior authorization for noninvasive testing procedures shall include, but not be limited to, Medi-Cal trend analysis, provider profiling data, provider and beneficiary history data, or appropriateness of the services as related to diagnosis, volume of services, utilization patterns, and specialty of provider. The existing prior authorization appeals process shall be available to these providers for denial of services. (Added by Stats. 1997, Ch. 294, Sec. 72. Effective August 18, 1997.)
  111. 14133.15.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director may place certain Medi-Cal recipients or services under utilization controls, limit benefits to one primary care provider, and extend those restrictions up to two years in specified cases.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.15. (a) The provision of services to beneficiaries eligible for medical assistance benefits may be subject to utilization controls, as provided for in Section 50793 of Title 22 of the California Administrative Code as the section existed on January 1, 1984, when the director finds that the utilization controls are necessary to carry out the provisions of this chapter. (b) Where the director determines that a recipient has been abusing drugs or services, the recipient may, in order to prevent his or her abuse, be placed on utilization controls for a maximum period of two years, which may be extended for an additional period upon a determination by the director that the potential for abuse still exists after notice and hearing, as set forth in subdivisions (f) and (g). (c) If the director determines that a recipient has violated utilization controls placed upon that recipient pursuant to subdivision (b), the director may provide that the recipient shall receive medical assistance benefits referred, ordered, or prescribed through only one primary care provider of services for a maximum period of two years, which may be extended for an additional period upon a determination by the director that the potential for abuse still exists after notice and hearing, as set forth in subdivisions (f) and (g). The director shall afford the beneficiary an opportunity to nominate a primary care provider for department consideration. Circumvention of beneficiary utilization controls includes, but is not limited to, the following acts: (1) Altering restricted Medi-Cal identification cards. (2) Obtaining temporary nonrestricted cards. (3) Establishing an additional nonrestricted eligibility status. (d) If a recipient is convicted of any misdemeanor or felony involving fraud or abuse either of medical assistance benefits or services, or in connection with any public assistance program, the director may restrict the recipient’s eligibility for medical assistance benefits for a maximum period of two years, which may be extended for an additional period upon a determination by the director that the potential for fraud or abuse still exists and upon giving notice to the recipient setting forth the facts upon which the determination is made. The record of conviction or a certified copy thereof, certified by the clerk of the court in which the conviction is had, shall be conclusive evidence of the fact that the conviction occurred. A plea or verdict of guilty, or a conviction following a plea of nolo contendere, is deemed to be a conviction within the meaning of this section. The restriction shall not take effect earlier than the date of the director’s order. Restriction following a conviction is not subject to the proceedings required in subdivision (g). (e) Where the director determines that a recipient deliberately abuses or misuses program benefits, the director may provide that the recipient shall receive medical assistance benefits referred, ordered, or prescribed through only one primary care provider of services for a maximum period of two years, which may be extended for an additional period upon a determination by the director that a potential for abuse still exists after notice and hearing as set forth in subdivisions (f) and (g). Deliberate abuse or misuse of program benefits includes, but is not limited to, the following: (1) Forging prescriptions. (2) Sale or lending of Medi-Cal identification cards. (3) Collusion with providers for services or supplies. (f) A recipient who commits a violation of subdivision (b), (c), or (e) shall be notified of the impending restriction, the reasons for the restriction and be provided an opportunity for a fair hearing. (g) A recipient who commits a violation of subdivision (b), (c), or (e) is subject to restriction of fee for service Medi-Cal assistance benefits. The proceedings for restriction shall be conducted in accordance with Chapter 7 (commencing with Section 10950) of Part 2, or any rule or regulation promulgated by the director pursuant to this section. (h) The imposition of restrictions, pursuant to this section, with respect to the eligibility of any individual shall not affect the eligibility of any other person for medical assistance benefits under this program, regardless of the relationship between that individual and the other person. (i) This section shall not apply in any instance where a bona fide emergency exists which requires immediate treatment. (Added by Stats. 1985, Ch. 425, Sec. 4.)
  112. 14133.16.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Hearing aids are covered when prescribed and supplied under the stated clinical steps, and Medi-Cal generally pays for one hearing aid assessment within 12 months.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.16. (a) Notwithstanding subdivision (l) of Section 14132, hearing aids are covered when supplied by a hearing aid dispenser on prescription of an otolaryngologist, or the attending physician where there is no otolaryngologist available in the community, plus an audiological evaluation, which shall be performed by or under the supervision of the attending physician or by a licensed audiologist. (b) Prior to prescribing a hearing aid, a physician or otolaryngologist shall perform a complete ear, nose, and throat examination. (c) Prior to coverage, a hearing aid assessment shall be performed by the dispensing practitioner, either a physician, a licensed audiologist, or a licensed hearing aid dispenser acting within the scope of practice as described in Section 3306 of the Business and Professions Code. (d) Coverage shall be based on the results of the examination, evaluation, and assessment required by this section. (e) One hearing aid assessment within a 12-month period is a covered benefit. In the event the beneficiary receives more than one hearing aid assessment within a 12-month period, Medi-Cal shall reimburse the first valid claim received by the program for only one hearing aid assessment unless additional assessments are deemed to be medically necessary. (Added by Stats. 2002, Ch. 704, Sec. 1. Effective January 1, 2003.)
  113. 14133.2.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director must add certain cancer drugs to the Medi-Cal contract drug list, and some drugs must be treated as Medi-Cal benefits if the manufacturer has the required rebate contract.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.2. (a) The director shall include in the Medi-Cal list of contract drugs any drug approved for the treatment of cancer by the federal Food and Drug Administration, so long as the manufacturer has executed a contract with the Health Care Financing Administration which provides for rebates in accordance with Section 1396r-8 of Title 42 of the United States Code. These drugs shall be exempt from the contract requirements of Section 14105.33. (b) In addition to any drug added to the list of contract drugs pursuant to subdivision (a), any drug that meets either of the following criteria and for which the manufacturer has executed a contract with the Health Care Financing Administration that provides for rebates in accordance with Section 1396r-8 of Title 42 of the United States Code, shall be a Medi-Cal benefit, subject to utilization controls, unless the contract requirements of Section 14105.33 have been complied with: (1) Any drug approved by the federal Food and Drug Administration for treatment of opportunistic infections associated with cancer. (2) Any drug or biologic used in an anticancer chemotherapeutic regimen for a medically accepted indication, which has either been approved by the federal Food and Drug Administration, or recognized for that use in a compendia listed in Section 1927 of the federal Social Security Act (42 U.S.C. Sec. 1396r-8). (Amended by Stats. 2009, Ch. 479, Sec. 6. (AB 830) Effective January 1, 2010.)
  114. 14133.225.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must not provide or pay for erectile dysfunction drugs or therapy for people required to register under Penal Code Section 290, except where federal law requires it.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.225. Notwithstanding any other law, the department shall not provide or pay for any prescription drug or other therapy to treat erectile dysfunction for any person who is required to register pursuant to Section 290 of the Penal Code, except to the extent required under federal law. The department may require from the Department of Justice the information necessary to implement this section. (Added by Stats. 2005, Ch. 469, Sec. 3. Effective October 4, 2005.)
  115. 14133.23.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section limits Medi-Cal drug benefits for full-benefit dual eligible beneficiaries to benefits with federal financial participation, with some emergency and time-limited exceptions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.23. (a) To the extent that federal financial participation is not available, the provision of drug benefits under this chapter to full-benefit dual eligible beneficiaries who are eligible for drug benefits under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a Medicare Advantage-Prescription Drug plan (MA-PD plan) under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.), is eliminated, except as otherwise provided under this section. (b) (1) Notwithstanding any other provision of law, only drug benefits for which federal financial participation is available shall be provided under this chapter to a full-benefit dual eligible beneficiary, except as otherwise provided under subdivision (c). (2) As a benefit under this chapter, the department, subject to the approval of the Department of Finance and only to the extent that federal financial participation is available, may elect to provide a drug or drugs in a class of drugs not covered under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.) to full-benefit dual eligible beneficiaries. (3) As a benefit under this chapter, and only to the extent that federal financial participation is available, the department shall provide a drug or drugs to full-benefit dual eligible beneficiaries who are otherwise eligible to receive the drug or drugs due to their entitlement under Title 42 United States Code, Chapter 7, Title XVIII, Part A or their enrollment under Title 42 United States Code, Chapter 7, Title XVIII, Part B. (4) Except as provided under paragraph (3) and subdivision (c), nothing in this section shall be interpreted to require the department to provide any drug or drugs not covered under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.) if federal financial participation is not available. (c) (1) The department shall review the drug formularies of prescription drug plans under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or MA-PD plans under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.) available to full-benefit dual eligible beneficiaries. (2) The department shall develop a process that would allow the department to provide to a full-benefit dual eligible beneficiary, on an emergency basis only, coverage for a drug or drugs not included on the full-benefit dual eligible beneficiary’s prescription drug plan’s formulary or by prior authorization under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or MA-PD plans under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.) for which federal financial participation is not available. (3) Only to the extent that the Legislature made a specific appropriation to fund the provision of emergency drug benefits for which federal financial participation is not available to full-benefit dual eligible beneficiaries, the department shall provide, through the process described in paragraph (2), these emergency drug benefits to a full-benefit dual eligible beneficiary only when all of the following conditions are met: (A) The drug is not available to the full-benefit dual eligible beneficiary under his or her plan’s drug formulary or by prior authorization. (B) The pharmacist provides or dispenses the drug as an emergency service. (C) The quantity of the drug provided or dispensed in no greater than a 60-day supply. (D) The pharmacist has not previously provided or dispensed nor has knowledge that another pharmacist has provided or dispensed the same drug for that full-benefit dual eligible beneficiary on or after January 1, 2006. (E) The date of service is from January 1, 2006, through December 31, 2006, inclusive. (4) The department may impose a pre- or post-service prepayment or postpayment review or audit, to review the medical necessity of emergency services provided to full-benefit dual eligible beneficiaries. (d) The department shall seek approval of any amendments to the state plan necessary to implement this section as required by Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.). (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret or make specific this section by means of all county letters, provider bulletins, or similar instructions. Thereafter, the department may 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. (f) (1) Notwithstanding any other provision of this section, and only to the extent that funds are appropriated for this purpose, the department shall provide on a time-limited basis, as described in paragraphs (7) and (8), drug benefits to a full-benefit dual eligible beneficiary who is not able to obtain drug benefits from his or her Medicare Drug Plan only when one or more of the following conditions are met: (A) The pharmacy has submitted a claim for the provision of drug benefits to the full-benefit dual eligible beneficiary’s Medicare Drug Plan and the claim has been denied payment for reasons other than processing errors or omissions made by the pharmacy, lack of medical necessity, or health or safety reasons. (B) The pharmacy is unable to submit a claim for the provision of drug benefits solely due to the unavailability of complete or accurate Medicare Drug Plan enrollment information from the full-benefit dual eligible beneficiary’s Medicare Drug Plan, the federal Centers for Medicare and Medicaid Services, or entities under contract with the Centers for Medicare and Medicaid Services to provide enrollment information. (C) The Medicare Drug Plan provides information that the full-benefit dual eligible beneficiary’s deductible or copayment amount is higher than the copayment amounts that are established by Medicare for full-benefit dual eligible beneficiaries. (2) The director may impose a pre- or post-service prepayment or postpayment review or audit to determine whether a pharmacy has accurately and in good faith established the existence of any condition certified by the pharmacy pursuant to subparagraph (A), (B), or (C) of paragraph (1) in support of a submitted claim to the department. (3) If the claim submitted by the pharmacy to the Medicare Drug Plan meets the circumstances described in subparagraph (C) of paragraph (1), the department shall pay the Medi-Cal rate less the Medicare Drug Plan reimbursement amount and the Medicare copayment amount. (4) To obtain reimbursement from the department, a pharmacy must be an enrolled provider in the Medi-Cal program and certify on its claims under penalty of perjury that one of the conditions specified in paragraph (1) exists. (5) The department shall seek reimbursement from the federal government of all funds spent to comply with the provisions of this subdivision. (6) To the extent that the department reimburses a pharmacy for claims authorized under this subdivision, the director shall have the right to recover or recoup the full cost expended by the state for that reimbursement from the full-benefit dual eligible beneficiary’s Medicare Drug Plan. (7) Reimbursement for claims authorized under this subdivision shall be limited to those drug benefits provided to a full-benefit dual eligible beneficiary from January 12, 2006, to February 15, 2006, inclusive. (8) After February 15, 2006, the Governor may, upon notice to the Joint Legislative Budget Committee, extend coverage for drug benefits to a full-benefit dual eligible beneficiary for coverage periods of up to 30 days each. In no event shall the reimbursement authorized by this paragraph extend beyond May 16, 2006. (9) Any drug benefits made available to full-benefit dual eligible beneficiaries under the authority of this subdivision shall be limited to the funds appropriated by the Legislature to the department for this purpose. These drug benefits shall not be deemed to be an entitlement. (g) (1) Notwithstanding any other provision of this section, and only to the extent that funds are appropriated for this purpose, beginning May 17, 2006, and ending January 31, 2007, the department shall provide emergency drug benefits to a full-benefit dual eligible beneficiary who is unable to obtain drug benefits from his or her Medicare Drug Plan only when one or more of the following conditions are met: (A) The pharmacy has submitted a claim for the provision of drug benefits to the full-benefit dual eligible beneficiary’s Medicare Drug Plan and the claim has been denied payment due to error by the Medicare Program and the pharmacy has made a good faith effort to resolve the error with the Medicare Drug Plan and the Medicare Program. (B) The pharmacy is unable to submit a claim for the provision of drug benefits solely due to incomplete or inaccurate Medicare Drug Plan enrollment information from the full-benefit dual eligible beneficiary’s Medicare Drug Plan, the federal Centers for Medicare and Medicaid Services, or entities under contract with the Centers for Medicare and Medicaid Services to provide enrollment information, and the pharmacy has attempted to resolve these problems with the Medicare facilitated enrollment contractor and the Medicare Drug Plan, where appropriate. (C) The Medicare Drug Plan provides information that the full-benefit dual eligible beneficiary’s deductible or copayment amount is higher than the copayment amounts that are established by Medicare for full-benefit dual eligible beneficiaries. (D) Request for prior authorization or exception to the full-benefit dual eligible beneficiary’s Medicare Drug Plan is required and was sought by the pharmacist, but the pharmacy does not receive a response within 24 hours for an emergency drug or within 72 hours for a nonemergency drug. When submitting a request for prior authorization to the department, a pharmacy shall show proof of the submission of the request that was made to either the Medicare Drug Plan or the beneficiary’s prescribing physician. (2) In providing these benefits, the department shall implement prepayment utilization controls, including prior authorization, and may implement postpayment reviews or audits to determine whether a pharmacy has accurately and in good faith established the existence of any condition certified by the pharmacy pursuant to subparagraph (A), (B), (C), or (D) of paragraph (1) in support of a submitted claim to the department. (3) If the claim submitted by the pharmacy to the Medicare Drug Plan meets the circumstances described in subparagraph (C) of paragraph (1), the department shall pay only the difference between the copayment amount established by Medicare for full-benefit dual eligible beneficiaries and the actual copayment amount charged. (4) To obtain reimbursement from the department, a pharmacy must be an enrolled provider in the Medi-Cal program and certify on its claims under penalty of perjury that one of the conditions specified in paragraph (1) exists. (5) To the extent that the department reimburses a pharmacy for claims authorized under this subdivision, the director shall have the right to recover or recoup the full cost expended by the state for that reimbursement from the full-benefit dual eligible beneficiary’s Medicare Drug Plan. (6) Any drug benefits made available to full-benefit dual eligible beneficiaries under the authority of this subdivision shall not be deemed to be an entitlement. Beginning September 1, 2006, the department shall not cover drug benefits when prior authorization or exception to the full-benefit dual eligible beneficiary’s Medicare Drug Plan is required, unless that authorization was sought by the physician and the Medicare Drug Plan does not provide a response within 24 hours for an emergency drug or within 72 hours for a nonemergency drug. (h) (1) For the purposes of this section, a “full-benefit dual eligible beneficiary” means an individual who meets both of the following criteria: (A) The beneficiary is eligible or would be eligible for coverage for the month for covered Part D drugs under a prescription drug plan under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.). (B) Notwithstanding any other provision of this section, the beneficiary is determined eligible for full-scope services, including drug benefits, for which federal financial participation is available. (2) For the purposes of this section, “Medicare Drug Plan” means a prescription drug plan under Part D of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.). (i) Subdivisions (a) and (b) and paragraph (3) of subdivision (c) shall become operative on January 1, 2006. (Amended by Stats. 2006, Ch. 24, Sec. 1. Effective May 15, 2006.)
  116. 14133.25.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director must identify outpatient-capable procedures, set outpatient performance conditions, and use utilization controls; the director may also require prior authorization for specified procedures and set differential reimbursement rates.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.25. (a) The director shall identify those surgical and medical procedures capable of outpatient performance and establish conditions for assuring performance in an outpatient rather than inpatient setting when medically appropriate. (b) The director shall identify and apply appropriate utilization controls to review outpatient and office medical and surgical procedures for medical necessity and program coverage. The director may under this section identify and require prior authorization for any specified outpatient or office medical or surgical procedure performed during a month without regard to the provisions of Section 14133.1, provided that, with respect to outpatient or office medical procedures, those medical procedures which remain not subject to prior authorization are sufficient in number and scope as to achieve the general purpose of Section 14133. 1. (c) The director may establish a schedule of differential reimbursement rates to the operating surgeon for surgery procedures. Those surgery procedures which can safely be performed on an outpatient basis may be reimbursed at a higher level when performed in an outpatient setting than the same procedures performed on an inpatient basis. (d) Provisions of this section shall not be applied to mental health services as defined under Division 5 (commencing with Section 5000) or Section 14021, or any other mental health services funded by the Medi-Cal program. (Amended by Stats. 1982, Ch. 1594, Sec. 60. Effective September 30, 1982.)
  117. 14133.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The director must require documented medical justification for prior authorization requests and set utilization controls for certain emergency services. The section does not apply to specified mental health services, and it preserves payment for certain federally mandated family planning and screening services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.3. (a) The director shall require fully documented medical justification from providers that the requested services are medically necessary or a medical necessity, as defined in Section 14059.5, on all requests for prior authorization. (b) For services not subject to prior authorization controls, offered by noncontract hospitals in closed health facility planning areas to beneficiaries who were experiencing life-threatening or emergency situations, but could not be stabilized sufficiently in order to facilitate being transported to contracting hospitals, the director shall additionally determine utilization controls that shall be applied to ensure that the health care services provided and the conditions treated, are medically necessary to prevent significant illness, alleviate severe pain, to protect life, or prevent significant disability. These utilization controls shall take into account those diseases, illnesses, or injuries that require preventive health services or treatment to prevent serious deterioration of health. (c) Nothing in this section shall preclude payment for family planning services or early and periodic screening, diagnosis, and treatment services mandated by federal law. (d) For the purposes of this section, a “noncontract hospital” means a hospital that has not contracted with the department for the provision of inpatient services pursuant to Article 2.6 (commencing with Section 14081). (e) This section shall not be applied to mental health services as defined under Division 5 (commencing with Section 5000) or Section 14021, or any other mental health services funded by the Medi-Cal program. (Amended by Stats. 2018, Ch. 855, Sec. 2. (SB 1287) Effective January 1, 2019.)
  118. 14133.37.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must process prior-authorization requests for covered drugs promptly, respond within 24 hours, and, when federal law allows, make at least a 72-hour emergency supply available.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.37. For drugs covered under this chapter requiring prior authorization, the department shall ensure the timely and efficient processing of authorization requests by doing all of the following: (a) Providing a response by telephone or other means of telecommunication within 24 hours of the receipt of an authorization request. (b) To the extent permitted by federal law, providing for the dispensing of at least a 72-hour supply of a covered drug in an emergency situation, as defined by federal regulation. (Added by Stats. 1991, Ch. 563, Sec. 2.)
  119. 14133.4.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The State Department of Health Services may not include prior authorization in utilization controls for portable X-ray services in nursing facilities and intermediate care facilities for the developmentally disabled.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.4. Notwithstanding any other provision of law, utilization controls adopted by the State Department of Health Services shall not include prior authorization for portable X-ray services provided in nursing facilities and all categories of intermediate care facilities for the developmentally disabled, as defined in Section 1250 of the Health and Safety Code. (Amended by Stats. 1990, Ch. 1329, Sec. 30. Effective September 26, 1990.)
  120. 14133.45.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department may not require prior authorization for renal dialysis treatment for eligible recipients with end stage renal disease, and it may implement this section by provider manual or similar notice.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.45. (a) Utilization controls adopted by the department shall not include prior authorization for renal dialysis treatment provided to eligible recipients for the treatment of end stage renal disease. (b) For purposes of this section, “end stage renal disease” is the same as defined in subdivision (d) of Section 1794.02 of the Health and Safety Code. (c) Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of the Government Code, the department may implement this section by provider manual or similar notice without further regulatory action. (Added by Stats. 2003, Ch. 321, Sec. 1. Effective January 1, 2004.)
  121. 14133.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must consider relevant beneficiary information and handle prior authorization requests for nonemergency medical transportation promptly, and it may not create separate field-office units for those requests.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.6. In acting upon prior authorization requests for nonemergency medical transportation services, the department shall consider all relevant information in its possession regarding the beneficiary for whom services are requested. The department shall act upon such requests in a timely and expeditious manner. The department shall not form separate units within its field offices to receive and act upon prior authorization requests for nonemergency medical transportation. The provisions of this section shall be applicable only in counties having a population in excess of 6,000,000. (Added by Stats. 1981, Ch. 1081, Sec. 1.)
  122. 14133.65.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Prior authorization for nonemergency medical transportation to and from dialysis treatment must be approved for up to one year if the patient has used the transportation for the previous 12 months, a physician supports the renewed request, and the department finds medical necessity.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.65. Prior authorization for the use of nonemergency medical transportation services by patients to and from dialysis treatment shall be approved for a period of up to one year when the patient has received the transportation services for the immediately preceding 12 months, the request for renewed prior authorization is supported by a physician’s certification that the patient’s condition is unlikely to improve during the period covered by the request, and the department has determined that there is medical necessity for the service. Whenever there is a change or improvement in the patient’s condition, the physician shall submit a new certification to the department. (Added by Stats. 1985, Ch. 863, Sec. 1.)
  123. 14133.7.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must not require emergency certification statements for certain hospital inpatient claims.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.7. The department shall not require emergency certification statements for hospital inpatient claims which have been reviewed and approved by the department for appropriateness of emergency admission or length of stay. (Added by Stats. 1981, Ch. 1164, Sec. 5.)
  124. 14133.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Bone marrow transplants for eligible Medi-Cal beneficiaries are reimbursable if the stated conditions are met.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.8. (a) A bone marrow transplant for the treatment of cancer for beneficiaries who are eligible for full-scope benefits under this chapter, shall be reimbursable under this chapter, when all of the following conditions are met: (1) The bone marrow transplant is recommended by the recipient’s physician. (2) The bone marrow transplant is performed in a hospital that is approved for participation in the Medi-Cal program. (3) The bone marrow transplant is a reasonable course of treatment and is approved by the hospital medical policy committee when there is an existing committee or a committee can be established. (4) The bone marrow transplant has been deemed appropriate for the recipient by the program’s medical consultant. The medical consultant shall not disapprove the bone marrow transplant solely on the basis that it is classified as experimental or investigational. (b) The program shall provide reimbursement for both donor and recipient surgery. (c) The department may establish inpatient rates of reimbursement not in accordance with the state plan for those hospitals not under contract with the state pursuant to Article 2.6 (commencing with Section 14081), provided that the state plan is subsequently amended to reflect the method of reimbursement. (d) This section shall not be construed as prohibiting reimbursement for any bone marrow transplants otherwise provided for under this chapter. (e) Any bone marrow transplant authorized by the department pursuant to this section shall be subject to utilization controls. (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or other instructions, without taking any further regulatory action. (Amended by Stats. 2007, Ch. 300, Sec. 6. Effective January 1, 2008.)
  125. 14133.85.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Prior authorization is generally not required for hospice services, except for inpatient hospice services and admissions that violate federal law.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.85. (a) (1) Except as otherwise provided in this subdivision, prior authorization shall not be required for hospice services. (2) Paragraph (1) shall not apply to any admission that violates federal law. (b) Prior authorization shall be required for inpatient hospice services. (c) This section shall become inoperative on July 1, 2026, and, as of January 1, 2027, is repealed. (Amended by Stats. 2025, Ch. 21, Sec. 107. (AB 116) Effective June 30, 2025. Inoperative July 1, 2026, by its own provisions. Repealed as of January 1, 2027, by its own provisions.)
  126. 14133.9.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    The department must provide a 24/7 toll-free phone line and knowledgeable contact for Medi-Cal providers, publish objective medical criteria, and decide prior authorization requests within specified time limits.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14133.9. The implementation of prior authorization permitted by subdivision (a) of Section 14133 shall be subject to all of the following provisions: (a) The department shall secure a toll free phone number for the use of providers of Medi-Cal services listed in Section 14132. For providers, the department shall provide access to an individual knowledgeable in the program to provide Medi-Cal providers with information regarding available services. Access shall include a toll-free phone number that provides reasonable access to that person. The number shall be operated 24 hours a day, seven days a week. (b) For major categories of treatment subject to prior authorization, the department shall publicize and continue to develop its list of objective medical criteria that indicate when authorization should be granted. Any request meeting these criteria, as determined by the department, shall be approved, or deferred as authorized in subdivision (e) by specific medical information. (c) The objective medical criteria required by subdivision (d) shall be adopted and published in accordance with the Administrative Procedure Act, and shall be made available at appropriate cost. (d) When a proposed treatment meets objective medical criteria, and is not contraindicated, authorization for the treatment shall be provided within an average of five working days. When a treatment authorization request is not subject to objective medical criteria, a decision on medical necessity shall be made by a professional medical employee or contractor of the department within an average of five working days. (e) Notwithstanding the provisions of subdivisions (c) and (d), the department shall adopt, by emergency regulations as provided by this subdivision, a list of elective services that the director determines may be nonurgent. In determining these services, the department shall be guided by commonly accepted medical practice parameters. Authorization for these services may be deferred for a period of up to 90 days. In making determinations regarding these referrals, the department may use criteria separate from, or in addition to, those specified in subdivision (c). These deferrals shall be determined through the treatment authorization request process. When a proposed service is on the list of elective services that the director determines may be considered nonurgent, authorization for the service shall be granted or deferred within an average of 10 working days. The State Department of Health Services may adopt emergency regulations to implement this subdivision in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The initial adoption of emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety or general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this subdivision shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations and shall remain in effect for no more than 120 days. (f) Final decisions of the department on denial of requests for prior authorization for inpatient acute hospital care shall be reviewable upon request of a provider by a Professional Standards Review Organization established pursuant to Public Law 92-603, or a successor organization if either of the following applies: (1) The original decision on the request was not performed by a Professional Standards Review Organization, or its successor organization. (2) The original decision on the request was performed by a Professional Standards Review Organization, or its successor organization, and the original decision was reversed by the department. The department shall contract with one or more of these organizations to, among other things, perform the review function required by this subdivision. The review performed by the contracting organization shall result in a finding that the department’s decision is either appropriate or unjustified, in accordance with existing law, regulation, and medical criteria. The cost of each review shall be borne by the party that does not prevail. The decision of this body shall be reviewable by civil action. (g) This section, and any amendments made to Section 14103.6 by Assembly Bill 2254 of the 1985–86 Regular Legislative Session, shall not apply to treatment or services provided under contracts awarded by the department under which the contractor agrees to assume the risk of utilization or costs of services. (Amended by Stats. 2012, Ch. 728, Sec. 206. (SB 71) Effective January 1, 2013.)
  127. 14134.2.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Three or more same-day laboratory services for the same patient that are commonly done automatically must be reimbursed at the automated-services rate; the director must exempt certain urgent or rural individual tests.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14134.2. The reimbursement rate for any three or more laboratory services for the same patient on the same day, which are commonly performed in an automated manner, as defined by the department, shall be reimbursed at the rate established for automated services. The director shall exempt from this provision laboratory services performed for urgent medical reasons or in rural areas, as defined by the department, if performed as individual tests. (Amended by Stats. 1981, Ch. 1163, Sec. 17. Effective October 2, 1981.)
  128. 14134.25.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    Medi-Cal covers tobacco cessation services, subject to utilization controls, and the department must seek needed federal approvals to implement the section.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14134.25. (a) Tobacco cessation services are covered benefits under the Medi-Cal program, subject to utilization controls. Tobacco cessation services shall include all intervention recommendations, as periodically updated, assigned a grade A or B by the United States Preventive Services Task Force. Tobacco cessation services shall include quit attempts based on medical necessity, as defined in Section 14059.5, and consistent with United States Preventive Services Task Force grade A and B recommendations, with no required break between attempts, for all beneficiaries 18 years of age and older who use tobacco. For beneficiaries under 18 years of age, tobacco cessation services shall be provided in accordance with both the American Academy of Pediatrics Bright Futures periodicity schedule and anticipatory guidance as periodically updated, as well as services assigned a grade A or B by the United States Preventive Services Task Force. (b) For purposes of this section, in addition to the services described in subdivision (a) and only to the extent consistent with the intervention recommendations, as periodically updated, assigned a grade A or B by the United States Preventive Services Task Force, tobacco cessation services for beneficiaries 18 years of age and older shall include all of the following: (1) At least four tobacco cessation counseling sessions per quit attempt that may be conducted in person or by telephone and individually or as part of a group, at the beneficiary’s option. (2) (A) A tobacco cessation treatment regimen of any medication approved by the federal Food and Drug Administration, and that is a covered Medi-Cal benefit, for tobacco cessation, including prescription and over-the-counter medications, in accordance with United States Preventive Services Task Force grade A and B recommendations. (B) A prescription from a provider with authority to prescribe and proof of Medi-Cal coverage shall be sufficient documentation to fill a prescription for over-the-counter tobacco cessation medications. (c) Beneficiaries who are covered under this section shall not be required to receive a particular form of tobacco cessation service as a condition of receiving any other form of tobacco cessation service. (d) Effective January 1, 2017, the department shall seek any federal approvals that the department determines are necessary to implement this section. (e) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained. (Amended by Stats. 2017, Ch. 561, Sec. 283. (AB 1516) Effective January 1, 2018.)
  129. 14134.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

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    This section sets rules for comprehensive perinatal services, including provider duties, staffing flexibility, department oversight, and reimbursement requirements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14134.5. All of the following requirements apply to the provision of services pursuant to subdivision (u) of Section 14132: (a) “Comprehensive perinatal provider” means any general practice physician, family physician and surgeon, obstetrician-gynecologist, pediatrician, certified nurse-midwife, a group, any of whose members is one of the above-named providers, or any preferred provider organization or clinic enrolled in the Medi-Cal program and certified pursuant to the standards of this section. (b) “Perinatal” means the period from the establishment of pregnancy to one month following delivery. (c) “Comprehensive perinatal services” shall include, but not be limited to, the provision of the combination of services developed through the former Department of Health Services Obstetrical Access Pilot Program provided or coordinated by a comprehensive perinatal provider. (d) The comprehensive perinatal provider shall schedule visits with appropriate providers and track the patient to verify whether services have been received. As part of the reimbursement for coordinating these services, the comprehensive perinatal provider shall ensure the provision of the following services either through the provider’s own service or through subcontracts or referrals to other providers: (1) A psychosocial assessment and when appropriate referrals to counseling. (2) Nutrition assessments and when appropriate referral to counseling on food supplement programs, vitamins, and breastfeeding. (3) Health, childbirth, and parenting education. (e) (1) Except where existing law prohibits the employment of physicians, a health care provider may employ or contract with all of the following medical and other practitioners for the purpose of providing the comprehensive services delineated in this section: (A) Physicians, including a general practitioner, a family physician and surgeon, a pediatrician, or an obstetrician-gynecologist. (B) Certified nurse-midwives. (C) Licensed midwives. (D) Nurses. (E) Nurse practitioners. (F) Physician assistants. (G) Social workers. (H) Health and childbirth educators. (I) Registered dietitians. (2) The department shall adopt regulations that define the qualifications of any of these practitioners who are not currently included under the regulations adopted pursuant to this chapter. Providers shall, as feasible, utilize staffing patterns that reflect the linguistic and cultural features of the populations they serve. (f) The California Medical Assistance Program and the Maternal and Child Health Branch of the State Department of Public Health, in consultation with the California Conference of Local Health Officers, shall establish standards for health care providers and services rendered pursuant to this subdivision. (g) The department shall assist local health departments to establish a community perinatal program whose responsibilities may include certifying and monitoring providers of comprehensive perinatal services. The department shall provide the local health departments with technical assistance for the purpose of implementing the community perinatal program. The department shall utilize, to the extent feasible, and to the extent funding for administrative costs is available, local health departments in the administration of the perinatal program. If these funds are unavailable, the department shall use alternative means to implement the community perinatal program. (h) (1) It is the intent of the Legislature that the department shall establish a method for reimbursement of comprehensive perinatal providers that shall include a fee for coordinating services and shall be sufficient to cover reasonable costs for the provision of comprehensive perinatal services. The department may utilize fees for service, capitated fees, or global fees to reimburse providers. However, if capitated or global fees are established, the department shall set minimum standards for the provision of services including, but not limited to, the number of prenatal visits, and the amount and type of psychosocial, nutritional, and educational services that patients receive. (2) Notwithstanding the type of reimbursement system, the comprehensive perinatal provider shall not be financially at risk for the provision of inpatient services. The provision of inpatient services that are not related to perinatal care shall not be subject to the requirements of this section. Inpatient services related to services pursuant to this subdivision shall be reimbursed, in accordance with Section 14081, 14086, 14087, or 14087.2, whichever is applicable. (i) The department shall develop systems for the monitoring and oversight of the comprehensive perinatal services provided in this section. The monitoring shall include, but shall not be limited to, the collection of information using the perinatal data form. (j) Participation for services provided pursuant to this section shall be voluntary. The department shall adopt patient rights safeguards for recipients of the comprehensive perinatal services. (k) The amendments made to this section by the act that added this subdivision do not revise or expand the scope of practice of licensed midwives, as defined in Article 24 (commencing with Section 2505) of Chapter 5 of Division 2 of the Business and Professions Code. (l) Notwithstanding subdivision (a), on the effective date of the regulations adopted by the Medical Board of California pursuant to Section 2507 of the Business and Professions Code, a licensed midwife shall be eligible to serve as a comprehensive perinatal provider. (m) For purposes of this section, “family physician” means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school. (Amended by Stats. 2019, Ch. 632, Sec. 17. (AB 1622) Effective January 1, 2020.)
  130. 14134.55.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must streamline and simplify existing Medi-Cal procedures to improve access to lactation supports and breast pumps for Medi-Cal recipients.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14134.55. The department shall streamline and simplify existing Medi-Cal program procedures in order to improve access to lactation supports and breast pumps among Medi-Cal recipients. (Added by Stats. 2007, Ch. 460, Sec. 5. Effective January 1, 2008.)
  131. 14134.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Long-term health care facilities may charge residents only the actual price paid for goods and services actually supplied, and may not charge for hospital gowns. They must also disclose listed charges, updates to those charges, and itemize resident bills.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14134.6. Long-term health care facilities may charge a resident only the actual price paid by the facility for goods and services actually supplied to the resident and may not charge for hospital gowns. Facilities in the original contract shall inform residents of charges for personal laundry and drycleaning, haircuts, beautician services, manicures, pedicures, phone calls, television rental, and any other services payable by the resident. The facility shall also inform residents of any changes in those charges, and shall indicate on a resident’s bill every good, product, service, and medication for which the resident is being charged, including, if the patient is a senior citizen, whether or not a senior discount was obtained on the medication. (Added by Stats. 1984, Ch. 1628, Sec. 2.)
  132. 14135.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The director must establish an enrollment fee, premium, or similar charge if federal law requires it, to help secure maximum federal financial participation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14135. To assure maximum federal financial participation under this chapter, the director shall establish an enrollment fee, premium or similar charge to the extent required by federal law. (Added by Stats. 1974, Ch. 1240.)
  133. 14136.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Cities and counties may regulate nonemergency medical transportation only if their rules do not conflict with state reimbursement standards, they cannot charge permit/license/inspection fees above actual cost, and they must give providers an itemized cost analysis before collecting those fees.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136. (a) No city or county shall establish equipment and personnel standards for the furnishing of nonemergency medical transportation services for eligible Medi-Cal beneficiaries which are in conflict with equipment and personnel standards for reimbursement established by the department pursuant to this chapter. No standard adopted by cities or counties shall require the use of ambulances to supply nonemergency medical transportation, where that standard would conflict with Section 14136.1. (b) No city or county shall establish any permit, license, or inspection fees in excess of the actual cost of providing services directly associated with the provision of a permit, license, or inspection of nonemergency medical transportation vehicles. (c) Prior to collection of any permit, license, or inspection fees, the city or county shall provide the nonemergency medical transportation provider from whom the fees will be collected with an itemized cost analysis specifying how the fees will be used. (d) Nothing in this section shall be construed to otherwise limit the authority of a city or county to license, inspect, or regulate nonemergency medical transportation services so long as the regulation is not in conflict with standards established by the department. (e) Nothing in this section shall be construed to prevent a city or county from allowing both emergency and nonemergency medical transportation services to operate within its jurisdiction under a sole franchise when such a franchise has been determined necessary to assure the economic viability of those services. (f) Nothing in this section shall be construed to restrict the authority of local government to issue or deny licenses or permits to operate medical transportation services within its jurisdiction on the basis of need and necessity findings. (Amended by Stats. 1988, Ch. 695, Sec. 1.)
  134. 14136.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    For payment to a medical transportation service provider, certain patients must be transported by ambulance; in other nonemergency medical transportation cases, an ambulance is not required.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136.1. It is the intent of the Legislature that, in order for payment to be made to a medical transportation service provider, a patient who requires continuous intravenous medication, medical monitoring, or observation during transport and patients being transferred from an acute care facility to another acute care facility shall be transported by ambulance. In other situations where nonemergency medical transportation is given, ambulances need not be used. (Added by Stats. 1980, Ch. 1075, Sec. 2.)
  135. 14136.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Prior authorization is not needed for nonemergency medical transportation to Medi-Cal beneficiaries in the stated hospital-to-facility transfer situation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136.3. No prior authorization shall be necessary for the provision of nonemergency medical transportation services to Medi-Cal beneficiaries when the beneficiary is being transported from an acute care hospital following a stay as an inpatient to a nursing facility or any category of intermediate care facility for the developmentally disabled licensed pursuant to Section 1250 of the Health and Safety Code. (Amended by Stats. 1990, Ch. 1329, Sec. 31. Effective September 26, 1990.)
  136. 14136.4.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The Medi-Cal field office may not deny a written request for authorization of nonemergency medical transportation services if it matches an earlier telephone prior authorization and the beneficiary was eligible.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136.4. A written treatment authorization request for nonemergency medical transportation services for which a department employed medical consultant had provided conditional prior authorization to the provider of services via telephone, shall not be denied by the Medi-Cal field office when the written treatment authorization request subsequently submitted by the provider substantiates the medical information given with the earlier verbal request, so long as the beneficiary was eligible to receive such services. (Added by Stats. 1982, Ch. 1372, Sec. 1.)
  137. 14136.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    An entity that received certain federal transportation funds must not be reimbursed for Medi-Cal medical transportation services at more than the provider’s usual fee for non-Medi-Cal patients.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136.5. No entity which has received funds under paragraph (2) of subsection (b) of Section 1601 of the federal Urban Mass Transportation Act shall receive reimbursement for medical transportation services rendered to beneficiaries of the Medi-Cal program in any amount greater or higher than the fee charged by the provider to persons for whom services are not reimbursed by Medi-Cal. (Added by Stats. 1982, Ch. 645, Sec. 1.)
  138. 14136.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    No reimbursement may be made for certain medical transportation services unless the provider’s significant beneficial interest was disclosed as required.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14136.8. No reimbursement shall be made for medical transportation services provided pursuant to subdivision (i) of Section 14132 when the services are prescribed or ordered by a person who has a significant beneficial interest in the medical transportation services rendered unless the nature and extent of that interest have been disclosed in accordance with, and subject to, Section 51466 of Title 22 of the California Administrative Code. (Added by Stats. 1984, Ch. 746, Sec. 1.)
  139. 14137.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The State Department of Health Services must seek necessary federal waivers, after review and approval by the State Health and Welfare Agency, to provide in-home and community-based care.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14137. The State Department of Health Services, following review and approval from the State Health and Welfare Agency, shall seek all necessary waivers from the United States Department of Health and Human Services in order to provide in-home and community-based care, as provided for under Section 2176 of the federal Omnibus Budget Reconciliation Act of 1981. The waiver proposal shall specifically include plans for the provision of services to any person who would be eligible for community-based and in-home services, as defined by the Department of Health Services, and who would be eligible for the Medi-Cal program, provided for pursuant to this chapter, except for the person’s income and who can, therefore, become eligible by meeting spend-down requirements. (Added by renumbering Section 14149 by Stats. 1986, Ch. 248, Sec. 271.)
  140. 14137.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must adopt emergency regulations to implement this section, and payment for care cannot be denied solely because a drug has treatment IND status.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14137.6. (a) Notwithstanding any other provision of law, and subject to federal financial participation, covered services under this chapter shall include, subject to utilization controls, medically necessary inpatient and outpatient services associated with the administration of any drug that has been classified by the department or the Food and Drug Administration as having treatment Investigational New Drug (IND) status, when the drug is being administered for the treatment of acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), or human immunodeficiency virus (HIV), to otherwise eligible persons. (b) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The adoption of the regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety. Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted by the department in order to implement this section shall not be subject to the review and approval of the Office of Administrative Law. These regulations shall become effective immediately upon filing with the Secretary of State. (c) No part of this section shall be construed to require the department to pay for the cost of treatment IND drugs provided for research purposes by pharmaceutical companies or any other sponsors at no cost. (d) Payment for care to any Medi-Cal eligible HIV infected person in need of treatment shall not be denied solely on the basis of the use of a drug having treatment IND status. (e) When medically feasible, every effort shall be made to administer drugs having treatment IND status on an outpatient basis. (Added by Stats. 1989, Ch. 1197, Sec. 2.)
  141. 14137.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    Approval for acute inpatient care must be based only on medical necessity documented in the proposed treatment plan.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14137.8. Approval of a request for acute inpatient care shall be solely dependent upon the medical necessity for this care, as documented in the proposed treatment plan. Treatment with Investigational New Drugs, clinical trials, or other ancillary or investigational services, if medical necessity is otherwise documented, shall not in itself be construed to be part of a research study protocol, and shall not constitute grounds for denial on that basis. (Added by Stats. 1992, Ch. 442, Sec. 2. Effective January 1, 1993.)
  142. 14138.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. )

    Verify source ↗

    The department must buy vaccines and biological products in bulk at the lowest possible cost, and contracts under this section may be nonbid and are exempt from the Public Contract Code.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4. The Medi-Cal Benefits Program [14131 - 14138] ( Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252. ) ## 14138. (a) To the extent permitted by federal law, the department shall purchase vaccines and biological products in bulk from the Centers for Disease Control or any other sources at the lowest cost possible, for use by providers of services under this chapter and the Child Health and Disability Prevention program under Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, in the immunization of eligible children. (b) It is the intent of the Legislature that, to the maximum extent possible, any savings of General Fund moneys realized from the program established pursuant to this section shall be reinvested in programs that are most likely to increase access to, and the quality of, immunization services for children. (c) In order to achieve maximum cost savings, the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts under this section may be on a nonbid basis and shall be exempt from the provisions of the Public Contract Code. (d) No part of this section shall be construed to require the department to undertake distribution of vaccines and biological products. (Amended by Stats. 1996, Ch. 1023, Sec. 478. Effective September 29, 1996.)
  143. 14138.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    This section defines key terms for the FQHC APM project and requires the department to maintain an approved list of alternative encounters.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.1. For purposes of this article, the following definitions apply: (a) “Alternative encounter” means an encounter provided by the participating FQHC that is approved by the department for the APM project, but that is not recognized as a billable visit as described in subdivision (g) of Section 14132.100. The department, in consultation with participating FQHCs, shall develop a list of approved alternative encounters for the APM project, which may be updated from time to time. (b) “Alternative payment methodology” (APM) has the same meaning as specified in Section 1396a(bb)(6) of Title 42 of the United States Code. (c) “APM aid category” means a Medi-Cal category of aid designated by the department. For all its APM enrollees in an APM aid category, a participating FQHC site shall receive compensation as described under the APM project. The APM aid categories may include, but are not limited to, all of the following categories of aid: (1) Adults. (2) Children. (3) Seniors and persons with disabilities. (4) The adult expansion population eligible pursuant to Section 14005.60. (d) “APM enrollee” means a member who is assigned by a principal health plan or subcontracting payer to a participating FQHC for primary care services and who is within one of the designated APM aid categories. (e) “APM project” means the project authorized by this article. (f) “APM scope of services” means the scope of services for a participating FQHC for which it is entitled to receive a per-visit rate pursuant to Section 14132.100, but only to the extent those services are covered pursuant to the contract between the department and the applicable principal health plan. (g) “APM supplemental capitation” means an APM aid category-specific PMPM amount that is paid by the department to a principal health plan having one or more participating FQHCs in its provider network. (h) “Clinic-specific PMPM” means the monthly, per assigned member, capitated amount the principal health plan or subcontracting payer is required to pay to the participating FQHC for the APM scope of services. The clinic-specific PMPM is exclusive of any incentive payments and shall be developed to reflect the amount the participating FQHC would have received under the prospective payment system methodology set forth in Section 14132.100. (i) “FQHC” means any community or public “federally qualified health center,” as defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code and providing services as defined in Section 1396d(a)(2)(C) of Title 42 of the United States Code. (j) “Member” means a Medi-Cal beneficiary who is enrolled with a principal health plan, including those beneficiaries delegated to a subcontracting payer. (k) “Participating FQHC” means an FQHC participating in the APM project at one or more of the FQHC’s sites. “Participating FQHC” also refers to an FQHC’s site that is participating in the APM project. (l) “PMPM” and “per member per month” both mean a monthly payment made for providing or arranging health care services for a member and may refer to a payment by the department to a principal health plan, or by a principal health plan to a subcontracting payer, or by a principal health plan or subcontracting payer to an FQHC, or from and to other entities as specified in this article. (m) “Principal health plan” means a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, within a county in which the APM project is implemented. (n) “Subcontracting payer” means an organization or entity that subcontracts directly or indirectly with a principal health plan to provide or arrange for the care of its members and contains one or more participating FQHCs in its provider network. (o) “Traditional encounter” means an encounter that is recognized as a billable visit, as described in subdivision (g) of Section 14132.100 or the approved Medi-Cal State Plan. (p) “Traditional wrap-around payment” means the supplemental payments payable to an FQHC in the absence of the APM project with respect to services provided to Medi-Cal managed care enrollees, which are made by the department pursuant to subdivision (e) of Section 14087.325 and subdivision (h) of Section 14132.100. (Amended by Stats. 2022, Ch. 47, Sec. 105. (SB 184) Effective June 30, 2022.)
  144. 14138.10.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The Legislature states that FQHCs should have a more flexible, patient-centered alternative payment model that supports alternative encounters and maintains funding stability.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.10. The Legislature finds and declares all of the following: (a) Health care today is more than a face-to-face visit with a provider, but rather a whole-person approach, often including a physician, a care team of other health care providers, technology inside and outside of a health center, and wellness activities, including nutrition and exercise classes, all of which are designed to be more easily incorporated into a patient’s daily life. (b) Accessible health care in a manner that fits a patient’s needs is important for improving patient satisfaction, building trust, and ultimately improving health outcomes. (c) FQHCs are essential community providers, providing high-quality, cost-effective comprehensive primary care services to underserved communities. (d) Today, FQHCs face certain restrictions because the current payment structure reimburses an FQHC only when there is a traditional encounter with a provider. Current law prohibits payment for both a primary care visit and mental health visit on the same day. (e) A more practical approach financially incentivizes FQHCs to provide the right care at the right time. Restructuring the current visit-based, fee-for-service model with a capitated equivalent affords FQHCs the assurance of payment and the flexibility to deliver care in the most appropriate patient-centered manner. (f) A reformed payment methodology will enable FQHCs to take advantage of alternative encounters. Alternative encounters, such as group visits and email consultations, are effective care delivery methods and contribute to a patient’s overall health and well-being. (g) An alternative payment methodology for FQHCs, designed and implemented as permitted by federal law, should do all of the following: (1) Provide patient-centered care delivery options to California’s expansive Medi-Cal population. (2) Promote cost efficiencies, and improve population health and patient satisfaction. (3) Improve the capacity of FQHCs to deliver high-quality care to a population growing in numbers and in complexity of needs. (4) Transition away from a payment system that rewards volume with a flexible alternative that recognizes the value added when Medi-Cal beneficiaries are able to more easily access the care they need and when providers are able to deliver care in the most appropriate manner to patients. (5) Promote timely, accurate, complete, and systemic reporting of alternative encounters at FQHCs. (6) Implement the APM where the FQHC receives at least the same amount of funding it would receive under the current payment system, and in a manner that does not disrupt patient care or threaten FQHC viability. (Repealed and added by Stats. 2022, Ch. 47, Sec. 107. (SB 184) Effective June 30, 2022.)
  145. 14138.12.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department must run an APM payment reform project for FQHCs, give required notices before implementation, and comply with federal approval requirements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.12. (a) (1) The department shall authorize a payment reform project for FQHCs using an APM in accordance with this article. (2) Implementation of the APM project shall begin no sooner than January 1, 2024, subject to any necessary federal approvals. (3) Before implementation of an APM project for a participating FQHC site, the department shall notify the FQHC site in writing of the applicable draft clinic-specific PMPM rate(s) for the participating FQHC site. A participating FQHC, with respect to one or more sites of its choosing, may opt to withdraw its participation in the project subject to a notice requirement as determined by the department, but not less than 120 days before implementation of an APM project. (4) At least 90 days prior to implementation of an APM project for a participating FQHC site, the department shall notify a principal health plan in writing of the principal health plan’s specific APM supplemental capitation rates for the participating FQHC. The notification from the department to the principal health plan shall be based on the rates submitted by the department for federal approval. If the APM supplemental capitation rates are modified after the notification to a principal health plan, the department shall notify a principal health plan of the revised rates. (5) At least 90 days prior to implementation of an APM project for a participating FQHC site, the department shall notify a principal health plan and the FQHC site in writing of the clinic-specific PMPM rate for the participating FQHC site. (b) The APM project shall comply with federal APM requirements and the department shall file a state plan amendment and seek any federal approvals as necessary for the implementation of this article. Nothing in this article shall be construed to authorize the department to seek federal approval to affirmatively waive Section 1396a(bb)(6) of Title 42 of the United States Code. (c) Nothing in this article shall be construed to limit or eliminate services provided by FQHCs as covered benefits in the Medi-Cal program. (Amended by Stats. 2022, Ch. 47, Sec. 109. (SB 184) Effective June 30, 2022.)
  146. 14138.13.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department must notify and invite FQHCs to apply for the APM project, develop eligibility criteria, and decide applications; selected health plans and subcontracting payers must participate, while a participating FQHC may leave with 180 days’ notice.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.13. (a) The department shall notify every FQHC in the state of the APM project and shall invite any interested FQHC to apply for participation in the APM with respect to one or more of the FQHC’s sites. Consistent with federal law, the state plan amendment described in subdivision (b) of Section 14138.12 shall specify that the department and each participating FQHC voluntarily agrees to the APM. (b) (1) The department shall develop, in consultation with interested FQHCs and principal health plans and consistent with federal law, the eligibility criteria to be used in evaluating applications from interested FQHCs for participation in the project, which shall include, but need not be limited to, the following: (A) The FQHC has the demonstrated ability to collect and submit encounter data in a form and manner that satisfies department requirements. (B) The FQHC is in good standing with the relevant state and federal regulators. (C) The FQHC has the financial and administrative capacity to undertake payment reform. (2) In addition to the criteria listed in paragraph (1), the department may take into consideration the number of APM enrollees assigned by a plan at each FQHC site as an eligibility requirement for FQHC participation. (3) In accordance with the process and criteria developed pursuant to paragraphs (1) and (2), the department shall approve or deny an interested FQHC site application for participation in the project. The department, at its sole discretion, may limit the number of participating FQHCs in the project and the number of counties in which the project will operate. (4) All principal health plans and applicable subcontracting payers are required to participate in the APM project pursuant to this article to the extent that one or more contracted FQHC sites located in the plan’s county are selected to participate in the project. (c) The APM shall be applied only with respect to a participating FQHC for services the FQHC provides to its APM enrollees that are within its APM scope of services. (d) Payment to the participating FQHC shall continue to be governed by the provisions of Sections 14087.325 and 14132.100 for services provided with respect to a person who is a Medi-Cal beneficiary, but who is not a Medi-Cal beneficiary within a designated APM aid category. (e) Payment to the participating FQHC for furnishing services within the scope of the APM to a Medi-Cal beneficiary within a designated APM aid category who is enrolled with a Medi-Cal managed care plan that is not contracted with the FQHC shall be at the per-visit rate determined pursuant to Section 14132.100. (f) After implementation of an APM project, a participating FQHC, with respect to one or more sites of its choosing, may opt to discontinue its participation in the project subject to a notice requirement of no less than 180 days before the beginning of the next managed care rating period. (Amended by Stats. 2022, Ch. 47, Sec. 110. (SB 184) Effective June 30, 2022.)
  147. 14138.14.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    This section sets how participating FQHCs are paid for APM services, limits certain traditional payments and reconciliation requests, bars contract termination to evade payment duties, and gives FQHCs a right to pursue remedies.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.14. (a) A participating FQHC shall be compensated for the APM scope of services provided to its APM enrollees pursuant to this section. (b) A participating FQHC shall receive from the principal health plan or applicable subcontracting payer reimbursement for each APM enrollee in the form of a clinic-specific PMPM. The department shall determine the clinic-specific PMPM taking into account all the following factors: (1) Historical utilization of applicable FQHC services in each APM aid category. (2) The participating FQHC’s prospective payment system rate and applicable adjustments relevant for the fiscal year, such as annual rate adjustments. (3) The projected mix of assigned members across the APM aid categories. (4) Other trend and utilization adjustments as appropriate in order to reflect the level of reimbursement that would have been received by the participating FQHCs in the absence of the APM project. (c) A participating FQHC and applicable principal health plan or subcontracting payer may enter into arrangements in which the clinic-specific PMPM amount required in subdivision (b) is paid in more than one capitated increment, as long as the total per-member capitation each month received by the participating FQHC is at least equal to the clinic-specific PMPM. (d) In cases where a subcontracting payer is involved, the principal health plan shall demonstrate and certify to the department that it has contracts or other arrangements in place that provide for meeting the requirements in subdivision (b) and to the extent that the subcontracting payer fails to comply with the applicable requirements in this article, the principal health plan shall then be responsible to ensure the participating FQHC receives all payments due under this article in a timely manner. (e) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100, and changes in the projected mix of assigned members across APM aid categories. (f) An FQHC site participating in the APM project shall not receive traditional wrap-around payments for visits within the APM scope of services it provides to its APM enrollees for any service period in which it participates in the APM project. A participating FQHC site shall not be entitled to make a reconciliation request pursuant to Section 14132.100 or 14087.325 in connection with visits within the APM scope of services provided to APM enrollees for any service period in which it participates in the APM project. (g) A principal health plan or subcontracting payer shall not terminate a contract with a participating FQHC for the specific purpose of circumventing the payment obligations implemented pursuant to this section. (h) FQHCs shall have the right to pursue any available remedy against Medi-Cal managed care plans or subcontracting payers, including judicial review, as appropriate in connection with the requirements of this section. (Amended by Stats. 2022, Ch. 47, Sec. 111. (SB 184) Effective June 30, 2022.)
  148. 14138.15.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department must calculate and pay APM-related capitation amounts to principal health plans, and principal health plans must report monthly enrollee counts.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.15. (a) A principal health plan shall be compensated by the department for the APM scope of services provided to its APM enrollees pursuant to this section. (b) For each principal health plan that contains at least one participating FQHC in its provider network, the department shall determine an APM supplemental capitation amount for each APM aid category to be paid by the department to the principal health plan, which shall be expressed as a PMPM amount. This supplemental capitation amount will be in addition to the funding for the APM scope of services already contained in the principal health plan’s capitated rates paid by the department and shall be actuarially sound in accordance with Section 438.4 of Title 42 of the Code of Federal Regulations. The department shall determine the APM supplemental capitation amount for each APM aid category, taking into account all of the following factors: (1) The clinic-specific PMPM amounts for each participating FQHC in the plan’s network. (2) The funding for the APM scope of services already contained in the principal health plan’s capitated rates. (3) The historical wrap-around payments paid by the department for participating FQHCs for assigned members in each APM aid category. (4) As applicable, the likely distribution of members among multiple participating FQHCs. (c) The principal health plan shall report to the department, in a form to be determined by the department in consultation with the principal health plan, the number of APM enrollees for each APM aid category in the plan each month. (d) The department shall pay each principal health plan its applicable APM supplemental capitation amount for the number of APM enrollees for each APM aid category reported by the principal health plan pursuant to subdivision (c), and shall appropriately fund each principal health plan to pay the per-visit rate for unassigned Medi-Cal beneficiaries described in subdivision (e) of Section 14138.13. (e) The department, in consultation with the principal health plans, shall develop methods to verify the information reported pursuant to subdivision (c), and may adjust the payments made pursuant to subdivision (d) as appropriate to reflect the verified number of APM enrollees for each APM aid category. (f) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100, and changes in the projected mix of assigned members across applicable APM aid categories. (Amended by Stats. 2022, Ch. 47, Sec. 112. (SB 184) Effective June 30, 2022.)
  149. 14138.16.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department must set up and define a risk corridor for the APM project’s principal health plans, and do so consistently with actuarial soundness.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.16. (a) For the duration of the APM project, the department shall establish a risk corridor structure for the principal health plans relating only to the APM supplemental capitation payments pursuant to Section 14138.15, to the extent consistent with principles of actuarial soundness and in accordance with Section 438.6(b)(1) of Title 42 of the Code of Federal Regulations. (b) The risk sharing of the costs under this section shall be constructed by the department with input from affected stakeholders so that it is symmetrical with respect to risk and profit. The department shall develop and specify the terms of the risk corridor in a form and manner specified by the department through all-plan letters or other technical guidance that shall be deemed incorporated into the contracts between each affected principal health plan and the department. (Amended by Stats. 2022, Ch. 47, Sec. 113. (SB 184) Effective June 30, 2022.)
  150. 14138.17.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department must create a payment adjustment structure for participating FQHCs under the APM project.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.17. (a) In order to ensure participating FQHCs have an incentive to manage visits and costs, while at the same time exercising a reasonable amount of flexibility to deliver care in the most efficient and quality driven manner, for the duration of the APM project the department shall, in accordance with this subdivision, establish a payment adjustment structure. The payment adjustment structure shall be developed with stakeholder input and shall meet the requirements of Section 1396a(bb)(6) of Title 42 of the United States Code and Part 438 (commencing with Section 438.1) of Subchapter C of Chapter IV of Title 42 of the Code of Federal Regulations. (b) The payment adjustment structure shall be applicable on a site-specific basis. (c) The payment adjustment structure shall permit an aggregate adjustment to the payments received when actual utilization of services for a participating FQHC’s site exceeds or falls below expectations that were reflected within the calculation of the rates developed pursuant to Sections 14138.14 and 14138.15. For purposes of this payment adjustment structure, both actual and expected utilization shall be expressed as the total number of traditional encounters that would be recognized pursuant to subdivision (h) of Section 14132.100 for the APM enrollees of the participating FQHC’s site across all APM aid categories and averaged on a per member per year basis. (d) An adjustment pursuant to this section shall occur no more than once per year per participating FQHC’s site during the APM project, and shall be requested within 90 days of the close of the rating period, except when additional time is permitted by the department. All adjustments shall be subject to approval by the department. (1) An adjustment to payments in the case of higher than expected utilization shall be triggered when utilization exceeds projections in any year. If an adjustment is required in a given year, the participating FQHC site shall receive an aggregate payment adjustment from the principal health plan or applicable subcontracting payer that is based upon the difference between its actual utilization for the year and the projected utilization for the year. The payment adjustment in each instance shall be calculated as follows: (A) The actual total utilization, expressed as traditional encounters, for the actual APM enrollees for the applicable year shall be determined. (B) The projected total utilization contained in the clinic-specific PMPMs for the actual APM enrollees for the applicable year shall be determined. (C) The amount in subparagraph (B) shall be subtracted from the amount in subparagraph (A). (D) The amount in subparagraph(C) shall be multiplied by the per-visit rate that was determined pursuant to Section 14132.100 for the participating FQHC site yielding the payment adjustment for the participating FQHC site. The payment adjustment shall be paid to the participating FQHC site by the principal health plan, or subcontracting payer, as applicable, in one aggregate payment. (2) To incentivize care delivery in ways that may vary from traditional delivery of care, participating FQHCs shall have the flexibility to experience a lower than expected visit utilization of up to 30 percent of projected utilization. The department shall develop, with input from affected stakeholders, objective criteria to ensure minimum standards for access and quality. If an FQHC site does not meet those established quality and access standards, the participating FQHC shall be required to return a portion of PMPM revenue based on a formula developed by the department with input from affected stakeholders. A participating FQHC shall not receive revenue lower than the amount calculated as follows: (A) The actual total utilization, expressed as traditional encounters, for the applicable year shall be determined. (B) The amount in subparagraph (A) shall be multiplied by the per-visit rate that was determined pursuant to Section 14132.100 for the participating FQHC site yielding the payment adjustment for the participating FQHC site. (e) Any adjustment made pursuant to this section may only be requested by a principal health plan, subcontracting payer, participating FQHC, or the department. (Amended by Stats. 2022, Ch. 47, Sec. 114. (SB 184) Effective June 30, 2022.)
  151. 14138.18.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    This article applies only if necessary federal approvals are obtained and federal financial participation is available; the department may change certain methods or provisions to comply with federal law, but only without defeating the article’s purpose.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.18. (a) This article shall be implemented only to the extent that any necessary federal approvals have been obtained and federal financial participation is available and not otherwise jeopardized. (b) (1) The department may modify any methodology or other provision specified in this article to the extent it deems necessary to meet the requirements of federal law or regulations, to obtain or maintain federal approval, or to ensure federal financial participation is available or is not otherwise jeopardized, if the modification does not violate the spirit, purposes, and intent of this article. (2) If the department determines that a modification is necessary pursuant to paragraph (1), the department shall consult with interested FQHCs and principal health plans to the extent practicable. (3) In the event of a modification made pursuant to this subdivision, the department shall notify affected FQHCs, principal health plans, the Joint Legislative Budget Committee, and the relevant policy and fiscal committees of the Legislature within 10 business days of the modification. (Repealed and added by Stats. 2022, Ch. 47, Sec. 116. (SB 184) Effective June 30, 2022.)
  152. 14138.21.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    This section says the article does not change certain FQHC payment amounts or reimbursement methods.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.21. This article shall not be deemed to affect the amounts paid or the reimbursement methodology applicable to FQHCs for dental services and for services that are provided outside the scope of a contract between the department and an applicable principal health plan that is in effect as of January 1, 2024, or for any other amounts for which the FQHC may be eligible outside of the prospective payment rate, including, but not limited to, incentives or supplemental payments. (Repealed and added by Stats. 2022, Ch. 47, Sec. 119. (SB 184) Effective June 30, 2022.)
  153. 14138.22.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department may implement, interpret, or make specific this article using letters or similar instructions, without further regulatory action.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.22. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action. (Repealed and added by Stats. 2022, Ch. 47, Sec. 121. (SB 184) Effective June 30, 2022.)
  154. 14138.23.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. )

    Verify source ↗

    The department may enter into exclusive or nonexclusive contracts for this article, including for expertise or technical assistance, and those contracts are exempt from specified procurement rules and DGS review or approval.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.1. Federally Qualified Health Center Alternative Payment Model Project [14138.1 - 14138.23] ( Heading of Article 4.1 amended by Stats. 2022, Ch. 47, Sec. 104. ) ## 14138.23. For purposes of implementing this article, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including, but not limited to, contracts for the purpose of obtaining subject matter expertise or other technical assistance. Any contract entered into or amended pursuant to this section shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, Section 19130 of the Government Code, Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services. (Amended by Stats. 2022, Ch. 47, Sec. 122. (SB 184) Effective June 30, 2022.)
  155. 14138.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.2. Reinvestment of Savings [14138.5 - 14139] ( Article 4.2 added by Stats. 1992, Ch. 1110, Sec. 3. )

    Verify source ↗

    The State Department of Health Services must give the Legislature a report every two years about listed child health program data.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.2. Reinvestment of Savings [14138.5 - 14139] ( Article 4.2 added by Stats. 1992, Ch. 1110, Sec. 3. ) ## 14138.5. The State Department of Health Services shall report to the Legislature on a biennial basis on all of the following data with respect to the child health and disability prevention program provided for pursuant to Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code: (a) The number of children, by age and by county, enrolled in each plan contracting with the department or with the California Medical Assistance Commission. (b) The improved reporting capabilities of the new contract for the Management Information System/Decision Support System (MIS/DSS), with specific emphasis on how it can be used to gather data from the PM 160 forms that are useful for analytical purposes. (c) Information on what actions are being taken to ensure compliance with Child Health and Disability Prevention Program examination requirements. (d) The statewide percentage of all children enrolled in managed care plans, by age, who received a comprehensive Child Health and Disability Prevention Program examination, and the percentage of all children enrolled who received a comprehensive Child Health and Disability Prevention Program examination, by county and by plan. (e) The number of children in each plan, by age, who are current on periodicity health assessments, with appropriate documentation. If the capability to report this information does not exist, a timeline of when the information will be available and the barriers that exist to reporting the information. (f) The number of children in each plan, by county and by age, who were referred for followup diagnosis or treatment following a Child Health and Disability Prevention Program comprehensive examination. (g) The number of children in each plan, by county and by age, who received needed diagnosis and treatment as a result of a Child Health and Disability Prevention Program examination. If the capability to report this information does not exist, a timeline of when it will be available and the barriers that exist to reporting this information. (Amended by Stats. 2001, Ch. 745, Sec. 255. Effective October 12, 2001.)
  156. 14139.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.2. Reinvestment of Savings [14138.5 - 14139] ( Article 4.2 added by Stats. 1992, Ch. 1110, Sec. 3. )

    Verify source ↗

    The department must spend certain savings from a bulk vaccine purchase program to expand immunization services and related access, and those funds may not replace existing state or local funding.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.2. Reinvestment of Savings [14138.5 - 14139] ( Article 4.2 added by Stats. 1992, Ch. 1110, Sec. 3. ) ## 14139. (a) The department shall expend, upon appropriation, any savings accrued from the establishment and implementation of a bulk purchase vaccine program to increase the participation of physicians and surgeons, public and community-based health clinics, and health care facilities as immunization providers under the Medi-Cal program and under the child health and disability prevention programs established pursuant to Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code and to increase access to, and the quality of, immunization services for publicly insured and uninsured children, and to provide funding to counties to assist in the administration of local immunization programs. These funds shall supplement, not supplant, existing state and local funds. (b) The department shall implement subdivision (a) at the earliest possible time after a bulk purchase program for child vaccines is implemented and savings from that program are realized. (c) The department is encouraged to enlist the help of state and local medical, nursing, and other appropriate associations and societies to enhance private provider outreach programs, that shall include, but not be limited to, components emphasizing the purposes of the public vaccine program and discouraging the practice of sending Medi-Cal and child health and disability prevention program eligible children into county and other public clinics for immunizations. (Amended by Stats. 1996, Ch. 1023, Sec. 479. Effective September 29, 1996.)
  157. 14140.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    This section defines “net worth,” “income,” and “family unit,” and exempts up to $10,000 of the applicant’s home from net-worth consideration.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14140. The following definitions shall apply to the provisions of this article: (a) “Net worth” means: (1) Personal property, which consists of cash, savings accounts, securities, and similar items; notes, mortgages, and deeds of trust; the cash surrender value of life insurance on the life of the applicant or beneficiary, on the life of the spouse, or any member of the family, except as provided in Section 11158; motor vehicles, except one which meets the transportation needs of the person or family; any other property or equity other than real estate, except that property specified in subdivisions (1), (2), and (3) of Section 11155. (2) Real property, including any interest in land of more than nominal interest which does not constitute the home of the applicant for aid under this chapter. The home of the applicant shall be exempt from consideration as net worth under this section to the extent of ten thousand dollars ($10,000) in assessed valuation, as assessed by the county assessor. (3) “Income” which consists of the sum of adjusted gross income as used for purposes of the Federal Income Tax Law. (b) “Family unit” means: (1) In the case of a patient who is not married or in a registered domestic partnership and is under 21 years of age living with his or her parent or parents, the patient and his or her parents. (2) In the case of a patient who is married or in a registered domestic partnership and is under 21 years of age, the patient and his or her spouse. (3) In the case of a patient over 21 years of age, the patient, and if married or in a registered domestic partnership, the patient’s spouse. (Amended by Stats. 2016, Ch. 50, Sec. 123. (SB 1005) Effective January 1, 2017.)
  158. 14141.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    The department must reevaluate net worth liability each year, using the time of the initial dialysis or parenteral hyperalimentation treatment as the reference point.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14141. Net worth liability shall be determined as of the time of the initial dialysis or parenteral hyperalimentation treatment and shall be reevaluated each year by the department. (Amended by Stats. 1980, Ch. 1240, Sec. 2.)
  159. 14142.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    People who are otherwise eligible for dialysis-related services under the referenced sections may be eligible for Medi-Cal dialysis coverage, but cost sharing and eligibility depend on family net worth.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14142. Notwithstanding Section 14005.4 or 14005.7, a person who is otherwise eligible for dialysis and related services under Section 14005.4 or 14005.7, except for his or her income and resource eligibility, is eligible for dialysis and related services under Medi-Cal pursuant to this article, as follows: (a) A person in a family unit with a net worth of less than five thousand dollars ($5,000) shall not be liable to pay for dialysis and related services. (b) A person in a family unit with a net worth of five thousand dollars ($5,000) or above shall pay 2 percent of the cost of dialysis and related services for each five thousand dollars ($5,000) of net worth, up to a maximum net worth of two hundred fifty thousand dollars ($250,000). Persons in a family unit with a net worth above two hundred fifty thousand dollars ($250,000) shall not be eligible to receive dialysis under Medi-Cal. (Amended by Stats. 1990, Ch. 833, Sec. 1. Effective September 14, 1990.)
  160. 14142.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    This section sets Medi-Cal eligibility and cost-sharing rules for parenteral hyperalimentation and related services based on family net worth.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14142.5. Notwithstanding Section 14005.4 or 14005.7, a person requiring parenteral hyperalimentation and related services is eligible for these services under Medi-Cal pursuant to this section, as follows: (a) A person in a family unit with a net worth of less than five thousand dollars ($5,000) shall not be liable to pay for parenteral hyperalimentation and related services. (b) A person in a family unit with a net worth of five thousand dollars ($5,000) or above shall pay 2 percent of the cost of parenteral hyperalimentation and related services for each five thousand dollars ($5,000) of net worth, up to a maximum net worth of two hundred fifty thousand dollars ($250,000). Persons in a family unit with a net worth above two hundred fifty thousand dollars ($250,000) shall not be eligible to receive parenteral hyperalimentation under Medi-Cal. (Added by Stats. 1990, Ch. 833, Sec. 2. Effective September 14, 1990.)
  161. 14143.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    Some dialysis or parenteral hyperalimentation patients must be provided the article’s health care benefits and services if they are California residents and eligible under the article, but only to the extent those services are not already available under other law or other entitlements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14143. The health care benefits and services specified in this article, to the extent that such benefits and services are neither provided under any other federal or state law nor provided nor available under other contractual or legal entitlements of the person, shall be provided to any dialysis or parenteral hyperalimentation patient who is a resident of this state and is made eligible by the provisions of this article. After such dialysis or parenteral hyperalimentation patient has utilized such contractual or legal entitlements, the percentages of payment liability under Section 14142 shall then be applied to the remaining cost of dialysis or parenteral hyperalimentation. (Amended by Stats. 1980, Ch. 1240, Sec. 4.)
  162. 14144.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    This section says the article does not apply to certain dialysis or parenteral hyperalimentation patients who are otherwise eligible for Medi-Cal, or to people eligible for renal dialysis under Public Law 92-603.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14144. The provisions of this article do not apply to indigent dialysis or parenteral hyperalimentation patients who are otherwise eligible for Medi-Cal or to any person eligible for renal dialysis under the provisions of Public Law 92-603 (H.R. 1). (Amended by Stats. 1980, Ch. 1240, Sec. 5.)
  163. 14144.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. )

    Verify source ↗

    Certain employed Medi-Cal dialysis and parenteral hyperalimentation recipients remain eligible for services, but must pay only the amounts set in Section 14142(b), with a 1% net-worth-based percentage obligation up to $500,000, and they are not subject to Section 14144.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.4. Dialysis, Parenteral Hyperalimentation, and Related Services [14140 - 14144.5] ( Heading of Article 4.4 amended by Stats. 1980, Ch. 1240, Sec. 1. ) ## 14144.5. Notwithstanding any provision of this article or of any other statute to the contrary, any person who is eligible under Section 14005.4 or 14005.7 for dialysis, parenteral hyperalimentation, and related services and who is employed and individually earning an amount which exceeds the minimum needs standard, and who receives dialysis services either through a self-dialysis unit of a dialysis clinic or through home dialysis or who receives parenteral hyperalimentation services through self-parenteral hyperalimentation, shall be eligible for dialysis, parenteral hyperalimentation , and related services under Medi-Cal pursuant to this article and shall, after utilizing other contractual or legal entitlements pursuant to Section 14143, be liable to pay only the amounts specified in subdivision (b) of Section 14142, except that such percentage obligations shall be 1 percent for each five thousand dollars ($5,000) of family unit net worth up to a maximum net worth of five hundred thousand dollars ($500,000). Persons eligible for services under this section shall not be subject to Section 14144. (Added by renumbering Section 14145 (as amended by Stats. 1980, Ch. 1240) by Stats. 1981, Ch. 714, Sec. 474.)
  164. 14145.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. )

    Verify source ↗

    The department may contract with a qualifying California nonprofit to serve as a long-term care integration center, and the center may carry out listed support activities; it must also send annual progress reports to the department and legislative budget committees.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. ) ## 14145. (a) Beginning with the 1998–99 fiscal year and contingent on appropriation of funds through the Budget Act, the department may contract with a nonprofit entity, incorporated in California that has been formed for the purpose of serving as the center for long-term care integration. The center may serve as a focal point for facilitating the development of community-based local organizing groups through a public-private partnership. (b) The nonprofit center may do all of the following: (1) Serve in an advisory capacity to the key stakeholders in long-term care integration, including consumers, consumer advocacy groups, researchers, representatives of service providers and purchasers, and local and state policymakers. (2) Assemble, organize, and make available technical information, data, expertise, and models on long-term care integration from across the state and nation. (3) Assist local communities with long-term care planning and analysis, development of service delivery and financing systems, statewide data sharing, and private fund development. (4) Coordinate goals and activities with the State Department of Health Services. (c) The center may build and sustain working partnerships by developing and supporting a cross-county, statewide network of consumers, providers and funders, as well as maintaining an ongoing relationship with the state. (d) The center may assist the local organizing groups (LOGs) in seeking local financial support, as well as to obtain foundation matching funds for statewide grant-making. (e) The center may coordinate and disseminate long-term care planning information by identifying key long-term care development issues, and disseminating the information to local planning groups, as needed. (f) The center may facilitate implementation by identifying and sharing useful tools and resources, designing models for service protocols of the local long-term care integration pilot projects, coordinating information systems, standardizing assessment elements, and providing low-cost training and technical assistance to the LOGs as they progress through common tasks necessary for local development and implementation. (g) The center may collect and track information across LOG sites. (h) The center may prepare annual progress reports, and shall provide these reports to the department and the budget committees of the Legislature. (Added by Stats. 1998, Ch. 310, Sec. 108. Effective August 19, 1998.)
  165. 14145.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. )

    Verify source ↗

    The department may administer grants for this article, and grantees must match 20% of the grant with cash or in-kind contributions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. ) ## 14145.1. (a) The department may administer grants for purposes of this article, that shall be awarded through a request for application process. (1) Grants may be awarded to local organizing groups (LOGs) that are existing or new community-based nonprofit organizations or government entities for purposes of implementing long-term care integration pilot projects, pursuant to Article 4.05 (commencing with Section 14139.05). (2) Grants may be available for LOGs in the planning phase, or the development phase of the project, or both. Planning phase grants shall be limited to a maximum award of fifty thousand dollars ($50,000). Development phase grants shall be limited to a maximum award of one hundred fifty thousand dollars ($150,000). The planning phase includes activities related to initial planning for a long-term care integration pilot project (LTCIPP). The development phase includes activities for implementing the planning phase, up to actual implementation of the pilot project. (b) Criteria for grant selection shall include, but not be limited to, the following: (1) For planning phase grants: (A) Identification of a LOG committed to development of a LTCIPP that includes major stakeholders, including, but not limited to, consumers, community-based providers, institutional providers, and public entities. (B) Evidence of local government support for development of a LTCIPP. (C) A description of current and planned consumer involvement. (D) A plan for the use of funds. (E) Specification of goals and objectives, and a work plan for achieving them. (F) A proposed strategy for project evaluation. (2) For development phase grants: (A) Identification of the authorized grantee sanctioned by the local government entity. (B) Identification of an entity for operation of the LTCIPP. (C) Definition of a governance structure. (D) An adopted work plan that includes all of the following: (i) A vision statement describing the long-term care system for the community. (ii) Description of the covered scope of services and programs to be integrated at the local level. (iii) Description of the target population. (iv) Plan for integration of funding for those services. (E) Specific work goals for the development phase. (F) A work schedule for completion. (G) A proposed strategy for project evaluation. (3) Both planning phase and development phase grant funds may be used for, but are not limited to, the following purposes: (A) Staff support. (B) Consulting contracts. (C) Community organizing support. (D) Data analysis. (c) Grantees shall be required to match a portion of the grant awarded, either with cash, or in-kind contributions totaling 20 percent of the total grant. The match required by this subdivision shall be supplemental to the funds appropriated for the LTCIPP. (Amended by Stats. 2001, Ch. 745, Sec. 256. Effective October 12, 2001.)
  166. 14145.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. )

    Verify source ↗

    The department must develop an alternative long-term care integration model, consult an advisory committee, not pay committee members, and report recommendations to the Legislature by December 1, 2003.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.5. Development and Implementation of Long-Term Care Integration Pilot Projects [14145 - 14145.3] ( Article 4.5 added by Stats. 1998, Ch. 310, Sec. 108. ) ## 14145.3. (a) The department shall develop at least, but not limited to, one alternative model to the Long-Term Care Integration Pilot Program authorized under Article 4.3 (commencing with Section 14139.05) that shall be designed to achieve the goals set forth in Section 14139.11. (b) The department or, at the discretion of the department, the center for long-term care integration referred to in subdivision (a) of Section 14145, shall consult with an established waiver technical advisory committee to assist in the development of an alternative model or models pursuant to subdivision (a). (c) No reimbursement or compensation shall be provided to committee members referred to in subdivision (b). (d) The department shall report the recommendations of the waiver technical advisory committee to the Legislature on or before December 1, 2003. (Added by Stats. 2002, Ch. 537, Sec. 1. Effective January 1, 2003.)
  167. 14146.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.6. Medi-Cal Medical Interpretation Services [14146 - 14146.5] ( Article 4.6 added by Stats. 2016, Ch. 600, Sec. 2. )

    Verify source ↗

    The department must study medical interpretation services, run a pilot project, report yearly to legislative budget committees, and may spend specified funds and seek federal funding, subject to stated conditions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.6. Medi-Cal Medical Interpretation Services [14146 - 14146.5] ( Article 4.6 added by Stats. 2016, Ch. 600, Sec. 2. ) ## 14146. (a) (1) The department shall work with identified stakeholders to conduct a study to identify current requirements for medical interpretation services as well as education, training, and licensure requirements, analyze other state Medicaid programs, and make recommendations on strategies that may be employed regarding the provision of medical interpretation services for Medi-Cal beneficiaries who are limited English proficient (LEP), in compliance with applicable state and federal requirements. (2) The study also shall assess and make recommendations based on pilot projects, studies, and available data that would further the objectives of this article, including funding for those activities and the allowable use of federal funding. (b) (1) The department shall work with identified stakeholders to establish a pilot project concurrent with the study. (2) A pilot project shall include up to four separate sites to evaluate the provision of medical interpretation services for LEP Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans and in fee-for-service Medi-Cal. In identifying sites, the department shall take into account the need for those services, the availability of a pool of medical interpreters that meet the language needs of the Medi-Cal population for use by providers and managed care plans, and the studies and available data identified under paragraph (2) of subdivision (a). (c) (1) The department may use or contract with an external vendor, vendors, or other contracted subject matter experts to implement the activities described in this section, including the pilot project. However, the vendor for the study shall not be used for the pilot project. The department shall consult with identified stakeholders regarding the draft initial scope of work that shall be used to seek and evaluate proposals pursuant to this section. (2) At a minimum, the pilot project shall be designed to evaluate all of the following: (A) Whether Medi-Cal beneficiary satisfaction is greater than for those beneficiaries without access to in-person medical interpretation. (B) Whether the satisfaction of physicians and surgeons, nurse practitioners, physician assistants, and other health professionals acting within their scope of practice increases. (C) Whether noncompliance with treatment regimens or avoidable medical errors are reduced. (D) Whether disparities in care are reduced, with respect to LEP Medi-Cal beneficiaries compared with Medi-Cal beneficiaries who are proficient in English. (E) Whether the Medi-Cal managed care plans identify improvements in quality of care. (F) The utilization of medical interpreters by providers and Medi-Cal managed care plans. (d) (1) Each year, commencing in 2017, during the annual state budget process, the department shall provide an update to the budget committees of the Legislature on the implementation of this article. (2) Any report submitted under this subdivision shall be submitted in compliance with Section 9795 of the Government Code. (e) (1) For activities under this section, the department may expend up to three million dollars ($3,000,000) under Provision 14 of Item 4260-101-0001 of Section 2.00 of the Budget Act of 2016 (Chapter 23 of the Statutes of 2016) for the support of activities related to a medical interpreters pilot project, study, or both. In addition, the department shall expend up to five million dollars ($5,000,000) for the pilot project under Provision 15 of Item 4260-101-0001 of Section 2.00 of the Budget Act of 2019 (Chapter 23 of the Statutes of 2019), which shall be available for expenditure, encumbrance, and liquidation until June 30, 2026. (2) The department may seek any available federal funding for support of activities relating to medical interpretation services as provided under this section. (3) Expenditure or encumbrance of the funds described in this subdivision is contingent upon approval by the Department of Finance. (Amended by Stats. 2025, Ch. 105, Sec. 62. (AB 144) Effective September 17, 2025. Inoperative July 1, 2026, pursuant to Section 14146.5. Repealed as of January 1, 2027, pursuant to Section 14146.5.)
  168. 14146.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.6. Medi-Cal Medical Interpretation Services [14146 - 14146.5] ( Article 4.6 added by Stats. 2016, Ch. 600, Sec. 2. )

    Verify source ↗

    This article becomes inoperative on July 1, 2026, and is repealed effective January 1, 2027.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.6. Medi-Cal Medical Interpretation Services [14146 - 14146.5] ( Article 4.6 added by Stats. 2016, Ch. 600, Sec. 2. ) ## 14146.5. This article shall become inoperative on July 1, 2026, and, as of January 1, 2027, is repealed. (Amended by Stats. 2025, Ch. 105, Sec. 63. (AB 144) Effective September 17, 2025. Repealed as of January 1, 2027, by its own provisions. Note: Repeal affects Article 4.6, commencing with Section 14146.)
  169. 14148.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

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    The department must extend Medicaid eligibility for pregnant individuals and infants up to the stated income limits, and counties must speed up Medi-Cal eligibility determinations for pregnant applicants.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148. (a) (1) (A) Except as provided in subparagraph (B), the department shall adopt the federal option provided under Section 4101 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) to extend eligibility for medical assistance under Medicaid to all pregnant individuals and infants with family incomes not in excess of 185 percent of the federal poverty level. (B) Effective January 1, 2014, the federal poverty level percentage income eligibility threshold used pursuant to subdivision (c) of Section 14005.64 to determine eligibility for medical assistance under this section pursuant to subparagraph (A) shall equal 208 percent of the federal poverty level. (C) Effective January 1, 2022, eligibility for medical assistance to pregnant individuals with family incomes not in excess of 208 percent of the federal poverty level, before the application of the 5-percent income disregard pursuant to subdivision (b) of Section 14005.64, shall be as described in Section 14005.22. (2) If a premium is imposed, the amount of the premium shall not exceed 10 percent of the amount by which the family’s income, less actual child care costs, exceeds 150 percent of the federal poverty level as provided in Section 1916(c) of the federal Social Security Act (42 U.S.C. Sec. 1396o(c)) as determined, counted, and valued in accordance with the requirements of Section 14005.64. The department shall implement this section by emergency regulation. (b) Upon order of the Department of Finance, the Controller shall transfer funds from Item 4260-101-001 of the Budget Act of 1988 to Item 4260-111-001 of the Budget Act of 1988 during the 1988–89 fiscal year for the purpose of funding outreach efforts for perinatal services. (c) Notwithstanding subdivision (a), the state may limit implementation of this section during the 1988–89 fiscal year, based upon the availability of department funds. The department may use maternal and child health funds to finance the increased costs of implementing an expansion of Medi-Cal eligibility to pregnant individuals and to children with incomes of up to 185 percent of federal poverty levels if both of the following conditions exist: (1) The department has allocated for expenditure at least sixteen million dollars ($16,000,000) in funds redirected from the Medi-Cal program for that expansion. (2) If, and to the extent, the department determines that estimates of costs based on actual data indicate that the funds are needed to cover costs. (d) To assist Medi-Cal eligible pregnant individuals in receiving prenatal care promptly, all pregnant individuals applying for Medi-Cal shall be determined to have an immediate need. Counties, within existing resources, shall expedite the eligibility determination process for all pregnant individuals on the basis of their immediate needs. Upon determination of eligibility, a Medi-Cal card shall be issued immediately. (e) The amendments made to subdivision (a) by Senate Bill 508 during the 2013–14 Regular Session shall be implemented only if and to the extent that federal financial participation is available and any necessary federal approvals have been obtained. (Amended by Stats. 2022, Ch. 47, Sec. 123. (SB 184) Effective June 30, 2022.)
  170. 14148.03.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    This section requires the department and county to use a simplified prenatal Medi-Cal application process and sets conditions for adopting and implementing the Prenatal Gateway.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.03. (a) Pursuant to options provided in federal law and notwithstanding any other provision of law, the form used by a provider to collect information about a pregnant person pursuant to the Medi-Cal temporary benefits program under Section 14148.7 as that program is implemented on January 1, 2003, shall itself qualify as a simplified application for the Medi-Cal program for pregnant people, or, if necessary to ensure federal financial participation, the form shall be modified to add only those elements required for federal financial participation and be as simple as the department considers practicable. (b) For purposes of this section, the department shall determine whether to grant eligibility for temporary benefits under Section 14148.7 and the county shall make the final eligibility determination for the Medi-Cal program. The department shall develop and adopt a process for transferring the application to the county and a followup process that is as simple as the department considers practicable to be used by the county if followup is necessary. Based on the department’s instructions, the county shall make a determination whether followup is necessary to determine the pregnant person’s final eligibility for the Medi-Cal program or to refer the pregnant person to the Medi-Cal Access Program. (c) The department shall adopt an electronic enrollment process for pregnant people to use when applying for the Medi-Cal program from a provider’s office. The application form for this electronic enrollment shall use the elements of the application form described in subdivision (a) and the procedures specified in subdivision (b). This electronic enrollment process shall be known as the Prenatal Gateway. In developing the Prenatal Gateway required by this subdivision, the department shall consult with consumer, provider, county, and health plan representatives. (d) The purpose of this section is to begin eligibility and benefits at the time of an eligible pregnant person’s visit to a provider and to continue eligibility and benefits until a final eligibility determination is made without the submission of any other application form to the department, the county, or a single point of entry and to make the followup process as simple as the department considers practicable. (e) The Prenatal Gateway may not be adopted until both of the following occur: (1) Sufficient moneys have been deposited in the Special Funds Account of the Gateway Fund to defray the costs of developing the Prenatal Gateway. (2) Sufficient new staff, not to exceed a total of three personnel years, is available at the department for the purposes of this section and Section 14148.04 and is funded through nonstate General Fund sources. Notwithstanding any other provision of law, the department may hire staff necessary to implement this section. (f) The department shall implement the Prenatal Gateway within 12 months after the date upon which both of the conditions required under subdivision (e) have occurred. (g) To implement this section, the department may contract with public or private entities, or utilize existing health care service provider enrollment and payment mechanisms, including the Medi-Cal program’s fiscal intermediary, only if services provided under the program are specifically identified and reimbursed in a manner that appropriately claims federal financial reimbursement. Contracts, including the Medi-Cal fiscal intermediary contract for the Child Health and Disability Prevention Program, and including any contract amendment, any system change pursuant to a change order, and any project or systems development notice shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, former Chapter 7 (commencing with Section 11700) of Part 1 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and any policies, procedures, or regulations authorized by these laws. (Amended by Stats. 2023, Ch. 372, Sec. 2. (AB 1481) Effective January 1, 2024.)
  171. 14148.05.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    This section creates the Gateway Fund and divides it into three accounts, with money to be used only for specified Prenatal Gateway and Newborn Hospital Gateway purposes.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.05. (a) There is hereby created in the State Treasury the Gateway Fund. (b) Moneys in the fund may be expended, upon appropriation by the Legislature, exclusively for purposes of establishing and maintaining the Prenatal Gateway, as provided for in Section 14148.03, and the Newborn Hospital Gateway, as provided for in Section 14148.04, and in accordance with subdivision (c). (c) The fund shall consist of the following accounts: (1) The Special Funds Account, which shall consist of all funds received by the Controller for purposes of Sections 14148.03 and 14148.04 from private foundations and other nongovernmental sources and interest accrued thereon. Moneys in this account shall be used exclusively for the purposes of Sections 14148.03 and 14148.04. The department shall not be responsible for securing funding from private foundations or other nongovernmental sources. (2) The Other Public Funds Account, which shall consist of all public funds, other than federal or state general funds, received by the Controller for purposes of Sections 14148.03 and 14148.04 from state or local sources, including, but not limited to, funds received under the California Families and Children Act of 1998, Division 108 (commencing with Section 130100) of the Health and Safety Code (Proposition 10), and the interest accrued thereon. (3) The Federal Funds Account, which shall consist of all public funds received by the Controller for purposes of Sections 14148.03 and 14148.04 from federal sources, and the interest accrued thereon. (Added by Stats. 2003, Ch. 895, Sec. 4. Effective January 1, 2004.)
  172. 14148.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must seek flexibility when implementing Section 121 of the Immigration Reform and Control Act of 1986 for Medi-Cal eligible people with confirmed pregnancies.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.1. To maximize federal financial participation, the department shall seek flexibility in implementing the requirements of Section 121 of the Immigration Reform and Control Act of 1986 (Public Law 99-603) for Medi-Cal eligible people with confirmed pregnancies. (Amended by Stats. 2023, Ch. 372, Sec. 3. (AB 1481) Effective January 1, 2024.)
  173. 14148.2.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The state department must explore and adopt policies to improve provider relations in the Medi-Cal maternity care program, and it must report to legislative committee chairs by July 1, 1989.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.2. In order to assure access to obstetrical providers in the Medi-Cal program, the state department shall explore and adopt policies which improve provider relations with Medi-Cal maternity care providers. Policies to be considered shall include, but not be limited to, those which reduce the annual percentage of obstetrical billings going to the department’s suspense file, simplify provider claim forms, establish toll-free telephone lines for the exclusive use of maternity care providers, and establish clear reimbursement guidelines. In addition, the department shall explore policies to assure that obstetrical claims are processed on a prompt and predictable basis, the feasibility of establishing a special claims processing unit for obstetrical claims, and the adequacy of current reimbursement levels and services reimbursed. The department shall advise the Chairs of the Assembly Health Committee and the Senate Health and Human Services Committee by July 1, 1989, on steps taken to improve provider relations and the impact these steps have had on provider participation. (Added by Stats. 1988, Ch. 980, Sec. 3.)
  174. 14148.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must seek federal approval to implement obstetrical case management for Medi-Cal eligible pregnant people when that service is provided through the Child Health and Disability Prevention program.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.3. The department shall seek federal approval to implement obstetrical case management for Medi-Cal eligible pregnant people when provided through the Child Health and Disability Prevention program authorized under Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. (Amended by Stats. 2023, Ch. 372, Sec. 4. (AB 1481) Effective January 1, 2024.)
  175. 14148.4.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must remove the Medi-Cal payment difference for obstetrical services and use any resulting savings to increase maternity care and delivery rates across the board.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.4. (a) The department shall eliminate the Medi-Cal reimbursement differential for obstetrical services by equalizing the rates of reimbursement for Caesarean section and non-Caesarean section care and delivery services. In implementing this section, savings that otherwise would have accrued due to lowered rates of reimbursement for Caesarean section services shall be used to fund across-the-board rate increases for all maternity care and delivery services. (b) Revisions to the existing rate structure required to implement this section shall be adopted as emergency regulations in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The adoption of these regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted to implement this act shall not be subject to the review and approval of the Office of Administrative Law. These regulations shall become effective immediately upon filing with the Secretary of State. (Repealed and added by Stats. 1989, Ch. 348, Sec. 2.)
  176. 14148.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must conduct outreach to improve participation in and access to perinatal services.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.6. The department shall engage in outreach activities in order to enhance participation in and access to perinatal services. (Added by Stats. 1989, Ch. 1446, Sec. 4. Effective October 2, 1989.)
  177. 14148.7.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must run PE4PP presumptive eligibility for pregnant people, keep coverage in place for certain Medi-Cal applicants, and require participating providers to give county contact information.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.7. (a) The department shall implement the federal options authorized by federal law to assist in the delivery of timely and continuing prenatal care by establishing the option of presumptive eligibility under Section 1396r-1 of Title 42 of the United States Code. (b) The program shall be known, and may be cited, as “Presumptive Eligibility for Pregnant People (PE4PP).” (c) For a pregnant person covered under PE4PP who applies for full-scope Medi-Cal benefits, if the application is submitted at any time from the date of their presumptive eligibility determination through the last day of the subsequent calendar month, the department shall ensure the pregnant person is covered under PE4PP until the pregnant person is either enrolled in full-scope Medi-Cal benefits or has received a written denial notice in response to their application for full-scope Medi-Cal benefits. (d) The department shall require providers participating in the PE4PP program to provide information to pregnant persons enrolled in PE4PP on how to contact the person’s county to expedite the county’s determination of a Medi-Cal application. (Amended by Stats. 2023, Ch. 372, Sec. 5. (AB 1481) Effective January 1, 2024.)
  178. 14148.75.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must adopt the federal Medicaid option as soon as administratively feasible to waive the resource standard for eligibility determinations for pregnant women, infants, and children.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.75. At the earliest date that it is administratively feasible, the department shall adopt the federal medicaid option under Section 1902(l)(3) of the federal Social Security Act (42 U.S.C. Sec. 1396a(l)(3)) to waive the use of a resource standard for determining the eligibility of pregnant women, infants, and children. (Amended by Stats. 1997, Ch. 624, Sec. 5. Effective January 1, 1998.)
  179. 14148.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must reimburse eligible alternative birth centers for delivery costs, but only within specified rate limits and subject to federal approval and other conditions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.8. (a) (1) The State Department of Health Care Services shall provide Medi-Cal reimbursements to alternative birth centers for facility-related delivery costs at a statewide all-inclusive rate per delivery that shall not exceed 80 percent of the average Medi-Cal reimbursement received by general acute care hospitals with Medi-Cal contracts and shall be based on an average hospital length of stay of 1.7 days. The reimbursement rate shall be updated annually and shall be based on the California Medical Assistance Commission’s annually published legislative report of average contract rates for general acute care hospitals with Medi-Cal contracts. However, the reimbursement shall not exceed the alternative birth center’s charges to any non-Medi-Cal patient for similar services. This paragraph shall apply to Medi-Cal reimbursement for facility-related delivery costs of alternative birth centers until the effective date of any necessary federal approval obtained by the department pursuant to paragraph (2). (2) Effective no earlier than July 1, 2017, the department shall reimburse facility-related Medi-Cal delivery costs of eligible alternative birth centers based on a statewide all-inclusive rate per delivery that shall not exceed 80 percent of the average diagnosis-related groups (DRG) Level 1 rates received by general acute care hospitals pursuant to Section 14105.28 and the applicable provisions of the Medi-Cal State Plan. Reimbursement pursuant to this paragraph shall not exceed the alternative birth center’s charges to any non-Medi-Cal patient for similar services. The department shall seek any federal approvals necessary to implement this paragraph. This paragraph shall not be implemented until any necessary federal approvals are obtained. This paragraph shall not be construed to make inoperative any existing payment reductions that are applicable to alternative birth center services, including, but not limited to, the payment reductions imposed pursuant to Section 14105.192, subject to paragraph (3). (3) Effective July 1, 2022, or the effective date specified in any necessary federal approvals obtained by the department to implement subparagraph (B) of paragraph (13) of subdivision (h) of Section 14105.192, whichever is later, reimbursement to alternative birth centers shall be exempt from the payment reductions imposed by subdivision (d) of Section 14105.192. (b) In order to be eligible for reimbursement pursuant to this section, an alternative birth center shall satisfy the following criteria as determined by the state department: (1) The facility shall meet all applicable requirements of Section 1204.3 of the Health and Safety Code. (2) The facility may utilize licensed midwives, certified nurse-midwives, certified nurse practitioners, and clinical nurse specialists when appropriate. (3) The facility shall meet the standards for certification established by the American Association of Birth Centers, or at least equivalent standards as determined by the department, including those relating to the proximity and involvement of hospitals, obstetricians, and pediatricians. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action. (d) This section does not alter the scope of practice for any health care professional or authorize the delivery of health care services in a setting or in a manner not authorized by the Health and Safety Code or the Business and Professions Code. (e) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (Amended by Stats. 2025, Ch. 595, Sec. 2. (AB 55) Effective January 1, 2026.)
  180. 14148.85.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. )

    Verify source ↗

    The department must receive and initially process Medi-Cal applications from pregnant people and from children under 19, at facilities other than the county welfare department.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.7. Perinatal Services Program [14148 - 14148.85] ( Article 4.7 added by Stats. 1988, Ch. 980, Sec. 3. ) ## 14148.85. The department shall provide for the receipt and initial processing of Medi-Cal applications from pregnant people and from children born after September 30, 1983, who have not yet attained 19 years of age, at facilities other than the county welfare department as described in Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 and following). (Amended by Stats. 2023, Ch. 372, Sec. 6. (AB 1481) Effective January 1, 2024.)
  181. 14148.9.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. )

    Verify source ↗

    This section states the Legislature’s findings and the intended goals of a perinatal outreach program: improve prenatal care access and quality, reduce unhealthy practices during pregnancy, and focus efforts on high-risk and underserved groups.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. ) ## 14148.9. (a) The Legislature finds and declares that there is a strong statistical relationship between early entry into prenatal care and healthy birth outcomes. An investment in early intervention is highly cost-effective and prevents untold suffering. (b) It is the intent of the Legislature that the goals of the program established pursuant to this article, in combination with other programs for pregnant women and children, shall be as follows: (1) To improve access to and quality of prenatal care by making existing programs serving poor women more accessible through outreach, coordination, and removal of barriers to care. (2) To combine efforts with other programs to measurably reduce the number of women who smoke, use drugs, or engage in other unhealthy practices during pregnancy. (c) In order to achieve these goals, it is the intent of the Legislature to improve and coordinate existing programs for pregnant women and infants and to remove barriers to care with an intense focus on women who are at high risk of delivering a low or high birth weight baby or a baby who will suffer from major health problems or disabilities. (d) The program implemented pursuant to this article shall focus on those target populations that are comprised of pregnant high risk women or potentially pregnant teenagers, pregnant women, and women of childbearing age who are likely to become pregnant who smoke, consume alcoholic beverages, or use controlled substances, Black, Hispanic, Native American, and Asian-Pacific Island women who are pregnant or of childbearing age, and uninsured women of childbearing age. (Amended (as added by Stats. 1991, Ch. 278) by Stats. 2006, Ch. 538, Sec. 706. Effective January 1, 2007.)
  182. 14148.91.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. )

    Verify source ↗

    The department must submit annual reports by March 15 on specified maternal and infant health data, and it must also commission a one-time income survey and stay within a $100,000 administrative-funds cap for that survey.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. ) ## 14148.91. (a) No later than March 15 of each year, the department shall report to the appropriate committees of the Legislature and the Governor, on a statewide and county-by-county basis, the most recent data on all of the following: (1) The number of live births to women receiving prenatal care in the first trimester, in the second trimester, and in the third trimester, as well as an analysis of barriers to care to the extent available. (2) The number of maternal deaths by race and ethnic group. (3) The number of live births by county, race, and ethnic group. (4) The number of fetal deaths of infants over 20 weeks’ gestation by race and ethnic group. (5) The number of infant deaths by county, race, and ethnic group from birth to 28 days postpartum. (6) The number of infant deaths by county, race, and ethnic group from 29 days postpartum to one year. (7) The number of live births under 2,500 grams and over 4,500 grams by race and ethnic group. (8) The number of live births under 1,500 grams by race and ethnic group. (9) The number of women eligible for prenatal, delivery, or postpartum care under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code in the past year. (10) The source of payment for prenatal care and delivery. (b) No later than March 15 of each year, the department shall report to the appropriate committees of the Legislature and the Governor on a statewide basis, to the extent data are available, all of the following: (1) The number of infants eligible for services under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code. (2) The number of newborn babies screened or diagnosed with Fetal Alcohol Syndrome. (3) The number of babies born with drug dependencies, HIV infection, and sexually transmitted diseases. (4) Whether the mother smoked, consumed alcoholic beverages, or used controlled substances without a prescription, during pregnancy. (c) (1) The department, in consultation with the Legislative Analyst, shall contract, using appropriate state administrative funds, with an appropriate entity for a one-time, statistical survey of the income of mothers, utilizing a statistically valid sample linked to the birth certificate. (2) The State Department of Health Services shall not use more than one hundred thousand dollars ($100,000) of administrative funds for the survey required by paragraph (1). (3) The income information required by paragraph (1) shall be categorized according to the following income categories: (A) Persons whose family income does not exceed 150 percent of the official federal poverty line. (B) Persons whose family income exceeds 150 percent of the official federal poverty line but does not exceed 185 percent of the official federal poverty line. (C) Persons whose family income exceeds 185 percent of the official federal poverty line but does not exceed 200 percent of the official federal poverty line. (D) Persons whose family income exceeds 200 percent of the official federal poverty line but does not exceed 225 percent of the official federal poverty line. (E) Persons whose family income exceeds 225 percent of the official federal poverty line. (F) Persons whose family income exceeds 250 percent of the official federal poverty line level but does not exceed 300 percent of the official federal poverty line. (d) The department shall, in addition to the information required by subdivision (a), report on trends in private insurance coverage of maternity care, to the extent the data is available. (Amended by Stats. 2004, Ch. 183, Sec. 388. Effective January 1, 2005.)
  183. 14148.98.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. )

    Verify source ↗

    Funds from the Health Education Account in the Cigarette and Tobacco Products Surtax Fund may not be used in a way that violates Section 30122(b)(1) of the Revenue and Taxation Code.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.8. Perinatal Outreach, Coordination, and Expansion Services [14148.9 - 14148.98] ( Article 4.8 added by Stats. 1991, Ch. 278, Sec. 14. ) ## 14148.98. No funds from the Health Education Account in the Cigarette and Tobacco Products Surtax Fund may be used in a manner that violates paragraph (1) of subdivision (b) of Section 30122 of the Revenue and Taxation Code. (Added by Stats. 1991, Ch. 1170, Sec. 13. Effective October 14, 1991.)
  184. 14149.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV [14149 - 14149.3] ( Article 4.9 added by Stats. 2002, Ch. 684, Sec. 1. )

    Verify source ↗

    This section states the Legislature’s intent to expand Medi-Cal eligibility for certain non-disabled people with HIV enrolled in ADAP, except for ADAP prescription drug benefits.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV [14149 - 14149.3] ( Article 4.9 added by Stats. 2002, Ch. 684, Sec. 1. ) ## 14149. (a) It is the intent of the Legislature in enacting this article, to expand eligibility for Medi-Cal benefits, with the exception of prescription drug benefits provided by the AIDS Drug Assistance Program (ADAP), to persons with HIV who are enrolled in ADAP and who are not disabled, but who, if disabled, would qualify for Medi-Cal benefits. (b) It is further the intent of the Legislature that this expansion of the existing Medi-Cal program be funded by cost savings achieved through the voluntary enrollment into the existing Medi-Cal managed care program of persons who are disabled as a result of AIDS, and who are either receiving Medi-Cal benefits on a fee-for-service basis as of January 1, 2003, or who become eligible to receive Medi-Cal benefits on or after January 1, 2003. (c) It is further the intent of the Legislature that the State Department of Health Services encourage the voluntary enrollment into the existing Medi-Cal managed care program of persons described in subdivision (b) in order to obtain sufficient cost savings to provide Medi-Cal benefits to the maximum feasible number of persons with HIV subject to the constraints of this article. (d) It is further the intent of the Legislature that all protections of state and federal law and regulations that apply to the state’s Medi-Cal managed care program shall apply to those persons who become eligible for Medi-Cal pursuant to this article. (Added by Stats. 2002, Ch. 684, Sec. 1. Effective January 1, 2003.)
  185. 14149.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV [14149 - 14149.3] ( Article 4.9 added by Stats. 2002, Ch. 684, Sec. 1. )

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    The department must expand Medi-Cal eligibility for certain people with HIV, with conditions and limits.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.9. Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV [14149 - 14149.3] ( Article 4.9 added by Stats. 2002, Ch. 684, Sec. 1. ) ## 14149.3. (a) Subject to subdivisions (b) and (c), paragraph (2) of subdivision (f), and subdivision (k), the department shall, commencing July 1, 2003, or the date that all necessary federal waivers have been obtained, whichever is later, expand eligibility for benefits under this chapter, with the exception of those prescription drug benefits provided pursuant to ADAP, to any person with HIV who meets both of the following criteria: (1) The person is enrolled in the ADAP program pursuant to Section 120960 of the Health and Safety Code, and maintains enrollment in that program. (2) The person would otherwise qualify for Medi-Cal benefits if the person were disabled as defined in subdivision (h). (b) Any person eligible for benefits pursuant to subdivision (a), and seeking enrollment in Medi-Cal pursuant to this article shall be enrolled on a first-come-first-served basis pursuant to an allocation mechanism that shall be developed by the department. (c) Any person who is eligible for enrollment in Medi-Cal pursuant to this article shall be required to elect a Medi-Cal managed care plan in those counties in which a managed care plan is available, unless the department determines that the cost-neutrality requirements provided for in subdivision (f) and the enrollment goals provided for in this article can be achieved without this requirement. (d) In implementing this article, the department shall ensure that all of the following standards are met: (1) All state and federal laws and regulations that apply to the state’s Medi-Cal managed care program shall apply to the expansion provided by this article and to the beneficiaries eligible for Medi-Cal pursuant to this article. (2) The Medi-Cal benefits provided under this article shall include prescription drugs not provided by the AIDS Drug Assistance Program. (3) All participating plans that assume full risk for all health care services, including inpatient and outpatient services, shall be licensed pursuant to the Knox-Keene Act (Article 1 commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), except as provided in Section 1343 of the Health and Safety Code. (4) Health care service plans participating in the Medi-Cal managed care program shall comply with the applicable sections of the Knox-Knee Act (Article 1 (commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), including Sections 1367 and 1374.16 of the Health and Safety Code and the regulations adopted pursuant to Section 1374.16 of the Health and Safety Code. (5) Primary care case management plans participating in the Medi-Cal managed care program shall comply with the applicable sections of Article 2.9 ( commencing Section 14088). Primary care case management plans are required to maintain grievance and appeal procedures consistent with the existing Medi-Cal managed care program, to address beneficiary grievances. (e) The department shall establish capitation rates to be paid to Medi-Cal managed care plans for services provided pursuant to this section. These capitation rates may not exceed 95 percent of the fee-for-service equivalent costs to the Medi-Cal program for medical services for persons with HIV. (f) (1) The department shall meet federal revenue neutrality requirements through the savings generated by the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS, and who are either receiving Medi-Cal benefits on a fee-for-service basis as of January 1, 2003, or who become eligible to receive Medi-Cal benefits on or after January 1, 2003. The savings generated by increased voluntary enrollments in Medi-Cal managed care shall be used to fund enrollment by individuals eligible for the expansion of Medi-Cal eligibility provided for pursuant to subdivision (a). Nothing in this subdivision shall preclude the department from implementing other means of meeting the federal revenue neutrality requirements, provided that all requirements of this article are met. (2) The department may not enroll individuals described in subdivision (a) until the department can ensure sufficient savings, pursuant to paragraph (1), equal to or greater than the cost of providing benefits to these individuals. (g) The department shall encourage the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS. The department shall conduct all outreach and awareness activities necessary to implement this requirement in a manner consistent with Section 14407 to ensure that persons who enroll in managed care do so voluntarily. These outreach and awareness activities shall include information on how electing managed care may alter provider relationships and how persons may revert to fee-for-service if they prefer to return to fee-for-service. (h) For the purposes of this section, “disabled” means a person who meets the eligibility criteria for the federal Supplemental Security Income for the Aged, Blind and Disabled program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of Title 42 of the United States Code). (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article, without taking any regulatory action, by means of an all-county letter or similar instruction. Thereafter, 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. (j) Commencing January 1, 2003, the department shall seek the appropriate federal waiver under Section 1115 of the Social Security Act (42 U.S.C. Sec. 1315) to implement the expansion of eligibility provided for pursuant to this section. The department shall maximize the federal reimbursement received for services provided under this article to those eligible pursuant to this section. (k) This article shall be implemented only if, and to the extent that, the department determines that federal financial participation is available pursuant to Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.). (Added by Stats. 2002, Ch. 684, Sec. 1. Effective January 1, 2003.)
  186. 14149.8.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.10. Medi-Cal Dental Program [14149.8- 14149.8.] ( Article 4.10 added by Stats. 2016, Ch. 613, Sec. 2. )

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    The department must speed up Medi-Cal dental provider enrollment and manage dental program operations, while Medi-Cal managed care plans must provide screenings, referrals, and liaison support.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.10. Medi-Cal Dental Program [14149.8- 14149.8.] ( Article 4.10 added by Stats. 2016, Ch. 613, Sec. 2. ) ## 14149.8. (a) The department shall expedite the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process. The department shall pursue and implement all of the following activities, to the extent permitted by federal law: (1) Create a dental-specific enrollment form. (2) Pursue an alternative automatic enrollment process for a provider already commercially credentialed by either a dental fee-for-service contractor or an administrative services contractor for the purpose of providing services as a commercial provider. (3) Discontinue requiring providers to resubmit an enrollment application that has been deemed incomplete if the missing information is available elsewhere within the application packet. (4) To the extent that the department expedites the enrollment of Medi-Cal dental providers by streamlining the Medi-Cal provider enrollment process, the department shall publish the criteria for those processes in applicable provider bulletins and manuals. (b) (1) The department shall maintain the provider network on a monthly basis by deactivating a billing provider who has not, over a continuous 12-month period, submitted a claim for reimbursement for services rendered. (2) Prior to deactivating a provider described in paragraph (1), the department shall send a notice to the provider informing the provider that the provider shall be deactivated from the dental program unless the provider requests reactivation within six months after the date of the notice. The department shall not disenroll a provider until six months after the date of that notice. This paragraph shall not be implemented until the date the department implements and programs the necessary system changes to the California Dental Medicaid Management Information Systems to implement this paragraph, or no sooner than July 1, 2017, whichever is later. (3) In order to improve the quality of the dental provider network, the department also shall exercise additional measures as appropriate and permitted by law, including, but not limited to, temporary suspensions. The parameters and criteria developed by the department for additional measures for deactivations and disenrollments shall be published in applicable provider bulletins and manuals. (c) (1) The department shall monitor access and utilization of Medi-Cal dental services in the fee-for-service and managed care delivery systems to assess opportunities to improve access and utilization, including an annual review of the treatment authorization review process. (2) The department shall assess opportunities to develop and implement innovative payment reform proposals within the Medi-Cal dental programs. (d) The department shall explore additional opportunities to improve the Medi-Cal Dental Program, in consultation with stakeholders and as deemed appropriate by the department and to the extent permitted by federal law, including, but not limited to, the following: (1) Aligning the provision of dental anesthesia services with that of medical anesthesia services, including the ability to bill for applicable facility fees and ancillary services. (2) Adjusting other utilization controls for specialty services, as appropriate, to promote access to care while still protecting program integrity. (3) Expanding the scope of beneficiary outreach activities required by an entity that is contracted with the department to more broadly address underutilization throughout the state. (e) Prior to implementing an action pursuant to subdivision (d), the department shall post the proposed action on its Internet Web site at least 30 days before implementation. (f) The department shall work with dental managed care plans that contract with the department for the purposes of implementing the Medi-Cal Dental Program, which includes, but is not limited to, contracts authorized pursuant to Sections 14087.46, 14089, and 14104.3, to provide beneficiaries with access to dental plan liaisons to assist in the coordination of care for enrolled members. (g) A Medi-Cal managed care health plan shall do all of the following: (1) Provide dental screenings for every eligible beneficiary as a part of the beneficiary’s initial health assessment. (2) Ensure that an eligible beneficiary is referred to an appropriate Medi-Cal dental provider. (3) Identify plan liaisons available to dental managed care contractors and dental fee-for-service contractors to assist with referrals to health plan covered services. (h) In accordance with Section 438.230(c)(3) of Title 42 of the Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plans provide that the department, the federal Centers for Medicare and Medicaid Services, the federal Office of the Inspector General, the federal Comptroller General, and their designees may, at any time, inspect and audit any records or documents of the managed care entity, or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this subdivision exists for 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later. (i) In accordance with Section 438.230(c)(3) of Title 42 of Code of Federal Regulations, effective for the rating period for contracts with dental managed care plans beginning on or after July 1, 2017, the department shall require that the dental managed care plan contractors retain, and require its subcontractors to retain, as applicable, all of the following information for a period of no less than 10 years: (1) Enrollee grievance and appeal records. (2) Base data. (3) Medical loss ratio reports. (4) The data, information, and documentation specified in federal Medicaid regulations, including Sections 438.604, 438.606, 438.608, and 438.610 of Title 42 of the Code of Federal Regulations. (j) (1) To increase the efficiency and timeliness of changes, any contract amendment, modification, or change order to any contract entered into by the department for the purposes of implementing the state Medi-Cal Dental Program shall be exempt, except as provided in paragraph (2), from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, as well as Sections 11545 and 11546 of the Government Code, in addition to any policies, procedures, or regulations authorized by those provisions. (2) Paragraph (1) shall not exempt the department from establishing a competitive bid process for awarding new contracts pursuant to Section 14104.3, as well as for awarding new dental contracts pursuant to Sections 14087.46 and 14089. (k) Prior to implementing any change pursuant to this section, the department shall consult with, and provide notification to, stakeholders, including representatives from counties, local dental societies, nonprofit entities, legal aid entities, and other interested parties. (l) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific policies and procedures pertaining to the dental fee-for-service program and dental managed care plans, as well as applicable federal waivers and state plan amendments, including the provisions set forth in this section, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until regulations are adopted. (2) No later than December 31, 2018, 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. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted. (m) This section shall be implemented only to the extent that all of the following occur: (1) The department obtains any federal approvals necessary to implement this section. (2) The department obtains federal matching funds to the extent permitted by federal law. (Amended by Stats. 2017, Ch. 511, Sec. 28. (AB 1688) Effective January 1, 2018.)
  187. 14149.9.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.11. Diabetes Prevention Program [14149.9- 14149.9.] ( Article 4.11 added by Stats. 2017, Ch. 52, Sec. 58. )

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    The department must establish and run the Diabetes Prevention Program in Medi-Cal, and managed care plans must make it available to enrolled beneficiaries.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.11. Diabetes Prevention Program [14149.9- 14149.9.] ( Article 4.11 added by Stats. 2017, Ch. 52, Sec. 58. ) ## 14149.9. (a) It is the intent of the Legislature that the department pursue policies and programs to assist Medi-Cal beneficiaries in preventing or delaying the onset of type 2 diabetes. (b) (1) The department shall establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems. (2) A Medi-Cal managed care plan shall make the DPP available to enrolled beneficiaries in accordance with this article. (c) In implementing the DPP, the department shall require that Medi-Cal providers offering DPP services comply with guidelines issued by the federal Centers for Disease Control and Prevention (CDC) and obtain CDC recognition in connection with the National Diabetes Prevention Program. (d) The DPP shall be an evidence-based, lifestyle change program designed to prevent or delay the onset of type 2 diabetes among individuals with prediabetes. (e) The DPP shall be made available to Medi-Cal beneficiaries no sooner than July 1, 2018. (f) A Medi-Cal provider may identify and recommend participation in the DPP to a beneficiary who meets the eligibility requirements of the federal Centers for Disease Control and Prevention Diabetes Prevention Recognition Program. (g) In implementing the DPP, the department shall require Medi-Cal providers offering DPP services to use a CDC-approved lifestyle change curriculum that does all of the following: (1) Emphasizes self-monitoring, self-efficacy, and problem solving. (2) Provides for coach feedback. (3) Includes participant materials to support program goals. (4) Requires participant weigh-ins to track and achieve program goals. (h) DPP services shall be provided by peer coaches, who promote realistic lifestyle changes, emphasize weight loss through healthy eating and physical activity, and implement the DPP curriculum. A trained peer coach may be a physician, a nonphysician practitioner, or an unlicensed person who has been trained to deliver the required curriculum content and possesses the skills, knowledge, and qualities specified in the National Diabetes Prevention Program guidelines. (i) A beneficiary who participates in the DPP shall be allowed to participate in 22 peer coaching sessions over a period of at least one year. Thereafter, the department shall provide a participating beneficiary who achieves and maintains a required minimum weight loss of 5 percent from the first core session, in accordance with CDC standards, with less intensive, ongoing maintenance sessions to help the beneficiary continue healthy behaviors. (j) (1) The department shall develop payment methodologies, or adjust existing methodologies, for reimbursing DPP services and activities in the Medi-Cal fee-for-service delivery system, not to exceed 80 percent of the federal Medicare Program reimbursement for comparable service, billing, and diagnosis codes under the federal Medicare Program. (2) For purposes of reimbursement under the Medi-Cal fee-for-service delivery system, an unlicensed peer coach shall have an arrangement with an enrolled Medi-Cal provider for purposes of reimbursement for rendered DPP services. (k) This article shall be implemented only to the extent that the department obtains federal financial participation to the extent permitted by federal law, and obtains any necessary federal approvals. (l) For the purposes of implementing this article, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. A contract may be statewide or on a more limited geographic basis. A contract entered into or amended pursuant to this subdivision shall be exempt from all of the following: (1) Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code. (2) Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code. (3) Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code. (4) Review or approval of any division of the Department of General Services. (m) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this article, policies and procedures pertaining to the DPP, and applicable waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department, by July 1, 2020, 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. Beginning six months after the effective date of this article, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted. (Amended by Stats. 2018, Ch. 34, Sec. 31. (AB 1810) Effective June 27, 2018.)
  188. 14149.95.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services [14149.95- 14149.95.] ( Article 4.12 added by Stats. 2024, Ch. 564, Sec. 1. )

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    The department must prepare clear EPSDT informational materials for Medi-Cal beneficiaries, and plans or the department must provide them on a set schedule.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services [14149.95- 14149.95.] ( Article 4.12 added by Stats. 2024, Ch. 564, Sec. 1. ) ## 14149.95. (a) The department shall prepare written informational materials that effectively explain and clarify the scope and nature of early and periodic screening, diagnostic, and treatment (EPSDT) services that are available under the Medi-Cal program. The informational materials shall use clear and nontechnical language. (b) (1) The informational materials shall include, but not be limited to, the information required in Section 441.56(a) of Title 42 of the Code of Federal Regulations or its successor. (2) The informational materials shall include content designed for youth, for purposes of delivery of that content to the beneficiaries described in paragraph (2) of subdivision (d). (3) The department may standardize the informational materials for use by the department and Medi-Cal managed care plans, as deemed appropriate by the department to implement this section. (c) (1) The department shall, in consultation with stakeholders, regularly review the informational materials to ensure that the materials are up to date. (2) To ensure that the informational materials use clear and nontechnical language that effectively informs Medi-Cal beneficiaries, the department shall test the quality, clarity, and cultural concordance of translations of the informational materials with Medi-Cal beneficiaries. (d) (1) A Medi-Cal managed care plan shall provide to the respective beneficiary who is eligible for EPSDT services, or to the parent or other authorized representative of that beneficiary, as applicable, the informational materials described in this section within a maximum number of calendar days, as specified by the department, after that beneficiary’s enrollment in a managed care plan and annually thereafter for beneficiaries who continue to be enrolled with the same Medi-Cal managed care plan. For beneficiaries in fee-for-service Medi-Cal, the department or its representative shall provide to the respective beneficiary who is eligible for EPSDT services, or to the parent or other authorized representative of that beneficiary, as applicable, the informational materials described in this section within 60 calendar days after that beneficiary’s initial Medi-Cal eligibility determination and annually thereafter, for beneficiaries who continue to be enrolled in fee-for-service Medi-Cal. (2) The department or the Medi-Cal managed care plan, as applicable, shall provide the content designed for youth, as described in paragraph (2) of subdivision (b), to a beneficiary who is 12 years of age or older but under 21 years of age, in accordance with the schedule described in paragraph (1). (e) For purposes of this section, the following definitions apply: (1) “EPSDT services” means services covered under subdivision (v) of Section 14132 and that meet the standards set forth in Section 1396d(r) of Title 42 of the United States Code. (A) In addition to the screening, vision, dental, and hearing services described in Section 1396d(r)(1)-(4) of Title 42 of the United States Code, EPSDT services include such other necessary health care, diagnostic services, treatment, and other measures described in Section 1396d(a) of Title 42 of the United States Code to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not those services are covered under the Medi-Cal State plan, in accordance with Section 1396d(r)(5) of Title 42 of the United States Code. (B) EPSDT services also include all age-specific assessments and services listed under the most current periodicity schedule by the American Academy of Pediatrics (AAP) and Bright Futures, and any other medically necessary assessments and services that exceed those listed by AAP and Bright Futures. (2) A service is “medically necessary” if it meets the applicable medical necessity standards set forth in Sections 14059.5 and 14184.402. (Amended by Stats. 2025, Ch. 67, Sec. 194. (AB 1170) Effective January 1, 2026.)
  189. 14150.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    If the department plans to withhold and not allocate part of the baseline county Medi-Cal eligibility allocation, it must notify specified legislative and county recipients within 60 calendar days after the annual Budget Act is chaptered.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14150. Within 60 calendar days of the date that the annual Budget Act is chaptered, the department shall notify the chairpersons of the fiscal committees of each house of the Legislature, the Chairperson and the Vice Chairperson of the Joint Legislative Budget Committee, and appropriate county representatives if the department plans to withhold and not allocate any of the baseline allocation for county Medi-Cal eligibility activities that are appropriated for Medi-Cal administration. (Added by Stats. 2002, Ch. 1161, Sec. 87. Effective September 30, 2002.)
  190. 14151.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    Certain counties must submit qualifying bills within 60 days after the start of the 1971–72 fiscal year, and the director may extend that filing period in limited cases.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14151. Bills for services rendered during the 1970–71 fiscal year to persons other than the beneficiaries under the California Medical Assistance Program submitted to the state by any county which has elected to come within the provisions of Section 14150.1 of the Welfare and Institutions Code are bills against the appropriation for the fiscal year during which the bills are submitted, and shall be submitted not later than 60 days following the start of the 1971–72 fiscal year. The director may, when he finds that delay in the submission of bills was caused by circumstances beyond the control of the county, extend the period of submissions of bills for a period not to extend beyond the end of the 1971–72 fiscal year. State general funds of $27,661,452 are made available from the 1971–72 appropriation to cover the state cost of such bills received. In the event such bills received are less than $27,661,452, the balance remaining may be used for the basic or supplemental schedules of benefits. (Repealed and added by Stats. 1971, Ch. 577.)
  191. 14152.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

    Verify source ↗

    Bills for 1970–71 Medi-Cal services must be submitted within two months after the month of service, with a special 60-day rule when the patient did not identify as a beneficiary.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14152. Bills for services rendered during the 1970–71 fiscal year to beneficiaries under the California Medical Assistance Program are bills against the appropriation for the fiscal year during which the bills are submitted, and shall be submitted not more than two months after the month in which the service is rendered, and shall be in the form prescribed by the director, except that in the event the patient does not identify himself to the provider as a Medi-Cal beneficiary, the provider shall be entitled to submit his statement at any time within 60 days after that date certified by the provider as the date said patient was first identified as a Medi-Cal beneficiary, provided, however, that such date certified by the provider as the date the patient was first so identified shall not be later than one year after the month in which the service was rendered. Further, the director may, where he finds that delay in the submission of bills was caused by circumstances beyond the control of the provider, extend the period for submission of bills for a period not to exceed one year. Funds in the amount of $106,269,000 are hereby made available from the 1971–72 appropriation to cover the cost of such 1970–71 services billed during the 1971–72 fiscal year. In the event such bills are less than $106,269,000 the balance remaining may be used for the basic or supplemental schedules of benefits. (Added by Stats. 1971, Ch. 577.)
  192. 14153.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

    Verify source ↗

    County welfare departments must submit Medi-Cal administrative claims under the procedures in Section 10604.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14153. Funds shall be advanced monthly to the respective counties for costs of administration of the Medi-Cal program in the manner prescribed in Chapter 9 (commencing with Section 15000). Funds may be advanced monthly to the respective counties for the costs of care under the provisions of this chapter upon the order of the Director of Finance and the State Director of Health Services utilizing resources made available through the Health Care Deposit Fund. County welfare departments shall submit administrative claims for the Medi-Cal program in accordance with procedures described in Section 10604.5. (Amended by Stats. 1991, Ch. 611, Sec. 75. Effective October 7, 1991.)
  193. 14154.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    The department must run a county cost-control plan for Medi-Cal eligibility administration, and counties must follow its standards and performance measures.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154. (a) (1) The department shall establish and maintain a plan whereby costs for county administration of the determination of eligibility for benefits under this chapter will be effectively controlled within the amounts annually appropriated for that administration. The plan, to be known as the County Administrative Cost Control Plan, shall establish standards and performance criteria, including workload, productivity, and support services standards, to which counties shall adhere. The plan shall include standards for controlling eligibility determination costs that are incurred by performing eligibility determinations at county hospitals, or that are incurred due to the outstationing of any other eligibility function. Except as provided in Section 14154.15, reimbursement to a county for outstationed eligibility functions shall be based solely on productivity standards applied to that county’s welfare department office. (2) (A) The plan shall delineate both of the following: (i) The process for determining county administration base costs, which include salaries and benefits, support costs, and staff development. (ii) The process for determining funding for caseload changes, cost-of-living adjustments, and program and other changes. (B) The annual county budget survey document utilized under the plan shall be constructed to enable the counties to provide sufficient detail to the department to support their budget requests. (3) The plan shall be part of a single state plan, jointly developed by the department and the State Department of Social Services, in conjunction with the counties, for administrative cost control for the California Work Opportunity and Responsibility to Kids (CalWORKs), CalFresh, and Medical Assistance (Medi-Cal) programs. Allocations shall be made to each county and shall be limited by and determined based upon the County Administrative Cost Control Plan. In administering the plan to control county administrative costs, the department shall not allocate state funds to cover county cost overruns that result from county failure to meet requirements of the plan. The department and the State Department of Social Services shall budget, administer, and allocate state funds for county administration in a uniform and consistent manner. (4) The department and county welfare departments shall develop procedures to ensure the data clarity, consistency, and reliability of information contained in the county budget survey document submitted by counties to the department. These procedures shall include the format of the county budget survey document and process, data submittal and its documentation, and the use of the county budget survey documents for the development of determining county administration costs. Communication between the department and the county welfare departments shall be ongoing as needed regarding the content of the county budget surveys and any potential issues to ensure the information is complete and well understood by involved parties. Any changes developed pursuant to this section shall be incorporated within the state’s annual budget process by no later than the 2011–12 fiscal year. (5) The department shall provide a clear narrative description along with fiscal detail in the Medi-Cal estimate package, submitted to the Legislature in January and May of each year, of each component of the county administrative funding for the Medi-Cal program. This shall describe how the information obtained from the county budget survey documents was utilized and, if applicable, modified and the rationale for the changes. (6) Notwithstanding any other law, the department shall develop and implement, in consultation with county program and fiscal representatives, a new budgeting methodology for Medi-Cal county administrative costs that reflects the impact of PPACA implementation on county administrative work. The new budgeting methodology shall be used to reimburse counties for eligibility processing and case maintenance for applicants and beneficiaries. (A) The budgeting methodology may include, but is not limited to, identification of the costs of eligibility determinations for applicants, and the costs of eligibility redeterminations and case maintenance activities for recipients, for different groupings of cases, based on variations in time and resources needed to conduct eligibility determinations. The calculation of time and resources shall be based on the following factors: complexity of eligibility rules, ongoing eligibility requirements, and other factors as determined appropriate by the department. The development of the new budgeting methodology may include, but is not limited to, county survey of costs, time and motion studies, in-person observations by department staff, data reporting, and other factors deemed appropriate by the department. (B) The new budgeting methodology shall be clearly described, state the necessary data elements to be collected from the counties, and establish the timeframes for counties to provide the data to the state. (C) The new budgeting methodology developed pursuant to this paragraph shall be implemented no sooner than the 2015–16 fiscal year. The department may develop a process for counties to phase in the requirements of the new budgeting methodology. (D) The department shall provide the new budgeting methodology to the legislative fiscal committees by March 1 of the fiscal year immediately preceding the first fiscal year of implementation of the new budgeting methodology. (E) To the extent that the funding for the county budgets developed pursuant to the new budget methodology is not fully appropriated in any given fiscal year, the department, with input from the counties, shall identify and consider options to align funding and workload responsibilities. (F) For purposes of this paragraph, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent amendments. (G) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this paragraph by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time any necessary regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the implementation of the new budgeting methodology pursuant to this paragraph, and notwithstanding Section 10231.5 of the Government Code, 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) Nothing in this section, Section 15204.5, or Section 18906 shall be construed to limit the administrative or budgetary responsibilities of the department in a manner that would violate Section 14100.1, and thereby jeopardize federal financial participation under the Medi-Cal program. (c) (1) The Legislature finds and declares that, in order for counties to do the work that is expected of them, it is necessary that they receive adequate funding, including adjustments for reasonable annual cost-of-doing-business increases. The Legislature further finds and declares that linking appropriate funding for county Medi-Cal administrative operations, including annual cost-of-doing-business adjustments, with performance standards will give counties the incentive to meet the performance standards and enable them to continue to do the work they do on behalf of the state. It is therefore the Legislature’s intent, upon an appropriation by the Legislature for this purpose, to provide appropriate funding to the counties for the effective administration of the Medi-Cal program at the local level to ensure that counties can reasonably meet the purposes of the performance measures as contained in this section. (2) It is the intent of the Legislature to not appropriate funds for the cost-of-doing-business adjustment for the 2008–09, 2009–10, 2010–11, 2011–12, 2012–13, 2014–15, 2015–16, 2016–17, 2017–18, 2024–25, and 2025–26 fiscal years. (d) The department is responsible for the Medi-Cal program in accordance with state and federal law. A county shall determine Medi-Cal eligibility in accordance with state and federal law. If in the course of its duties the department becomes aware of accuracy problems in any county, the department shall, within available resources, provide training and technical assistance as appropriate. This section shall not be interpreted to eliminate any remedy otherwise available to the department to enforce accurate county administration of the program. In administering the Medi-Cal eligibility process, each county shall meet the following performance standards each fiscal year: (1) Complete eligibility determinations as follows: (A) Ninety percent of the general applications without applicant errors and are complete shall be completed within 45 days. (B) Ninety percent of the applications for Medi-Cal based on disability shall be completed within 90 days, excluding delays by the state. (2) (A) The department shall establish best-practice guidelines for expedited enrollment of newborns into the Medi-Cal program, preferably with the goal of enrolling newborns within 10 days after the county is informed of the birth. The department, in consultation with counties and other stakeholders, shall work to develop a process for expediting enrollment for all newborns, including those born to mothers receiving CalWORKs assistance. (B) Upon the development and implementation of the best-practice guidelines and expedited processes, the department and the counties may develop an expedited enrollment timeframe for newborns that is separate from the standards for all other applications, to the extent that the timeframe is consistent with these guidelines and processes. (3) Perform timely annual redeterminations, as follows: (A) Ninety percent of the annual redetermination forms shall be mailed to the recipient by the anniversary date. (B) Ninety percent of the annual redeterminations shall be completed within 60 days of the recipient’s annual redetermination date for those redeterminations based on forms that are complete and have been returned to the county by the recipient in a timely manner. (C) Ninety percent of those annual redeterminations where the redetermination form has not been returned to the county by the recipient shall be completed by sending a notice of action to the recipient within 45 days after the date the form was due to the county. (e) The department shall develop procedures in collaboration with the counties and stakeholder groups for determining county review cycles, sampling methodology and procedures, and data reporting. (f) On January 1 of each year, each applicable county, as determined by the department, shall report to the department on the county’s results in meeting the performance standards specified in this section. The report shall be subject to verification by the department. County reports shall be provided to the public upon written request. (g) If the department finds that a county is not in compliance with one or more of the standards set forth in this section, the county shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the county shall take to improve its performance on the standard or standards with which the county is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the county in order to avoid a sanction. (h) (1) If a county does not meet the performance standards for completing eligibility determinations and redeterminations as specified in this section, the department may, at its sole discretion, reduce the allocation of funds to that county in the following year by 2 percent. Any funds so reduced may be restored by the department if, in the determination of the department, sufficient improvement has been made by the county in meeting the performance standards during the year for which the funds were reduced. If the county continues not to meet the performance standards, the department may reduce the allocation by an additional 2 percent for each year thereafter in which sufficient improvement has not been made to meet the performance standards. (2) No reduction of the allocation of funds to a county shall be imposed pursuant to this subdivision for failure to meet performance standards during any period of time in which the cost-of-doing-business increase is suspended. (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and except as provided in subparagraph (G) of paragraph (6) of subdivision (a), the department shall, without taking any further regulatory action, implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of all-county letters or similar instructions. (Amended by Stats. 2026, Ch. 27, Sec. 87. (SB 164) Effective June 29, 2026.)
  194. 14154.1.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

    Verify source ↗

    County Medi-Cal administrative reimbursement must follow the County Administrative Cost Control Plan, and the department must consider all Medi-Cal applications for allocations on and after July 1, 1987.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154.1. Reimbursement for any Medi-Cal county administrative costs shall be made subject to the requirements specified in the County Administrative Cost Control Plan, established pursuant to Section 14154. However, notwithstanding any other provision of law, for applications taken on or after July 1, 1987, and thereafter, the department shall make allocations for Medi-Cal county administrative expenses taking into consideration all Medi-Cal applications. However, if the department determines that a county is inappropriately processing non-Medi-Cal applications through the Medi-Cal process, then the department shall not allocate state general funds for nonapproved Medi-Cal applications which exceed a specified level. That level shall be determined by multiplying the county’s number of approved applications by the ratio of nonapproved applications to approved applications processed by the county during the base period used in the cost control plan which is in effect for the fiscal year the inappropriate processing of non-Medi-Cal applications occurred. Reimbursement to Los Angeles County hospitals shall be limited on the same basis. (Amended by Stats. 1987, Ch. 1046, Sec. 1.)
  195. 14154.15.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    Counties may ask the department to augment their cost-control plan for outstationing eligibility workers, but county welfare departments must petition under department guidelines to participate.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154.15. (a) Any county may petition the department for an augmentation of its County Administrative Cost Control Plan in order to implement a plan, as provided for in Section 1105 of the federal Social Security Act (42 U.S.C. Sec. 1305), for the outstationing of one or more eligibility workers at all types of outstation locations, as defined in Section 435.904(c)(3) of Title 42 of the Code of Federal Regulations in order to facilitate receipt and processing of applications for Medi-Cal eligibility for pregnant women, infants and children as specified by Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 and following). In order to participate pursuant to this section, a county welfare department shall petition under this section in accordance with guidelines established by the department. The petition shall include, but not be limited to, information about the need for outstation workers at alternative sites and the language skills needed by the outstation workers. (b) In reviewing a petition from a county for an augmentation of its County Administrative Cost Control Plan for outstationing purposes, the department shall take into account the likely success rate of applications processed by the proposed outstationed eligibility workers, the amount of travel and training time required to implement and continue the outstationing plan, and other productivity factors associated with the outstationing plan. (c) The department may approve those proposed augmentations which, based on its review of the outstationing plan, offer potential to increase eligibility determinations and access to Medi-Cal perinatal services by pregnant women and Medi-Cal services by infants and children specified by Title XIX of the Social Security Act (42 U.S.C., Sec. 1396 and following). The department shall review the approved plan annually to determine if the plan shall be renewed, altered, discontinued, or incorporated into the county administrative funding base. (d) In addition to any augmentations authorized by this section, the department may, at its discretion, advance administrative funding to a county welfare department for which it approves an augmentation of its County Administrative Cost Control Plan, to cover the initial incremental costs of outstationed eligibility workers under this section. (e) The department shall conduct a one-time outreach plan to educate county welfare directors, county health officers, and county elected officials on the opportunities and advantages of outstationing Medi-Cal eligibility workers to facilitate access by pregnant women to Medi-Cal perinatal services and Medi-Cal eligibility for infants and children. (Amended by Stats. 1997, Ch. 294, Sec. 75. Effective August 18, 1997.)
  196. 14154.2.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    The Legislature states that ambiguities about payment provisions for certain Medi-Cal eligibility-processing costs should be clarified, and that federal financial participation in Medi-Cal administration costs should be pursued whenever possible.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154.2. (a) The Legislature finds that ambiguities have arisen regarding payment provisions relating to certain costs incurred in processing Medi-Cal eligibility applications for various fiscal years, and believes the ambiguities should be alleviated by means of legislation clarifying the Legislature’s intent regarding such provisions. (b) The Legislature recognizes that federal financial participation in the costs of administering the Medi-Cal program is an important element in funding such costs, and desires that federal financial participation be pursued and obtained whenever possible. With respect to Medi-Cal administration costs, for eligibility determinations, it is not and has not been the Legislature’s intent to preclude federal financial participation which would otherwise be available from the Health Care Financing Administration. (Added by Stats. 1987, Ch. 1227, Sec. 1. Effective September 27, 1987.)
  197. 14154.3.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    This section says counties may have to repay certain federal Medi-Cal funds if they are deferred or disallowed, and the department must timely appeal such federal decisions.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154.3. (a) A provision of a Budget Act or other statute shall not be interpreted or applied to limit the amount of federal financial participation, otherwise available under federal law, which may be reimbursable to counties in support of Medi-Cal administration costs for eligibility determinations. A provision of a Budget Act or another statute shall not be interpreted or applied to restrict the amount of federal financial participation for Medi-Cal administration costs, for eligibility determinations, otherwise available under federal law, which may be claimed by the department, and, upon receipt from the federal government, transferred by the department to a county. (b) The Budget Acts referred to in subdivision (a) include, but are not limited to: (1) Chapter 510 of the Statutes of 1980, including Item 288 of Section 2 thereof. (2) Chapter 99 of the Statutes of 1981, including Items 426-101-001 and 426-101-890 of Section 2.00 thereof. (3) Chapter 326 of the Statutes of 1982, including Items 4260-101-001 and 4260-101-890 of Section 2.00 thereof. (4) Chapter 324 of the Statutes of 1983, including Items 4260-101-001 and 4260-101-890 of Section 2.00 thereof. (5) Chapter 258 of the Statutes of 1984, including Items 4260-101-001 and 4260-101-890 of Section 2.00 thereof. (6) Chapter 111 of the Statutes of 1985, including Items 4260-101-001 and 4260-101-890 of Section 2.00 thereof. (7) Chapter 186 of the Statutes of 1986, including Items 4260-101-001 and 4260-101-890 of Section 2.00 thereof. Provisions of the Budget Acts listed in paragraphs (1) to (7), inclusive, shall not be interpreted or applied as a prohibition regarding the amount of costs counties may incur for Medi-Cal eligibility administration activities. The provisions of those Budget Acts shall be interpreted and applied as a means of limiting the allocation of state general funds to be paid in support of Medi-Cal eligibility determination activities. (c) To the extent necessary to effectuate the intent of subdivisions (a) and (b), the following Budget Act provisions shall be inoperative: (1) Provision 17.5 of Item 426-101-890 of Section 2.00 of Chapter 99 of the Statutes of 1981. (2) The incorporation by reference of Provision 16 of Item 4260-101-001 of Section 2.00 of Chapter 326 of the Statutes of 1982 into Provision 1 of Item 4260-101-890 of that chapter. (3) The incorporation by reference of Provision 15 of Item 4260-101-001 of Section 2.00 of Chapter 324 of the Statutes of 1983 into Provision 1 of Item 4260-101-890 of Section 2.00 of that chapter. (d) Sections 14154 and 14154.1 shall not be interpreted or applied to restrict the amount of federal financial participation, not deferred or disallowed by federal law or regulation which may be reimbursable to any county for Medi-Cal administration costs for eligibility determinations. The County Administrative Cost Control Plan established pursuant to Section 14154 shall not be interpreted or applied as a prohibition regarding the amount of costs counties may incur for Medi-Cal county administration costs. That plan shall be interpreted and applied only as a means of limiting the allocation of state general funds to be paid in support of those county costs. (e) Should federal financial participation be deferred or disallowed regarding funds transferred by the department to a county for costs incurred for Medi-Cal eligibility determinations, and that federal financial participation was matched by county expenditures, the county which received those federal funds shall repay the funds in question at such time as the federal deferral or disallowance has been issued. If the federal deferral or disallowance is noticed or issued prior to the transfer of the federal funds from the department to a county, the department shall not be responsible for transferring the federal funds to the county until the deferral or disallowance issue regarding these funds has been resolved. (f) The department shall timely appeal from the federal deferrals or disallowances and the affected county may assist the department in preparing and presenting a pending appeal regarding a federal deferral or disallowance. (g) Medi-Cal eligibility determination activities are undertaken by counties on behalf of the department. Reasonable and necessary costs incurred by counties relating to the eligibility determination activities shall be recognized as costs incurred by the state for purposes of inclusion in the nonfederal share of Medi-Cal eligibility determination expenditures for claiming federal financial participation. (h) Subdivision (e) shall not apply to agreements between the department and a county executed prior to September 27, 1987. (Amended by Stats. 2008, Ch. 179, Sec. 247. Effective January 1, 2009.)
  198. 14154.5.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    Counties must regularly process MEDS alerts, reconcile records, and meet reporting and correction deadlines; the department may approve corrective plans and reduce funds if performance benchmarks are not met.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14154.5. (a) Each county shall work, on a routine basis, any error alert from the department’s Medi-Cal Eligibility Data System (MEDS). Any alert that affects eligibility or the spend down of excess income that is received by the 10th working day of the month shall be processed in time for the change to be effective the beginning of the following month. Any alert that affects eligibility or the spend down of excess income that is received after the 10th working day of the month shall be processed in time for the change to be effective the beginning of the month after the following month. The department shall consult with the County Welfare Directors Association to define those alerts that affect eligibility or the spend down of excess income. (b) The county shall submit reconciliation files of its Medi-Cal eligible population to the department every three months, based upon a schedule determined by the department and in a format prescribed by the department, to identify any discrepancies between eligibility files in the county records and eligibility as reflected in MEDS. Counties shall be notified of any changes to the standard format for submitting reconciliation files sufficiently in advance to allow for budgeting, scheduling, development, testing, and implementation of any required change in county automated eligibility systems. (c) For those records that are on the county’s files, but not on MEDS, the county shall receive worker alerts from the department that identify these cases, and the county shall fix any data discrepancies. Any worker alert received by the 10th working day of the month shall be processed in time for the change to be effective the beginning of the following month. Any worker alert received after the 10th working day of the month shall be processed in time for the change to be effective the beginning of the month after the following month. (d) In regard to any record that is on MEDS but not on the county’s file, the county shall either correct the county record or MEDS, whichever is appropriate, within the same timeframes specified in subdivision (c). (e) The department shall terminate a MEDS-eligible record if the person is not eligible on the county’s file when there has been no eligibility update on the MEDS record for six months. (f) (1) If the department finds that a county is not performing all of the following activities, the county shall, within 60 days, submit a corrective action plan to the department for approval: (A) Conducting reconciliations as required in subdivision (b). (B) Processing 95 percent of worker alerts referred to in subdivisions (c) and (d), within the timeframes specified. (C) Processing 90 percent of the error alerts referred to in subdivision (a) that affect eligibility or the spend down of excess income, within the timeframes specified. (2) The corrective action plan shall, at a minimum, include steps that the county shall take to improve its performance on the requirements with which the county is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the county in order to avoid sanctions. (g) (1) If the county does not meet the interim benchmarks for improvement standards, the department may, in its sole discretion, reduce the allocation of funds to that county in the following year by 2 percent. Any funds so reduced may be restored by the department if, in the determination of the department, sufficient improvement has been made by the county in meeting the performance standards during the year for which the funds were reduced. (2) No reduction of the allocation of funds to a county shall be imposed pursuant to this subdivision for failure to meet performance standards during any period of time in which the cost-of-doing-business increase is suspended. (h) The department, in consultation with the County Welfare Directors Association, shall investigate features that could be installed in MEDS to reduce the number of alerts and streamline the reconciliation process. (i) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions. Thereafter, the department may 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. (Amended by Stats. 2023, Ch. 42, Sec. 154. (AB 118) Effective July 10, 2023.)
  199. 14157.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    Creates a Health Care Deposit Fund and requires the Controller to deposit certain federal and county funds into it, then use the fund for specified health care expenditures.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14157. There is hereby established a Health Care Deposit Fund from which expenditures of state, county and federal funds for health care and administration under this chapter and Chapter 8 (commencing with Section 14200) shall be made upon order of the Controller in accordance with certifications made by the director. The Controller shall deposit in this fund all federal funds as received under the provisions of Title XIX of the Social Security Act and all county funds received under this chapter. All money in the Health Care Deposit Fund is hereby appropriated, for expenditure for the purposes specified in this chapter and Chapter 8 (commencing with Section 14200). (Amended by Stats. 1977, Ch. 1252.)
  200. 14157.6.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

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    Certain federal and county funds must be moved from the Health Care Deposit Fund to the General Fund, and if the Medical Assistance Program has a projected deficiency, those funds must be reappropriated and spent after required written notice and at least 30 days.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14157.6. Notwithstanding any other provision of law, any federal and county funds, excluding county funds used for the purposes of Section 4011.1 of the Penal Code, received under the provisions of Section 14157 during each fiscal year, as reimbursement for expenditures for health care services authorized under this chapter made from funds transferred to the Health Care Deposit Fund from the General Fund in prior years, shall be transferred from the Health Care Deposit Fund to the General Fund. When a projected deficiency exists in the Medical Assistance Program, these federal and county funds are hereby appropriated from the General Fund to the Health Care Deposit Fund and shall be expended as soon as practicable, but not sooner than 30 days after notification in writing of the necessity therefor, to the chairperson of the committee in each house which considers appropriations, and the Joint Legislative Budget Committee, for the state’s share of payments for medical care and services, county administration, and fiscal intermediary services. (Added by Stats. 1984, Ch. 268, Sec. 56.2. Effective June 30, 1984.)

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