Welfare and Institutions Code — Part 13 | WIC — United States — California law | Esheria

Welfare and Institutions Code

Part 13 of 35 · provisions 2,401–2,600

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

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  1. 14184.500.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )

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    The department must run the State Plan Dental Improvement Program, cover specified Medi-Cal dental benefits starting no sooner than January 1, 2022, pay qualified dental providers under a supplemental payment methodology, and seek federal approval for needed 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 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.500. (a) The department shall implement the State Plan Dental Improvement Program in accordance with the CalAIM Terms and Conditions and as described in this section, with the goal of further improving accessibility of Medi-Cal dental services and oral health outcomes for statewide and targeted populations, as a successor program to the Dental Transformation Initiative described in Section 14184.70. (b) Commencing no sooner than January 1, 2022, subject to subdivision (f) of Section 14184.102, both of the following shall be covered Medi-Cal benefits for the specified populations, when medically necessary and subject to utilization controls: (1) Caries Risk Assessment bundle for eligible children 0 to 6 years of age, inclusive. (2) Silver diamine fluoride for eligible children 0 to 6 years of age, inclusive, and for eligible beneficiaries residing in skilled nursing facilities or intermediate care facilities or that receive services in facilities overseen by the State Department of Developmental Services, as determined by the department. (c) (1) Commencing no sooner than January 1, 2022, subject to subdivision (f) of Section 14184.102, the department shall make supplemental payments to qualified dental providers for increased utilization of certain preventive dental services, and for the establishment or maintenance of beneficiary continuity of care through a dental home. (2) The department shall develop the methodology for making supplemental payments pursuant to this subdivision, including, but not limited to, the eligibility criteria for receiving payments, the amount of payments, and the applicable preventive dental services that are eligible for payments. (A) For payments for increased utilization of certain preventive services, the department shall make a supplemental payment to a qualified dental service office location for each eligible paid claim made for those Current Dental Terminology codes specified by the department and approved in the CalAIM Terms and Conditions. To the extent the department deems practicable, the supplemental payment shall be applied at the same time as the underlying eligible paid claim is made. (B) For payments for the establishment or maintenance of beneficiary continuity of care through a dental home, the department shall make a supplemental payment to each eligible service office location statewide based on the number of Medi-Cal beneficiaries for which eligible paid claims were submitted using at least one of Current Dental Terminology exam codes, as specified by the department, in two or more consecutive calendar years. (d) To the extent permissible under federal law and authorized under the CalAIM Terms and Conditions, for purposes of eligibility for payments described in this section, qualified dental providers may include safety net clinics that provide services defined under subdivision (a) or (b) of Section 14132.100. Supplemental payments made pursuant to this section to safety net clinics shall be considered separate and apart from either the Prospective Payment Service reimbursement for federally qualified health centers or rural health clinics, or Memorandum of Agreement reimbursement for Tribal Health Centers. (e) The department shall seek federal approval of any state plan amendments it deems necessary to implement subdivisions (b) and (c). (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
  2. 14184.51.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department must conduct, or arrange for someone else to conduct, the PRIME program evaluation required by the Special Terms and 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.51. The department shall conduct, or arrange to have conducted, the evaluation of the PRIME program required under the Special Terms and Conditions. (Added by Stats. 2016, Ch. 42, Sec. 3. (AB 1568) Effective July 1, 2016. Operative July 25, 2016, pursuant to Stats. 2016, Ch. 42, Sec. 8, and enactment of SB 815 as Ch. 111.)
  3. 14184.60.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department must run the Whole Person Care pilot program, and WPC pilots must include required participating entities, reporting, and approved 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.60. (a) (1) The department shall establish and operate the Whole Person Care pilot program as authorized under the demonstration project to allow for the development of WPC pilots focused on target populations of high-risk, high-utilizing Medi-Cal beneficiaries in local geographic areas. The overarching goal of the program is the coordination of health, behavioral health, and social services, as applicable, in a patient-centered manner to improve beneficiary health and well-being through a more efficient and effective use of resources. (2) The Whole Person Care (WPC) pilots shall provide an option to a county, a city and county, a health or hospital authority, or a consortium of any of the above entities serving a county or region consisting of more than one county, to receive support to integrate care for particularly vulnerable Medi-Cal beneficiaries who have been identified as high users of multiple systems and who continue to have or are at-risk of poor health outcomes. Through collaborative leadership and systematic coordination among public and private entities, pilot entities will identify common beneficiaries, share data between systems, coordinate care in real time, and evaluate individual and population progress in order to meet the goal of providing comprehensive coordinated care for the beneficiary resulting in better health outcomes. (3) Investments in the localized pilots will build and strengthen relationships and systems infrastructure and will improve collaboration among WPC lead entities and WPC participating entities. The results of the WPC pilots will provide learnings for potential future local efforts beyond the term of the demonstration. (4) WPC pilots shall include specific strategies to increase integration among local governmental agencies, health plans, providers, and other entities that serve high-risk, high-utilizing beneficiaries; increase coordination and appropriate access to care for the most vulnerable Medi-Cal beneficiaries; reduce inappropriate inpatient and emergency room utilization; improve data collection and sharing among local entities; improve health outcomes for the WPC target population; and may include other strategies to increase access to housing and supportive services. (5) WPC pilots shall be approved by the department through the process outlined in the Special Terms and Conditions. (6) Receipt of Whole Person Care services is voluntary. Individuals receiving these services shall agree to participate in the WPC pilot, and may opt out at any time. (b) For purposes of this article, the following definitions apply: (1) “Medi-Cal managed care plan” means an organization or entity that enters into a contract with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), Article 2.91 (commencing with Section 14089), or Chapter 8 (commencing with Section 14200). (2) “WPC community partner” means an entity or organization identified as participating in the WPC pilot that has significant experience serving the target population within the pilot’s geographic area, including physician groups, community clinics, hospitals, and community-based organizations. (3) “WPC lead entity” means the entity designated for a WPC pilot to coordinate the Whole Person Care pilot and to be the single point of contact for the department. WPC lead entities may be a county, a city and county, a health or hospital authority, a designated public hospital, a district and municipal public hospital, or an agency or department thereof, a federally recognized tribe, a tribal health program operated under a Public Law 93-638 contract with the federal Indian Health Service, or a consortium of any of these entities. (4) “WPC participating entity” means those entities identified as participating in the WPC pilot, other than the WPC lead entity, including other local governmental entities, agencies within local governmental entities, Medi-Cal managed care plans, and WPC community partners. (5) “WPC target population” means the population or populations identified by a WPC pilot through a collaborative data approach across partnering entities that identifies common Medi-Cal high-risk, high-utilizing beneficiaries who frequently access urgent and emergency services, including across multiple systems. At the discretion of the WPC lead entity, and in accordance with guidance as may be issued by the department during the application process and approved by the department, the WPC target population may include individuals who are not Medi-Cal patients, subject to the funding restrictions in the Special Terms and Conditions regarding the availability of federal financial participation for services provided to these individuals. (c) (1) WPC pilots shall have flexibility to develop financial and administrative arrangements to encourage collaboration with regard to pilot activities subject to the Special Terms and Conditions, the provisions of any WPC pilot agreements with the department, and the applicable provisions of state and federal law, and any other guidance issued by the department. (2) The WPC lead entity shall be responsible for operating the WPC pilot, conducting ongoing monitoring of WPC participating entities, arranging for the required reporting, ensuring an appropriate financial structure is in place, and identifying and securing a permissible source of the nonfederal share for WPC pilot payments. (3) Each WPC pilot shall include, at a minimum, all of the following entities as WPC participating entities in addition to the WPC lead entity. If a WPC lead entity cannot reach an agreement with a required participant, the WPC lead entity may request an exception to this requirement from the department. (A) At least one Medi-Cal managed care plan operating in the geographic area of the WPC pilot to work in partnership with the WPC lead entity when implementing the pilot specific to Medi-Cal managed care beneficiaries. (B) The health services agency or agencies or department or departments for the geographic region where the WPC pilot operates, or any other public entity operating in that capacity for the county or city and county. (C) The local entities, agencies, or departments responsible for specialty mental health services for the geographic area where the WPC pilot operates. (D) At least one other public agency or department, which may include, but is not limited to, county alcohol and substance use disorder programs, human services agencies, public health departments, criminal justice or probation entities, and housing authorities, regardless of how many of these fall under the same agency head within the geographic area where the WPC pilot operates. (E) At least two other community partners serving the target population within the applicable geographic area. (4) The department shall enter into a pilot agreement with each WPC lead entity approved for participation in the WPC pilot program. The information and terms of the approved WPC pilot application shall become the pilot agreement between the department and the WPC lead entity submitting the application and shall set forth, at a minimum, the amount of funding that will be available to the WPC pilot and the conditions under which payments will be made, how payments may vary or under which the pilot program may be terminated or restricted. The pilot agreement shall include a data sharing agreement that is sufficient in scope for purposes of the WPC pilot, and an agreement regarding the provision of the nonfederal share. The pilot agreement shall specify reporting of universal and variant metrics that shall be reported by the pilot on a timeline specified by the department and projected performance on them. The pilot agreement may include additional components and requirements as issued by the department during the application process. Modifications to the WPC pilot activities and deliverables may be made on an annual basis in furtherance of WPC pilot objectives, to incorporate learnings from the operation of the WPC pilot as approved by the department. (5) Notwithstanding any other law, including, but not limited to, Section 5328 of this code, and Sections 11812 and 11845.5 of the Health and Safety Code, the sharing of health information, records, and other data with and among WPC lead entities and WPC participating entities shall be permitted to the extent necessary for the activities and purposes set forth in this section. This provision shall also apply to the sharing of health information, records, and other data with and among prospective WPC lead entities and WPC participating entities in the process of identifying a proposed target population and preparing an application for a WPC pilot. (d) WPC pilots may target the focus of their pilot on individuals at risk of or experiencing homelessness who have a demonstrated medical need, including behavioral health needs, for housing or supportive services, subject to the restrictions on funding contained in the Special Terms and Conditions. In these instances, WPC participating entities may include local housing authorities, local continuum of care (CoCs) programs, community-based organizations, and others serving the homeless population as entities collaborating and participating in the WPC pilot. WPC pilot housing interventions may include the following: (1) Tenancy-based care management services. For purposes of this section, “tenancy-based care management services” means supports to assist the target population in locating and maintaining medically necessary housing. These services may include the following: (A) Individual housing transition services, such as individual outreach and assessments. (B) Individual housing and tenancy-sustaining services, including tenant and landlord education and tenant coaching. (C) Housing-related collaborative activities, such as services that support collaborative efforts across public agencies and the private sector that assist WPC participating entities in identifying and securing housing for the target population. (2) Countywide housing pools. (A) WPC pilots may establish a countywide housing pool (housing pool) that will directly provide needed support for medically necessary housing services, with the goal of improving access to housing and reducing churn in the Medi-Cal population. (B) The housing pool may be funded through WPC pilot payments or direct contributions from community entities, or from state or local government. WPC pilot payments for the operation of a housing pool shall be subject to the restrictions in the Special Terms and Conditions and other applicable provisions of federal law. Housing pool funds that are not WPC pilot payments shall be maintained separately from WPC pilot payments and may be allocated to fund support for long-term housing, including rental housing subsidies. The housing pool may leverage local resources to increase access to subsidized housing units. The housing pool may also incorporate a financing component to reallocate or reinvest a portion of the savings from the reduced utilization of health care services into the housing pool. As applicable to an approved WPC pilot, WPC investments in housing units or housing subsidies, including any payment for room and board, shall not be eligible for federal financial participation, unless recognized as reimbursable under federal Centers for Medicare and Medicaid Services policy. (e) (1) Payments to WPC pilots shall be disbursed twice a year to the WPC lead entity following the submission of the reports required pursuant to subdivision (f), to the extent all applicable requirements are met. The amount of funding for each WPC pilot and the timing of the payments shall be specified by the department upon the department approving a WPC application, consistent with the Special Terms and Conditions. During the 2016 calendar year only, payments shall be available for the planning, development, and submission of a successful WPC pilot application, including the submission of deliverables as set forth in the WPC pilot application and the WPC pilot annual report, to the extent authorized under the demonstration project and approved by the department. (2) The department shall issue a WPC pilot application and selection criteria consistent with the Special Terms and Conditions, under which applicants shall demonstrate the ability to meet the goals of the WPC pilots as outlined in this section and the Special Terms and Conditions. The department shall approve applicants that meet the WPC pilot selection criteria established by the department, and shall allocate available funding to those approved WPC pilots up to the full amount of federal financial participation authorized under the demonstration project for WPC pilots during each calendar year from 2016 to 2020, inclusive, to the extent there are sufficient numbers of applications that meet the applicable criteria. In the event that otherwise unallocated federal financial participation is available after the initial award of WPC pilots, the department may solicit applications for the remaining available funds from WPC lead entities of approved WPC pilots or from additional applicants, including applicants not approved during the initial application process. (3) In the event a WPC pilot does not receive its full annual payment amount, the WPC lead entity may request that the remaining funds be carried forward into the following calendar year, or may amend the scope of the WPC pilot, including, services, activities, or enrollment, for which this unallocated funding may be made available, subject to the Special Terms and Conditions and approval by the department. If the department denies a WPC lead entity request to carry forward unused funds and funds are not disbursed in this manner, the department may make the unexpended funds available for other WPC pilots or additional applicants not approved during the initial application process, to the extent authorized in the Special Terms and Conditions. (4) Payments to the WPC pilot are intended to support infrastructure to integrate services among local entities that serve the WPC target population, to support the availability of services not otherwise covered or directly reimbursed by Medi-Cal to improve care for the WPC target population, and to foster other strategies to improve integration, reduce unnecessary utilization of health care services, and improve health outcomes. WPC pilot payments shall not be considered direct reimbursement for expenditures incurred by WPC lead entities or WPC participating entities in implementing these strategies or reforms. WPC pilot payments shall not be considered payments for services otherwise reimbursable under the Medi-Cal program, and shall not offset or otherwise supplant payment amounts otherwise payable by the Medi-Cal program, including payments to and by Medi-Cal managed care plans, for Medi-Cal covered services. (5) WPC pilots are not intended as, and shall not be construed to constitute, health care coverage for individuals receiving services, and WPC pilots may determine the scope, type, and extent to which services are available, to the extent consistent with the Special Terms and Conditions. For purposes of the WPC pilots, WPC lead entities shall be exempt from Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, and shall not be considered Medi-Cal managed care health plans subject to the requirements applicable to the two-plan model and geographic managed care plans, as contained in Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), and Article 2.91 (commencing with Section 14089), and the corresponding regulations, and shall not be considered prepaid health plans, as defined in Section 14251. (f) WPC lead entities shall submit mid-year and annual reports to the department, in accordance with the schedules and guidelines established by the department and consistent with the Special Terms and Conditions. No later than 60 days after submission, the department shall determine the extent to which pilot requirements were met and the associated interim or annual payment due to the WPC pilot. (g) The department, in collaboration with WPC lead entities, shall facilitate learning collaboratives to allow WPC pilots to share information and lessons learned from the operation of the WPC pilots, best practices with regard to specific beneficiary populations, and strategies for improving coordination and data sharing among WPC pilot entities. (h) The nonfederal share of any payments under the WPC pilot program shall consist of voluntary intergovernmental transfers of funds provided by participating governmental agencies or entities, in accordance with this section and the terms of the pilot agreement. (1) The Whole Person Care Pilot Special Fund is hereby established in the State Treasury. Notwithstanding Section 13340 of the Government Code, moneys deposited in the Whole Person Care Pilot Special Fund pursuant to this section shall be continuously appropriated, without regard to fiscal years, to the department for the purposes specified in this section. All funds derived pursuant to this section shall be deposited in the State Treasury to the credit of the Whole Person Care Pilot Special Fund. (2) The Whole Person Care Pilot Special Fund shall consist of moneys that a participating governmental agency or entity elects to transfer to the department into the fund as a condition of participation in the WPC pilot program, to the extent permitted under Section 433.51 of Title 42 of the Code of Federal Regulations, the Special Terms and Conditions, and any other applicable federal Medicaid laws. Except as provided in paragraph (3), moneys derived from these intergovernmental transfers in the Whole Person Care Pilot Special Fund shall be used as the nonfederal share of Whole Person Care pilot payments authorized under the demonstration project. Any intergovernmental transfer of funds provided for purposes of the WPC pilot program shall be made as specified in this section. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to applicable federal Medicaid laws and the Special Terms and Conditions, and in the form and manner as required by the department. (3) The department shall claim federal financial participation for WPC pilot payments using moneys derived from intergovernmental transfers made pursuant to this section and deposited in the Whole Person Care Pilot Special Fund to the full extent permitted by law. The moneys disbursed from the fund, and all associated federal financial participation, shall be distributed to WPC lead entities in accordance with paragraph (1) of subdivision (e). In the event federal financial participation is not available with respect to a payment under this section and either is not obtained, or results in a recoupment of funds from one or more WPC lead entities, the department shall return any intergovernmental transfer fund amounts associated with the payment for which federal financial participation is not available to the applicable transferring entities within 14 days from the date of the associated recoupment or other determination, as applicable. (4) This section shall not be construed to require any local governmental agency or entity, or any other provider, plan, or similar entity, to participate in the WPC pilot program. As a condition of participation in the WPC pilot program, participating governmental agencies or entities agree to provide intergovernmental transfers of funds necessary to meet the nonfederal share obligation for any Whole Person Care pilot program payment made pursuant to this section and the Special Terms and Conditions. Any intergovernmental transfer of funds made pursuant to this section shall be considered voluntary for purposes of all federal law. No state General Fund moneys shall be used to fund the nonfederal share of any WPC pilot program payment. (Amended by Stats. 2017, Ch. 561, Sec. 286. (AB 1516) Effective January 1, 2018.)
  4. 14184.600.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )

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    The department must create and publish a county performance dashboard and carry out several oversight and monitoring actions for the CCS 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 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.600. (a) As a component of the CalAIM initiative, on and after July 1, 2022, the department, in consultation with representatives of county welfare departments and other affected stakeholders, shall develop and make publicly available a dashboard that reflects each county’s performance in meeting the measures established pursuant to subdivision (d) of Section 14154 and Section 14154.5. (b) During the CalAIM term, subject to subdivision (f) of Section 14184.102, the department, in consultation with counties and other affected stakeholders, shall develop and implement all of the following initiatives to enhance oversight and monitoring of county administration of the California Children’s Services (CCS) program, pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code: (1) Establish statewide performance, reporting, and budgetary standards, and accompanying audit tools, used to assess county compliance with federal and state requirements applicable to the CCS program. (2) Conduct periodic CCS quality assurance reviews and audits to assess compliance with the standards established in paragraph (1). (3) Assess each CCS program to ensure appropriate allocation of resources necessary for compliance with standards, policies, guidelines, performance, and compliance requirements. (4) Determine and implement a process to inform each CCS program of, and make available on its internet website, the latest standards, policies, guidelines, and new performance and compliance requirements imposed pursuant to this section. (5) Establish a statewide, tiered enforcement framework to ensure prompt corrective action for counties that do not meet standards established in paragraph (1), including providing technical assistance to counties on measures where performance is consistently below expectations and on any issues that may be identified to create a continuous quality improvement process prior to the imposition of fiscal penalties. (6) Require each county to enter into memoranda of understanding with the department to document each county’s obligations in administering the CCS program. (c) During the CalAIM term, the department shall convene a workgroup consisting of counties and other applicable stakeholders to develop and implement one or more initiatives designed to improve the collection and use of beneficiary demographic and contact information in administering the Medi-Cal program and other applicable public assistance programs. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
  5. 14184.61.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department must conduct, or arrange for, evaluations of the WPC pilot program required by the Special Terms and 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.61. The department shall conduct, or arrange to have conducted, the evaluations of the WPC pilot program required under the Special Terms and Conditions. (Added by Stats. 2016, Ch. 42, Sec. 5. (AB 1568) Effective July 1, 2016. Operative July 25, 2016, pursuant to Stats. 2016, Ch. 42, Sec. 8, and enactment of SB 815 as Ch. 111.)
  6. 14184.70.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department must run the Dental Transformation Initiative (DTI) under the Special Terms and Conditions and pay eligible providers and service office locations according to the program 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.70. (a) (1) The department shall implement the Dental Transformation Initiative, or DTI, in accordance with the Special Terms and Conditions, with the goal of improving the oral health care for Medi-Cal children zero to 20 years of age, inclusive. (2) The DTI is intended to improve the oral health care for Medi-Cal children with a particular focus on increasing the statewide proportion of qualifying children enrolled in the Medi-Cal Dental Program who receive a preventive dental service by 10 percentage points over a five-year period. (3) The DTI includes the following four domains as outlined in the Special Terms and Conditions: (A) Preventive Services. (B) Caries Risk Assessment. (C) Continuity of Care. (D) Local Dental Pilot Projects. (4) Under the DTI, incentive payments within each domain will be available to qualified providers who meet the requirements of the domain. (b) For purposes of this article, the following definitions apply: (1) “DTI incentive payment” means a payment made to an eligible contracted service office location pursuant to the DTI component of the Special Terms and Conditions. (2) “DTI pool” means the funding available under the Special Terms and Conditions for the purposes of the DTI program, as described in paragraph (1) of subdivision (c). (3) “DTI program year” means a calendar year beginning on January 1 and ending on December 31 during which the DTI component is authorized under the Special Terms and Conditions, beginning with the 2016 calendar year, and, as applicable, each calendar year thereafter through 2020, and any years or partial years during which the DTI is authorized under an extension or successor to the demonstration project. (4) “Safety net clinics” means centers or clinics that provide services defined under subdivision (a) or (b) of Section 14132.100 that are eligible for DTI incentive payments in accordance with the Special Terms and Conditions. DTI incentive payments received by safety net clinics shall be considered separate and apart from either the Prospective Payment System reimbursement for federally qualified health centers or rural health centers, or Memorandum of Agreement reimbursement for Tribal Health Centers. Each safety net clinic office location shall be considered a dental service office location for purposes of the domains authorized by the Special Terms and Conditions. (5) “Service office location” means the business, or pay-to address, in which the provider, which may be an individual, partnership, group, association, corporation, institution, or entity that provides dental services, renders dental services. This may include a provider that participates in either the dental fee-for-service or dental managed care Medi-Cal delivery systems. (c) (1) The DTI shall be funded at a maximum of one hundred forty-eight million dollars ($148,000,000) annually, and for five years totaling a maximum of seven hundred forty million dollars ($740,000,000), except as provided in the Special Terms and Conditions. To the extent any of the funds associated with the DTI are not fully expended in a given DTI program year, those remaining prior DTI program year funds may be available for DTI payments in subsequent years, notwithstanding the annual limits stated in the Special Terms and Conditions. The department may earn additional demonstration authority, up to a maximum of ten million dollars ($10,000,000), to be added to the DTI pool for use in paying incentives to qualifying providers under DTI by achieving higher performance improvement, as indicated in the Special Terms and Conditions. (2) Providers in either the dental fee-for-service or dental managed care Medi-Cal delivery systems are permitted to participate in the DTI. The department shall make DTI incentive payments directly to eligible contracted service office locations. Incentive payments shall be issued to the service office location based on the services rendered at the location and that service office location’s compliance with the criteria enumerated in the Special Terms and Conditions. (3) Incentive payments from the DTI pool are intended to support and reward eligible service office locations for achievements within one or more of the project domains. The incentive payments shall not be considered as a direct reimbursement for dental services under the Medi-Cal State Plan. (A) The department may provide DTI incentive payments to eligible service office locations on a semiannual or annual basis, or in a manner otherwise consistent with the Special Terms and Conditions. (B) The department shall disburse DTI incentive payments to eligible service office locations that did not previously participate in Medi-Cal before the demonstration and that render preventive dental services during the demonstration to the extent the service office location meets or exceeds the goals specified by the department in accordance with the Special Terms and Conditions. (C) Safety net clinics are eligible for DTI incentive payments specified in the Special Terms and Conditions. Participating safety net clinics shall be responsible for submitting data in a manner specified by the department for receipt of DTI incentive payments. Each safety net clinic office location shall be considered a dental service office location for purposes of specified domains outlined in the Special Terms and Conditions. (D) Dental managed care provider service office locations are eligible for DTI incentive payments, as specified in the Special Terms and Conditions, and these payments shall be considered separate from payment received from a dental managed care plan. (E) Service office locations shall submit all data in a manner acceptable to the department within one year from the date of service or by January 31 for the preceding year that the service was rendered, whichever occurs sooner, to be eligible for DTI incentive payments associated with that timeframe. (d) The domains of the DTI are as follows: (1) Increase Preventive Services Utilization for Children: This domain aims to increase the statewide proportion of qualifying children enrolled in Medi-Cal who receive a preventive dental service in a given year. The statewide goal is to increase the utilization among children enrolled in the dental fee-for-service and dental managed care delivery systems by at least 10 percentage points by the end of the demonstration. (2) Caries Risk Assessment and Disease Management Pilot: (A) This domain will initially only be available to participating service office locations in select pilot counties, designated by the department, as specified in the Special Terms and Conditions. Participating service office locations shall elect to be approved by the department to participate in this domain of the DTI program. To the extent the department determines the pilots to be successful, the department may seek to implement this domain on a statewide basis and subject to the availability of funding under the DTI pool available for this purpose. (B) Medi-Cal dentists voluntarily participating in this pilot shall be eligible to receive DTI incentive payments for implementing preidentified treatment plans for children based upon that child beneficiary’s risk level as determined by the service office location via a caries risk assessment, which shall include motivational interviewing and use of antimicrobials, as indicated. The department shall identify the criteria and preidentified treatment plans to correspond with the varying degrees of caries risk, low, moderate, and high, while the rendering provider shall develop and implement the appropriate treatment plan based on the needs of the beneficiary. (C) The department shall identify and select pilot counties through an analysis of counties with a high percentage of restorative services, a low percentage of preventive services, and indication of likely participation by enrolled service office locations. (3) Increase Continuity of Care: A DTI incentive payment shall be paid to eligible service office locations that have maintained continuity of care through providing examinations for their enrolled child beneficiaries under 21 years of age, as specified in the Special Terms and Conditions. The department shall begin this effort in select counties and shall seek to implement on a statewide basis if the pilot is determined to be successful and subject to the availability of funding under the DTI pool. If successful, the department shall consider an expansion no sooner than nine months following the end of the second DTI program year. (4) Local Dental Pilot Projects (LDPPs): LDPPs shall address one or more of the three domains identified in paragraph (1), (2), or (3) through alternative local dental pilot projects, as authorized by the department pursuant to the Special Terms and Conditions. (A) The department shall require local pilots to have broad-based provider and community support and collaboration, including engagement with tribes and Indian health programs, with DTI incentive payments available to the pilot based on goals and metrics that contribute to the overall goals of the domains described in paragraphs (1), (2), and (3). (B) The department shall solicit proposals at the beginning of the demonstration and shall review, approve, and make DTI incentive payments to approved LDPPs in accordance with the Special Terms and Conditions. (C) A maximum of 15 LDPPs shall be approved and no more than 25 percent of the total funding in the DTI pool shall be used for LDPPs. (Amended by Stats. 2017, Ch. 561, Sec. 287. (AB 1516) Effective January 1, 2018.)
  7. 14184.700.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )

    Verify source ↗

    The department may provide PATH funding to qualified entities or providers, but it must set the payment rules and cannot charge a similar fee on related intergovernmental transfers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.700. (a) Subject to subdivision (f) of section 14184.102 and the availability of sufficient nonfederal share funds for this purpose in each CalAIM year, the department may make incentive payments, grants, or other financial support available to qualified entities or providers under the Providing Access and Transforming Health (PATH) program to support services, infrastructure, and capacity building in advancing and complimenting select goals and components of CalAIM as described in this article. (b) The department, in consultation with affected entities and providers, shall establish the methodologies, parameters, and eligibility criteria for PATH payments pursuant to this section, in accordance with the CalAIM Terms and Conditions. (c) For purposes of PATH payments made pursuant to this section, qualified entities or providers may include, but need not be limited to, counties, Medi-Cal managed care plans, designated public hospital systems, community-based organizations, county sheriffs, adult and juvenile correctional facilities, or chief probation officers, to the extent approved in the CalAIM Terms and Conditions. (d) The nonfederal share of PATH payments may consist of voluntary intergovernmental transfers of funds provided by eligible governmental agencies or other public entities pursuant to Section 14164. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to Section 433.51 of Title 42 of the Code of Federal Regulations, any other applicable federal Medicaid laws, and the CalAIM Terms and Conditions, and in the form and manner specified by the department. Any intergovernmental transfer of funds made pursuant to this section shall be considered voluntary for purposes of all state and federal laws. Notwithstanding any other law, the department shall not assess the fee described in subdivision (d) of Section 14301.4 or any other similar fee on the intergovernmental transfers made pursuant to this section. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
  8. 14184.71.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

    Verify source ↗

    The department must conduct, or arrange for, the evaluation of the DTI required under the Special Terms and 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.71. The department shall conduct, or arrange to have conducted, the evaluation of the DTI required under the Special Terms and Conditions. (Added by Stats. 2016, Ch. 42, Sec. 7. (AB 1568) Effective July 1, 2016. Operative July 25, 2016, pursuant to Stats. 2016, Ch. 42, Sec. 8, and enactment of SB 815 as Ch. 111.)
  9. 14184.72.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

    Verify source ↗

    The department must include specified data, analyses, and an awareness plan in its report on the DTI evaluation submitted to CMS and made publicly 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.72. In connection with the evaluation of the DTI required by Section 14184.71, the department’s report of data and quality measures submitted to the federal Centers for Medicare and Medicaid Services (CMS) and made publicly available pursuant to the Special Terms and Conditions for the Increase Preventive Services Utilization for Children domain shall include, but not be limited to, all of the following: (a) A detailed description of how the department has operationalized the domain, including information identifying which entities have responsibility for the components of the domain. (b) The number of individual incentives paid and the total amount expended under the domain for the current program year. (c) An awareness plan that describes all of the following: (1) How the department has generated awareness of the availability of incentives for providing preventive dental services to children, including steps taken to increase awareness of the DTI among dental and primary care providers. (2) How the department has generated awareness among beneficiaries of the availability of, the importance of, and how to access preventive dental services for children. (3) The different approaches to raising awareness undertaken among specific groups, including age groups, rural and urban residents, and primary language groups. These approaches shall be developed in conjunction with interested dental and children’s health stakeholders. (d) An annual analysis of whether the awareness plan described in subdivision (c) has succeeded in generating the utilization necessary, by subgrouping, to meet the goals of the domain, and a description of changes to the awareness plan needed to address any identified deficiencies. (e) Data describing both of the following: (1) The use of, and expenditures on, preventive dental services. (2) The use of, and expenditures on, other nonpreventive dental services. (f) A discussion of the extent to which the metrics described for the domain are proving to be useful in understanding the effectiveness of the activities undertaken in the domain. (g) An analysis of changes in cost per capita. (h) A descriptive analysis of program integrity challenges generated by the domain and how those challenges have been, or will be, addressed. (i) A descriptive analysis of the overall effectiveness of the activities in the domain in meeting the intended goals of the domain, any lessons learned, and any recommended adjustments. (Added by Stats. 2016, Ch. 613, Sec. 3. (AB 2207) Effective January 1, 2017.)
  10. 14184.73.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

    Verify source ↗

    The department must include specified data, spending, and impact information in its report of data and quality 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.73. In connection with the evaluation of the DTI required by Section 14184.71, the department’s report of data and quality measures submitted to the federal Centers for Medicare and Medicaid Services and made publicly available pursuant to the Special Terms and Conditions for the Caries Risk Assessment (CRA) and Disease Management Pilot domain shall include, but not be limited to, all of the following: (a) A detailed description of how the department has operationalized the domain, including information identifying which entities have responsibility for the components of the domain. (b) The number of individual incentives paid and the total amount expended, by county, under the domain in the current demonstration year. (c) A descriptive assessment of the impact of the domain on targeted children in the age ranges of under one year of age, one through two years of age, three through four years of age, and five through six years of age, for all of the following: (1) Provision of CRAs. (2) Provision of dental exams. (3) Use of, and expenditures on, preventive dental services. (4) Use of, and expenditures on, dental treatment services. (5) Use of, and expenditures on, dental-related general anesthesia, including facility costs. (Added by Stats. 2016, Ch. 613, Sec. 4. (AB 2207) Effective January 1, 2017.)
  11. 14184.74.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

    Verify source ↗

    The department must include specified items in its report of data and quality measures for the DTI evaluation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.74. In connection with the evaluation of the DTI required by Section 14184.71, the department’s report of data and quality measures submitted to the federal Centers for Medicare and Medicaid Services and made publicly available pursuant to the Special Terms and Conditions for the Increase Continuity of Care domain shall include, but not be limited to, all of the following: (a) A detailed description of how the department has operationalized the domain, including information identifying which entities have responsibility for the components of the domain. (b) The number of individual incentives paid and the total amount expended, by county, under the domain in the current demonstration year. (c) A descriptive assessment of the impact of the domain, with respect to targeted children, of all of the following: (1) Provision of dental exams. (2) Use of, and expenditures on, preventive dental services. (3) Use of, and expenditures on, other nonpreventive dental services. (d) A discussion of the extent to which the metrics prescribed for the domain are proving to be useful in understanding the effectiveness of the activities undertaken in the domain. (e) An analysis of change in cost per capita. (f) A descriptive analysis of program integrity challenges generated by the domain and how those challenges have been, or will be, addressed. (g) A descriptive analysis of the overall effectiveness of the activities in the domain in meeting the intended goals of the domain, any lessons learned, and any recommended adjustments. (Added by Stats. 2016, Ch. 613, Sec. 5. (AB 2207) Effective January 1, 2017.)
  12. 14184.75.

    ## 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

    Verify source ↗

    The department must include specific information in its data and quality measures report for the DTI evaluation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.75. In connection with the evaluation of the DTI required by Section 14184.71, the department’s report of data and quality measures submitted to the federal Centers for Medicare and Medicaid Services and made publicly available pursuant to the Special Terms and Conditions for the Local Dental Pilot Program domain shall include, but not be limited to, all of the following: (a) A detailed description of how the department has operationalized this aspect of the demonstration project, including the solicitation and selection process. (b) The number of pilot projects funded and the total amount expended, by project, under the domain in the current demonstration year. (c) A description of the pilot projects selected for award that for each project shall include, but not be limited to, all of the following: (1) Specific strategies for the project. (2) Target populations. (3) Payment methodologies. (4) Annual budget for the project. (5) Expected duration of the project. (6) Performance metrics by which the project shall be measured. (7) The intended goal of the project. (d) An assessment of the pilot projects selected for award that includes for each project all of the following: (1) Project performance and outcomes. (2) Project replicability. (3) Challenges encountered and actions undertaken to address those challenges. (4) Information on payments made by the department to the project. (e) A descriptive assessment of the impact of the Local Dental Pilot Program domain on achieving the goals of the Increase Preventive Services Utilization for Children, Caries Risk Assessment and Disease Management Pilot, and Increase Continuity of Care domains. (f) A descriptive analysis of program integrity challenges generated by the domain and how those challenges have been, or will be, addressed. (Added by Stats. 2016, Ch. 613, Sec. 6. (AB 2207) Effective January 1, 2017.)
  13. 14184.80.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department must amend the EQRO contract, submit the access assessment design to federal CMS, and set up an advisory committee; the committee and EQRO must help develop and report on the assessment, with several posting and submission deadlines.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.80. (a) Within 90 days of the effective date of the act that added this section, the department shall amend its contract with the external quality review organization (EQRO) currently under contract with the department and approved by the federal Centers for Medicare and Medicaid Services to complete an access assessment. This one-time assessment is intended to do all of the following: (1) Evaluate primary, core specialty, and facility access to care for managed care beneficiaries based on the current health plan network adequacy requirements set forth in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and Medicaid managed care contracts, as applicable. (2) Consider State Fair Hearing and Independent Medical Review (IMR) decisions, and grievances and appeals or complaints data. (3) Report on the number of providers accepting new beneficiaries. (b) The department shall submit to the federal Centers for Medicare and Medicaid Services for approval the access assessment design no later than 180 days after approval by the federal Centers for Medicare and Medicaid Services of the EQRO contract amendment. (c) The department shall establish an advisory committee that will provide input into the structure of the access assessment. The EQRO shall work with the department to establish the advisory committee, which will provide input into the assessment structure, including network adequacy requirements and metrics, that should be considered. (d) The advisory committee shall include one or more representatives of each of the following stakeholders to ensure diverse and robust input into the assessment structure and feedback on the initial draft access assessment report: (1) Consumer advocacy organizations. (2) Provider associations. (3) Health plans and health plan associations. (4) Legislative staff. (e) The advisory committee shall do all of the following: (1) Begin to convene within 60 days of approval by the federal Centers for Medicare and Medicaid Services of the EQRO contract amendment. (2) Participate in a minimum of two meetings, including an entrance and exit event, with all events and meetings open to the public. (3) Provide all of the following: (A) Feedback on the access assessment structure. (B) An initial draft access assessment report. (C) Recommendations that shall be made available on the department’s Internet Web site. (f) The EQRO shall produce and publish an initial draft and a final access assessment report that includes a comparison of health plan network adequacy compliance across different lines of business. The report shall include recommendations in response to any systemic network adequacy issues, if identified. The initial draft and final report shall describe the state’s current compliance with the access and network adequacy standards set forth in the Medicaid Managed Care proposed rule (80 FR 31097) or the finalized Part 438 of Title 42 of the Code of Federal Regulations, if published before submission of the assessment design to the federal Centers for Medicare and Medicaid Services. (g) The access assessment shall do all of the following: (1) Measure health plan compliance with network adequacy requirements as set forth in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and Medicaid managed care contracts, as applicable. The assessment shall consider State Fair Hearing and IMR decisions, and grievances and appeals or complaints data, and any other factors as selected with input from the advisory committee. (2) Review encounter data, including a review of data from subcapitated plans. (3) Measure health plan compliance with timely access requirements, as set forth in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and Medicaid managed care contracts using a sample of provider-level data on the soonest appointment availability. (4) Review compliance with network adequacy requirements for managed care plans, and other lines of business for primary and core specialty care areas and facility access, as set forth in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and Medicaid managed care contracts, as applicable, across the entire health plan network. (5) Applicable network adequacy requirements of the proposed or final Notice of Proposed Rulemaking, as determined under the approved access assessment design, that are not already required under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) shall be reviewed and reported on against a metric range as identified by the department and approved by the federal Centers for Medicare and Medicaid Services in the access assessment design. (6) Determine health plan compliance with network adequacy through reviewing information or data from a one-year period using validated network data and utilize it for the time period following conclusion of the preassessment stakeholder process but no sooner than the second half of the 2016 calendar year in order to ensure use of the highest quality data source available. (7) Measure managed care plan compliance with network adequacy requirements within the department and managed care plan contract service areas using the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and network adequacy standards within Medicaid managed care contracts, accounting for each of the following: (A) Geographic differences, including provider shortages at the local, state, and national levels, as applicable. (B) Previously approved alternate network access standards, as provided for under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) and Medicaid managed care contracts. (C) Access to in-network providers and out-of-network providers separately, presented and evaluated separately, when determining overall access to care. (D) The entire network of providers available to beneficiaries at the state contractor plan level. (E) Other modalities used for accessing care, including telemedicine. (h) The department shall post the initial draft report for a 30-day public comment period after it has incorporated the feedback from the advisory committee. The initial draft report shall be posted for public comment no later than 10 months after the federal Centers for Medicare and Medicaid Services approves the assessment design. (i) The department shall also make publicly available the feedback from the advisory committee at the same time it posts the initial draft of the report. (j) The department shall submit the final access assessment report to the federal Centers for Medicare and Medicaid Services no later than 90 days after the initial draft report is posted for public comment. (Amended by Stats. 2017, Ch. 561, Sec. 288. (AB 1516) Effective January 1, 2018.)
  14. 14184.800.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )

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    Qualifying inmates of public institutions may be eligible for targeted Medi-Cal services for a limited period before release, subject to eligibility rules and approved terms.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.800. (a) Notwithstanding any other law, commencing no sooner than January 1, 2023, a qualifying inmate of a public institution shall be eligible to receive targeted Medi-Cal services for 90 days, or the number of days approved in the CalAIM Terms and Conditions with respect to an eligible population of qualifying inmates if different than 90 days, prior to the date they are released from a public institution, if otherwise eligible for those services under this chapter and subject to subdivision (f) of Section 14184.102. (b) Targeted Medi-Cal services made available to qualifying inmates pursuant to subdivision (a) shall be limited to those services approved in the CalAIM Terms and Conditions. (c) To the extent federal approval is obtained to implement this section, the department shall arrange for an independent, third-party evaluation of the hypotheses and outcomes associated with providing targeted Medi-Cal services to qualifying inmates as described in the CalAIM Terms and Conditions. The department shall post the evaluation report on its internet website following submission to the federal Centers for Medicare and Medicaid Services. (Amended by Stats. 2022, Ch. 47, Sec. 130. (SB 184) Effective June 30, 2022.)
  15. 14184.90.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )

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    The department may authorize a San Mateo County dental integration pilot program, but only under listed conditions and after federal approvals; the department must also do several pre-start tasks, and some enrollees may keep seeing the same provider if specified 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 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.90. (a) Subject to appropriation by the Legislature, beginning no sooner than July 1, 2019, and consistent with Section 14184.20, the department may authorize a dental integration pilot program in San Mateo County as a component of the Medi-Cal 2020 demonstration project established by this article, or any extension or amendment to the Medi-Cal 2020 demonstration project pursuant to subdivision (j) of Section 14184.20. The pilot program shall be designed to test the impact to oral care access, quality, and utilization, as well as medical cost impacts by the delivery of covered dental care services as a managed care benefit under the operation of the Health Plan of San Mateo. (b) Before the start date of the approved pilot program, the department shall do all of the following: (1) Seek input from affected stakeholders including, but not limited to, the Health Plan of San Mateo, currently enrolled Medi-Cal dental providers, other dental providers, and consumer advocates. (2) Establish objectives for improving dental utilization through the pilot program. (3) Establish objectives for improving access to oral health care through the pilot program. (4) Determine that the Health Plan of San Mateo meets the department’s readiness requirements, including, but not limited to, the demonstration of an adequate network of dental care providers. (c) Under the approved pilot program, covered Medi-Cal dental care services currently provided under the Medi-Cal fee-for-service system to enrollees of the Health Plan of San Mateo shall be made the responsibility of the Health Plan of San Mateo, including covered dental care services provided through safety net clinics, such as federally qualified health centers. For the duration of the approved pilot program, enrollees of the Health Plan of San Mateo will no longer receive covered Medi-Cal dental care services through the Medi-Cal fee-for-service system. (d) To minimize interruptions in ongoing dental care, enrollees impacted by the approved pilot program who have been in treatment with a specific Medi-Cal dental provider for more than 12 months shall be permitted to continue to receive covered dental services from that provider, if all of the following are met: (1) The provider is willing to continue to treat the enrollee at existing Medi-Cal fee-for-service rates, or at another rate or rate methodology as agreed upon by the plan and provider. (2) The provider remains an eligible provider of dental services in Medi-Cal. (3) The Health Plan of San Mateo has not identified a significant quality issue with the provider. (e) The pilot program described in this section shall be authorized for no more than a period of six years. (f) Pursuant to subdivision (e) of Section 14184.20, and to the extent the department obtains federal approval for the pilot program described in this section, the department shall contract with an external entity to conduct an evaluation of the pilot program to be completed and published no later than December 31 of the sixth state fiscal year the pilot program is in operation. The evaluation shall include all of the following: (1) Assessment of the pilot program’s ability to meet the utilization objectives established in this section. (2) Assessment of the pilot program’s ability to meet the improved access objectives established in this section. (3) Assessment of overall dental utilization and changes in utilization compared to utilization in the fee-for-service system that occurred prior to the pilot program. (4) Assessment of the medical cost impacts of the pilot program, if any, such as reductions in emergency room visits. (5) Assessment of the impacts to the available provider network for dental services in the pilot program compared to the provider network available in the fee-for-service system before the pilot program. (g) The funding for the evaluation described in subdivision (f) shall be provided by the Health Plan of San Mateo to the department. The department shall seek federal matching funds if available. (h) The department shall consult with the Health Plan of San Mateo no later than six months before the start date of the approved pilot program regarding any necessary adjustments to its capitation rates developed pursuant to Section 14301.1 and methods required to integrate dental care services for plan enrollees. (i) (1) This section shall not be implemented until all necessary federal approvals have been obtained. (2) This section shall be implemented only to the extent the department determines federal financial participation is available and is not otherwise jeopardized. (Added by Stats. 2018, Ch. 47, Sec. 3. (SB 849) Effective June 27, 2018.)
  16. 14184.900.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )

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    The department must begin implementing Employment Supports and BridgeCare no earlier than 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 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.900. (a) Commencing no sooner than January 1, 2027, in accordance with the CalAIM Terms and Conditions and subdivision (f) of Section 14184.102, the department shall implement Employment Supports. (b) Commencing no sooner than January 1, 2027, in accordance with the CalAIM Terms and Conditions and subdivision (f) of Section 14184.102, the department shall implement BridgeCare to provide home- and community-based services and caregiver supports to individuals enrolled in the federal Medicare Program who meet the near dual eligibility criteria outlined in the CalAIM Terms and Conditions. (Added by Stats. 2026, Ch. 27, Sec. 92. (SB 164) Effective June 29, 2026.)
  17. 14185.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.6. Drug Utilization Under Medi-Cal Managed Care Programs [14185- 14185.] ( Article 5.6 added by Stats. 1998, Ch. 975, Sec. 1. )

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    Certain managed care plans must process drug prior-authorization requests quickly, provide at least a 72-hour emergency supply, and let enrolled beneficiaries continue a pre-enrollment single-source drug in an ongoing therapy.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.6. Drug Utilization Under Medi-Cal Managed Care Programs [14185- 14185.] ( Article 5.6 added by Stats. 1998, Ch. 975, Sec. 1. ) ## 14185. (a) A managed care plan, as defined in accordance with subdivision (a) of Section 14093.05, that has prescription drugs as one of its benefits and that enters into a contract with the department pursuant to this chapter or Chapter 8 (commencing with Section 14200), shall ensure the timely and efficient processing of authorization requests for drugs, when prescribed for plan enrollees, that are covered under the terms of the plan’s contract with the department and require prior authorization from the plan, by providing both of the following: (1) A response within 24 hours or one business day to a request for prior authorization made by telephone or other telecommunication device. (2) The dispensing of at least a 72-hour supply of a covered outpatient drug in an emergency situation. (b) A managed care plan, as defined in accordance with subdivision (a) of Section 14093.05, that has prescription drugs as one of its benefits and that enters into a contract with the department pursuant to this chapter or Chapter 8 (commencing with Section 14200), shall permit a Medi-Cal beneficiary enrolled in the plan to continue use of a single-source drug which is part of a prescribed therapy in effect for the beneficiary immediately prior to the date of enrollment, whether or not the drug is covered by the plan, until the prescribed therapy is no longer prescribed by the contracting physician. (c) This section shall not alter or affect the terms of a contract between the department and a managed care plan regarding the responsibilities of the plan to cover prescription drugs prescribed by a physician other than the treating or attending physician of the plan. (Added by Stats. 1998, Ch. 975, Sec. 1. Effective September 30, 1998.)
  18. 14186.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. )

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    This section defines terms used in the article, including Medi-Cal managed care plan, person experiencing homelessness, field medicine, and field medicine provider.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. ) ## 14186. For purposes of this article, the following definitions apply: (a) “Medi-Cal managed care plan” has the same meaning as set forth in Section 14184.101. (b) “Person experiencing homelessness,” or a variation thereof, means a person who lacks a fixed, regular, and adequate nighttime residence. This may include living in shelters, transitional housing, or places not meant for habitation, like cars or outdoors. (c) “Field medicine” means a set of health and social services developed specifically to address the unique needs and circumstances of persons experiencing homelessness utilizing a whole-person, patient-centered approach to provide medically necessary health care services, and to address social drivers of health that impede health care access. (d) “Field medicine provider” means a licensed medical provider, including, but not limited to, a physician and surgeon, osteopathic physician and surgeon, physician assistant, nurse practitioner, or certified nurse-midwife, who conducts patient visits outside of the four walls of health facilities, clinics, or other locations, and instead directly on the street, in environments where persons experiencing homelessness might be, such as living in a car, recreational vehicle, encampment, abandoned building, or other outdoor areas. (Added by Stats. 2025, Ch. 374, Sec. 3. (AB 543) Effective January 1, 2026.)
  19. 14186.1.

    ## 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 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. )

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    The department must seek any federal approvals needed to implement this article, and it may temporarily implement or explain the article through certain letters and bulletins until needed regulations are adopted.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. ) ## 14186.1. (a) (1) The department shall seek any federal approvals necessary to implement this article. (2) Each section of this article shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and is not otherwise jeopardized. (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 article by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until any necessary regulations are adopted. (Added by Stats. 2025, Ch. 374, Sec. 3. (AB 543) Effective January 1, 2026.)
  20. 14186.2.

    ## 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 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. )

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    The Legislature says implementation of this article should not duplicate other Medi-Cal provisions and should work alongside 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 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. ) ## 14186.2. It is the intent of the Legislature that implementation of this article not be duplicative of implementation of other Medi-Cal provisions, including, but not limited to, those regarding community health worker services, enhanced care management, and community supports, as described in Sections 14132.36, 14184.205, and 14184.206, respectively. It is the intent of the Legislature that the field medicine-related provisions set forth in this article coexist with those other Medi-Cal benefits in order to fill significant gaps within the health care system for persons experiencing homelessness. (Added by Stats. 2025, Ch. 374, Sec. 3. (AB 543) Effective January 1, 2026.)
  21. 14186.3.

    ## 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 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. )

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    Medi-Cal managed care plans that choose field medicine coverage must let homeless members receive covered services directly from in-network field medicine providers and must support referrals, communication, and homelessness 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 5.7. Medi-Cal Field Medicine [14186 - 14186.3] ( Article 5.7 added by Stats. 2025, Ch. 374, Sec. 3. ) ## 14186.3. (a) A Medi-Cal managed care plan may elect to offer Medi-Cal covered services through an in-network, contracted field medicine provider pursuant to this article. (b) A Medi-Cal managed care plan that elects to offer Medi-Cal covered services through an in-network, contracted field medicine provider shall allow a Medi-Cal member who is experiencing homelessness to receive those services directly from an in-network, contracted field medicine provider, regardless of the member’s in-network assignment, such as primary care provider (PCP) or independent practice association (IPA) assignment. (c) (1) A Medi-Cal managed care plan that elects to offer Medi-Cal covered services through an in-network, contracted field medicine provider shall allow an in-network, contracted field medicine provider enrolled in the Medi-Cal program to directly refer a member who is experiencing homelessness for covered services, including specialist, diagnostic services, medications, durable medical equipment, transportation, or other medically necessary covered services, within the appropriate network of the Medi-Cal managed care plan or in-network IPA. (2) The Medi-Cal managed care plan or IPA shall create referral and authorization mechanisms in order to facilitate the referrals described in paragraph (1). (d) Medi-Cal managed care plans contracting with field medicine providers pursuant to this section shall have appropriate mechanisms, procedures, or protocols to ensure timely communication between the in-network, contracted field medicine provider, the Medi-Cal member’s plan or IPA, and the member’s assigned primary care provider for purposes of care coordination and to prevent the duplication of services. (e) (1) A Medi-Cal managed care plan shall provide a method for a Medi-Cal member to inform the Medi-Cal managed care plan online, in person, or via telephone that the member is experiencing homelessness. (2) The department shall inform a Medi-Cal managed care plan if a Medi-Cal member has indicated that they are experiencing homelessness based on information furnished on the Medi-Cal application. (f) In the case of a Medi-Cal beneficiary who is experiencing homelessness and who receives services within the fee-for-service delivery system, the department shall reimburse a field medicine provider enrolled in the Medi-Cal program for providing Medi-Cal covered services. (Added by Stats. 2025, Ch. 374, Sec. 3. (AB 543) Effective January 1, 2026.)
  22. 14188.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. )

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    This section lets Proposition 56 funding be used for Medi-Cal managed care value-based payment programs, and it directs the department to set up and manage those programs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. ) ## 14188. (a) The Legislature finds and declares both of the following: (1) Value-based payment (VBP) strategies offer financial incentives to health care providers that improve their performance on predetermined measures or meet specified targets that focus on quality and efficiency of care. (2) Funding pursuant to the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, or Proposition 56, which was approved by voters at the November 8, 2016, statewide general election, is intended, in part, to supplement payments to Medi-Cal providers to ensure quality care in the Medi-Cal program. (b) In accordance with Proposition 56 and subject to an appropriation by the Legislature, Proposition 56 funding may be used, pursuant to Section 14188.2, for directed payment programs or incentive arrangements in Medi-Cal managed care, including VBPs required of Medi-Cal managed care plans as designated by the department and as described in this article. The purpose of the VBPs shall be to help improve care for some of the most vulnerable or at-risk populations in the Medi-Cal managed care delivery system. (c) Effective no earlier than July 1, 2019, the department shall implement the VBP programs described in Section 14188.1, only to the extent that federal financial participation is available and that any necessary federal approvals have been obtained. The department shall develop the structure and parameters of the VBP programs, including designation of those Medi-Cal managed care plans that are required to participate in VBP programs. The department may modify the VBP programs to the extent it deems necessary to obtain or maintain federal approval, if needed to target spending in a manner that furthers the purpose of the programs, or based on evaluation of the programs. (d) (1) The department shall require the designated Medi-Cal managed care plans to make VBPs to network providers that meet the requirements of the VBP programs implemented pursuant to Section 14188.1, in the amounts, form, and manner as directed by the department. (2) The department shall not require a county mental health plan contracted with the department pursuant to Chapter 8.9 (commencing with Section 14700), or a county Drug Medi-Cal organized delivery system authorized in the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver as applicable, to participate in any VBP program described in Section 14188.1. (3) VBPs made pursuant to this article shall be in addition to any other payments made by the designated Medi-Cal managed care plans to applicable network providers for services or other performance-based incentives. (e) For purposes of this article, “VBP” means value-based payment. (Amended by Stats. 2020, Ch. 12, Sec. 64. (AB 80) Effective June 29, 2020.)
  23. 14188.1.

    ## 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. )

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    The department must develop value-based payment programs for Medi-Cal managed care, and plans/providers may qualify for incentive payments under those programs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. ) ## 14188.1. Subject to Section 14188, the department shall develop all of the following VBP programs: (a) A VBP program that is aimed at improving behavioral health integration in Medi-Cal managed care. (1) Designated Medi-Cal managed care plans may earn incentive payments for achieving milestones and measures through partnerships with qualified network providers that adopt a team-based care approach for individuals with serious mental health conditions or other chronic health conditions. (2) Different levels of incentive payments may be available depending on the level of integration, using either a coordination or collocation approach. Partial incentive payments may be available for meeting above-minimum standards. (3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article. (b) A VBP program that is aimed at improving prenatal and postpartum care in Medi-Cal managed care. (1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network primary care or appropriate specialist providers that meet achievement levels on selected prenatal and postpartum care measures, as determined by the department. (2) Qualified network primary care or appropriate specialist providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards. (3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article. (c) A VBP program that is aimed at improving chronic disease management in Medi-Cal managed care. (1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network providers that meet achievement levels on selected chronic disease care measures, as determined by the department. The measures shall be in chronic disease care areas, including, but not limited to, diabetes care and control of hypertension, using measures currently recognized for those areas in the Healthcare Effectiveness Data and Information Set (HEDIS) or other nationally recognized measures that the department deems appropriate. (2) Qualified network providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards. (3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article. (d) A VBP program that is aimed at improving quality and outcomes for children in Medi-Cal managed care. (1) Designated Medi-Cal managed care plans shall make incentive payments to qualified network providers that meet achievement levels on selected childhood health care quality measures, as determined by the department. The measures shall be developed using measures currently recognized for those areas in HEDIS or other nationally recognized measures that the department deems appropriate. (2) Qualified network providers may be eligible for maximum incentive payments if they meet the designated high-performance standards, and partial incentive payments for meeting above-minimum standards. (3) The requirements for receiving an incentive payment and the methodology for determining the value of the payment shall be determined by the department, in accordance with this article. (Amended by Stats. 2021, Ch. 143, Sec. 408. (AB 133) Effective July 27, 2021. Section inoperative on July 1, 2021, pursuant to Section 14188.4.)
  24. 14188.2.

    ## 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. )

    Verify source ↗

    The VBP programs in Section 14188.1 are to be funded from money appropriated for those programs from the Healthcare Treatment Fund, under the Budget Act of 2019 or a later Budget Act.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. ) ## 14188.2. (a) The VBP programs described in Section 14188.1 shall be funded using moneys appropriated to the department for purposes of those programs in the Budget Act of 2019, or a Budget Act in a subsequent fiscal year, from the Healthcare Treatment Fund established pursuant to subdivision (a) of Section 30130.55 of the Revenue and Taxation Code. (b) The Legislature finds and declares that the expenditures authorized by this article are all of the following: (1) Made in accordance with the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Article 2.5 (commencing with Section 30130.50) of Chapter 2 of Part 13 of Division 2 of the Revenue and Taxation Code). (2) Based on criteria developed and periodically updated as part of the annual state budget process, in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code. (3) Consistent with the purposes and conditions of expenditures described in subdivision (a) of Section 30130.55 of the Revenue and Taxation Code. (Added by Stats. 2019, Ch. 38, Sec. 50. (SB 78) Effective June 27, 2019.)
  25. 14188.3.

    ## 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. )

    Verify source ↗

    The department may use contracts and written instructions to implement this article, and those contracts are exempt from certain contracting and review 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. ) ## 14188.3. (a) To implement this article, 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, 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. (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 article, in whole or in part, by means of plan letters or other similar instructions, without taking regulatory action. (Added by Stats. 2019, Ch. 38, Sec. 50. (SB 78) Effective June 27, 2019.)
  26. 14188.4.

    ## 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. )

    Verify source ↗

    The department may implement the Section 14188.1 payments only if the Legislature appropriates money for the state fiscal year and the necessary federal approvals are obtained without jeopardizing federal 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 5.8. Value-Based Incentives in Medi-Cal Managed Care [14188 - 14188.4] ( Article 5.8 added by Stats. 2019, Ch. 38, Sec. 50. ) ## 14188.4. (a) Notwithstanding any other law, the department shall only implement the payments described under Section 14188.1 for a service period during a state fiscal year subject to appropriation by the Legislature for that state fiscal year. (b) This section shall be implemented only to the extent that the department obtains any necessary federal approvals and determines that federal financial participation is not otherwise jeopardized. (c) Notwithstanding any other law, this section shall supersede any law suspending authority for any program described in Section 14188.1. The law on suspending authority includes, but is not limited to, provisions under the Budget Act of 2019, the Budget Act of 2020, and enacted legislation providing for appropriations related to those acts. (d) The Legislature finds and declares that this section complies with all of the following: (1) Made in accordance with the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Article 2.5 (commencing with Section 30130.50) of Chapter 2 of Part 13 of Division 2 of the Revenue and Taxation Code). (2) Based on criteria developed and periodically updated as part of the annual state budget process, in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code. (3) Consistent with the purposes and conditions of expenditures described in subdivision (a) of Section 30130.55 of the Revenue and Taxation Code. (Repealed and added by Stats. 2021, Ch. 143, Sec. 410. (AB 133) Effective July 27, 2021.)
  27. 14189.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. )

    Verify source ↗

    Medi-Cal managed care plans must provide covered mental health benefits, except those provided by county mental health plans under the Specialty Mental Health Services 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 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. ) ## 14189. Medi-Cal managed care plans shall provide mental health benefits covered in the state plan excluding those benefits provided by county mental health plans under the Specialty Mental Health Services Waiver. The department may require the managed care plans to cover mental health pharmacy benefits to the extent provided in the contracts between the department and the Medi-Cal managed care plans. (Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. (SB 1 1x) Effective September 30, 2013.)
  28. 14190.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. )

    Verify source ↗

    The department must convene an advisory group, provide regular pharmacy-transition updates, and include fiscal assumptions for the outpatient pharmacy benefit transition in the Governor’s proposed budget.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. ) ## 14190. (a) The department shall convene an advisory group to receive feedback on the changes, modifications, and operational timeframes regarding the implementation of pharmacy benefits offered in the Medi-Cal program. This advisory group shall be composed of organizations and entities such as hospitals, clinics, health plans, and consumer advocates. (b) The department, through this advisory group as well as through other existing stakeholder meetings, shall provide regular updates on the pharmacy transition that include the following: (1) A description of the changes in the division of responsibilities between the department and managed care plans as a result of a transition of the outpatient pharmacy benefit to fee-for-service. (2) A description of anticipated changes, if any, to beneficiary access to prescription medications. (c) The department shall include in the Governor’s proposed budget the fiscal assumptions for the transition of the outpatient pharmacy benefit to a fee-for-service benefit. (Added by Stats. 2019, Ch. 38, Sec. 51. (SB 78) Effective June 27, 2019.)
  29. 14190.1.

    ## 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 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. )

    Verify source ↗

    Medi-Cal managed care plans must do annual outreach and education about covered mental health benefits, submit and post related plans and assessments, and follow department approval 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 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. ) ## 14190.1. (a) Subject to subdivision (b), and no later than January 1, 2025, a Medi-Cal managed care plan shall conduct annual outreach and education for its enrollees, based on a plan that the Medi-Cal managed care plan develops and submits to the department upon the department’s approval of the Medi-Cal managed care plan’s Population Needs Assessment, regarding the mental health benefits that are covered by the Medi-Cal managed care plan pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402. (1) The outreach and education plan shall be informed by the Medi-Cal managed care plan’s stakeholder engagement, including the community advisory committee established by the Medi-Cal managed care plan, and by local stakeholders representing diverse racial and ethnic communities. (2) The outreach and education plan shall be informed by the Medi-Cal managed care plan’s Population Needs Assessment and an assessment of utilization of covered mental health benefits by race, ethnicity, language, age, sexual orientation, gender identity, and disability, and shall ensure that materials and messaging are appropriate for the diversity of the plan enrollee membership. The Medi-Cal managed care plan shall submit the utilization assessment to the department. (3) The outreach and education plan shall meet cultural and linguistic appropriateness standards, in alignment with the National Standards for Culturally and Linguistically Appropriate Services, shall incorporate best practices in stigma reduction, and shall provide multiple points of contact for enrollees to access mental health benefits. (b) (1) The department shall review the new or updated outreach and education plan submitted by each Medi-Cal managed care plan as described in this section and shall approve or modify the plan within 180 calendar days since submission, to ensure appropriate local stakeholder engagement, alignment with the Population Needs Assessment, and cultural and linguistic appropriateness. (2) Implementation of a Medi-Cal managed care plan’s outreach and education plan described in this section shall be subject to approval by the department pursuant to paragraph (1). (3) Each Medi-Cal managed care plan shall publicly post, on its internet website and in an accessible manner, its approved outreach and education plan and its utilization assessment described in paragraph (2) of subdivision (a), excluding any personally identifiable information. (c) The department shall consult with stakeholders representative of diverse racial and ethnic communities, including, but not limited to, consumer advocates, mental health stigma reduction experts, community-based organizations, and Medi-Cal managed care plan stakeholders, to develop the standards by which outreach and education plans will be reviewed and approved. (d) Approval standards may include, but are not limited to, any of the following: (1) Outreach and education methods that include, but are not limited to, online outreach, mail, telephone, partnerships with community-based organizations, partnerships with primary care providers, and use of navigators, community health workers, and other providers trained to conduct outreach and education. (2) Alignment of the culturally and linguistically tailored outreach and education strategies with the National Standards for Culturally and Linguistically Appropriate Services, utilization assessment and Population Needs Assessment. (3) Inclusion of consumer-friendly information in existing member-facing communication channels, including the Medi-Cal managed care plan’s internet website. (4) An independent evaluation plan to assess and improve outreach to enrollees related to nonspecialty mental health services upon the department’s approval of a Medi-Cal managed care plan’s Population Needs Assessment. (e) A Medi-Cal managed care plan shall also conduct annual outreach and education, based on a plan that the Medi-Cal managed care plan develops, to inform primary care providers regarding the mental health benefits covered by the Medi-Cal managed care plan pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402. (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 all-county letters, plan letters, provider bulletins, information notices, or other similar guidance, until any necessary regulations are adopted. (g) 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 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. (Added by Stats. 2022, Ch. 879, Sec. 1. (SB 1019) Effective January 1, 2023.)
  30. 14190.2.

    ## 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 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. )

    Verify source ↗

    The department must regularly assess Medi-Cal managed care mental health benefits, adopt survey tools by January 1, 2025, and publish public reports starting in April 2026.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.9. Medi-Cal Managed Care Plan Mental Health Benefits [14189 - 14190.2] ( Article 5.9 added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 30. ) ## 14190.2. (a) Once every three years, the department shall assess enrollee experience with mental health benefits covered by Medi-Cal managed care plans pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402. (b) No later than January 1, 2025, the department shall adopt survey tools and methodologies that shall meet all of the following conditions: (1) Assess experience with the full range of mental health benefits covered by Medi-Cal managed care plans pursuant to Section 14189 and paragraph (1) of subdivision (b) of Section 14184.402. (2) Assess consumer experience in various domains, including, but not limited to, receipt of treatment quickly, how well clinicians communicate, cultural competency of providers, communication with the plan and provider, receipt of treatment and information from the plan, including information related to patients’ rights, the treatment plan and options, and the sides effects of medication, perceived improvement, overall rating of counseling and other treatment, and overall rating of the plan. (3) Assess consumer experience in a manner that utilizes survey best practice methods for data collection and reporting, including, but not limited to, staff training on data collection, the legality and use of data collection, how to work with patients to improve comfort levels in sharing the data, oversampling and collection of self-reported demographic data at the individual encounter level, and the use of data through existing enrollment and renewal processes. (c) The department shall consider, and may utilize, existing tools in order to ensure alignment with national standards and state health care programs. (d) (1) The department shall publish reports, commencing with a report in April 2026 and once every three years thereafter, on its internet website on consumer experience with mental health benefits covered by Medi-Cal managed care plans. (2) The reports shall include plan-by-plan data, provide granularity for subpopulations, and address inequities based on key demographic factors, including, but not limited to, language, race, ethnicity, disability status, sexual orientation, and gender identity, to the extent that survey response rates produce statistically valid results. The reports shall exclude any personally identifiable information. (3) The reports shall provide recommendations for improving access to mental health benefits covered by Medi-Cal managed care plans. (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, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar guidance, until any necessary regulations are adopted. (f) 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 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. (Added by Stats. 2022, Ch. 879, Sec. 2. (SB 1019) Effective January 1, 2023.)
  31. 14191.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. )

    Verify source ↗

    Medi-Cal payment for voluntary nonemergency sterilization requires informed-consent documents, and the department must issue regulations and a standard consent form.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. ) ## 14191. Notwithstanding any other provision of law, no payment for care or services shall be made under Medi-Cal to the attending physician under this chapter for the costs of any voluntary nonemergency sterilization unless the treatment authorization request is accompanied by the documents evidencing informed consent required by regulations of the department. In the event that the department does not require a treatment authorization request, such documents evidencing informed consent shall accompany the billing of the attending physician. The department shall promulgate regulations under this article and shall adopt a standard informed consent form in English and Spanish which is readily understandable to Medi-Cal beneficiaries for use by health providers performing voluntary nonemergency sterilizations. The failure of the attending physician performing the sterilization to fulfill his obligations under this section shall not be construed as requiring the department to deny or withhold reimbursement under Medi-Cal to other providers participating in the sterilization. (Added by Stats. 1975, Ch. 220.)
  32. 14192.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. )

    Verify source ↗

    A health facility’s willful failure to comply with the department’s regulations under this article can lead to suspension as a Medi-Cal provider.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. ) ## 14192. Willful failure on the part of a health facility to comply with the provisions of the regulations of the department under this article shall constitute cause for suspension as a provider of services under Medi-Cal. (Added by Stats. 1975, Ch. 220.)
  33. 14193.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. )

    Verify source ↗

    The department must send data about a physician and surgeon’s willful failure to comply with the department’s regulations under this article to the Medical Board of California.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. ) ## 14193. The department shall transmit any data acquired by it regarding willful failure of a physician and surgeon to comply with the regulations of the department under this article to the Medical Board of California. (Amended by Stats. 1989, Ch. 886, Sec. 107.)
  34. 14194.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. )

    Verify source ↗

    The department must submit compliance reports to the Legislature 6, 12, and 24 months after the article’s operative date.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6. Sterilizations [14191 - 14194] ( Article 6 added by Stats. 1975, Ch. 220. ) ## 14194. The department shall submit reports to the Legislature as to compliance by health facilities with the requirements of this article, 6, 12, and 24 months after its operative date. (Added by Stats. 1975, Ch. 220.)
  35. 14195.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The Legislature states its intent to provide medical assistance, including prescribed drugs, to eligible poor people and to establish an open drug formulary and drug utilization review system under 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195. It is the intent of the Legislature to provide medical assistance, including prescribed drugs, to the state’s eligible poor in a manner consistent with the provisions of the federal Medicaid Act, provided for under Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.). It is the further intent of the Legislature to test the effectiveness of an open formulary drug therapy program. In order to help achieve this goal, the Legislature hereby establishes an open drug formulary under the Medi-Cal program wherein a beneficiary may receive the most appropriate, most effective, and most cost-efficient drug available for the treatment of his or her illness. It is also the intent of the Legislature in enacting this article to establish a drug utilization review system which will evaluate and enhance the therapeutic outcome of drugs prescribed for persons eligible for Medi-Cal pursuant to this chapter. (Amended by Stats. 1987, Ch. 1340, Sec. 1.)
  36. 14195.2.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The open drug formulary must be carried out in one pilot project site in northern California, in Sacramento and Placer Counties, and it cannot start until federal approval and full federal financial participation are secured.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.2. The open drug formulary, as established pursuant to this article, shall be implemented in one pilot project site. The site shall be located in a northern California test area, comprised of Sacramento and Placer Counties which includes urban, suburban, and rural settings. This pilot project shall not be implemented until federal approval is secured and full federal financial participation is assured. (Amended by Stats. 1987, Ch. 1340, Sec. 3.)
  37. 14195.3.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    In the open drug formulary pilot project, a provider may be reimbursed for a beneficiary’s drug if it was prescribed by a licensed provider within that provider’s scope and approved by the FDA, and prior authorization is not required when the provider finds the drug medically necessary.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.3. (a) For purposes of the open drug formulary pilot project as established by this article, a provider may be reimbursed for any drug prescribed to a beneficiary if the drug is prescribed by a licensed provider within the scope of his or her practice, as defined by law, and if the drug is approved for use by the federal Food and Drug Administration. (b) Controlled substances shall be prescribed pursuant to the requirements of federal laws and regulations and the requirements set forth in Chapter 4 (commencing with Section 11150) of Division 10 of the Health and Safety Code. (c) For purposes of the open drug formulary pilot project as established by this article, there shall be no requirement that prior authorization be obtained by a provider before prescribing any drug to a beneficiary if the provider determines the drug to be a medical necessity in the treatment of the beneficiary. (d) For purposes of the open drug formulary pilot project as established by this article, a drug determined to be a medical necessity shall be one whose use in the treatment is reasonable and consistent with the objectives of the federal Medicaid Act as set forth in Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.). (Added by Stats. 1985, Ch. 135, Sec. 7. Effective July 1, 1985.)
  38. 14195.4.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    This section establishes a Medi-Cal Therapeutic Drug Utilization and Review Committee and sets its membership and appointment structure.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.4. A Medi-Cal Therapeutic Drug Utilization and Review Committee is hereby established. The committee shall be composed of 17 members who shall serve at the pleasure of the appointing powers as follows: (a) The Governor shall appoint two representatives from the State Department of Health Services, one representative from the Health and Welfare Agency, and two representatives from schools of pharmacy. (b) The Governor, the Speaker of the Assembly, and the Senate Rules Committee shall each appoint one representative from the following groups: (1) Licensed pharmacists. (2) Licensed physicians. (3) Drug manufacturers. (4) Medi-Cal beneficiaries. (Added by renumbering Section 14195.1 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 4. Effective July 1, 1985.)
  39. 14195.5.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The committee must set and oversee standards for Medi-Cal therapeutic drug utilization review, including monitoring drug use, information systems, consultation with experts, and prescribing 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.5. The Medi-Cal Therapeutic Drug Utilization and Review Committee shall set standards for evaluation of the therapeutic outcomes of prescribed drugs to be applied by an expert contractor to the department. The committee shall have the following responsibilities: (a) Developing policy for monitoring and controlling therapeutically inappropriate drug utilization. (b) Overseeing the establishment of a computer-based information system using the State Medicaid MMIS System, which shall provide timely information on drug prescription and consumption and shall be capable of tracking prescriptions by drug, by illness, by beneficiary, and by provider. The committee shall consult with expert contractors experienced in therapeutically oriented drug utilization review in the discharge of this responsibility. (c) Establishing standards, in consultation with an expert contractor experienced in the therapeutically oriented drug utilization review, for dosage, duration, and effectiveness of medications with respect to a particular diagnosis. (d) Setting standards to serve as guidelines on misprescribing, overprescribing, and contraindicated drug use, and protocols for informing prescribers of inappropriate prescribing. (Added by renumbering Section 14195.2 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 5. Effective July 1, 1985.)
  40. 14195.6.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The department must develop a request for proposals and may award a contract to an expert contractor. The contractor must also provide quarterly reports and include an analysis requirement in the 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.6. The department shall develop a request for a proposal, and may award a contract to an expert contractor to implement the standards and practices established by the Medi-Cal Therapeutic Drug Utilization Review System through use of a therapeutically oriented drug utilization review system by July 1, 1989. The contract shall include a requirement to analyze the therapeutic outcomes of the Medi-Cal Drug Program using the California MMIS for the period of July 1, 1987, through the date the standards established by this article are implemented. Thereafter, the contractor shall submit quarterly reports to the department and the Legislature analyzing therapeutic outcomes in a manner that will allow comparisons with the experience analyzed for the period of July 1, 1987, until implementation of the standards established by this article. The analysis shall include reports on at least the following items: (a) Compatibility of medication to diagnosis. (b) Overprescribing of drugs. (c) Prescription of contraindicated or incompatible drugs. (d) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or all categories of intermediate care for the developmentally disabled occurring because of the factors specified in subdivisions (a) to (c), inclusive. (e) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or any category of intermediate care facility for the developmentally disabled avoided due to changes in drug regimes which result from compliance by prescribers and beneficiaries with the standards established pursuant to this article. The department is authorized to require the contractor to phase in implementation of the prescriber notification, as established by protocols for informing prescribers of inappropriate prescribing. (Amended by Stats. 1990, Ch. 1329, Sec. 33. Effective September 26, 1990.)
  41. 14195.7.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    This article does not apply to certain services provided under capitated rate or primary care case contracts unless both contract parties agree the article’s standards would benefit the enrolled Medi-Cal eligibles.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.7. This article shall not apply to any service rendered by a provider in conjunction with any capitated rate or primary care case contract negotiated pursuant to this chapter or Chapter 8 (commencing with Section 14200) by either the department or the California Medical Assistance Commission unless both parties to the contract mutually agree that application of the standards established by this article would be beneficial to the Medi-Cal eligibles enrolled in plans operating pursuant to capitated rate contracts. (Added by Stats. 1984, Ch. 1636, Sec. 5.)
  42. 14195.9.

    ## 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 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The director may not use Section 14120 discretion to cut reimbursement for pharmaceutical services providers because of increased drug costs from implementing the open formulary concept.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14195.9. In no case shall the director’s discretion under Section 14120 be exercised to reduce reimbursement to providers of pharmaceutical services because of increased costs in the drug component of the Medi-Cal program arising from the implementation of the open formulary concept. (Added by Stats. 1984, Ch. 1636, Sec. 5.)
  43. 14196.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. )

    Verify source ↗

    The department must adopt emergency regulations needed to implement this article, seek any necessary federal waivers, and seek maximum federal reimbursement for the related Drug Establishment Review System.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.1. Medi-Cal Therapeutic Drug Utilization Review [14195 - 14196] ( Article 6.1 added by Stats. 1984, Ch. 1636, Sec. 5. ) ## 14196. (a) The department shall adopt any regulations necessary to implement this article. These regulations 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, and, for the purposes of the Administrative Procedure Act, shall be deemed an emergency, and necessary for the immediate preservation of the public peace, health and safety, or general welfare. (b) Any provision of this article which is in conflict with any federal statute or regulation shall be inapplicable to the extent of that conflict but the remainder of the provisions shall be in effect to the extent no conflict exists. The department shall seek all federal waivers necessary to implement this article. The provisions for which federal waivers cannot be obtained shall not be implemented, but provisions for which waivers are either obtained or found to be unnecessary shall be unaffected by the inability to obtain federal waivers for the other provisions. (c) The department shall seek maximum federal reimbursement for the MMIS-based Drug Establishment Review System established by this article. (Added by Stats. 1984, Ch. 1636, Sec. 5.)
  44. 14196.2.

    ## 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 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. )

    Verify source ↗

    The department must provide transition services for eligible individuals leaving inpatient facilities, may issue guidance by letters or bulletins instead of regulations, and must stop enrolling beneficiaries on January 1, 2026 and stop providing services on 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 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. ) ## 14196.2. (a) (1) The Legislature finds and declares that in order to reduce the risk of transmission of COVID-19 during the current pandemic and to further the objectives of the Money Follows the Person Rebalancing Demonstration, a temporary program is hereby established to facilitate the transition of individuals from an inpatient facility who have resided in that setting for fewer than 60 days. (2) The department shall provide services consistent with the Money Follows the Person Rebalancing Demonstration program, pursuant to Section 6071 of Public Law 109-171, and subsequent amendments, for transitioning eligible individuals out of inpatient facilities. (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 article by means of letters, provider bulletins, or similar instructions, without taking regulatory action. (c) Commencing January 1, 2026, the department shall cease to enroll beneficiaries pursuant to this article and commencing January 1, 2027, the department shall cease to provide services pursuant to this article. (Amended by Stats. 2022, Ch. 898, Sec. 2. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)
  45. 14196.4.

    ## 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 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. )

    Verify source ↗

    This section defines “eligible individual” and “inpatient facility” for this article.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. ) ## 14196.4. The following definitions apply for purposes of this article: (a) “Eligible individual” means a Medi-Cal beneficiary who meets both of the following requirements: (1) The individual meets the definition of an “eligible individual” under Section 6071(b)(2) of Public Law 109-171, and subsequent amendments, except that the individual is not required to have resided for at least 60 consecutive days in an inpatient facility. (2) The individual is targeted to receive assistance in transitioning from an inpatient facility to a qualified residence, identified in the agreement between the department and the federal Centers for Medicare and Medicaid Services for the Money Follows the Person Rebalancing Demonstration, except the individual shall not be required to have resided for at least 60 consecutive days in an inpatient facility. (b) “Inpatient facility” has the same meaning as that term is defined in Section 6071(b)(3) of Public Law 109-171, and subsequent amendments. (Amended by Stats. 2021, Ch. 143, Sec. 412. (AB 133) Effective July 27, 2021. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)
  46. 14196.6.

    ## 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 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. )

    Verify source ↗

    This article stays in effect only until January 1, 2028, when it is repealed.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.2. Short-Term Community Transitions [14196.2 - 14196.6] ( Heading of Article 6.2 amended by Stats. 2022, Ch. 898, Sec. 1. ) ## 14196.6. This article shall remain in effect only until January 1, 2028, and as of that date is repealed. (Repealed and added by Stats. 2022, Ch. 898, Sec. 4. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, by its own provisions. Note: Repeal affects Art. 6.2, commencing with Section 14196.2.)
  47. 14197.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

    Verify source ↗

    Medi-Cal managed care plans must maintain provider networks and appointment access within listed distance and time limits, and the department must monitor compliance and may authorize alternative access arrangements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197. (a) It is the intent of the Legislature that the department implement and monitor compliance with the time or distance requirements set forth in Sections 438.68, 438.206, and 438.207 of Title 42 of the Code of Federal Regulations and this section, to ensure that all Medi-Cal managed care covered services are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner, as those standards were enacted in May 2016. (b) Commencing January 1, 2018, for covered benefits under its contract, as applicable, a Medi-Cal managed care plan shall maintain a network of providers that are located within the following time or distance standards for the following services: (1) For primary care, both adult and pediatric, 10 miles or 30 minutes from the beneficiary’s place of residence. (2) For hospitals, 15 miles or 30 minutes from the beneficiary’s place of residence. (3) For dental services provided by a Medi-Cal managed care plan, 10 miles or 30 minutes from the beneficiary’s place of residence. (4) For obstetrics and gynecology primary care, 10 miles or 30 minutes from the beneficiary’s place of residence. (c) Commencing July 1, 2018, for the covered benefits under its contracts, as applicable, a Medi-Cal managed care plan shall maintain a network of providers that are located within the following time or distance standards for the following services: (1) For specialists, as defined in subdivision (i), adult and pediatric, including obstetric and gynecology specialty care, as follows: (A) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (2) For pharmacy services, 10 miles or 30 minutes from the beneficiary’s place of residence. (3) For outpatient mental health services, as follows: (A) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (4) (A) For outpatient substance use disorder services other than opioid treatment programs, as follows: (i) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (ii) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (iii) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Madera, Mariposa, Mendocino, Merced, Modoc, Monterey, Mono, Napa, Nevada, Plumas, San Benito, San Bernardino, San Luis Obispo, Santa Barbara, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tulare, Tuolumne, Yolo, and Yuba. (B) For opioid treatment programs, as follows: (i) Up to 15 miles or 30 minutes from the beneficiary’s place of residence for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (ii) Up to 30 miles or 60 minutes from the beneficiary’s place of residence for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (iii) Up to 45 miles or 75 minutes from the beneficiary’s place of residence for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (iv) Up to 60 miles or 90 minutes from the beneficiary’s place of residence for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (d) (1) (A) A Medi-Cal managed care plan shall comply with the appointment time standards developed pursuant to Section 1367.03 of the Health and Safety Code, Section 1300.67.2.2 of Title 28 of the California Code of Regulations, subject to any authorized exceptions in Section 1300.67.2.2 of Title 28 of the California Code of Regulations, and the standards set forth in contracts entered into between the department and Medi-Cal managed care plans. (B) Commencing July 1, 2018, subparagraph (A) applies to Medi-Cal managed care plans that are not, as of January 1, 2018, subject to the appointment time standards described in subparagraph (A). (C) A Medi-Cal managed care plan shall ensure that each subcontractor network complies with the appointment time standards described in subparagraph (A), unless already required to ensure compliance. (2) A Medi-Cal managed care plan shall comply with the following availability standards for skilled nursing facility services and intermediate care facility services, as follows: (A) Within five business days of the request for the following counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara. (B) Within seven business days of the request for the following counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura. (C) Within 14 calendar days of the request for the following counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba. (D) Within 14 calendar days of the request for the following counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne. (3) A county Drug Medi-Cal organized delivery system shall provide an appointment within three business days to an opioid treatment program. (4) A dental managed care plan shall provide an appointment within four weeks of a request for routine pediatric dental services and within 30 calendar days of a request for specialist pediatric dental services. (e) The department may authorize a Medi-Cal managed care plan to use clinically appropriate video synchronous interaction, as defined in paragraph (5) of subdivision (a) of Section 2290.5 of the Business and Professions Code, as a means of demonstrating compliance with the time or distance standards established pursuant to this section, as defined by the department. The use of telehealth providers to meet time or distance standards does not absolve the Medi-Cal managed care plan of responsibility to provide a beneficiary with access, including transportation, to in-person services if the beneficiary prefers. (f) (1) The department may develop policies for granting credit in the determination of compliance with time or distance standards established pursuant to this section when Medi-Cal managed care plans contract with specified providers to use clinically appropriate video synchronous interaction, as defined in paragraph (5) of subdivision (a) of Section 2290.5 of the Business and Professions Code, and only for Medi-Cal managed care plans that cover at least 85 percent of the population points in the ZIP Code. (2) The department, upon request of a Medi-Cal managed care plan, may authorize alternative access standards for the time or distance standards established under this section if either of the following occurs: (A) The requesting Medi-Cal managed care plan has exhausted all other reasonable options to obtain providers to meet the applicable standard. (B) The department determines that the requesting Medi-Cal managed care plan has demonstrated that its delivery structure is capable of delivering the appropriate level of care and access. (3) (A) If a Medi-Cal managed care plan cannot meet the time or distance standards set forth in this section, the Medi-Cal managed care plan shall submit a request for alternative access standards to the department, in the form and manner specified by the department. (B) An alternative access standard request may be submitted at the same time as the Medi-Cal managed care plan submits its annual demonstration of compliance with time or distance standards, if known at that time and at any time the Medi-Cal managed care plan is unable to meet time or distance standards. (C) A Medi-Cal managed care plan is not required to submit a previously approved alternative access standard request to the department for review and approval on an annual basis, unless the Medi-Cal managed care plan requires modifications to its previously approved request. However, the Medi-Cal managed care plan shall submit this previously approved alternative access standard request to the department at least every three years for review and approval when the plan is required to demonstrate compliance with time or distance standards. (i) Medi-Cal managed care plans that do not meet time or distance standards without the use of an alternative access standards request shall submit to the department documentation demonstrating efforts to contract with providers in those areas, based on guidance by the department. (ii) Effective no sooner than contract periods commencing on or after January 1, 2026, the Medi-Cal managed care plan shall inform enrollees of their option to use or not use telehealth, covered transportation services, or out-of-network providers to access covered services if the health care provider is located outside of the time or distance standards specified in subdivision (c) in a manner specified by the department. (D) A Medi-Cal managed care plan shall close out any corrective action plan deficiencies in a timely manner to ensure that beneficiary access is adequate and shall continually work to improve access in its provider network. (4) A request for alternative access standards shall be approved or denied on a ZIP Code and provider type, including specialty type, basis by the department within 90 days of submission of the request. The Medi-Cal managed care plan shall also include a description of the reasons justifying the alternative access standards based on those facts and circumstances. Effective no sooner than contract periods commencing on or after July 1, 2020, the Medi-Cal managed care plan shall include a description on how the Medi-Cal managed care plan intends to arrange for enrollees to access covered services if the health care provider is located outside of the time or distance standards specified in subdivision (c). The department may stop the 90-day timeframe, on one or more occasions as necessary, in the event of an incomplete submission or to obtain additional information from the Medi-Cal managed care plan requesting the alternative access standards. Upon submission of sufficient additional information to the department, the 90-day timeframe shall resume at the same point in time it was previously stopped, except if there is less than 30 days remaining in which case the department shall approve or deny the request within 30 days of submission of sufficient additional information. If the department rejects the Medi-Cal managed care plan’s proposal, the department shall inform the Medi-Cal managed care plan of the department’s reason for rejecting the proposal. The department shall post any approved alternative access standards on its internet website. (5) (A) As part of the department’s evaluation of a request submitted by a Medi-Cal managed care plan to utilize an alternative access standard pursuant to this subdivision, the department shall evaluate and determine whether the resulting time or distance is reasonable to expect a beneficiary to travel to receive care. (B) Effective for contract periods commencing on or after January 1, 2027, as part of the department’s evaluation of a request pursuant to this subdivision, the department shall also consider the sufficiency of payment rates offered by the Medi-Cal managed care plan to the provider type or for the service type for which an alternative access standard is being requested. (6) The department may authorize a Medi-Cal managed care plan to use clinically appropriate video synchronous interaction, as defined in paragraph (5) of subdivision (a) of Section 2290.5 of the Business and Professions Code, as part of an alternative access standard request. (g) (1) (A) Effective for contract periods commencing on or after July 1, 2018, a Medi-Cal managed care plan shall, on an annual basis and when requested by the department, demonstrate to the department the Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards developed pursuant to this section. The report shall measure compliance separately for adult and pediatric services for primary care, behavioral health, and core specialist services. (B) (i) Effective for contract periods commencing on or after January 1, 2026, a Medi-Cal managed care plan shall, on an annual basis and when requested by the department, demonstrate to the department each subcontractor network’s compliance with the time or distance and appointment time standards developed pursuant to this section, including how the Medi-Cal managed care plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, such as through the use of either Medi-Cal covered transportation or clinically appropriate video synchronous interaction, as specified in paragraph (6) of subdivision (f), if the enrollees of a Medi-Cal managed care plan needed to obtain health care services from a health care provider or a facility located outside of the time or distance standards, as specified in subdivision (c), in accordance with the CalAIM 1915(b) Waiver Special Terms and Conditions A4. (ii) This subparagraph shall not apply to dental managed care plans, or to Medi-Cal behavioral health delivery systems as defined in subdivision (i) of Section 14184.101. (2) Effective for contract periods commencing on or after July 1, 2020, the Medi-Cal managed care plan shall demonstrate, on an annual basis, and when requested by the department, to the department how the Medi-Cal managed care plan arranged for the delivery of Medi-Cal covered services to Medi-Cal enrollees, such as through the use of either Medi-Cal covered transportation or clinically appropriate video synchronous interaction, as specified in paragraph (6) of subdivision (f), if the enrollees of a Medi-Cal managed care plan needed to obtain health care services from a health care provider or a facility located outside of the time or distance standards, as specified in subdivision (c). The report shall measure compliance separately for adult and pediatric services for primary care, behavioral health, and core specialist services. (3) (A) Effective for contract periods commencing on or after July 1, 2018, the department shall evaluate on an annual basis a Medi-Cal managed care plan’s compliance with the time or distance and appointment time standards implemented pursuant to this section. This evaluation may include, but need not be limited to, annual and random surveys, investigation of complaints, grievances, or other indicia of noncompliance. Nothing in this subdivision shall be construed to limit the appeal rights of a Medi-Cal managed care plan under its contracts with the department. (B) Effective for contract periods commencing on or after January 1, 2029, the evaluation by the department for appointment time standards compliance as described in this paragraph shall be performed using a direct testing method, which shall include, but need not be limited to, a “secret shopper” method. The direct testing shall be used to evaluate compliance with the appointment time standards set forth in subdivision (d) for appointments. To determine compliance with the urgent care standard, the evaluation shall measure the network’s ability to provide urgent care within 48 hours pursuant to Section 1367.03 of the Health and Safety Code and Section 1300.67.2.2(c)(5)(A) of Title 28 of the California Code of Regulations. The evaluation shall also utilize a method for accounting for and reporting the number of providers who are unavailable or unreachable for purposes of the evaluation. (C) Failure to comply with the evaluations required by this paragraph may result in contract termination or the issuance of sanctions pursuant to Section 14197.7. (4) The department shall publish annually on its internet website a report that details the department’s findings in evaluating a Medi-Cal managed care plan’s compliance under paragraph (2). At a minimum, the department shall specify in this report those Medi-Cal managed care plans, if any, that were subject to a corrective action plan due to noncompliance with the time or distance and appointment time standards implemented pursuant to this section during the applicable year and the basis for the department’s finding of noncompliance. The report shall include a Medi-Cal managed care plan’s response to the corrective plan, if available. (h) The department shall consult with Medi-Cal managed care plans, including dental managed care plans, mental health plans, and Drug Medi-Cal Organized Delivery System programs, health care providers, consumers, providers and consumers of long-term services and supports, and organizations representing Medi-Cal beneficiaries in the implementation of the requirements of this section. (i) For purposes of this section, the following definitions apply: (1) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract 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), including dental managed care programs developed pursuant to Section 14087.46. (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 2.9 (commencing with Section 14088). (F) Article 2.91 (commencing with Section 14089). (G) Chapter 8 (commencing with Section 14200), including dental managed care plans. (H) Chapter 8.9 (commencing with Section 14700). (I) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver, as applicable. (2) “Specialist” means any of the following: (A) Cardiology/interventional cardiology. (B) Nephrology. (C) Dermatology. (D) Neurology. (E) Endocrinology. (F) Ophthalmology. (G) Ear, nose, and throat/otolaryngology. (H) Orthopedic surgery. (I) Gastroenterology. (J) Physical medicine and rehabilitation. (K) General surgery. (L) Psychiatry. (M) Hematology. (N) Oncology. (O) Pulmonology. (P) HIV/AIDS specialists/infectious diseases. (3) “Subcontractor network” means a provider network of a subcontractor or downstream subcontractor, wherein the subcontractor or downstream subcontractor is delegated risk and is responsible for arranging for the provision of, and paying for, covered services as stated in their subcontractor or downstream subcontractor agreement. (j) (1) The department may require enhanced time or distance standards that are more stringent than those set forth in this section in its contracts with Medi-Cal managed care plans. However, the other requirements of this section shall otherwise apply. (2) The department shall ensure that enhanced time or distance standards contracted for with Medi-Cal managed care plans are consistent across contracts for similar geographic classifications. (3) The department shall publish all enhanced time and distance standards adopted by contract with a rationale for the enhanced standards. (k) 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, 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 regulations are adopted. (l) 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. (m) (1) In alignment with federal regulation that requires the department to conduct analyses when developing or adjusting network adequacy standards, the department shall publish on the department’s internet website by January 1, 2027, a workplan that includes an explanation of the department’s approach to updating network adequacy standards, a description of the data, and a summary of the analyses that will inform the department’s approach. (2) By January 1, 2027, the department shall convene a stakeholder workgroup to assist in the development of evidence-based network adequacy standards informed by the analyses described in paragraph (1). (3) The department shall provide a 30-day public comment period before implementing any changes to network adequacy standards. (n) This section shall remain in effect only until January 1, 2029, and as of that date is repealed, unless a later enacted statute that is enacted before January 1, 2029, deletes or extends that date. (Amended by Stats. 2025, Ch. 418, Sec. 1. (SB 530) Effective January 1, 2026. Repealed as of January 1, 2029, by its own provisions.)
  48. 14197.04.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    A qualifying Medi-Cal managed care plan must help an enrollee get a specialist appointment when the enrollee must travel beyond access 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.04. (a) (1) A Medi-Cal managed care plan that has received approval from the department to utilize an alternative access standard pursuant to subdivision (f) of Section 14197, upon the request of an enrollee who is required to travel farther than the time or distance standards, as established in subdivision (c) of Section 14197, shall assist that enrollee in obtaining an appointment with an appropriate specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197. (2) For purposes of complying with the requirement to assist an enrollee, as specified in paragraph (1), a Medi-Cal managed care plan shall do either of the following: (A) Make its best effort to establish a member-specific case agreement, at the Medi-Cal fee-for-service rate or a rate mutually agreed upon by the specialist provider and the plan, with an appropriate specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197. (B) Arrange for an appointment with a network specialist provider within the time or distance standards established pursuant to subdivision (c) of Section 14197, and the appointment time standards established pursuant to subdivision (d) of Section 14197. (3) The requirements of paragraph (1) shall not apply if there is not a specialist provider with an office location within the applicable time or distance standards in relation to the area within which the enrollee resides or the Medi-Cal managed care plan has attempted to establish a member-specific case agreement with the specialist provider for any enrollee pursuant to subparagraph (A) of paragraph (2) in the most recent fiscal year and the provider refused to enter into a member-specific case agreement. (b) If a specialist provider is unavailable to render necessary health care services pursuant to subdivision (a) to an enrollee within the time or distance standards established pursuant to subdivision (c) of Section 14197 and the appointment time standards established pursuant to subdivision (d) of Section 14197, as specified in subdivision (a), the Medi-Cal managed care plan or the Medi-Cal fee-for-service program, as determined appropriate by the department, shall arrange for Medi-Cal covered transportation for an enrollee to obtain covered Medi-Cal services pursuant to Section 14132. (c) A Medi-Cal managed care plan that has received approval from the department to utilize an alternative access standard pursuant to subdivision (f) of Section 14197 shall inform its affected members of the approved alternative access standards in a manner and timeframe, as determined by the department. (d) (1) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract 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), including dental managed care programs developed pursuant to Section 14087.46. (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), including dental managed care plans. (G) Chapter 8.9 (commencing with Section 14700). (H) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver, as applicable. (2) “Specialist provider” has the same meaning as “specialist” as defined in paragraph (2) of subdivision (i) of Section 14197. (Amended by Stats. 2022, Ch. 47, Sec. 133. (SB 184) Effective June 30, 2022.)
  49. 14197.05.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The EQRO must compile specified Medi-Cal managed care data by plan and county, report it in chart form, develop a methodology on facility-placement experience, and report the results. The department must make the information publicly available under federal 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.05. (a) As part of the federally required external quality review organization (EQRO) review of Medi-Cal managed care plans in the annual detailed technical report required by Section 438.364 of Title 42 of the Code of Federal Regulations, effective for contract periods commencing on or after July 1, 2018, the EQRO designated by the department shall compile the data described in subdivision (b), by plan and by county, for the purpose of informing the status of implementation of the requirements of Section 14197. (b) (1) The information compiled by the EQRO shall include all of the following: (A) Number of requests for alternative access standards in the plan service area for time and distance, categorized by provider types, including specialists, and by adult and pediatric. (B) Number of allowable exceptions for the appointment time standard, if known, categorized by provider types, including specialists, and by adult and pediatric. (C) Distance and driving time between the nearest network provider and ZIP Code of the beneficiary furthest from that provider for requests for alternative access standards. (D) Approximate number of beneficiaries impacted by alternative access standards or allowable exceptions. (E) Percentage of providers in the plan service area, by provider and specialty type, that are under a contract with a Medi-Cal managed care plan. (F) The number of requests for alternative access standards approved or denied by ZIP Code and provider and specialty type, and the reasons for the approval or denial of the request for alternative access standards. If an approval is authorized, the reasons for approval shall identify whether the approval was granted for either of the following reasons: (i) A provider was not located in the requested ZIP Code. (ii) The Medi-Cal managed care plan was unable to enter into a contract with a provider or providers in the requested ZIP Code. (G) The process of ensuring out-of-network access. (H) Descriptions of contracting efforts and explanation for why a contract was not executed. (I) Timeframe for approval or denial of a request for alternative access standards by the department. (J) Consumer complaints, if any. (2) The information described in paragraph (1) shall be presented in a chart format to enable comparison among counties, provider types, and plans. (c) The EQRO shall develop a methodology to assess information that will help inform the experience of individuals placed in a skilled nursing facility or intermediate care facility and the distance that they are placed from their place of residence. The EQRO shall report the results from the use of this methodology in the EQRO annual Medi-Cal managed care plan technical report. (d) The department shall comply with the requirements of subsection (c) of Section 438.364 of Title 42 of the Code of Federal Regulations in making the information described in this section publicly available. (Amended by Stats. 2019, Ch. 465, Sec. 5. (AB 1642) Effective January 1, 2020.)
  50. 14197.07.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    A Medi-Cal managed care plan must ensure tuberculosis care access and coordinate with local health departments for enrollees with active tuberculosis disease.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.07. (a) A Medi-Cal managed care plan shall ensure access to care for latent tuberculosis infection and active tuberculosis disease and coordination with local health department tuberculosis control programs for plan enrollees with active tuberculosis disease, including, but not limited to, both of the following: (1) Arranging for and coordinating outpatient diagnostic and treatment services to all plan enrollees with suspected or active tuberculosis disease to minimize delays in initiating isolation and treatment of infectious patients. These outpatient services shall include physical examination, drug therapy, laboratory testing, and radiology. (2) Consulting with local health departments to assess the risk of noncompliance with drug therapy for each plan enrollee who requires placement on antituberculosis drug therapy, in accordance with the plan’s existing contract with the department. (b) For purposes of this section, “Medi-Cal managed care plan” has the same meaning as set forth in Section 14197.08. (Added by Stats. 2024, Ch. 951, Sec. 3. (AB 2132) Effective January 1, 2025.)
  51. 14197.08.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    A Medi-Cal managed care plan must identify child enrollees missing blood lead screening records, remind providers about screening and guidance duties, and keep/refile refusal and missed-screening records; the department may enforce compliance and issue 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.08. (a) A contract between the department and a Medi-Cal managed care plan shall require the Medi-Cal managed care plan to do both of the following: (1) Identify, on a quarterly basis, every enrollee who is a child without a record of completing the blood lead screening tests required pursuant to Chapter 9 (commencing with Section 37100) of Division 1 of Title 17 of the California Code of Regulations. (2) On a quarterly basis, remind the contracting network provider who is a health care provider responsible for performing the periodic health assessment of the child enrollee pursuant to Section 37100 of Title 17 of the California Code of Regulations of the requirement to perform required blood lead screening tests for that child, and the requirement to provide oral or written anticipatory guidance to a parent or guardian of the child, including at a minimum, the information that children may be harmed by exposure to lead. (b) The department shall develop and implement procedures, and may impose sanctions pursuant to Section 14197.7, to ensure that a Medi-Cal managed care plan is compliant with the requirements specified in subdivision (a). (1) As part of these procedures, the department shall require a Medi-Cal managed care plan to maintain a record of all child enrollees six years of age or younger who have missed a required blood lead screening and identify the age at which the required blood lead screenings were missed, including which children are without any record of a completed blood lead screening at each age, and provide that record to the department annually and upon request for auditing and compliance purposes. (2) If the child enrollee, or the child enrollee’s parent, guardian, or authorized representative refuses a required blood lead screening test, the Medi-Cal managed care plan shall ensure a statement of voluntary refusal is signed by the child enrollee, if an emancipated minor, or by the child enrollee’s parent, guardian, or authorized representative, and is documented in the child enrollee’s medical record. If the refusing party declines to sign the statement of voluntary refusal, it shall be noted in the child enrollee’s medical record. Documented unsuccessful attempts to provide the blood lead screening tests shall be considered evidence of the Medi-Cal managed care plan meeting the requirements in subdivision (a). (c) For purposes of this section, the following definitions apply: (1) “Medi-Cal managed care plan” means an individual, organization, or entity that enters into a contract with the department to provide general health care services to enrolled Medi-Cal beneficiaries pursuant to any of the following: (A) Chapter 3 (commencing with Section 101675) of Part 4 of Division 101 of the Health and Safety Code. (B) Article 2.7 (commencing with Section 14087.3), excluding dental managed care programs developed pursuant to Section 14087.46. (C) Article 2.8 (commencing with Section 14087.5). (D) Article 2.81 (commencing with Section 14087.96). (E) Article 2.82 (commencing with Section 14087.98). (F) Article 2.9 (commencing with Section 14088). (G) Article 2.91 (commencing with Section 14089). (H) Chapter 8 (commencing with Section 14200), excluding dental managed care programs developed pursuant to Section 14087.46. (2) “Network provider” has the same meaning as in Section 438.2 of Title 42 of the Code of Federal Regulations. (d) Notwithstanding Chapter 3.5 (commencing 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. (Added by Stats. 2020, Ch. 216, Sec. 3. (AB 2276) Effective January 1, 2021.)
  52. 14197.09.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    Medi-Cal managed care plans must require certain staff and subcontractors to complete TGI-focused cultural competency training, and the department must oversee compliance, approvals, reporting, and 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.09. (a) (1) No later than 12 months after the working group develops its recommendations for curriculum pursuant to subdivision (b) of Section 150950 of the Health and Safety Code, and no later than March 1, 2025, a Medi-Cal managed care plan shall require all of its subcontractors, downstream subcontractors, and all of its managed care plan staff who are in direct contact with beneficiaries in the delivery of care or beneficiary services to complete evidence-based cultural competency training for the purpose of providing trans-inclusive health care for individuals who identify as transgender, gender diverse, or intersex (TGI). (2) An evidence-based cultural competency training implemented pursuant to paragraph (1) shall include all of the following: (A) Information about the effects, including, but not limited to, ongoing personal effects, of historical and contemporary exclusion and oppression of TGI communities. (B) Information about communicating more effectively across gender identities, including TGI-inclusive terminology, using people’s correct names and pronouns, even when they are not reflected in records or legal documents; avoiding language, whether verbal or nonverbal, that demeans, ridicules, or condemns TGI individuals; and avoiding making assumptions about gender identity by using gender-neutral language and avoiding language that presumes all individuals are heterosexual, cisgender or gender conforming, or nonintersex. (C) Discussion on health inequities within the TGI community, including family and community acceptance. (D) Perspectives of diverse, local constituency groups and TGI-serving organizations, including, but not limited to, the California Transgender Advisory Council. (E) Recognition of the difference between personal values and professional responsibilities with regard to serving TGI people. (F) Facilitation by TGI-serving organizations. (3) Cultural competency training implemented by a Medi-Cal managed care plan that includes TGI components, as required by its managed care plan contract with the department, shall meet this requirement. This cultural competency training shall consider recommendations made by the working group pursuant to Section 150950 of the Health and Safety Code. (4) Use of any training curricula for purposes of implementing paragraph (1) shall be subject to approval by the department, following stakeholder engagement with local constituency groups and TGI-serving organizations, including, but not limited to, the California Transgender Advisory Council. (5) After first-time completion of the evidence-based cultural competency training, in the form of initial basic training, an individual described in paragraph (1) shall complete a refresher course if a complaint has been filed, and a decision has been made in favor of the complainant, against that individual for not providing trans-inclusive health care, or on a more frequent basis if deemed necessary by the Medi-Cal managed care plan or the department for purposes of providing trans-inclusive health care. (b) (1) No later than 12 months after the working group develops its recommendations for curriculum pursuant to subdivision (b) of Section 150950 of the Health and Safety Code, and no later than March 1, 2025, the department shall develop and implement procedures, and may impose sanctions pursuant to Section 14197.7, to ensure that a Medi-Cal managed care plan is compliant with the requirements described in subdivision (a). (2) The department shall track and monitor complaints received by the department related to trans-inclusive health care and publicly report this data with other complaint data on its website or with other public reports containing complaint data. (c) No later than 12 months after the working group develops its recommendations for curriculum pursuant to subdivision (b) of Section 150950 of the Health and Safety Code, and no later than March 1, 2025, a Medi-Cal managed care plan shall include information within or accessible from the plan’s provider directory, and accessible through the plan’s call center, that identifies which of the Medi-Cal managed care plan’s in-network providers have affirmed that they offer and have provided gender-affirming services, including, but not limited to, feminizing mammoplasty, male chest reconstruction, mastectomy, gender-confirming facial surgery, hysterectomy, oophorectomy, penectomy, orchiectomy, feminizing genitoplasty, metoidioplasty, phalloplasty, scrotoplasty, voice masculinization or feminization, hormone therapy related to gender dysphoria or intersex conditions, gender-affirming gynecological care, or voice therapy related to gender dysphoria or intersex conditions. This information shall be updated when an in-network provider requests its inclusion or exclusion as a provider that offers and provides gender-affirming services. Nothing in this act alters any business establishment’s obligation to provide full and equal services to customers or patients regardless of their sex and other protected characteristics, pursuant to the Unruh Civil Rights Act (Section 51 of the Civil Code) and other applicable law. (d) For purposes of this section, the following definitions apply: (1) “Medi-Cal managed care plan” means an individual, organization, or entity that enters into a contract with the department to provide general health care services to enrolled Medi-Cal beneficiaries pursuant to any of the following: (A) Article 2.7 (commencing with Section 14087.3), excluding dental managed care programs developed pursuant to Section 14087.46. (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 2.9 (commencing with Section 14088). (F) Article 2.91 (commencing with Section 14089). (G) Chapter 8 (commencing with Section 14200), excluding dental managed care plans. (H) Chapter 8.9 (commencing with Section 14700). (I) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184), the California Advancing and Innovating Medi-Cal Demonstration pursuant to Section 14184.401, or a successor demonstration or waiver, as applicable. (2) The requirements described in this section that are imposed on a “Medi-Cal managed care plan” also apply to a Program of All-Inclusive Care for the Elderly (PACE) organization operating pursuant to Chapter 8.75 (commencing with Section 14591). The sanctions described in subdivision (b) also apply to a PACE organization, which may be imposed by the department or the State Department of Public Health pursuant to Section 14592 or any other provisions applicable to PACE organizations. (3) “TGI” means transgender, gender diverse, or intersex. (4) “TGI-serving organization” has the same meaning as set forth in paragraph (2) of subdivision (f) of Section 150900 of the Health and Safety Code. (5) “Trans-inclusive health care” means comprehensive health care that is consistent with the standards of care for individuals who identify as TGI, honors an individual’s personal bodily autonomy, does not make assumptions about an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect. (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, 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. (2) The department shall adopt regulations for purposes of this section by July 1, 2027, 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 provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations are adopted. (Added by Stats. 2022, Ch. 822, Sec. 7. (SB 923) Effective January 1, 2023.)
  53. 14197.1.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must ensure certain covered mental health and substance use disorder benefits comply with specified federal rules, may use guidance letters to implement the section until regulations are adopted, and must publish noncompliance findings and corrective action plans on its website.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.1. (a) The department shall ensure that all covered mental health benefits and substance use disorder benefits, as those terms are defined in Section 438.900 of Title 42 of the Code of Federal Regulations, are provided in compliance with Parts 438, 440, 456, and 457 of Title 42 of the Code of Federal Regulations, as amended March 30, 2016, as published in the Federal Register (81 Fed. Reg. 18390), and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services. (b) 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, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. In doing so, the director shall consult with managed care plans and consumer advocates. By July 1, 2022, the department shall adopt regulations, where appropriate, 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. (c) The department shall make any findings of noncompliance and corrective action plans available on its Internet Web site. (d) For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following: (1) Article 2.7 (commencing with Section 14087.3), excluding dental managed care programs developed pursuant to Section 14087.46. (2) Article 2.8 (commencing with Section 14087.5). (3) Article 2.81 (commencing with Section 14087.96). (4) Article 2.82 (commencing with Section 14087.98). (5) Article 2.91 (commencing with Section 14089). (6) Chapter 8 (commencing with Section 14200), excluding dental managed care plans. (7) Chapter 8.9 (commencing with Section 14700). (8) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10. (Added by Stats. 2017, Ch. 768, Sec. 3. (SB 171) Effective January 1, 2018.)
  54. 14197.11.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    This section lets the department contract with certain alternate health care service plans to serve eligible Medi-Cal managed care beneficiaries, while restricting denial or self-disenrollment and requiring related reports, assessments, and 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.11. (a) Notwithstanding any other law, subject to subdivisions (e) and (g), the department may enter into one or more comprehensive risk contracts with an alternate health care service plan (AHCSP) to serve as a primary Medi-Cal managed care plan for eligible beneficiaries described in subdivision (b) in geographic regions that are designated by the department pursuant to subdivision (c) and that are regions in which the AHCSP already provides commercial coverage in the individual, small group, or large group market. (b) The following beneficiary populations enrolling in Medi-Cal managed care shall be eligible to enroll, or choose to maintain their enrollment, in an AHCSP contracted with the department pursuant to subdivision (a): (1) A beneficiary who was previously a member of the AHCSP as their Medi-Cal managed care plan at any point from January 1, 2023, to December 31, 2023, inclusive. (2) An existing member of the AHCSP who is transitioning into Medi-Cal managed care. (3) A beneficiary who was a member of the AHCSP at any time during the 12 months preceding the effective date of the beneficiary’s Medi-Cal eligibility. (4) A beneficiary with an AHCSP family linkage. (5) A beneficiary who was previously enrolled in a primary Medi-Cal managed care plan other than the AHCSP at any point from January 1, 2023, to December 31, 2023, inclusive, but who was assigned to, and made the responsibility of, the AHCSP under a subcontract with the Medi-Cal managed care plan. (6) A dual eligible beneficiary residing in a geographic region approved by the department for purposes of this subdivision and for which the department has contracted with the AHCSP pursuant to subdivision (a). (7) A beneficiary who is in foster care in this state or is otherwise eligible on the basis of their receipt of services through a child welfare agency pursuant to Section 300 or a former foster youth eligible pursuant to Section 14005.28 residing in a geographic region for which the department has contracted with the AHCSP pursuant to subdivision (a). A beneficiary who was previously enrolled in the AHCSP as their primary Medi-Cal managed care plan under this paragraph may remain in the AHCSP even if the beneficiary is no longer receiving services through a child welfare agency pursuant to Section 300. (8) (A) A beneficiary not listed in paragraphs (1) to (7), inclusive, who resides in a geographic region for which the department has contracted with the AHCSP pursuant to subdivision (a) and is assigned to the AHCSP according to the department’s default enrollment process for beneficiaries that fail to elect a Medi-Cal managed care plan in accordance with Section 14016.5. The department shall annually determine the rate of default enrollment for beneficiaries into the AHCSP in each applicable county or geographic region based on the AHCSP’s projected capacity. (B) If the default enrollment into the AHCSP described in subparagraph (A) results in a default rate of 20 percent or higher for two consecutive months in an applicable county or counties as described in subdivision (c) of Section 14016.55, the department may elect not to conduct a one-time beneficiary survey, notwithstanding the requirement of subdivision (c) of Section 14016.55. (c) Notwithstanding any other law, the department may contract with an AHCSP as a Medi-Cal managed care plan in any geographic region of the state for which federal approval is available and received pursuant to subdivision (g), for which the AHCSP maintains appropriate licensure or an approved exemption from the Department of Managed Health Care, and in which the AHCSP already provides commercial coverage in the individual, small group, or large group market. To the extent permissible under federal law, the department may enter into either a single comprehensive risk contract for all geographic areas where the AHCSP is approved to operate as a Medi-Cal managed care plan or multiple contracts to serve the different geographic areas. If the department enters into a single comprehensive risk contract, capitation rates shall be determined on a county or regional basis. (1) The AHCSP shall not deny enrollment to any individual eligible pursuant to subdivision (b) unless the department or the Department of Managed Health Care has ordered the AHCSP to cease enrollment in an applicable service area. (2) (A) The AHCSP shall not, on its own, disenroll any eligible beneficiary described in subdivision (b). (B) The Health Care Options Program shall disenroll any member of an AHCSP if the member meets any one of the reasons for disenrollment enumerated in Section 53891 of Title 22 of the California Code of Regulations, except that the Health Care Options Program shall not disenroll a member who meets the conditions described in subdivision (f) of Section 53845 of Title 22 of the California Code of Regulations. The Health Care Options Program shall follow the disenrollment process described in Section 53889 of Title 22 of the California Code of Regulations. (3) Except for those standards and requirements relating to beneficiary enrollment that the department determines are inapplicable to the AHCSP, the comprehensive risk contract or contracts with the AHCSP pursuant to this section shall include the same standards and requirements as those for other Medi-Cal managed care plans, including any requirements imposed by the CalAIM Terms and Conditions, as the term is defined in subdivision (c) of Section 14184.101, and any terms and conditions imposed by a successor federal waiver or demonstration project and the same standards and requirements as for other Medi-Cal managed care plans in effect at that time. (4) (A) In addition to the comprehensive risk contract or contracts described in this section, the AHCSP shall enter into a memorandum of understanding with the department to memorialize any standards or requirements that are in addition to, or different than, those imposed on other Medi-Cal managed care plans as described in paragraph (3). Upon execution, the department shall post the memorandum of understanding on its internet website. (B) The memorandum of understanding entered into pursuant to subparagraph (A) shall include, but need not be limited to, the AHCSP’s commitment to increase enrollment of new Medi-Cal members over the course of the relevant contract terms and any requirements related to the AHCSP’s collaboration with, and support of, applicable safety net providers, including federally qualified health centers (FQHCs), as follows: (i) The AHCSP shall work with FQHCs in AHCSP service areas selected by the AHCSP and the department, at the request of the FQHC, to provide assistance with population health management and clinical transformation. (ii) The department and the AHCSP shall identify the highest need specialties and geographic areas where the AHCSP will provide, using the AHCSP’s physicians, outpatient specialty care and services to address related needs, including, but not limited to, diagnostic testing and outpatient procedures for Medi-Cal beneficiaries who are not enrollees of the AHCSP. (C) Within six months after the end of each applicable rating period for which the department contracts with the AHCSP pursuant to this section, commencing with the 2024 calendar year, the department shall publish a report describing the implementation of those standards and requirements imposed by the memorandum of understanding for the applicable rating period and post the report on its internet website. (5) During the relevant terms of the contracts entered into pursuant to subdivision (a), the AHCSP shall periodically consult with counties and other affected local stakeholders in those geographic regions in which the AHCSP operates, in a form and manner as directed by the department. The AHCSP shall enter into memoranda of understanding with local agencies pursuant to Medi-Cal managed care contract requirements. (d) It is the intent of the Legislature that Medi-Cal beneficiaries enrolled in the AHCSP be assigned to a primary care physician who is contracted with the AHCSP through its exclusive contracts with a single medical group subject to the limitations imposed by federal law. (e) Except when an AHCSP was already contracted with the department as a Medi-Cal managed care plan as of January 1, 2022, contracts entered into pursuant to subdivision (a) shall be effective no sooner than January 1, 2024. (f) Before the initial effective date of a contract entered into pursuant to this section, the department shall conduct an assessment of the AHCSP’s readiness to meet behavioral health network adequacy requirements pursuant to Medi-Cal managed care contract requirements and Section 14197 and shall post those findings on the department’s internet website, including any corrective action plan imposed due to noncompliance and the department’s basis for that finding of noncompliance, if any. (g) 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. (h) The capitation rates established for contracts entered into pursuant to subdivision (a) shall be set annually in accordance with Section 14301.1. It is the intent of the Legislature that all Medi-Cal managed care plans be paid in an actuarially sound manner according to the projected acuity of the populations they serve under contract with the department. (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, in whole or in part, by means of plan letters or other similar instructions, without taking any further regulatory action. (j) Notwithstanding any other law, 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, 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. (k) For purposes of this section, the following definitions shall apply: (1) “Alternate health care service plan” means a nonprofit health care service plan with at least 4,000,000 enrollees statewide that owns or operates pharmacies and provides professional medical services to enrollees in specific geographic regions through an exclusive contract with a single medical group in each specific geographic region in which it is licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code). If the AHCSP cannot comply with any terms of the Knox-Keene Health Care Service Plan Act, it shall request a modification of its license from the Department of Managed Health Care pursuant to Section 1352 of the Health and Safety Code, including regulations promulgated thereunder, or request an exemption from the Department of Managed Health Care pursuant to subdivision (b) of Section 1343 of the Health and Safety Code. (2) “AHCSP family linkage” includes when any of the following individuals are current AHCSP members on the effective date of the beneficiary’s Medi-Cal eligibility. (A) A beneficiary’s spouse or domestic partner. (B) A beneficiary’s dependent child, foster child, or stepchild under 26 years of age. (C) A beneficiary’s dependent who is disabled and over 21 years of age. (D) A parent or stepparent of a beneficiary under 26 years of age. (E) A beneficiary’s grandparent, guardian, foster parent, or other relative of a beneficiary under 26 years of age with appropriate documentation of familial relationship, as determined by the department. (3) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (4) “Dual eligible beneficiary” has the same meaning as set forth in paragraph (1) of subdivision (f) of Section 14184.200. (5) “Medi-Cal managed care plan” has the same meaning as set forth in subdivision (j) of Section 14184.101. (6) “Member” means an enrollee of the AHCSP. A beneficiary is not an enrollee solely by virtue of receiving a service through an AHCSP provider or AHCSP-contracted provider. (l) In 2026, the department shall report to the health and fiscal committees of the Legislature to provide an update on the implementation of this section. (Added by Stats. 2022, Ch. 73, Sec. 4. (AB 2724) Effective January 1, 2023.)
  55. 14197.2.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    Medi-Cal managed care plans must meet an 85% minimum medical loss ratio, report the ratio each reporting year, and provide remittances if they fall below the standard. The department must calculate remittance amounts, post specified MLR information online, and seek needed federal 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.2. (a) This section implements the state option in subsection (j) of Section 438.8 of Title 42 of the Code of Federal Regulations. (b) Commencing July 1, 2019, a Medi-Cal managed care plan shall comply with a minimum 85 percent medical loss ratio (MLR) consistent with Section 438.8 of Title 42 of the Code of Federal Regulations. The ratio shall be calculated and reported for each MLR reporting year by the Medi-Cal managed care plan consistent with Section 438.8 of Title 42 of the Code of Federal Regulations. (c) (1) Effective for contract rating periods commencing on or after July 1, 2023, a Medi-Cal managed care plan shall provide a remittance for an MLR reporting year if the ratio for that MLR reporting year does not meet the minimum MLR standard of 85 percent. The department shall determine the remittance amount on a plan-specific basis for each rating region of the plan and shall calculate the federal and nonfederal share amounts associated with each remittance. (2) After the department returns the requisite federal share amounts associated with any remittance funds collected in any applicable fiscal year to the federal Centers for Medicare and Medicaid Services, the remaining amounts remitted by a Medi-Cal managed care plan pursuant to this section shall be deposited in the General Fund. (d) Except as otherwise required under this section, and until June 30, 2022, the requirements under this section do not apply to a health care service plan under a subcontract with a Medi-Cal managed care plan to provide covered health care services to Medi-Cal beneficiaries enrolled in the Medi-Cal managed care plan. This subdivision shall be inoperative on July 1, 2022. (e) The department shall post on its internet website all of the following information: (1) The aggregate MLR of all Medi-Cal managed care plans. (2) The MLR of each Medi-Cal managed care plan, and, as applicable, the MLR of each subcontractor plan or other delegated entity, under contract with the Medi-Cal managed care plan, that is required to report an MLR pursuant to the CalAIM Terms and Conditions. (3) Any required remittances owed by each Medi-Cal managed care plan, and, as applicable, any required remittances owed by each subcontractor plan or other delegated entity to that Medi-Cal managed care plan pursuant to the CalAIM Terms and Conditions. (f) For purposes of this section, the following definitions apply: (1) “Medical loss ratio (MLR) reporting year” shall have the same meaning as that term is defined in Section 438.8 of Title 42 of the Code of Federal Regulations. (2) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract 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) Article 1 (commencing with Section 14200) of Chapter 8. (G) Article 7 (commencing with Section 14490) of Chapter 8. (3) “CalAIM Terms and Conditions” shall have the same meaning as that term is defined in subdivision (c) of Section 14184.101. (g) 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. (h) 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 letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action. (Amended by Stats. 2026, Ch. 27, Sec. 93. (SB 164) Effective June 29, 2026.)
  56. 14197.3.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    A Medi-Cal managed care plan must give beneficiaries written, timely notice of adverse benefit determinations and must resolve appeals within 30 calendar days, or within 72 hours for expedited appeals.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.3. (a) A Medi-Cal managed care plan shall give a beneficiary timely and adequate notice of an adverse benefit determination in writing consistent with the requirements in Sections 438.404, 438.408, and 438.10 of Title 42 of the Code of Federal Regulations. For purposes of this subdivision, “adverse benefit determination” means either of the following: (1) Any action described in Section 10950. (2) Any health care service eligible for coverage and payment under a Medi-Cal managed care plan contract that has been denied, modified, or delayed by a decision of the Medi-Cal managed care plan, or by one of its contracting providers. (b) Except as provided in subdivision (c), a Medi-Cal managed care plan shall resolve an appeal no more than 30 calendar days from the day the Medi-Cal managed care plan receives the appeal. (c) A Medi-Cal managed care plan shall resolve an expedited appeal no longer than 72 hours after the Medi-Cal managed care plan receives the appeal. A Medi-Cal managed care plan shall establish and maintain an expedited review process for a beneficiary or the beneficiary’s provider to request an expedited resolution of an appeal based on either of the following circumstances: (1) If the Medi-Cal managed care plan determines, for a request from the beneficiary, or the provider indicates, in making the request on the beneficiary’s behalf or supporting the beneficiary’s request, that taking the time for a standard resolution under the timeframe described in subdivision (b) could seriously jeopardize the beneficiary’s life, physical or mental health, or ability to attain, or regain, maximum function. (2) When the beneficiary’s condition is such that the beneficiary faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the timeframe described in subdivision (b) would be detrimental to the beneficiary’s life or health or could jeopardize the beneficiary’s ability to regain maximum function. (d) For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following: (1) Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46. (2) Article 2.8 (commencing with Section 14087.5). (3) Article 2.81 (commencing with Section 14087.96). (4) Article 2.82 (commencing with Section 14087.98). (5) Article 2.9 (commencing with Section 14088). (6) Article 2.91 (commencing with Section 14089). (7) Chapter 8 (commencing with Section 14200), including dental managed care plans. (8) Chapter 8.9 (commencing with Section 14700). (9) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10. (Added by Stats. 2017, Ch. 738, Sec. 7. (AB 205) Effective January 1, 2018.)
  57. 14197.4.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must set up and run Medi-Cal payment programs that increase contract services payments and provide quality incentive payments for designated public hospital systems, and later for district and municipal public hospitals.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.4. (a) The Legislature finds and declares all of the following: (1) Designated public hospital systems play an essential role in the Medi-Cal program, providing high-quality care to a disproportionate number of low-income Medi-Cal and uninsured populations in the state. Because Medi-Cal covers approximately one-third of the state’s population, the strength of these essential public health care systems is of critical importance to the health and welfare of the people of California. (2) Designated public hospital systems provide comprehensive health care services to low-income patients and lifesaving trauma, burn, and disaster-response services for entire communities, and train the next generation of doctors and other health care professionals, such as nurses and paramedical professionals, who are critical to new team-based care models that achieve more efficient and patient-centered care. (3) The Legislature intends to continue to provide levels of support for designated public hospital systems in light of their reliance on Medi-Cal funding to provide quality care to everyone, regardless of insurance status, ability to pay, or other circumstance, the significant proportion of Medi-Cal services provided under managed care by these public hospital systems, and federal requirements related to Medicaid managed care. (4) It is the intent of the Legislature that Medi-Cal managed care plans and designated public hospital systems that may enter into contracts to provide services for Medi-Cal beneficiaries shall in good faith negotiate for, and implement, contract rates, the provision and arrangement of services and member assignment that are sufficient to ensure continued participation by Medi-Cal managed care plans and designated public hospital systems and to maintain access to services for Medi-Cal managed care beneficiaries and other low-income patients. (5) It is the intent of the Legislature that, in order to ensure both the financial viability of Medi-Cal managed care plans and support the participation of designated public hospital systems in Medi-Cal managed care, the department shall provide Medi-Cal managed care plans actuarially sound rates reflecting the directed contract services payments implemented to comply with federal requirements relating to Medicaid managed care. (b) Commencing with the 2017–18 state fiscal year for designated public hospital systems, and commencing with the 2023 calendar year for district and municipal public hospitals, and for each state fiscal year or rate year, as applicable, thereafter, and notwithstanding any other law, the department shall require each Medi-Cal managed care plan to increase contract services payments to the designated public hospital systems and to district and municipal public hospitals by amounts determined under a directed payment methodology that meets federal requirements and as described in this subdivision. The directed payments may be determined and applied as distributions from directed payment pools, as uniform dollar or percentage increases, or on other bases, and may incorporate acuity adjustments or other factors. (1) The directed payments may separately account for inpatient hospital services and noninpatient hospital services. The directed payments shall be developed and applied separately for classes of designated public hospital systems and district and municipal public hospitals. The department, in consultation with the designated public hospital systems and district and municipal public hospitals, as applicable, shall establish the classes of designated public hospital systems and district and municipal public hospitals, as applicable, consistent with the objectives set forth in subdivisions (a) and (d) and that take into account differences in services provided, service delivery systems, and the level of risk assumed from Medi-Cal managed care plans. For designated public hospital systems, the factors to be considered shall include, but are not limited to, operation by the University of California, designated public hospital systems comprised of multiple acute care hospitals, level 1 or level 2 trauma designation, and the assumption of risk for the provision of inpatient hospital services. (2) To the extent permitted by federal law and to meet the objectives identified in subdivisions (a) and (d), the department shall develop and implement the directed payment program in consultation with designated public hospital systems and district and municipal public hospitals or Medi-Cal managed care plans, or all, as follows: (A) The department, in consultation with the designated public hospital systems and district and municipal public hospitals, as applicable, shall annually determine on a prospective basis the aggregate amount of payments that will be directed to each class of designated public hospital systems and district and municipal public hospitals pursuant to this subdivision and the classification of each designated public hospital system and district and municipal public hospital. Once the department determines the classification for each designated public hospital system and district and municipal public hospital for a particular state fiscal year or rate year, that classification shall not be eligible to change until no sooner than the subsequent year. For state fiscal years or rate years following the 2017–18 state fiscal year, the aggregate amounts of payments to a class of designated public hospital systems shall account for trend adjustments to the aggregate amounts available during the prior year, subject to any modifications to account for changes in the classification of designated public hospital systems, changes required by federal law, changes to account for the size of the payments made pursuant to subdivision (c), or other material changes. (B) The department, in consultation with the designated public hospital systems and district and municipal public hospitals, as applicable, shall develop the methodologies for determining the required directed payments for each designated public hospital system and district and municipal public hospital. (C) To the extent necessary to meet the objectives identified in subdivisions (a) and (d) or to comply with federal requirements, the department may, in consultation with the designated public hospital systems and district and municipal public hospitals, as applicable, adjust or modify the amounts of the aggregate directed payments for any class of designated public hospital systems and district and municipal public hospitals, the method for determining the distribution of the directed payment amounts within any class of designated public hospital systems and district and municipal public hospitals, and may modify, consolidate, or subdivide the classes of designated public hospital systems and district and municipal public hospitals established pursuant to paragraph (1). (D) After the aggregate amounts and the distribution methodology of directed payments for each designated public hospital system and district and municipal public hospital class have been established, the department shall consult with the designated public hospital systems, district and municipal public hospitals, and each affected Medi-Cal managed care plan with regard to the impact on the Medi-Cal managed care plan capitation ratesetting process and implementation of the directed payment requirements, including applicable interim and final payment processes, to ensure that 100 percent of the aggregate amounts are paid to the applicable designated public hospital system and district and municipal public hospital. (3) The required directed payment amounts shall be paid by the Medi-Cal managed care plans as adjustments, in a form and manner specified by the department, to the total amounts of contract services payments otherwise paid to the designated public hospital systems and district and municipal public hospitals. (4) The directed payments required under this subdivision shall be implemented and documented by each Medi-Cal managed care plan, designated public hospital system, and district and municipal public hospital, as applicable, in accordance with all of the following parameters and any guidance issued by the department: (A) A Medi-Cal managed care plan and the designated public hospital systems and district and municipal public hospitals shall determine the manner, timing, and amount of payment for contract services, including through fee-for-service, capitation, or other permissible manner. The rates of payment for contract services agreed upon by the Medi-Cal managed care plan and the designated public hospital system and district and municipal public hospital, as applicable, shall be established and documented without regard to the directed payments and quality incentive payments required by this section. (B) The required directed payment enhancements provided pursuant to this subdivision shall not supplant amounts that would otherwise be payable by a Medi-Cal managed care plan to a designated public hospital system or district and municipal public hospital for an applicable state fiscal year or rate year, and the Medi-Cal managed care plan shall not impose a fee or retention amount that would result in a direct or indirect reduction to the amounts required under this subdivision. (C) A contract between a Medi-Cal managed care plan and a designated public hospital system or district and municipal public hospital shall not be terminated by either party for the specific purpose of circumventing or otherwise impacting the payment obligations implemented pursuant to this subdivision. (D) If a Medi-Cal managed care plan subcontracts or delegates responsibility to a separate entity for either or both the arrangement or payment of services, the Medi-Cal managed care plan shall be responsible for paying the designated public hospital system and district and municipal public hospital, as applicable, the directed payment described in this subdivision with respect to the services it provides that are covered by that arrangement. The designated public hospital system or district and municipal public hospital, as applicable, and the applicable subcontractor or delegated entity shall work together with the Medi-Cal managed care plan to provide the information necessary to facilitate the Medi-Cal managed care plan’s compliance with the payment requirements under this subdivision. (5) Each state fiscal year, a Medi-Cal managed care plan shall provide to the department, at the times and in the form and manner specified by the department, an accounting of amounts paid or payable to the designated public hospital systems and district and municipal public hospitals with which it contracts, including both contract rates and the directed payments, to demonstrate compliance with this subdivision. To the extent that the department determines that a Medi-Cal managed care plan is not in compliance with the requirements of this subdivision, or is otherwise circumventing the purposes thereof, to the material detriment of an applicable designated public hospital system, the department may, after providing notice of its determination to the affected Medi-Cal managed care plan and allowing a reasonable period for the Medi-Cal managed care plan to cure the specified deficiencies, reduce the default assignment into the Medi-Cal managed care plan with respect to all Medi-Cal managed care beneficiaries by up to 25 percent in the applicable county, so long as the other Medi-Cal managed care plan or Medi-Cal managed care plans in the applicable county have the capacity to receive the additional default membership. The department’s determination whether to exercise discretion under this paragraph shall not be subject to judicial review, except that a Medi-Cal managed care plan that has its default assignment reduced pursuant to this paragraph may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department under this paragraph. Nothing in this paragraph shall be construed to preclude or otherwise limit the right of any Medi-Cal managed care plan or designated public hospital system to pursue a breach of contract action, or any other available remedy as appropriate, in connection with the requirements of this subdivision. (6) Capitation rates paid by the department to a Medi-Cal managed care plan shall be actuarially sound and account for the Medi-Cal managed care plan’s obligation to pay the directed payments to designated public hospital systems and district and municipal public hospitals in accordance with this subdivision. The department may require Medi-Cal managed care plans and the designated public hospital systems and district and municipal public hospitals to submit information regarding contract rates and expected or actual utilization of services, at the times and in the form and manner specified by the department. To the extent consistent with federal law and actuarial standards of practice, the department shall utilize the most recently available data and reasonable projections, as determined by the department, when accounting for the directed payments required under this subdivision, and shall account for additional clinics, practices, or other health care providers added to a designated public hospital system or district and municipal public hospital. In implementing the requirements of this section, including the Medi-Cal managed care plan ratesetting process, the department may additionally account for material adjustments, as appropriate under federal law and actuarial standards, as described above, and as determined by the department, to contracts entered into between a Medi-Cal managed care plan or applicable subcontracted or delegated entity and a designated public hospital system or district and municipal public hospital, as applicable. (c) Commencing with the 2017–18 state fiscal year for designated public hospital systems, and commencing with the 2020–21 state fiscal year for district and municipal public hospitals, and for each state fiscal year or rate year, as applicable, thereafter, the department, in consultation with the designated public hospital systems, district and municipal public hospitals, and applicable Medi-Cal managed care plans, as applicable, shall establish and implement a program or programs under which a designated public hospital system or a district and municipal public hospital may earn performance-based quality incentive payments from the Medi-Cal managed care plan with which they contract in accordance with this subdivision. (1) Payments shall be earned by each designated public hospital system based on its performance in achieving identified targets for quality of care. (A) The department, in consultation with the designated public hospital systems and applicable Medi-Cal managed care plans, shall establish and provide a method for updating uniform performance measures for the performance-based quality incentive payment program and parameters for the designated public hospital systems to select the applicable measures. The performance measures shall advance at least one goal identified in the state’s Medicaid quality strategy. Through and until June 30, 2020, performance measures pursuant to this subdivision shall not duplicate measures utilized in the PRIME program established pursuant to Section 14184.50. (B) Each designated public hospital system shall submit reports to the department containing information required to evaluate its performance on all applicable performance measures, at the times and in the form and manner specified by the department. A Medi-Cal managed care plan shall assist a designated public hospital system in collecting and distributing information necessary for these reports. (2) The department, in consultation with each designated public hospital system, shall determine a maximum amount that each class established pursuant to paragraph (1) of subdivision (b) may earn in quality incentive payments for the state fiscal year or rate year. (3) The department shall calculate the amount earned by each designated public hospital system based on its performance score established pursuant to paragraph (1). (A) This amount shall be paid to the designated public hospital system by each of its contracted Medi-Cal managed care plans. If a designated public hospital system contracts with multiple Medi-Cal managed care plans, the department shall identify each Medi-Cal managed care plan’s proportionate amount of the designated public hospital system’s payment. The timing and amount of the distributions and any related reporting requirements for interim payments shall be established and agreed to by the designated public hospital system and each of the applicable Medi-Cal managed care plans. (B) A contract between a Medi-Cal managed care plan and designated public hospital system shall not be terminated by either party for the specific purpose of circumventing or otherwise impacting the payment obligations implemented pursuant to this subdivision. (C) Each Medi-Cal managed care plan shall be responsible for payment of the quality incentive payments described in this subdivision, subject to funding by the department pursuant to paragraph (5). (4) Commencing with the 2020–21 state fiscal year, payments under this paragraph shall be earned by a district and municipal public hospital based on its performance in achieving identified targets for quality of care. (A) The department, in consultation with district and municipal public hospitals, shall establish a class of district and municipal public hospitals, or multiple classes to the extent federal approval is available, for purposes of payments under this paragraph. (B) The department, in consultation with district and municipal public hospitals, shall determine a maximum amount that the class, or classes, of district and municipal public hospitals established pursuant to subparagraph (A) may earn in quality incentive payments for an applicable state fiscal year or rate year. (C) The department, in consultation with district and municipal public hospitals and applicable Medi-Cal managed care plans, shall establish and provide a method for updating uniform performance measures for the performance-based quality incentive payments and parameters for district and municipal public hospitals to select the applicable measures. The performance measures shall advance at least one goal identified in the state’s Medicaid quality strategy. (D) Each district and municipal public hospital shall submit reports to the department containing information required to evaluate its performance on all applicable performance measures, at the time and in the form and manner specified by the department. Medi-Cal managed care plans shall assist a district and municipal public hospital in collecting and distributing information necessary for these reports. (E) The department shall calculate the amount earned by each district and municipal public hospital based on its performance score established pursuant to subparagraphs (C) and (D). This amount shall be paid to the district and municipal public hospital by each of its contracted Medi-Cal managed care plans. If a district and municipal public hospital contracts with multiple Medi-Cal managed care plans, the department shall identify each Medi-Cal managed care plan’s proportionate amount of the district and municipal public hospital’s payment. The timing and amount of the distributions and any related reporting requirements for interim payments shall be established and agreed to by the district and municipal public hospital and each of the applicable Medi-Cal managed care plans. (F) A contract between a Medi-Cal managed care plan and district and municipal public hospital shall not be terminated by either party for the specific purpose of circumventing or otherwise impacting the payment obligations implemented pursuant to this paragraph. (G) Each Medi-Cal managed care plan shall be responsible for payment of the quality incentive payments described in this paragraph, subject to funding by the department pursuant to paragraph (5). (5) The department shall provide appropriate funding to each Medi-Cal managed care plan, to account for and to enable them to make the quality incentive payments described in this subdivision, through the incorporation into actuarially sound capitation rates or any other federally permissible method. The amounts designated by the department for the quality incentive payments made pursuant to this subdivision shall be reserved for the purposes of the performance-based quality incentive payment program. (d) (1) In determining the amount of the required directed payments described in paragraph (2) of subdivision (b), and the aggregate size of the quality incentive payment program described in paragraph (2) of subdivision (c), the department shall consult with designated public hospital systems to establish levels for these payments that, in combination with one another, are projected to result in aggregate payments that will advance the quality and access objectives reflected in prior payment enhancement mechanisms for designated public hospital systems. To the extent necessary to meet these objectives or to comply with any federal requirements, the department may, in consultation with the designated public hospital systems, adjust or modify either or both the directed payments or quality incentive payment program. Once these payment levels are established, the department shall consult with the designated public hospital systems and the Medi-Cal managed care plans in the development of the Medi-Cal managed care rates needed for the directed payments and the structure of the quality incentive payment program. (2) (A) For the 2017–18 state fiscal year, the department shall, as soon as practicable after receipt of necessary federal approvals pursuant to paragraph (1) of subdivision (g), provide written notice of the directed payment and quality incentive payment amounts established pursuant to this section. A Medi-Cal managed care plan’s obligation to pay the directed payments and quality incentive payments required under subdivisions (b) and (c), respectively, to a designated public hospital system for the 2017–18 state fiscal year shall be contingent on the receipt of the written notice described in this subparagraph. (B) For each annual determination, commencing with the 2018–19 state fiscal year and each state fiscal year or rate year thereafter, the department shall provide written notice, as soon as practicable, to each affected Medi-Cal managed care plan, designated public hospital system, and, commencing with the 2020–21 state fiscal year, each district and municipal public hospital of the applicable Medi-Cal managed care plan’s directed payment amounts, the classification of designated public hospital systems and district and municipal public hospitals, as applicable, quality incentive payment amounts, and any other information deemed necessary for the Medi-Cal managed care plan to fulfill its payment obligations under subdivisions (b) and (c), as applicable, for the subject state fiscal year or rate year. If the modification of either or both directed payment amounts or quality incentive payment amounts is necessary after receipt of the written notification, the department shall notify the Medi-Cal managed care plan, designated public hospital system, and district and municipal public hospital, as applicable, in writing of the revised amounts before implementation of the revised amounts. (e) (1) The provisions of paragraphs (3), (4), and (5) of subdivision (a), paragraphs (3) and (4) of subdivision (b), paragraphs (3) and (5) of subdivision (c), and paragraph (2) of subdivision (d) shall be deemed incorporated into each contract between a designated public hospital system and a Medi-Cal managed care plan, and its subcontractor or designee, as applicable, and any claim for breach of those provisions may be brought by the designated public hospital system or the Medi-Cal managed care plan directly in a court of competent jurisdiction. (2) Commencing with the 2020–21 state fiscal year, the provisions of paragraph (4) of subdivision (c) and paragraph (2) of subdivision (d) shall be deemed incorporated into each contract between a district and municipal public hospital and a Medi-Cal managed care plan, and its subcontractor or designee, as applicable, and any claim for breach of those provisions may be brought by the district and municipal public hospital or the Medi-Cal managed care plan directly in a court of competent jurisdiction. (f) (1) (A) The nonfederal share of the portion of the capitation rates specifically associated with directed payments required under subdivision (b) and the quality incentive payments established pursuant to subdivision (c) may consist of voluntary intergovernmental transfers of funds provided by designated public hospitals or district and municipal public hospitals and their affiliated governmental entities, or other public entities, pursuant to Section 14164. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to applicable federal Medicaid laws, and in the form and manner specified by the department. Any intergovernmental transfer of funds made pursuant to this section shall be considered voluntary for purposes of all federal laws. (B) Notwithstanding any other law, commencing with the 2025 calendar year, the department may, upon acceptance of the voluntary intergovernmental transfers described in subparagraph (A), assess a fee not to exceed 5 percent on intergovernmental transfers pursuant to this section to reimburse the department for the administrative costs of operating the programs pursuant to this section and for the support of the Medi-Cal program. (2) (A) When applicable for voluntary intergovernmental transfers described in paragraph (1) that are associated with payments to designated public hospital systems, the department, in consultation with the designated public hospital systems, shall develop and maintain a protocol to determine the available funding for the nonfederal share associated with payments for each applicable state fiscal year or rate year pursuant to this section. The protocol developed and maintained pursuant to this paragraph shall account for any applicable contributions made by public entities to the nonfederal share of Medi-Cal managed care expenditures, including, but not limited to, contributions previously made by those specific public entities for the 2015–16 state fiscal year pursuant to Section 14182.15 or 14199.2, but excluding any contributions made pursuant to Sections 14301.4 and 14301.5. Nothing in this section shall be construed to limit or otherwise alter any existing authority of the department to accept intergovernmental transfers for purposes of funding the nonfederal share of Medi-Cal managed care expenditures. (B) When applicable for voluntary intergovernmental transfers described in paragraph (1) that are associated with payments to district and municipal public hospital systems, the department, in consultation with district and municipal public hospital systems, shall develop and maintain a protocol to determine the available funding for the nonfederal share associated with payments for each applicable state fiscal year or rate year pursuant to this section. Nothing in this section shall be construed to limit or otherwise alter any existing authority of the department to accept intergovernmental transfers for purposes of funding the nonfederal share of Medi-Cal managed care expenditures. (g) (1) 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. (2) For any state fiscal year in which this section is implemented, in whole or in part, and notwithstanding any other law, the department or a Medi-Cal managed care plan shall not be required to make any payment pursuant to Section 14182.15, 14199.2, or 14301.5. Nothing in this section shall be construed to preclude or otherwise impose limitations on payment amounts or arrangements that may be negotiated and agreed to between the relevant parties, including, but not limited to, the continuation of existing or the creation of new quality incentive or pay-for-performance programs in addition to the quality incentive payment program described in subdivision (c) and contract services payments that may be in excess of the directed payment amounts required under subdivision (b). (h) (1) The department shall seek any necessary federal approvals for the directed payments and the quality incentive payments set forth in this section. (2) The department shall consult with the designated public hospital systems and district and municipal public hospitals with regard to the development of the directed payment levels established pursuant to subdivisions (b) and (c) of this section, as applicable, and shall consult with designated public hospital systems, district and municipal public hospitals, and Medi-Cal managed care plans with regards to the implementation of payments under this section. (3) The director, after consultation with the designated public hospital systems, district and municipal public hospitals, and Medi-Cal managed care plans, may modify the requirements set forth in this section to the extent necessary to meet federal requirements or to maximize available federal financial participation. If federal approval is only available with significant limitations or modifications, or if there are changes to the federal Medicaid program that result in a loss of funding currently available to the designated public hospital systems or to the district and municipal public hospitals, the department shall consult with the designated public hospitals systems, the district and municipal public hospitals, and Medi-Cal managed care plans, as applicable, to consider alternative methodologies. (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 all-county letters, plan letters, provider bulletins, or other similar instructions, without taking regulatory action. The department shall make use of appropriate processes to ensure that affected designated public hospital systems, the district and municipal public hospitals, and Medi-Cal managed care plans, as applicable, are timely informed of, and have access to, applicable guidance issued pursuant to this authority, and that this guidance remains publicly available until all payments made pursuant to this section are finalized. (j) (1) (A) Directed payments and quality incentive payments to designated public hospital systems pursuant to subdivisions (b) and (c) shall cease to be operative on the first day of the state fiscal year or rate year beginning on or after the date the department determines, after consultation with the designated public hospital systems, that implementation of this section is no longer financially or programmatically supportive of the Medi-Cal program. This determination shall be based solely on the following factors: (i) The projected amount of nonfederal share funds available is insufficient to support implementation of the payments to designated public hospital systems pursuant to subdivisions (b) and (c) in the subject state fiscal year or rate year. (ii) The degree to which the payment arrangements for designated public hospital systems will no longer materially advance the goals and objectives reflected in this section and in the department’s managed care quality strategy drafted and implemented pursuant to Section 438.340 of Title 42 of the Code of Federal Regulations in the subject state fiscal year or rate year. (B) In making its determination, the department shall consider all reasonable options for mitigating the circumstances set forth in subparagraph (A), including, but not limited to, options for curing projected funding shortfalls and options for program revisions and strategy updates to better coordinate payment requirements with the goals and objectives of this section and the managed care quality strategy. (C) The department shall post notice of the determination on its internet website, and shall provide written notice of the determination to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (2) (A) Directed payments and quality incentive payments to district and municipal public hospitals pursuant to subdivisions (b) and (c) shall cease to be operative on the first day of the state fiscal year or rate year beginning on or after the date the department determines, after consultation with the district and municipal public hospitals, that implementation of this section is no longer financially or programmatically supportive of the Medi-Cal program. This determination shall be based solely on the following factors: (i) The projected amount of nonfederal share funds available is insufficient to support implementation of the payments to district and municipal hospitals pursuant to subdivisions (b) and (c) in the subject state fiscal year or rate year. (ii) The degree to which the payment arrangement for district and municipal hospitals will no longer materially advance the goals and objectives reflected in this section and in the department’s managed care quality strategy drafted and implemented pursuant to Section 438.340 of Title 42 of the Code of Federal Regulations in the subject state fiscal year or rate year. (B) In making its determination, the department shall consider all reasonable options for mitigating the circumstances set forth in subparagraph (A), including, but not limited to, options for curing projected funding shortfalls and options for program revisions and strategy updates to better coordinate payment requirements with the goals and objectives of this section and the managed care quality strategy. (C) The department shall post notice of the determination on its internet website, and shall provide written notice of the determination to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (k) The department, in consultation with the designated public hospital systems and the Medi-Cal managed care plans, shall provide the Legislature with the federally approved evaluation plan required in Section 438.6(c)(2)(i)(D) of Title 42 of the Code of Federal Regulations to measure the degree to which the payments authorized under this section advance at least one of the goals and objectives of the department’s managed care quality strategy. The department, in consultation with the designated public hospital systems and the Medi-Cal managed care plans, shall report to the Legislature the results of this evaluation once the department determines that the evaluation is finalized and complete according to the terms of any applicable federal approval and no earlier than January 1, 2021. (l) (1) The department may, after consultation with the designated public hospital systems, the district and municipal public hospitals, and Medi-Cal managed care plans, as applicable, exclude certain Medi-Cal managed care enrollee categories of aid, or subcategories thereof, or certain categories of medical assistance provided under a Medi-Cal managed care plan, or subcategories thereof, from the definition of “contract services payments” for purposes of the directed payment requirements described in subdivision (b). (2) The department shall seek federal approval to implement this subdivision. (m) For purposes of this section, the following definitions apply: (1) “Contract services payments” means the amount paid or payable to a designated public hospital system, including amounts paid or payable under fee-for-service, capitation amounts before any adjustments for service payment withholds or deductions, or payments made on any other basis, under a network provider contract with a Medi-Cal managed care plan for medically necessary and covered services, drugs, supplies, or other items provided to an eligible Medi-Cal beneficiary enrolled in the Medi-Cal managed care plan, excluding services provided to individuals who are dually eligible for both the Medicare and Medi-Cal programs and any additional exclusions that are approved pursuant to subdivision (l). Contract services includes all covered services, drugs, supplies, or other items the designated public hospital system provides, or is responsible for providing, or arranging or paying for, pursuant to a network provider contract entered into with a Medi-Cal managed care plan. If a Medi-Cal managed care plan subcontracts or delegates responsibility to a separate entity for either or both the arrangement or payment of services, “contract services payments” also include amounts paid or payable for the services provided by, or otherwise the responsibility of, the designated public hospital system that are within the scope of services of the subcontracted or delegated arrangement so long as the designated public hospital system holds a network provider contract with the primary Medi-Cal managed care plan. (2) “Designated public hospital” has the same meaning as set forth in subdivision (f) of Section 14184.10. (3) “Designated public hospital system” means a designated public hospital and its affiliated government entity clinics, practices, and other health care providers, including the respective affiliated hospital authority and county government entities described in Chapter 5 (commencing with Section 101850) and Chapter 5.5 (commencing with Section 101852), of Part 4 of Division 101 of the Health and Safety Code. (4) (A) “Medi-Cal managed care plan” means an applicable organization or entity that enters into a contract with the department pursuant to any of the following: (i) Article 2.7 (commencing with Section 14087.3). (ii) Article 2.8 (commencing with Section 14087.5). (iii) Article 2.81 (commencing with Section 14087.96). (iv) Article 2.82 (commencing with Section 14087.98). (v) Article 2.91 (commencing with Section 14089). (vi) Chapter 8 (commencing with Section 14200). (B) “Medi-Cal managed care plan” does not include any of the following: (i) A mental health plan contracting to provide mental health care for Medi-Cal beneficiaries pursuant to Chapter 8.9 (commencing with Section 14700). (ii) A plan not covering inpatient services, such as primary care case management plans, operating pursuant to Section 14088.85. (iii) A Program of All-Inclusive Care for the Elderly organization operating pursuant to Chapter 8.75 (commencing with Section 14591). (5) “Network provider” has the same meaning as that term is defined in Section 438.2 of Title 42 of the Code of Federal Regulations, and does not include arrangements where a designated public hospital system or a district and municipal public hospital provides or arranges for services under an agreement intended to cover a specific range of services for a single identified patient for a single inpatient admission, including any directly related followup care, outpatient visit or service, or other similar patient specific nonnetwork contractual arrangement, such as a letter of agreement or single case agreement, with a Medi-Cal managed care plan or subcontractor of a Medi-Cal managed care plan. (6) “District and municipal public hospital” means a nondesignated public hospital, as defined in subdivision (k) of Section 14184.10, that is a contracted network provider of one or more Medi-Cal managed care plans, and that had an approved project plan under the PRIME program established pursuant to Section 14184.50 or is otherwise authorized to participate in a quality incentive directed payment program pursuant to the applicable terms of federal approval obtained by the department pursuant to paragraph (1) of subdivision (h). (Amended by Stats. 2024, Ch. 40, Sec. 68. (SB 159) Effective June 29, 2024.)
  58. 14197.45.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    A Medi-Cal managed care plan must help eligible enrollees with complex cancer diagnoses get referrals and specialist care, and must try to contract with qualifying cancer centers in each county it operates in.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.45. (a) Notwithstanding any other law, for covered benefits under its contract, as applicable, a Medi-Cal managed care plan shall comply with all of the following: (1) Make a good faith effort to contract with at least one National Cancer Institute (NCI)-designated comprehensive cancer center, site affiliated with the NCI Community Oncology Research Program (NCORP), or qualifying academic cancer center, within its contracted provider network and its subcontracted provider network, if applicable, within each county in which the Medi-Cal managed care plan operates, for provision of services to any eligible enrollee diagnosed with a complex cancer diagnosis. For purposes of this paragraph, the NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center shall enroll in the Medi-Cal program if there is a state-level enrollment pathway, or the Medi-Cal managed care plan shall vet the qualifications of the facility to ensure they can meet the standards of participation required to contract with a Medi-Cal managed care plan. (2) (A) Allow any eligible enrollee diagnosed with a complex cancer diagnosis to request a referral to receive medically necessary services through any of the following in-network providers unless the enrollee chooses a different cancer treatment provider: (i) An NCI-designated comprehensive cancer center. (ii) An NCORP-affiliated site. (iii) A qualifying academic cancer center. (B) (i) If the Medi-Cal managed care plan is unsuccessful in its good faith contracting efforts pursuant to paragraph (1), the Medi-Cal managed care plan shall allow an enrollee to request a referral to receive medically necessary services through an out-of-network NCI-designated comprehensive cancer center, out-of-network NCORP-affiliated site, or out-of-network qualifying academic cancer center, unless the enrollee chooses a different cancer treatment provider. (ii) Clause (i) shall only apply if the Medi-Cal managed care plan and the out-of-network NCI-designated comprehensive cancer center, out-of-network NCORP-affiliated site, or out-of-network qualifying academic cancer center come to agreement with respect to payment. (3) (A) After approving a referral request pursuant to paragraph (2), allow an eligible enrollee diagnosed with a complex cancer diagnosis to access oncology, hematology, or other relevant specialists through a contracted NCI-designated comprehensive cancer center, a contracted NCORP-affiliated site, or a contracted qualifying academic cancer center, for the enrollee’s condition and identified needs as medically necessary. (B) If the NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center refers an enrollee with a complex cancer condition to an out-of-network specialist pursuant to subparagraph (B) of paragraph (2), this paragraph shall only apply if the Medi-Cal managed care plan and the out-of-network specialist come to an agreement with respect to payment. (4) A denial of an enrollee’s referral request shall be based upon a determination by the treating provider that the request to receive services at an NCI–designated comprehensive cancer center, or an NCORP-affiliated site, or a qualifying academic cancer center is not medically necessary, the requested services are not available at, or not applicable to the enrollee’s cancer diagnosis at, the requested NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center, or the NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center is an out-of-network provider and the Medi-Cal managed care plan and the out-of-network NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center are unable to come to agreement with the respect to payment. (5) Ensure that the services of an NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center available to an eligible enrollee are sufficient in amount, duration, and scope as medically necessary for the treatment of the enrollee’s condition. (6) Refrain from arbitrarily denying or reducing the amount, duration, or scope of required services solely because of diagnosis, type of illness, or condition of the enrollee. (b) A Medi-Cal managed care plan shall notify all enrollees of their right to request a referral to access care through an NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center, if they are diagnosed with a complex cancer diagnosis. (c) For the purposes of this section, the following definitions apply: (1) (A) “Complex cancer diagnosis” means a diagnosis for which there is no standard FDA-approved treatment or for which known highly effective therapy for metastatic cancer has failed and any of the following diagnoses: hematological malignancies, acute leukemia, advanced, relapsed, refractory non-Hodgkin lymphoma and multiple myeloma, including BPDCN and T-cell leukemias and lymphomas, and advanced stage, relapsed solid tumors refractory to standard FDA-approved treatment options, advanced stage rare solid tumors for which there is no known effective standard treatment options, or any other condition as determined pursuant to paragraph (2) of subdivision (d). “Advanced stage” cancer means stage IV metastatic cancer. (B) The department is authorized to periodically update and further define “complex cancer diagnosis” pursuant to the process outlined in subdivision (d). (2) “Eligible enrollee” means an individual enrolled with a particular Medi-Cal managed care plan who receives a complex cancer diagnosis. (3) “National Cancer Institute (NCI) Community Oncology Research Program (NCORP)-affiliated site” is a cancer center that has received an approved grant from NCI through NCORP that provides cancer clinical trials and care delivery studies. (4) “NCI-designated comprehensive cancer center” is a cancer center that meets ongoing standards for cancer prevention, clinical services, and research, as determined by regular reviews and evaluations by NCI. (5) “Qualifying academic cancer center” is a research and clinical cancer center that meets all the following criteria: (A) It is an institution with a medical oncology or hematology subspecialty expertise in each of the diagnoses included in paragraph (1). (B) It has a portfolio of phases 1, 2, and 3 clinical trials available for eligible enrollees. (C) It provides fellowship programs in medical oncology, hematology or hematological oncology, radiation oncology, or a surgical oncology specialty. (D) It provides inpatient and outpatient supportive care services. (E) It covers clinical, anatomic, and molecular pathology with subspecialty expertise for each of the cancer types included in paragraph (1). (F) It provides a program accredited by the American College of Surgeons (ACS) Commission on Cancer (CoC). (G) It has accreditation for the main campus by the Foundation for the Accreditation of Cellular Therapy. (d) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar guidance, without taking further regulatory action. (2) The department, in consultation with stakeholders, shall develop a process for updating and further defining a “complex cancer diagnosis” on a periodic basis. (e) 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. (f) For purposes of implementing this section, the department may enter into an exclusive or nonexclusive contract, or amend existing contracts, on a bid or negotiated basis. Contracts 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, and shall be exempt from the review or approval of any division of the Department of General Services. (Amended by Stats. 2023, Ch. 131, Sec. 232. (AB 1754) Effective January 1, 2024.)
  59. 14197.5.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must run the Cost-Based Reimbursement Clinic Directed Payment Program and adjust payments and funding rules for affected Medi-Cal managed care plans, subject to federal approval and available nonfederal share 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.5. (a) Notwithstanding any other law, but no sooner than July 1, 2019, the Cost-Based Reimbursement Clinic Directed Payment Program shall be in operation. (b) For purposes of this section, the following definitions apply: (1) “Cost-based reimbursement clinics” or “CBRCs” have the same meaning as the providers described in subdivision (a) of Section 14105.24. (2) “Cost-Based Reimbursement Clinic Directed Payment Program” or “CBRC DPP” or “program,” means a directed payment initiative implemented pursuant to subsection (c) of Section 438.6 of Title 42 of the Code of Federal Regulations or other applicable federal authority that requires affected Medi-Cal managed care plans to compensate CBRCs that are network providers for all network contract services provided to enrollees of the applicable Medi-Cal managed care plan as those clinics would be reimbursed according to the Medi-Cal cost-based, fee-for-service methodology as described in Section 14105.24. Services provided to enrollees who are dually eligible for both the Medicare and Medi-Cal programs are excluded for purposes of this program. (3) “Medi-Cal managed care plan” or “plan” has the same meaning as described in paragraph (4) of subdivision (m) of Section 14197.4. (4) “Network provider” has the same meaning as that term is defined in paragraph (5) of subdivision (m) of Section 14197.4. (c) (1) The department shall increase the capitation amounts paid to affected plans in each fiscal year by the amount the department deems necessary for the plan to comply with the requirements of this section, subject to the availability of nonfederal share funding described in subdivision (d). (2) The directed payment amounts paid under this section shall not supplant amounts that would otherwise be payable by a plan to a CBRC for an applicable fiscal year, and the plan shall not impose a fee or retention amount that would result in a direct or indirect reduction to the amounts required under this section. (d) The nonfederal share of the increases described in subdivision (c) may be funded through voluntary, intergovernmental transfers from affected counties or other public entities pursuant to Section 14164. Subject to an appropriation in the annual Budget Act, the first thirty million dollars ($30,000,000) of nonfederal share in each fiscal year, or any lesser amount as determined by the department pursuant to paragraph (2) of subdivision (e), shall be financed by other state funds appropriated to the department for this purpose. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify, in the form and manner specified by the department, that the transferred funds qualify for federal financial participation pursuant to applicable Medicaid laws. Any intergovernmental transfer of funds made pursuant to this section shall be considered voluntary for purposes of all federal laws. Notwithstanding any other law, the department shall not assess the fee described in subdivision (d) of Section 14301.4 nor any other similar fee. (e) (1) The department shall consult with the affected counties on a periodic basis, as determined appropriate by the department, to assess the extent to which implementation of the directed payments under this section in a particular fiscal year is likely to be federally approved and remains financially and programmatically supportive of the Medi-Cal program. (2) After consulting with the affected counties pursuant to paragraph (1), the department may do either of the following: (A) Reduce the total size of CBRC DPP payments to be made in that applicable fiscal year. If the department elects to reduce the total size of payments, the amount of state funding required to be provided first as nonfederal share for an applicable fiscal year pursuant to subdivision (d) shall be reduced as calculated and determined by the department. (B) Elect to not implement CBRC DPP payments for an applicable fiscal year or years. (f) Notwithstanding any other law, for any fiscal year in which the department implements the CBRC DPP payments, the amount of state funding provided as described in subdivision (d) shall not be included in the total revenues as defined in paragraph (7) of subdivision (b) of Section 17612.5. (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 letters, provider bulletins, or other similar instructions, without taking regulatory action. (h) 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. (Added by Stats. 2018, Ch. 34, Sec. 32. (AB 1810) Effective June 27, 2018.)
  60. 14197.6.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must set up or revise a directed payment reimbursement methodology for children’s hospitals, and Medi-Cal managed care plans must reimburse them under that arrangement.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.6. (a) For purposes of this section, the following definitions apply: (1) “Children’s hospital” has the same meaning as that term is defined in Section 10727. (2) “Medi-Cal managed care plan” has the same meaning as that term is defined in subdivision (j) of Section 14184.101. (b) Notwithstanding any other law, for dates of service no sooner than July 1, 2024, the department shall establish a directed payment reimbursement methodology, or revise one or more existing directed payment reimbursement methodologies, applicable to children’s hospitals. Medi-Cal managed care plans shall reimburse children’s hospitals in accordance with the requirements of the directed payment arrangement established by the department pursuant to this section and guidance issued pursuant to subdivision (e). (c) The department shall establish the form and manner of the directed payments authorized pursuant to this section, in consultation with representatives of children’s hospitals and in accordance with the requirements for directed payment arrangements described in Section 438.6(c) of Title 42 of the Code of Federal Regulations and any associated federal guidance. (d) In implementing this section, the department shall seek any federal approvals that it deems necessary. 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) 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 this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar instructions, without taking any further regulatory action. (f) The department shall develop the methodologies and parameters for the payments implemented pursuant to subdivisions (b) and (c) and may revise the methodologies and parameters for purposes, including, but not limited to, obtaining or maintaining any necessary federal approvals as required by subdivision (d). (g) Commencing no sooner than July 1, 2024, and notwithstanding Section 13340 of the Government Code, one hundred fifteen million dollars ($115,000,000) annually shall be continuously appropriated to the department from the General Fund to support the payments implemented pursuant to this section, except that such amount may be adjusted pursuant to subdivision (h). (h) If the Protect Access to Healthcare Act of 2024 (A.G. No. 23-0024) is approved by the voters, and if children’s hospitals receive increased reimbursement rates or payments pursuant to Section 14199.108, 14199.108.3, 14199.112, or 14199.116, or if children’s hospitals receive increased reimbursement rates or payments funded pursuant to subdivision (c) of Section 14105.200, then the amount available for directed payments to children’s hospitals as specified in subdivision (g) and the amount directed pursuant to subdivision (c) may be reduced by the estimated total amount of such increases, as determined by the Department of Health Care Services, in an amount not to exceed seventy-five million dollars ($75,000,000) annually. (i) It is the intent of the Legislature that the payments implemented pursuant to this section are to augment amounts that would otherwise be payable to children’s hospitals by a Medi-Cal managed plan or the department. It is not the intent of the Legislature that the payments implemented pursuant to this section replace amounts that would otherwise be payable by a Medi-Cal managed care plan or the department to children’s hospitals. (Added by Stats. 2024, Ch. 40, Sec. 69. (SB 159) Effective June 29, 2024.)
  61. 14197.7.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The director may terminate a contractor’s contract or impose sanctions if the contractor fails to comply or there is other good cause.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.7. (a) (1) Notwithstanding any other law, if the director finds that an entity that contracts with the department for the delivery of health care services (contractor), including a Medi-Cal managed care plan or a prepaid health plan, fails to comply with contract requirements, state or federal law or regulations, or the state plan or approved waivers, or for other good cause, the director may terminate the contract or impose sanctions as set forth in this section. (2) Good cause includes, but is not limited to, a finding of deficiency that results in improper denial or delay in the delivery of health care services, potential endangerment to patient care, disruption in the contractor’s provider network, failure to approve continuity of care, that claims accrued or to accrue have not or will not be recompensed, or a delay in required contractor reporting to the department. (b) The director may identify findings of noncompliance or good cause through any means, including, but not limited to, findings in audits, investigations, contract compliance reviews, quality improvement system monitoring, routine monitoring, facility site surveys, encounter and provider data submissions, grievances and appeals, network adequacy reviews, assessments of timely access requirements, reviews of utilization data, health plan rating systems, fair hearing decisions, complaints from beneficiaries and other stakeholders, whistleblowers, and contractor self-disclosures. (c) (1) Except when the director determines there is an immediate threat to the health of Medi-Cal beneficiaries receiving health care services from the contractor, at the request of the contractor, the department shall hold a public hearing to commence 30 days after notice of intent to terminate the contract has been received by the contractor. (2) The department shall present evidence at the hearing showing good cause for the termination. (3) The department shall assign an administrative law judge who shall provide a written recommendation to the department on the termination of the contract within 30 days after conclusion of the hearing. (4) (A) Reasonable notice of the hearing shall be given to the contractor, Medi-Cal beneficiaries receiving services through the contractor, and other interested parties, including any other person and organization the director may deem necessary. (B) The notice shall state the effective date of, and the reason for, the termination. (d) In lieu of contract termination, the director shall have the power and authority to require or impose a plan of correction and issue one or more of the following sanctions against a contractor for findings of noncompliance or good cause, including, but not limited to, those specified in subdivision (a): (1) Temporarily or permanently suspend enrollment and marketing activities. (2) Require the contractor to suspend or terminate contractor personnel or subcontractors. (3) Issue one or more of the temporary suspension orders set forth in subdivision (j). (4) Impose temporary management consistent with the requirements specified in Section 438.706 of Title 42 of the Code of Federal Regulations. (5) Suspend default enrollment of enrollees who do not select a contractor for the delivery of health care services. (6) Impose civil monetary sanctions consistent with the dollar amounts and violations specified in Section 438.704 of Title 42 of the Code of Federal Regulations, as follows: (A) A limit of twenty-five thousand dollars ($25,000) for each determination of the following: (i) The contractor fails to provide medically necessary services that the contractor is required to provide, under law or under its contract with the department, to an enrollee covered under the contract. (ii) The contractor misrepresents or falsifies information to an enrollee, potential enrollee, or health care provider. (iii) The contractor distributes directly, or indirectly through an agent or independent contractor, marketing materials that have not been approved by the state or that contain false or materially misleading information. (B) A limit of one hundred thousand dollars ($100,000) for each determination of the following: (i) The contractor conducts an act of discrimination against an enrollee on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or a practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services. (ii) The contractor misrepresents or falsifies information that it furnishes to the federal Centers for Medicare and Medicaid Services or to the department. (C) A limit of fifteen thousand dollars ($15,000) for each beneficiary the director determines was not enrolled because of a discriminatory practice under clause (i) of subparagraph (B). This sanction is subject to the overall limit of one hundred thousand dollars ($100,000) under subparagraph (B). (e) Notwithstanding the monetary sanctions imposed for the violations set forth in paragraph (6) of subdivision (d), the director may impose monetary sanctions in accordance with this section based on any of the following: (1) The contractor violates a federal or state statute or regulation. (2) The contractor violates a provision of its contract with the department. (3) The contractor violates a provision of the state plan or approved waivers. (4) The contractor fails to meet quality metrics or benchmarks established by the department. Any changes to the minimum quality metrics or benchmarks made by the department that are effective on or after January 1, 2020, shall be established in advance of the applicable reporting or performance measurement period, unless required by the federal government. (5) The contractor fails to demonstrate that it has an adequate network to meet anticipated utilization in its service area. (6) The contractor fails to comply with network adequacy standards, including, but not limited to, time and distance, timely access, and provider-to-beneficiary ratio requirements pursuant to standards and formulae that are set forth in federal or state law, regulation, state plan, or contract and that are posted in advance to the department’s internet website. (7) The contractor fails to comply with the requirements of a corrective action plan. (8) The contractor fails to submit timely and accurate network provider data. (9) The director identifies deficiencies in the contractor’s delivery of health care services. (10) The director identifies deficiencies in the contractor’s operations, including the timely payment of claims. (11) The contractor fails to comply with reporting requirements, including, but not limited to, those set forth in Section 53862 of Title 22 of the California Code of Regulations. (12) The contractor fails to timely and accurately process grievances or appeals. (f) (1) Monetary sanctions imposed pursuant to subdivision (e) may be separately and independently assessed and may also be assessed for each day the contractor fails to correct an identified deficiency. For a deficiency that impacts beneficiaries, each beneficiary impacted constitutes a separate violation. Monetary sanctions shall be assessed in the following amounts: (A) Up to twenty-five thousand dollars ($25,000) for a first violation. (B) Up to fifty thousand dollars ($50,000) for a second violation. (C) Up to one hundred thousand dollars ($100,000) for each subsequent violation. (2) For monetary sanctions imposed on a contractor that is funded from one or more of the realigned accounts described in paragraphs (2) to (4), inclusive, of subdivision (n), the department shall calculate a percentage of the funds attributable to the contractor to be offset per month pursuant to paragraphs (2) to (4), inclusive, of subdivision (n) until the amount offset equals the amount of the penalty imposed pursuant to paragraph (1). (g) When assessing sanctions pursuant to this section, the director shall determine the appropriate amount of the penalty for each violation based upon one or more of the following nonexclusive factors: (1) The nature, scope, and gravity of the violation, including the potential harm or impact on beneficiaries. (2) The good or bad faith of the contractor. (3) The contractor’s history of violations. (4) The willfulness of the violation. (5) The nature and extent to which the contractor cooperated with the department’s investigation. (6) The nature and extent to which the contractor aggravated or mitigated any injury or damage caused by the violation. (7) The nature and extent to which the contractor has taken corrective action to ensure the violation will not recur. (8) The financial status of the contractor, including whether the sanction will affect the ability of the contractor to come into compliance. (9) The financial cost of the health care service that was denied, delayed, or modified. (10) Whether the violation is an isolated incident. (11) The amount of the penalty necessary to deter similar violations in the future. (12) Other mitigating factors presented by the contractor. (h) (1) Except in exigent circumstances in which there is an immediate risk to the health of beneficiaries, as determined by the department, the director shall give reasonable written notice to the contractor of the intention to impose any of the sanctions authorized by this section and others who may be directly interested, including any other persons and organizations the director may deem necessary. (2) The notice shall include the effective date for, the duration of, and the reason for each sanction proposed by the director. (3) A contractor may request the department to meet and confer with the contractor to discuss information and evidence that may impact the director’s final decision to impose sanctions authorized by this section. (4) The director shall grant a request to meet and confer prior to issuance of a final sanction if the contractor submits the request in writing to the department no later than two business days after the contractor’s receipt of the director’s notice of intention to impose sanctions. (i) Notwithstanding subdivision (d), the director shall terminate a contract with a contractor that the United States Secretary of Health and Human Services has determined does not meet the requirements for participation in the Medicaid program contained in Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code. (j) (1) The department may make one or more of the following temporary suspension orders as an immediate sanction: (A) Temporarily suspend enrollment activities. (B) Temporarily suspend marketing activities. (C) Require the contractor to temporarily suspend specified personnel of the contractor. (D) Require the contractor to temporarily suspend participation by a specified subcontractor. (2) The temporary suspension orders shall be effective no earlier than 20 days after the notice specified in subdivision (k). (k) (1) Prior to issuing a temporary suspension order, or temporarily withholding funds pursuant to subdivision (o), the department shall provide the contractor with a written notice. (2) The notice shall state the department’s intent to impose a temporary suspension or temporary withhold and specify the nature and effective date of the temporary suspension or temporary withhold. (3) The contractor shall have 30 calendar days from the date of receipt of the notice to file a written appeal with the department. (4) Upon receipt of a written appeal filed by the contractor, the department shall, within 15 days, set the matter for hearing, which shall be held as soon as possible but not later than 30 days after receipt of the notice of hearing by the contractor. (5) The hearing may be continued at the request of the contractor if a continuance is necessary to permit presentation of an adequate defense. (6) The temporary suspension order shall remain in effect until the hearing is completed and the department has made a final determination on the merits. However, the temporary suspension order shall be deemed vacated if the director fails to make a final determination on the merits within 60 days of the close of the record for the matter. (7) The department shall stay imposition of a temporary withhold, pursuant to subdivision (o), until the hearing is completed and the department has made a final determination on the merits within 60 days of the close of the record for the matter. (l) (1) A contractor may request a hearing in connection with sanctions applied pursuant to subdivision (d) or (e) within 15 working days after the notice of the effective date of the sanctions has been given by sending a letter so stating to the address specified in the notice. (2) The department shall stay collection of monetary sanctions upon receipt of the request for a hearing. (3) Collection of the sanction shall remain stayed until the effective date of the final decision of the department. (m) Except as otherwise provided in this section, all hearings to review the imposition of sanctions, including temporary suspension orders, the withholding or offsetting of funds pursuant to subdivision (n), or the temporary withholding of funds pursuant to subdivision (o) shall be held pursuant to the procedures set forth in Section 100171 of the Health and Safety Code. (n) (1) If the director imposes monetary sanctions pursuant to this section on a contractor, except for a contractor described in paragraphs (2) to (5), inclusive, the amount of the sanction may be collected by withholding the amount from capitation or other associated payments owed to the contractor. (2) If the director imposes monetary sanctions on a contractor that is funded from the Mental Health Subaccount, the Mental Health Equity Subaccount, the Vehicle License Collection Account of the Local Revenue Fund, or the Mental Health Account, the director may offset the monetary sanctions from the respective account. The offset is subject to paragraph (2) of subdivision (q). (3) If the director imposes monetary sanctions on a contractor that is funded from the Behavioral Health Subaccount of the Local Revenue Fund 2011, the director may offset the monetary sanctions from that account from the distribution attributable to the applicable contractor. The offset is subject to paragraph (2) of subdivision (q). (4) If the director imposes monetary sanctions on a contractor that is funded from another mental health or substance use disorder realignment fund from which the Controller is authorized to make distributions to the contractor, the director may offset the monetary sanctions from these funds if the funds described in paragraphs (2) and (3) are insufficient for the purposes described in this subdivision, as appropriate. The offset is subject to paragraph (2) of subdivision (q). (5) (A) If the director imposes monetary sanctions pursuant to subdivision (e) of Section 5963.04, the director may offset the monetary sanctions from the Behavioral Health Services Fund from the distribution attributable to the applicable contractor. (B) With respect to an individual contractor, the department shall not collect via offset more than 25 percent of the total amount of the funds distributed from the Behavioral Health Services Fund that are attributable to the contractor in a given month. (C) If the department is not able to collect the full amount of monetary sanctions imposed on a contractor in a given month, the department shall continue to offset the amounts attributable to the contractor in subsequent months until the full amount of monetary sanctions has been collected. The offset is subject to paragraph (3) of subdivision (q). (o) (1) (A) Whenever the department determines that a mental health plan or an entity that contracts with the department to provide Drug Medi-Cal services has violated state or federal law, a requirement of this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.8 (commencing with Section 14600), or Chapter 8.9 (commencing with Section 14700), or any regulations, the state plan, a term or condition of an approved waiver, or a provision of its contract with the department, the department may temporarily withhold payments of federal financial participation and payments from the accounts listed in paragraphs (2) to (4), inclusive, of subdivision (n). (B) The department shall temporarily withhold amounts it deems necessary to ensure the mental health plan or the entity that contracts with the department to provide Drug Medi-Cal services promptly corrects the violation. (C) The department shall release the temporarily withheld funds when it determines the mental health plan or the entity that contracts with the department to provide Drug Medi-Cal services has come into compliance. (2) (A) A mental health plan or an entity that contracts with the department to provide Drug Medi-Cal services may appeal the imposition of a temporary withhold pursuant to this subdivision in accordance with the procedures described in subdivisions (k) and (m). (B) Imposition of a temporary withhold shall be stayed until the effective date of the final decision of the department. (p) This section shall be read in conjunction with, and apply in addition to, any other applicable law that authorizes the department to impose sanctions or otherwise take remedial action upon contractors. (q) (1) (A) Notwithstanding any other law, nonfederal moneys collected by the department pursuant to this section, except for moneys collected from a contractor funded from one or more of the realigned accounts described in paragraphs (2) to (4), inclusive, of subdivision (n), shall be deposited into the General Fund for use and, upon appropriation by the Legislature, to address workforce issues in the Medi-Cal program and improve access to care in the Medi-Cal program. (B) Beginning July 1, 2024, and continuing until June 30, 2027, unless otherwise specified in law, nonfederal moneys collected by the department pursuant to this section, except for moneys collected from a contractor funded from one or more of the realigned accounts described in paragraphs (2) to (4), inclusive, of subdivision (n), shall be deposited into the General Fund for use and, upon appropriation by the Legislature, for the nonfederal share of Medi-Cal costs for health care services furnished to children, adults, seniors, and persons with disabilities, and persons dually eligible for the Medi-Cal program and the Medicare Program. (2) (A) Monetary sanctions imposed via offset on a contractor that is funded from one or more of the realigned accounts described in paragraphs (2) to (4), inclusive, of subdivision (n) shall be redeposited into the account from which the monetary sanctions were offset pursuant to paragraphs (2) to (4), inclusive, of subdivision (n). (B) The department shall notify the Department of Finance of the percentage reduction for the affected county. (C) The Department of Finance shall subsequently notify the Controller, and the Controller shall redistribute the monetary sanction amount to nonsanctioned counties based on each county’s prorated share of the monthly base allocations from the realigned account. (D) With respect to an individual contractor, the department shall not collect via offset more than 25 percent of the total amount of the funds distributed from the applicable account or accounts that are attributable to the contractor in a given month. (E) If the department is not able to collect the full amount of monetary sanctions imposed on a contractor funded from one or more of the realigned accounts described in paragraphs (2) to (4), inclusive, of subdivision (n) in a given month, the department shall continue to offset the amounts attributable to the contractor in subsequent months until the full amount of monetary sanctions has been collected. (3) Monetary sanctions imposed via offset on a contractor pursuant to subdivision (e) of Section 5963.04 shall be redeposited into the account from which the monetary sanctions were offset pursuant to paragraph (5) of subdivision (n). (r) 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. (s) This section shall be implemented only to the extent that necessary federal approvals have been obtained and that federal financial participation is available. (t) For purposes of this section, “contractor” means an individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries or other individuals receiving behavioral health services, as applicable, pursuant to any of the following: (1) Article 2.7 (commencing with Section 14087.3), including dental managed care programs developed pursuant to Section 14087.46. (2) Article 2.8 (commencing with Section 14087.5). (3) Article 2.81 (commencing with Section 14087.96). (4) Article 2.82 (commencing with Section 14087.98). (5) Article 2.9 (commencing with Section 14088). (6) Article 2.91 (commencing with Section 14089). (7) Chapter 8 (commencing with Section 14200), including dental managed care plans. (8) Chapter 8.9 (commencing with Section 14700). (9) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184) or a successor demonstration or waiver, as applicable. (10) Chapter 2 (commencing with Section 5650) of Part 2 of Division 5, solely for purposes of imposition of corrective action plans, monetary sanctions, or temporary withholds pursuant to subdivision (e) of Section 5963.04. (11) Section 12534 of the Government Code. (12) The Home- and Community-Based Alternatives (HCBA) Waiver pursuant to state law and Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)). (13) The Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591). (u) This section shall become operative on January 1, 2025, if amendments to the Mental Health Services Act are approved by the voters at the March 5, 2024, statewide primary election. (Amended by Stats. 2025, Ch. 21, Sec. 113. (AB 116) Effective June 30, 2025.)
  62. 14197.71.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department may align contract terms, must set minimum quality metrics, and must require annual reporting and an annual county attestation; it also must issue guidance and implement the section by January 1, 2027, subject to federal approval and funding 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.71. (a) The department may, at its discretion, align relevant terms of its contract with a Medi-Cal behavioral health delivery system with the terms of its contract with a Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, for those requirements that apply to both entities. Requirements that apply to both entities include, but are not limited to, all of the following: (1) Organization and administration of the plan, including key administrative staffing requirements. (2) Financial information. (3) Information systems. (4) Quality improvement systems. (5) Utilization management. (6) Provider network. (7) Provider compensation arrangements. (8) Provider oversight and monitoring. (9) Access and availability of services, including, but not limited to, reporting of waitlists for behavioral health services or attesting to no waitlists. (10) Care coordination and data sharing. (11) Member services. (12) Member grievances and appeals data. (13) Reporting requirements. (14) Other contractual requirements determined by the department. (b) The department shall establish minimum quality metrics to measure and evaluate the quality and efficacy of services and programs covered under Medi-Cal behavioral health delivery systems. (c) (1) Each Medi-Cal behavioral health delivery system shall report annually to the county board of supervisors on utilization, quality, patient care expenditures, and other data as determined by the department. (2) The board of supervisors shall annually submit an attestation to the department that the county is meeting its obligations to provide realigned programs and services pursuant to clauses (i), (iv), and (v) of subparagraph (B) of paragraph (16) of subdivision (f) of Section 30025 of the Government Code. (d) (1) Notwithstanding any other state or local law, including, but not limited to, Section 5328 of this code and Sections 11812 and 11845.5 of the Health and Safety Code, the sharing of health, social services, housing, and criminal justice information, records, and other data with and among the department, other state departments, including the State Department of Public Health and the State Department of Social Services, Medi-Cal managed care plans, as defined in subdivision (j) of Section 14184.101, Medi-Cal behavioral health delivery systems, as defined in subdivision (i) of Section 14184.101, counties, health care providers, social services organizations, care coordination and case management teams, and other authorized provider or plan entities, and contractors of all of those entities, shall be permitted to the extent necessary and consistent with federal law. (2) The department shall issue guidance identifying permissible data-sharing arrangements. (e) For purposes of this section, the term “Medi-Cal behavioral health delivery system” means an entity or local agency that contracts with the department to provide covered behavioral health Medi-Cal benefits pursuant to Section 14184.400 and Chapter 8.9 (commencing with Section 14700) or a county Drug Medi-Cal Organized Delivery System pilot authorized under the CalAIM Terms and Conditions and described in Section 14184.401 or authorized under the Medi-Cal 2020 Demonstration Project Act pursuant to Article 5.5 (commencing with Section 14184). (f) This section shall be implemented only to the extent that necessary federal approvals have been obtained and federal financial participation is available and not otherwise jeopardized. (g) The department shall implement this section no later than January 1, 2027. (Added by Stats. 2023, Ch. 790, Sec. 112. (SB 326) Effective April 17, 2024. Approved in Proposition 1 at the March 5, 2024, election. Operative January 1, 2025, pursuant to Sec. 117 of Proposition 1.)
  63. 14197.8.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must list skilled nursing facilities in the Medi-Cal managed care plan provider directory and update that directory every year.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.8. (a) (1) As part of the health care options information posted by the department, in the provider directory that lists accepted Medi-Cal managed care plans, through the Medi-Cal Managed Care Health Care Options internet website and any other applicable mechanisms, the directory shall include skilled nursing facilities as one of the available searchable provider types. (2) This subdivision shall be implemented in conjunction with implementation of any other provisions relating to the directory described in this subdivision, including, but not limited to, Sections 14016.5, 14087.305, and 14089 of this code, Section 53886 of Title 22 of the California Code of Regulations, and Section 1396a(a)(83) of Title 42 of the United States Code, or their applicable successors. (b) The department shall annually update the provider directory described in subdivision (a) to ensure that information is accurate and readily accessible to the public. (c) For purposes of this section, the following definitions apply: (1) “Medi-Cal managed care plan” has the same meaning as set forth in Section 14184.101. (2) “Skilled nursing facility” has the same meaning as set forth in Section 1250 of the Health and Safety Code. (Added by Stats. 2025, Ch. 309, Sec. 1. (SB 250) Effective January 1, 2026.)
  64. 14197.9.

    ## 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. )

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    The department must require certain unlicensed Medi-Cal managed care plans to follow specified Health and Safety Code requirements, and it may use contracts and informal instructions 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 6.3. Medi-Cal Managed Care Plans [14197 - 14197.9] ( Article 6.3 added by Stats. 2017, Ch. 738, Sec. 7. ) ## 14197.9. (a) To the extent permitted under federal law, the department shall require a Medi-Cal managed care plan that is not licensed by the Department of Managed Health Care to comply with the applicable requirements in Article 11.9 (commencing with Section 1399.870) of Chapter 2.2 of Division 2 of the Health and Safety Code for the purpose of serving applicable Medi-Cal beneficiaries. (b) For purposes of this section, “Medi-Cal managed care plan” means an individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to this chapter or Chapter 8 (commencing with Section 14200). (c) (1) For purposes of implementing the Ensuring Access to Medicaid Services Final Rule, and the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule, which were published in Volume 89, Number 92 of the Federal Register on May 10, 2024, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. (2) Notwithstanding any other law, 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, Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, the Statewide Information Management Manual, the State Administrative Manual, and the State Contracting Manuals, and shall be exempt from the review or approval of any division of the Department of General Services. (3) This subdivision shall become inoperative on January 1, 2029. (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 all-county letters, plan letters, provider bulletins, information notices, or other similar instructions, without taking any further regulatory action. (Amended by Stats. 2025, Ch. 418, Sec. 2. (SB 530) Effective January 1, 2026.)
  65. 14198.1.

    ## 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 6.5. Regional Burn and Trauma Center Program [14198.1 - 14198.2] ( Article 6.5 added by Stats. 1998, Ch. 314, Sec. 1. )

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    Hospitals that received funds under Section 14198 must keep burn and trauma services and keep providing Medi-Cal-related medical services through 2028.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.5. Regional Burn and Trauma Center Program [14198.1 - 14198.2] ( Article 6.5 added by Stats. 1998, Ch. 314, Sec. 1. ) ## 14198.1. (a) A hospital or its successor entity, that has received funds pursuant to Section 14198 shall maintain burn and trauma services and continue to provide medical services to beneficiaries of Medi-Cal or a successor program through the year 2028. (b) The state and a hospital subject to this section shall negotiate in good faith to ensure continued hospital participation in the Medi-Cal program and to ensure adequate access to services for Medi-Cal patients. (Added by Stats. 1998, Ch. 314, Sec. 1. Effective August 19, 1998.)
  66. 14198.2.

    ## 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 6.5. Regional Burn and Trauma Center Program [14198.1 - 14198.2] ( Article 6.5 added by Stats. 1998, Ch. 314, Sec. 1. )

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    This section creates the Regional Burn and Trauma Center Fund and sets rules for what money can go in, how it must be used, and who can accept or recoup 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 6.5. Regional Burn and Trauma Center Program [14198.1 - 14198.2] ( Article 6.5 added by Stats. 1998, Ch. 314, Sec. 1. ) ## 14198.2. (a) The Regional Burn and Trauma Center Fund is hereby created in the State Treasury, under the administrative control of the State Department of Health Services, for the purposes specified in Section 14198 upon appropriation by the Legislature. Except as otherwise limited by this section, the fund shall consist of the following: (1) All public moneys transferred by public agencies to the department for deposit into the fund, as permitted under Section 433.51 of Title 42 of the Code of Federal Regulations or any other applicable federal medicaid laws. (2) All private moneys donated by private individuals or entities to the department for deposit in the fund, as permitted under applicable federal medicaid laws and regulations. Private donations may come from private individuals, foundations, or entities that do not meet the definition of a provider entity, as contained in federal regulatory law. (3) Any amounts appropriated by the Legislature for this program may be transferred to the fund. (4) Any interest that accrues on amounts in the fund. (b) Any public moneys transferred by public agencies, or private moneys donated by private individuals or entities to the department for deposit in the fund, shall be expended before any state appropriation is utilized as the nonfederal match of the supplemental reimbursement. Total combined funds made available under this section shall not exceed fifty million dollars ($50,000,000). It is the intent of the Legislature that funding from the General Fund shall not exceed twenty-five million dollars ($25,000,000). (c) Unless otherwise prohibited by law, any public or private agency transferring moneys to the fund may utilize for that purpose any revenues, grants, or allocations received from the state for health care programs or purposes. Unless otherwise prohibited by law, a public or private agency may also utilize its general operating funds, or any other public or private moneys or revenues for purposes of transfers to the fund. (d) The department shall have discretion as to whether to accept moneys offered to the department for deposit in the fund. If the department accepts moneys pursuant to this section, the department shall obtain federal matching funds to the full extent permitted by law. The department shall accept only those funds that are certified by the transferring entity or donating entity as qualifying for federal financial participation under the terms of the Medicaid Voluntary Contributions and Provider-Specific Tax Amendments of 1991 (Public Law 102-234), or Section 433.51 of Title 42 of the Code of Federal Regulations, as applicable, and may return any funds transferred or donated in error. (e) Moneys in the fund shall be used as the source for the nonfederal share of payments to the Regional Burn and Trauma Center to be constructed pursuant to this article. Moneys shall be allocated from the fund by the department and matched by federal funds in accordance with customary Medi-Cal accounting procedures for purposes of payments under subdivision (e). Distributions from the fund shall be supplemental to any and all other amounts that this hospital would have received under the selective provider contracting program. (f) For purposes of recognizing the Regional Burn and Trauma Center replacement costs incurred for services rendered to Medi-Cal beneficiaries, payments from the fund shall be negotiated between the California Medical Assistance Commission and the entity contracting under this article. Payments from the fund shall be used solely for the purposes identified in the contract between the hospital and the state. (g) The state shall be held harmless for any federal disallowance resulting from this section. A hospital receiving supplemental reimbursement pursuant to this section shall be liable for any reduced federal financial participation resulting from the implementation of this section with respect to that hospital. The state may recoup any federal disallowance from the hospital. (h) Funds available pursuant to this article shall only be used for projects, or for that portion of projects, that are available and accessible to Medi-Cal patients treated under this article or by successor programs. (Added by Stats. 1998, Ch. 314, Sec. 1. Effective August 19, 1998.)
  67. 14199.1.

    ## 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 6.6. Medicaid Expansion Under The Federal Affordable Care Act [14199.1 - 14199.2] ( Article 6.6 added by Stats. 2013, Ch. 24, Sec. 2. )

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    This section requires Medi-Cal managed care plans in public hospital health system counties to assign default members to primary care providers under specified percentage targets 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 6.6. Medicaid Expansion Under The Federal Affordable Care Act [14199.1 - 14199.2] ( Article 6.6 added by Stats. 2013, Ch. 24, Sec. 2. ) ## 14199.1. (a) The Legislature finds and declares the following: (1) Beginning January 1, 2014, many low-income individuals will be eligible for Medi-Cal coverage pursuant to federal law, as part of health care reform. (2) In implementing this expansion of Medi-Cal coverage, it is critical to maintain the role of county public hospital health systems that have traditionally served Medi-Cal and uninsured beneficiaries to ensure adequate access to care is available for the new Medi-Cal members, and to preserve the policy goal to support and strengthen traditional safety net providers who treat a high volume of uninsured and Medi-Cal patients. (b) For purposes of this section, the following definitions shall apply: (1) “County public hospital health system” shall have the meaning provided in subdivision (f) of Section 17612.2. (2) “Default members” means newly eligible beneficiaries enrolled in each Medi-Cal managed care plan who do not affirmatively select a primary care provider as part of the enrollment process. (3) “Enrollment target” means the number of newly eligible beneficiaries assigned to primary care providers within a county public hospital health system, not to exceed the number of unduplicated Low Income Health Program and uninsured patient count in the county public hospital health system. The unduplicated patient count shall be certified by the county public hospital health system and provided to the department, along with its proposed enrollment target, by November 30, 2013. The county public hospital health system may notify the department of a proposed reduction to its enrollment target based on its capacity to accept new patients. A standardized protocol for determining the target shall be developed by the department in consultation with the public hospital health system counties. (4) “Low Income Health Program” shall mean the LIHP as defined in subdivision (c) of Section 15909.1. (5) “Medi-Cal managed care plan” means an organization or entity that enters into a contract with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), Article 2.91 (commencing with Section 14089), or Chapter 8 (commencing with Section 14200). (6) “Newly eligible beneficiaries” shall have the meaning provided in subdivision (s) of Section 17612.2. (7) “Primary care provider” means a primary care physician or nonphysician medical practitioner, medical group, clinic, or a medical home. (8) “Public hospital health system county” shall have the meaning provided in subdivision (u) of Section 17612.2. (c) Subject to subdivision (d), default members who reside in a public hospital health system county shall be assigned by each Medi-Cal managed care plan in the county to a primary care provider in accordance with the following: (1) Throughout the three-year period ending on December 31, 2016, at least 75 percent of default members shall be assigned by each Medi-Cal managed care plan to primary care providers within the county public hospital health system until the county public hospital health system meets its enrollment target. (2) Following the expiration of the three-year period set forth in paragraph (1), at least 50 percent of default members shall be assigned by each Medi-Cal managed care plan to primary care providers within the county public hospital health system until the county public hospital health system meets its applicable enrollment target. (3) Paragraphs (1) and (2) shall not apply with respect to a county public hospital health system during any time period in which the county public hospital health system meets or exceeds its applicable target. For time periods during which paragraphs (1) and (2) do not apply, default members shall be assigned to primary care providers in the same manner as other Medi-Cal members of the Medi-Cal managed care plan who do not affirmatively select primary care providers. Medi-Cal managed care plans shall not modify the assignment procedures due to the default assignment requirements of this section with respect to primary care providers within the county public hospital health system. (4) In implementing the assignment process set forth in paragraphs (1) and (2), to the extent legally permissible and consistent with federal and state privacy and patient confidentiality laws, each Medi-Cal managed care plan shall first assign to a primary care provider within the county public hospital health system those default members who have accessed care within the county public hospital health system two or more times within the past 12 months. The department and the county public hospital health systems shall work together to share patient information in order to provide the Medi-Cal managed care plans with data demonstrating which default members have accessed the county public hospital health system providers prior to assignment to a primary care provider. (5) If at any time a county public hospital health system notifies a contracted Medi-Cal managed care plan that it has reached its maximum capacity for the assignment of default members, the requirements set forth in paragraphs (1) and (2) shall not apply to the Medi-Cal managed care plan so notified. Once the county public hospital health system notifies a Medi-Cal managed care plan that it has capacity to accept assignment of default members, the requirements set forth in paragraphs (1) and (2) shall apply effective on the first day of the month following that notice. (6) A Medi-Cal managed care plan shall not assign default members to a primary care provider within the county public hospital health system if that primary care provider has notified the Medi-Cal managed care plan that it does not have capacity to accept new patients. (d) The default process described in this section shall not apply to Low Income Health Program enrollees subject to Section 14005.61. (e) Nothing set forth in this section shall alter, reduce, or modify in any manner the way in which Medi-Cal managed care plans assign other Medi-Cal members to the county public hospital health systems. (f) (1) The department shall modify its contracts with the Medi-Cal managed care plans in public hospital health system counties to include the assignment requirements set forth in this section. (2) Each Medi-Cal managed care plan shall demonstrate and certify that it has contracts or other arrangements in place with county public hospital health systems that provide for implementing the requirements of this section. To the extent a Medi-Cal managed care plan is not compliant with any of the requirements of this section, the department shall reduce by 25 percent the default assignment into the Medi-Cal managed care plan with respect to all Medi-Cal beneficiaries, as long as the other Medi-Cal managed care plan or plans in that county have the capacity to receive the additional default membership. (g) Nothing in this section shall modify the ability of newly eligible beneficiaries to select or change their primary care providers. (h) The department shall seek any necessary federal approvals to implement the provisions of this section. (Amended by Stats. 2013, Ch. 358, Sec. 6. (SB 98) Effective September 26, 2013.)
  68. 14199.100.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This chapter may be cited as the Protect Access to Health Care Act of 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.100. Title This chapter shall be known and may be cited as the Protect Access to Health Care Act of 2024. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  69. 14199.101.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section states the voters’ findings that California needs to protect and improve access to health care, Medi-Cal coverage, and affordable prescription 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.101. Findings and Declarations The people of the State of California find and declare all of the following: (a) In 2019, Governor Newsom and the Legislature embarked on a series of investments and initiatives to improve the health care delivery system in California. These actions included extending health care coverage to all low-income Californians, starting California’s own generic drug production to deliver low-cost insulin to patients, providing much-needed mental health services to all California schoolchildren, and initiating a multiyear commitment to the improvement of the Medi-Cal program. (b) While these past several years have seen significant investment and initial outcomes appear to be successful, these investments are at risk in future years and need to be protected. (c) About 2 out of every 5 Californians, between 12 million and 15 million people, rely on the Medi-Cal program for health care coverage. This includes approximately four million children and two million seniors and people with disabilities. (d) However, just being enrolled in the Medi-Cal program does not guarantee access to quality health care. Most Medi-Cal reimbursement rates have not been adjusted in more than a decade, and some providers have not seen a payment increase in over 25 years. As a result, doctors and other health care providers struggle to take on new Medi-Cal patients. Relatedly, Medi-Cal patients, and in some areas entire communities, face a loss of access to critical and emergency care as essential hospital services such as labor and delivery are at risk of being reduced or eliminated. (e) The problem is exacerbated by a shortage of health care professionals in our state. The current strains on our health care system have left many health care workers physically and mentally exhausted, and thousands have left the profession altogether. This has left our health care system overstretched and made it even harder for the most vulnerable Californians to get access to care, including access to family planning services and other reproductive health care. (f) Medi-Cal patients may wait weeks or months to see doctors who are specialists. The situation is more challenging in rural areas of the state that have fewer primary care providers per person, which results in delays or inability to access basic health care services. (g) Obtaining adequate mental health services can take even longer. California suffers not only from a shortage of mental health care professionals, but also from a shortage of psychiatric beds and treatment for patients with serious mental health conditions. When patients with serious mental health needs cannot obtain adequate care, they frequently wait days in the emergency room or may ultimately be left untreated and become homeless. (h) All Californians continue to struggle with high prescription drug prices. When Californians cannot access the medications they need, our entire health care system suffers. (i) The lack of health care access and affordable prescription drugs for patients poses a health care risk for all Californians. When Medi-Cal patients are unable to refill a prescription or find a doctor, mental health facility, or other health care provider to treat them, they often end up in emergency rooms. This puts additional, and avoidable, strains on our state’s emergency rooms. When Medi-Cal patients are forced to rely on emergency rooms as their primary source of health care, the additional strain makes it harder for all patients to obtain life-saving care. (j) Medi-Cal patients need the same access to health care and prescription medications as patients with private or employer-based health insurance. This is best and most directly accomplished by increasing reimbursement rates for doctors, hospitals, and other health care providers that treat Medi-Cal patients to at least cover the costs of providing care and by bringing down the cost of prescription drugs. (k) California is one of several states that levy taxes on managed care plans to obtain extra federal dollars to help pay for health care access. This chapter addresses many of the current flaws in Medi-Cal funding. First, it ensures the existing tax is continued permanently so that California obtains its fair share of federal health care funding. Second, it guarantees that all of the revenue from the continued tax will be spent on investments to improve access to critical health care services and makes it impossible to divert these dollars to unrelated uses. (l) In addition, this chapter helps make essential medications affordable and accessible to more patients by increasing funding for the state to produce and distribute generic prescription drugs. By expanding California’s capacity to produce its own generic prescription drugs, this chapter will inject competition into the prescription drug market and help address critical drug shortages. This will reduce prescription drug prices for all Californians. (m) By ensuring permanent funding for increased Medi-Cal provider payments, generic prescription drug programs, and increasing our health care workforce, bed capacity, and treatment options, and protecting these dollars from unauthorized uses, this chapter will improve our overall health care system by providing all patients with greater access to quality health care and affordable drugs. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  70. 14199.102.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section states the chapter’s purpose: expand health care access, fund generic prescription drugs, and keep the funding stream from being diverted or used to replace existing 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 1. Title, Findings and Declarations, Statement of Purpose [14199.100 - 14199.102] ( Article 1 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.102. Statement of Purpose In enacting this chapter, the purpose and intent of the people of the State of California is to do all of the following: (a) Increase access to quality health care by establishing a permanent, dedicated funding stream to be used for increasing reimbursement rates and other supports to health care providers that treat Medi-Cal patients and investments in building an adequate health care workforce, bed capacity, and treatment options. (b) Increase access to affordable prescription drugs by establishing a permanent, dedicated funding stream to be used to produce and distribute generic prescription drugs through the California Affordable Drug Manufacturing Act of 2020. (c) Prevent the revenue stream permanently continued by this chapter from ever being used to fund unauthorized or unrelated programs or from being used to supplant or replace existing sources of moneys that currently fund health care access and affordable prescription drug programs in this state. (d) Continue a dedicated funding stream that is fully permitted by federal law, while also ensuring that taxpayers and employers do not bear the financial burden for the implementation of this chapter. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  71. 14199.103.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section creates the Protect Access to Health Care Fund in the State Treasury and related subfunds, and directs certain remaining funds to be transferred in 2027 or when encumbered balances are exhausted.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.103. Creation of the Protect Access to Health Care Fund (a) (1) The Protect Access to Health Care Fund (fund) is hereby established in the State Treasury. (2) Notwithstanding any other law: (A) The fund is a special fund, permanently separate and apart from the General Fund or any other state fund or account. (B) Notwithstanding Section 16305.7 of the Government Code, any interest or dividends earned on moneys in the fund shall be retained in the fund and used solely as set forth in this chapter. (b) The Health Care Oversight & Accountability Subfund is hereby established in the fund. (c) The Improving Access to Health Care Subfund is hereby established in the fund. (d) Notwithstanding any other law: (1) (A) Effective January 1, 2027, any remaining moneys in the Managed Care Enrollment Fund created pursuant to Section 14199.82 that are not necessary to fund liabilities or encumbrances to support the subcomponents of the Medi-Cal program set forth in subdivision (d) of Section 14199.82 for expenditures associated with the 2023, 2024, 2025, and 2026 payments shall be transferred to the Medi-Cal Access and Support Account. (B) Effective on the date on which all remaining encumbered moneys in the Managed Care Enrollment Fund have been exhausted, the Managed Care Enrollment Fund is hereby abolished, and Section 14199.82 shall become inoperative, and is hereby repealed one year after becoming inoperative. (2) (A) Effective January 1, 2027, any remaining moneys in the Medi-Cal Provider Payment Reserve Fund created pursuant to Section 14105.200 that are not necessary to fund liabilities or encumbrances for the purposes set forth in Section 14105.200 for expenditures associated with the 2023, 2024, 2025, and 2026 calendar years shall be transferred to the Medi-Cal Access and Support Account. (B) Effective on the date on which all remaining encumbered moneys in the Medi-Cal Provider Payment Reserve Fund have been exhausted, the Medi-Cal Provider Payment Reserve Fund is hereby abolished, and Section 14105.200 shall become inoperative, and is hereby repealed one year after becoming inoperative. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  72. 14199.104.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The Controller must audit certain fund recipients every four years, report the findings to state officials, publish them online, and assess compliance with Section 14199.107. The Controller is also entitled to reimbursement for audit and review costs up to $750,000 per audit and review, and the Treasurer’s office must publish decennial inflation adjustments.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.104. Fund Oversight and Accountability (a) The people of the State of California hereby declare their unqualified intent for the moneys deposited into the fund to be used to support the purposes set forth in this chapter without delay or interruption. The purpose of this section is to provide oversight and accountability mechanisms to guarantee that the people’s intent is carried out. (b) (1) Every four years, the Controller shall conduct an independent financial audit of the programs receiving moneys from the fund. The Controller shall report the findings to the Governor and both houses of the Legislature, and shall make the findings available to the public on its internet website. (2) The Controller’s audit shall also assess the department’s annual compliance with Section 14199.107. (c) (1) The Controller shall be separately reimbursed from moneys in the Health Care Oversight & Accountability Subfund for actual costs incurred in conducting the financial audit required by subdivision (b) of this section and the reviews required by subdivision (b) of Section 14199.107 in an amount not to exceed seven hundred fifty thousand dollars ($750,000) per audit and review. (2) The seven hundred fifty thousand dollars ($750,000) per audit and review maximum limit shall be adjusted decennially to reflect any increase in inflation as measured by the Consumer Price Index for All Urban Consumers (CPI-U). The Treasurer’s office shall calculate and publish the adjustments required by this paragraph. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  73. 14199.105.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The fund and its subfunds must be treated as trust funds, and the money in them can only be used for the chapter’s specified 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.105. Treatment of Moneys Deposited in and Expended from the Fund Notwithstanding any other law: (a) The fund, and every subfund, account, and subaccount within the fund, is hereby declared to be a trust fund, trust subfund, trust account, or trust subaccount. (b) Except as provided in Sections 16310 and 16381 of the Government Code as those sections read on January 1, 2023, moneys in the fund shall not be borrowed, loaned, or otherwise transferred to the General Fund or any other state or local fund or account. Moneys deposited into the fund, and any subfund, account, or subaccount within the fund, including any interest or dividends earned thereon, shall only be used for the specific purposes set forth in this chapter. Action shall not be taken that permanently or temporarily changes the status of the fund or any subfund, account, or subaccount within the fund as a trust fund, trust subfund, trust account, or trust subaccount, or borrows, diverts, or appropriates the moneys in the fund in a manner inconsistent with this chapter. (c) (1) The taxes imposed by Article 7.1 (commencing with Section 14199.80) of Chapter 7 during calendar years 2025 and 2026, and Article 6 (commencing with Section 14199.123) and the moneys derived therefrom, including interest and penalties but less payment of refunds, are required to be deposited into the fund as set forth in Article 3 (commencing with Section 14199.108). The fund is a special fund and trust fund permanently and irrevocably separate and apart from the General Fund. Notwithstanding Section 13340 of the Government Code, moneys in the fund are continuously appropriated to the department without regard to fiscal year for the purposes set forth in this chapter. (2) (A) Therefore, the taxes and the moneys resulting therefrom described in paragraph (1) shall not be considered to be part of the General Fund, as that term is used in Chapter 1 (commencing with Section 16300) of Part 2 of Division 4 of Title 2 of the Government Code, shall not be considered General Fund revenues for purposes of Section 8 of Article XVI of the California Constitution and its implementing statutes, and shall not be considered “General Fund revenues,” “state revenues,” “moneys,” or “General Fund proceeds of taxes” for purposes of subdivisions (a) and (b) of Section 8 of Article XVI of the California Constitution and its implementing statutes. (B) This paragraph does not change the character of the taxes and the moneys resulting therefrom described in paragraph (1) as “state revenues” or “state tax revenues” for purposes of Title XIX and Title XXI of the Federal Social Security Act. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  74. 14199.106.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must use and spend the fund’s money for this chapter’s purposes, publish its chosen accounting basis, and follow limits on reimbursement and court-related transfers.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.106. Administration (a) (1) The department shall be annually reimbursed from moneys in the Health Care Oversight & Accountability Subfund for actual and necessary costs incurred in administering this chapter in an amount not to exceed 0.0005 percent of the moneys annually deposited into the fund or four million dollars ($4,000,000), whichever is greater. Any interagency agreements entered into by the department for administration of this chapter shall be covered by the amount provided in this subdivision. (2) The limit in paragraph (1) shall be adjusted decennially to reflect any increase in inflation as measured by the Consumer Price Index for All Urban Consumers (CPI-U). The Treasurer’s office shall calculate and publish the adjustments required by this paragraph. (b) (1) (A) On and after January 1, 2027, the department has a nondiscretionary ministerial duty to use all of the moneys in the fund, and each subfund, account, and subaccount within the fund, to accomplish the purposes of this chapter on an annual basis. Therefore, on and after January 1, 2027, the department shall make every reasonable effort to exhaust or otherwise encumber all of the moneys in the fund by the end of each calendar year or fiscal year. (B) The department may choose to comply with this requirement on a calendar year or fiscal year basis and may account for such expenditures on an accrual or cash basis. The department shall publish its choices under this subparagraph on its internet website. (C) For purposes of this paragraph, unexhausted moneys in the fund that are allocated for expenditures associated with payments to Medi-Cal providers pursuant to a federally approved methodology, or a methodology for which federal approval is pending, shall be considered otherwise encumbered at the end of each applicable calendar year or fiscal year. (2) In any challenge alleging that the department is violating this nondiscretionary ministerial duty, the court shall apply its independent judgment and deference shall not be accorded to the department. (c) (1) If, in any challenge brought to remedy a violation of this chapter, a restraining order or preliminary injunction is issued, the plaintiffs or petitioners shall not be required to post a bond obligating the plaintiffs or petitioners to indemnify the government defendants or the State of California for any damage the restraining order or preliminary injunction may cause. (2) (A) If any challenge to invalidate an action that violates this chapter is successful by way of a final judgment issued by a court of competent jurisdiction, then an amount of moneys necessary to restore the fund, subfund, account, or subaccount from which the moneys were unlawfully taken or diverted to its financial status had the unlawful action not been taken shall be transferred from the General Fund to the fund, subfund, account, or subaccount, as applicable, upon appropriation by the Legislature. Interest calculated at the Pooled Money Investment Fund rate from the date or dates the moneys were unlawfully taken or diverted shall accrue to the amounts required to be transferred pursuant to this paragraph. Within 30 calendar days of the appropriation made by the Legislature, the Controller shall make the transfer required by this paragraph and issue a notice to the parties, the department, and the committee that the transfer has been completed. (B) If the Legislature fails to appropriate sufficient moneys to satisfy a final judgment described in subparagraph (A) within 365 days of the issuance of that judgment, the court shall direct the Controller to use moneys in the Medi-Cal Access and Support Account to restore the moneys that were unlawfully taken or diverted, including interest. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  75. 14199.107.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    Fund money cannot be used to replace existing state revenue sources and must be used to expand or enhance health care-related benefits, services, workforce, and payment rates, with specified 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 2. Protect Access to Health Care Fund [14199.103 - 14199.107] ( Article 2 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.107. Nonsupplantation (a) (1) Except as otherwise specified in Article 4 (commencing with Section 14199.109), moneys in the fund shall not be used to replace or supplant state revenue sources already in existence before the effective date of this chapter. Moneys in the fund shall only be used to expand the health care benefits, health care services, health care workforce, and payment rates above and beyond those already in effect or in existence as of January 1, 2024. (2) In order to ensure compliance with paragraph (1) and achieve the purposes of this chapter, and except as otherwise specified in Article 4 (commencing with Section 14199.109), moneys in the fund shall be used only to increase and enhance, and not replace or supplant, each and every preexisting state revenue source for the services and programs that receive additional financial support pursuant to Article 3 (commencing with Section 14199.108) and Article 4 (commencing with Section 14199.109) of this chapter. (3) Except as otherwise specified in Article 4 (commencing with Section 14199.109), moneys in the fund shall not be used to supplant any preexisting state revenue source used to provide Medi-Cal services, benefits, or coverage, moneys used for the California Affordable Drug Manufacturing Act of 2020, or the health care workforce provisions set forth in this chapter. (b) (1) The department shall annually issue a public written report providing a detailed explanation of whether or not, and how, compliance with subdivision (a) is being achieved. The report shall be posted on the department’s internet website. (2) As part of its audit responsibilities under Section 14199.104, the Controller shall independently review the reports prepared by the department pursuant to paragraph (1) and publicly issue a separate written opinion regarding whether or not compliance with subdivision (a) is being achieved. Costs incurred by the Controller attributable to this requirement shall be reimbursable pursuant to subdivision (c) of Section 14199.104. (c) In any challenge alleging that the moneys in the fund, and the subfunds, accounts, and subaccounts established within the fund, are being used to supplant preexisting state revenues already used for the purposes described in this chapter, the court shall apply its independent judgment and deference shall not be accorded to the department. (d) For purposes of this section, Sections 14199.84 and 14199.123 shall be deemed to be the same state revenue source. (e) Additional express references in this chapter to prohibitions on supplanting funding does not imply greater nonsupplantation protection for the accounts containing those references, or lesser nonsupplantation protection for accounts lacking those references. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  76. 14199.108.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The Controller must deposit and transfer specified health-care tax revenues into the fund and then distribute them among designated subfunds and accounts under set percentages and caps.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.108. Deposit and Allocation of Moneys Notwithstanding any other law: (a) (1) On and after January 1, 2025, all moneys annually derived from the tax imposed pursuant to Article 7.1 (commencing with Section 14199.80) of Chapter 7 shall be deposited into the fund. (2) On and after January 1, 2027, all moneys annually derived from the tax imposed by Article 6 (commencing with Section 14199.123) shall be deposited into the fund. (b) (1) Sufficient moneys shall be annually transferred by the Controller from the fund to the Health Care Oversight & Accountability Subfund to cover all of the following: (A) For the 2025 and 2026 calendar years only, the amount of moneys necessary to cover the appropriations made pursuant to Section 14199.108.3. (B) Commencing with the 2025 calendar year and each calendar year thereafter, the nonfederal share of increased capitation payments to Medi-Cal managed care plans to account for their projected tax obligation pursuant to Section 14199.84 or Article 6 (commencing with Section 14199.123), for the subject calendar year or years, as applicable. (C) Reimbursement of the Controller for its responsibilities under this chapter. (D) Payment of the department’s administrative costs. (E) Repayment of any refunds, as applicable. (F) Costs incurred pursuant to Section 14199.133. (2) Notwithstanding Section 13340 of the Government Code, all moneys within the Health Care Oversight & Accountability Subfund are hereby continuously appropriated, without regard to fiscal years, to the department to be used as set forth in this subdivision. (3) Any unencumbered moneys remaining in the Health Care Oversight & Accountability Subfund at the end of a calendar year shall be transferred to the Improving Access to Health Care Subfund. (c) For each applicable calendar year, after the transfers required by subdivision (b) to the Health Care Oversight & Accountability Subfund, all remaining moneys in the fund shall be transferred to the Improving Access to Health Care Subfund. (d) In each calendar year, the first four billion three hundred million dollars ($4,300,000,000) transferred to the Improving Access to Health Care Subfund shall be deposited by the Controller in the following amounts in the following accounts that are hereby created within the Improving Access to Health Care Subfund: (1) Twenty-two percent in the Primary Care Account. (2) Twenty-two percent in the Specialty Care Account. (3) Two and one-half of 1 percent in the Emergency Department Physicians Account. (4) Five and three-quarters of 1 percent in the Outpatient and Clinic Access Account. (5) Five and one-half of 1 percent in the Family Planning Account. (6) One and one-quarter of 1 percent in the Reproductive Health Account. (7) Three percent in the Emergency Medical Transportation Account. (8) Eight and three-quarters of 1 percent in the Emergency Department and Hospital Services Account. (9) Three and one-half of 1 percent in the Designated Public Hospital Account, subject to subdivision (g). (10) Four and one-half of 1 percent in the Improving Mental Health Account, subject to subdivision (g). (11) Six and one-quarter of 1 percent in the Health Care Workers Account. (12) Three and one-half of 1 percent in the Clinic Quality Account. (13) Three and one-half of 1 percent in the Improved Dental Services Account. (14) Eight percent to the Medi-Cal Access and Support Account. (e) Commencing January 1, 2027, and notwithstanding Section 13340 of the Government Code, all moneys within the accounts described in subdivision (d), and any subaccounts therein, are hereby continuously appropriated, without regard to fiscal years, to the department to be used as set forth in Article 4 (commencing with Section 14199.109). (f) (1) On and after January 1, 2030, the maximum allowable balance of unencumbered moneys in any of the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) shall be 200 percent of the average annual amount deposited therein during the immediately preceding two calendar years. This shall be known as the “maximum allowable balance.” (2) As long as an account described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) is at or above its maximum allowable balance, moneys otherwise required to be deposited into that account shall instead be deposited on a pro rata basis into the other accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) that are not at or above their maximum allowable balance. (3) This subdivision does not apply if an account reaches its maximum allowable balance as a result of the department violating its nondiscretionary ministerial duty set forth in subdivision (b) of Section 14199.106. (4) This subdivision does not apply if all of the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) are all simultaneously at or above their maximum allowable balance. (g) (1) Notwithstanding the percentage allocation described in paragraph (9) of subdivision (d), the maximum dollar amount deposited into the Designated Public Hospital Account shall not exceed one hundred fifty million dollars ($150,000,000) per calendar year. Once the amount deposited in any calendar year into the Designated Public Hospital Account reaches one hundred fifty million dollars ($150,000,000), any excess moneys allocated pursuant to paragraph (9) of subdivision (d) shall instead be deposited into the Emergency Department and Hospital Services Account. (2) Notwithstanding the percentage allocation described in paragraph (10) of subdivision (d), the maximum dollar amount deposited into the Improving Mental Health Account shall not exceed two hundred million dollars ($200,000,000) per calendar year. Once the amount deposited in any calendar year into the Improving Mental Health Account reaches two hundred million dollars ($200,000,000), any excess moneys allocated pursuant to paragraph (10) of subdivision (d) shall instead be deposited into the Emergency Department and Hospital Services Account. (h) After four billion three hundred million dollars ($4,300,000,000) is first deposited pursuant to subdivision (d), in each calendar year the next four hundred million dollars ($400,000,000) transferred to the Improving Access to Health Care Subfund shall be deposited into the Medi-Cal Access and Support Account. (i) (1) After four billion three hundred million dollars ($4,300,000,000) is first deposited pursuant to subdivision (d) and the next four hundred million dollars ($400,000,000) is deposited pursuant to subdivision (h), in each calendar year the next two hundred twenty-six million dollars ($226,000,000) transferred to the Improving Access to Health Care Subfund shall be deposited as follows: (A) Thirty-two million dollars ($32,000,000) into the Community Health Workers Account. (B) Sixty-four million dollars ($64,000,000) into the Health Care Workforce Loan Repayment Account. (C) One hundred twenty million dollars ($120,000,000) into the Medi-Cal Workforce Subaccount. (D) Ten million dollars ($10,000,000) into the Affordable Prescription Drugs Account. (2) Commencing January 1, 2027, and notwithstanding Section 13340 of the Government Code, all moneys within the accounts described in paragraph (1), and any subaccounts therein, are hereby continuously appropriated, without regard to fiscal years, to the department to be used as set forth in Article 4 (commencing with Section 14199.109). (j) After the deposits required by subdivisions (d), (h), and (i) are completed, all remaining moneys transferred to the Improving Access to Health Care Subfund in a calendar year shall be deposited and used as follows: (A) Twenty-five percent to the accounts described in paragraphs (1) to (13), inclusive, of subdivision (d) on a pro rata basis according to and consistent with the relative distribution among those paragraphs. (B) Seventy-five percent to the Medi-Cal Access and Support Account. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  77. 14199.108.3.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The section appropriates specified sums from the Health Care Oversight & Accountability Subfund to the department for listed health care purposes during 2025 and 2026, and sets later inoperative and repeal dates.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.108.3. Expenditures During Calendar Years 2025 and 2026 (a) During each of calendar year 2025 and calendar year 2026 only, and notwithstanding Section 13340 of the Government Code, moneys are hereby continuously appropriated without regard to fiscal years from the Health Care Oversight & Accountability Subfund to the department in the following amounts for the following purposes: (1) Two billion dollars ($2,000,000,000) to cover a portion of the nonfederal share of Medi-Cal managed care rates for health care services furnished to children, adults, seniors, and persons with disabilities, and persons dually eligible for the Medi-Cal and Medicare programs. (2) Six hundred ninety-one million dollars ($691,000,000) for primary care, including obstetrics and nonspecialty mental health services. (3) Five hundred seventy-five million dollars ($575,000,000) for specialty care. (4) Two hundred forty-five million dollars ($245,000,000) for community and outpatient procedures. (5) Ninety million dollars ($90,000,000) for abortion and family planning services. (6) Fifty million dollars ($50,000,000) for services and supports for primary care. (7) Three hundred fifty-five million dollars ($355,000,000) for emergency room facilities and physicians. (8) One hundred fifty million dollars ($150,000,000) for designated public hospitals. (9) Fifty million dollars ($50,000,000) for ground emergency medical transportation. (10) Three hundred million dollars ($300,000,000) for behavioral health facility throughputs. (11) Seventy-five million dollars ($75,000,000) for graduate medical education. (12) Seventy-five million dollars ($75,000,000) for Medi-Cal workforce. (b) The allocation of moneys appropriated pursuant to subdivision (a) shall be subject to the stakeholder input requirements of Section 14199.121. (c) This section shall become inoperative on January 1, 2027, and is hereby repealed on January 1, 2028. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135. Inoperative January 1, 2027, by its own provisions. Repealed as of January 1, 2028, by its own provisions.)
  78. 14199.108.5.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    Certain increased or supplemental payments must be added on top of existing reimbursement and cannot replace other amounts or be counted in annual reconciliation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 3. Deposit and Allocation of Moneys in the Fund [14199.108 - 14199.108.5] ( Article 3 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.108.5. Treatment of Increased or Supplemental Payments Increased or supplemental payments made pursuant to Sections 14199.108.3, 14199.109, 14199.110, 14199.110.5, 14199.112, 14199.113, 14199.114, 14199.115, 14199.116, 14199.117, 14199.119, 14199.120.5, and 14199.120.6 shall: (a) Be in addition to existing reimbursement rates and any other payments made by a Medi-Cal managed care plan or the department and shall not supplant amounts that would otherwise be payable by a Medi-Cal managed care plan or the department to a recipient of moneys provided by Article 4 (commencing with Section 14199.109). (b) Be considered separate and apart from any other reimbursement, and shall not be considered during, or factored into, any annual reconciliation. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  79. 14199.109.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must raise primary care reimbursement rates and make sure Medi-Cal managed care plans pass those increases through. It may also use different payment mechanisms, if federal approval is obtained and stakeholder input is taken.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.109. Primary Care Account (a) Moneys in the Primary Care Account shall be used for the purpose of providing Medi-Cal patients with increased access to quality primary care services as set forth in this section. (b) (1) The department shall, subject to the stakeholder input requirements of Section 14199.121, increase reimbursement rates for primary care services above those in effect on January 1, 2024, and shall ensure that Medi-Cal managed care plans provide those increases in a manner consistent with the intent and purposes of this chapter. (2) In addition to paragraph (1), in implementing this section, the department may, subject to federal approval and after obtaining stakeholder input pursuant to Section 14199.121, utilize different payment mechanisms, including quality incentive payments or value-based payment models, to recruit, retain, and improve primary care provider participation in Medi-Cal and improve quality. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  80. 14199.110.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must set up payment methodologies to expand access to Medi-Cal specialty care, and Medi-Cal managed care plans or subcontracted entities must pay specialists accordingly.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.110. Specialty Care Account (a) Moneys in the Specialty Care Account shall be used for the purpose of increasing Medi-Cal patient access to specialty care services as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, establish and implement one or more payment methodologies that meet federal requirements and that require each Medi-Cal managed care plan or its subcontracted entities to expand beneficiary access to Medi-Cal covered specialty care services. The payment methodology or methodologies developed by the department shall address the following objectives: (1) Increase the number of Medi-Cal managed care plan-contracting specialists. (2) Retain existing Medi-Cal managed care plan-contracting specialists within the plan’s network of contracting providers. (3) Increase the number of Medi-Cal patients an existing Medi-Cal managed care plan-contracting specialist serves. (4) Provide expanded specialist appointment availability for Medi-Cal patients. (5) Support specialists in coordinating and overseeing the care of patients as part of a multidisciplinary care team. (c) A Medi-Cal managed care plan or a subcontracted entity shall provide payments to specialists consistent with the payment methodologies developed by the department pursuant to this section. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  81. 14199.110.5.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Emergency Department Physicians Account must be used to increase reimbursements for emergency department physicians treating Medi-Cal patients, and the department must set up payment methodologies for that 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.110.5. Emergency Department Physicians Account (a) Moneys in the Emergency Department Physicians Account shall be used for the purpose of increasing reimbursements for emergency department physicians treating Medi-Cal patients as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, establish and implement one or more payment methodologies to increase reimbursements for emergency department physicians treating Medi-Cal patients. The payment methodology or methodologies shall be consistent with the purposes of this chapter, shall be designed to improve access and support for emergency department services, and shall not be conditioned on a physician’s contracted network provider status. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  82. 14199.111.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The section creates the Community Health Workers Account and requires the department to set up a grant program to expand community health worker services, subject to stakeholder input 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.111. Community Health Workers Account (a) The Community Health Workers Account is hereby created within the Improving Access to Health Care Subfund. Moneys in the Community Health Workers Account shall be used for the purpose of increasing access to community health workers in Medi-Cal programs as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, establish a grant program to expand the number of locations and populations served by community health workers providing services on behalf of community-based organizations, community providers, and clinics. (c) (1) On and after January 1, 2030, the maximum allowable balance of unencumbered moneys in this account shall be sixty-four million dollars ($64,000,000). As long as this account is at or above sixty-four million dollars ($64,000,000), moneys otherwise required to be deposited into this account shall instead be deposited on a pro rata basis into the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) that are not at or above their maximum allowable balance. (2) This subdivision does not apply if this account is at or above sixty-four million dollars ($64,000,000) as a result of the department violating its nondiscretionary ministerial duty set forth in subdivision (b) of Section 14199.106, or if the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) are all simultaneously at or above their maximum allowable balance. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  83. 14199.112.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Outpatient and Clinic Access Account must be used to increase net reimbursements for eligible outpatient facilities and services; the department must develop and implement payment methods to do that, subject to stakeholder input 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.112. Outpatient and Clinic Access Account (a) Moneys in the Outpatient and Clinic Access Account shall be used for the purpose of increasing net reimbursements for outpatient facilities, including ambulatory surgical centers and clinics, that provide eligible outpatient services and procedures to Medi-Cal patients. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, develop, seek federal approval for, and implement one or more payment methodologies that provide increased net reimbursement for eligible outpatient facilities, regardless of licensure type, in a manner consistent with the purposes of this chapter. (c) Moneys in the Outpatient and Clinic Access Account shall be used only to increase net reimbursement levels for those eligible outpatient services and procedures above existing net reimbursement levels in effect for the eligible outpatient services and procedures as of January 1, 2024. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  84. 14199.113.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Family Planning Account must be used to expand family planning services and related benefits, rates, payments, and grants.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.113. Family Planning Account (a) Moneys in the Family Planning Account shall be used for the purpose of expanding the scope and availability of family planning services as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the account for all of the following purposes: (1) Expanding the scope of benefits offered pursuant to the State-Only Family Planning Program and the Family PACT program. (2) Increasing reimbursement rates for: (A) Family planning services and family planning-related services in the Medi-Cal program. (B) Comprehensive clinical family planning services in the Family PACT program. (C) Family planning services in the State-Only Family Planning Program. (3) Authorizing the department, subject to the stakeholder input requirements of Section 14199.121, to fund practice transformation activities and to establish alternative payment methodologies, including, but not limited to, bundled payments, directed payments to both network and nonnetwork providers, capitated payments, and value-based payments for family planning, family planning-related services, and sexual and reproductive health services. (4) Providing grant funding to qualified family planning providers to offset the costs of providing uncompensated outpatient services and supports. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  85. 14199.114.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The department must use money in the Reproductive Health Account for abortion and abortion-related services, subject to stakeholder input 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.114. Reproductive Health Account (a) Moneys in the Reproductive Health Account shall be used as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the Reproductive Health Account for the purpose of protecting, preserving, and expanding access to abortion and abortion-related services, including to increase payment rates for abortion and abortion-related services. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  86. 14199.115.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section directs specified account funds to increase payments for private ground and air ambulance transport providers, and gives the department limited authority to adjust payment methods to comply with federal 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.115. Emergency Medical Transportation Account (a) Moneys in the Emergency Medical Transportation Account shall be used for the purpose of increased payments to private ground emergency medical transport providers and emergency air ambulance transport providers as set forth in this section. (b) Eighty percent of the moneys in the account shall be deposited into the Ground Emergency Medical Transportation Subaccount, which is hereby created in the Emergency Medical Transportation Account. Moneys in this subaccount shall be used for the purpose of increased payments to private ground emergency medical transport providers as follows: (1) The department shall, subject to the stakeholder input requirements of Section 14199.121, establish and implement increased net reimbursement to private ground emergency medical transport providers for ground emergency medical transports above the rates in effect as of January 1, 2024. To the extent permitted by federal law, the department shall increase net reimbursement based on the regional cost of living where the transport was rendered. (2) The increased Medi-Cal payments described in paragraph (1) shall be applicable to fee-for-service rates to private ground emergency medical transport providers and payments from Medi-Cal managed care plans to private ground emergency medical transport providers. The department shall structure the increased Medi-Cal managed care payments pursuant to this subdivision so that private ground emergency medical transport providers that receive payments for ground emergency medical transports rendered to managed care patients pursuant to Section 14129.3 or any successor statute are eligible to receive payments for ground emergency medical transports rendered to Medi-Cal managed care patients pursuant to this section. (3) Moneys in the Ground Emergency Medical Transportation Subaccount shall be used only to increase net reimbursement levels for private ground emergency medical transport providers above existing net reimbursement levels in effect for private ground emergency medical transport providers as of January 1, 2024. The director may modify or make adjustments to any methodology, fee amount, or other provision specified in Article 3.91 (commencing with Section 14129) of Chapter 7, as authorized by subdivision (b) of Section 14129.6, only to the extent necessary to meet the requirements of federal law or regulations or to obtain federal approval pursuant to Section 14129.6 after the implementation of this subdivision. (c) Twenty percent of the moneys in the account shall be deposited into the Air Ambulance Emergency Medical Transportation Subaccount, which is hereby created in the Emergency Medical Transportation Account. Moneys in this subaccount shall be used for the purpose of increased Medi-Cal payments for emergency air ambulance transport providers as follows: (1) The department shall, subject to the stakeholder input requirements of Section 14199.121, establish and implement increased Medi-Cal payments for air emergency ambulance transport providers above the rates in effect as of January 1, 2024. (2) The increased rates described in paragraph (1) shall be applicable to Medi-Cal fee-for-service payment rates to emergency air ambulance transport providers and payments from Medi-Cal managed care plans to emergency air ambulance transport providers. (3) Payments made pursuant to this subdivision shall be in addition to any other Medi-Cal payments to emergency air ambulance transport providers and shall not supplant amounts that would otherwise be payable under Medi-Cal to an emergency air ambulance transport provider. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  87. 14199.116.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Emergency Department and Hospital Services Account must be used to protect and improve hospital care for Medi-Cal patients, and the department may adjust payments from the account.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.116. Emergency Department and Hospital Services Account (a) Moneys in the Emergency Department and Hospital Services Account shall be used for the purpose of protecting access to, and improving the quality of, hospital care, including access to inpatient acute care and emergency departments, for Medi-Cal patients, as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, develop, seek federal approval for, and implement one or more payment methodologies that provide increased net reimbursement to public and private hospitals for eligible hospital services. The department may adjust payments with moneys in the account. (c) Moneys in the Emergency Department and Hospital Services Account shall be used only to increase net reimbursement levels for those eligible hospital services above existing net reimbursement levels in effect for the eligible hospital services as of January 1, 2024. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  88. 14199.117.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The department must use money from the Designated Public Hospital Account for specified hospital reimbursement and payment purposes, subject to stakeholder input 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.117. Designated Public Hospital Account (a) Moneys in the Designated Public Hospital Account shall be used for the purpose of sustaining and promoting access to hospital and nonhospital care at designated public hospital systems. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the account to provide increased net reimbursement or new payments for designated public hospitals and health systems, including, but not limited to, quality incentive payments under existing or successor payment mechanisms or payments in support of services provided by designated hospital systems or that enhance their capabilities, or to provide financial support for the nonfederal share of the Medi-Cal payments to the designated public hospital systems. The department may apply the moneys in the Designated Public Hospital Account for these purposes. (c) Moneys in the Designated Public Hospital Account shall be used only to increase net reimbursement levels for designated public hospital systems for the eligible services above existing net reimbursement levels for the eligible services in effect as of January 1, 2024. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  89. 14199.118.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Creates the Affordable Prescription Drugs Account and requires the department to use its money for specified drug-access purposes, with a $20 million balance limit starting January 1, 2030.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.118. Affordable Prescription Drugs Account (a) The Affordable Prescription Drugs Account is hereby created within the Improving Access to Health Care Subfund. Moneys in the Affordable Prescription Drugs Account shall be used as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the Affordable Prescription Drugs Account for the purpose of providing increased funding for the California Affordable Drug Manufacturing Act of 2020 to increase competition, lower prices, and address shortages in the market for generic prescription drugs, to reduce the cost of prescription drugs for public and private purchasers, taxpayers, and consumers, and to increase patient access to affordable drugs. (c) (1) On and after January 1, 2030, the maximum allowable balance of unencumbered moneys in this account shall be twenty million dollars ($20,000,000). As long as this account is at or above twenty million dollars ($20,000,000), moneys otherwise required to be deposited in this account shall instead be deposited on a pro rata basis into the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) that are not at or above their maximum allowable balance. (2) This subdivision does not apply if this account is at or above twenty million dollars ($20,000,000) as a result of the department violating its nondiscretionary ministerial duty set forth in subdivision (b) of Section 14199.106, or if the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) are all simultaneously at or above their maximum allowable balance. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  90. 14199.119.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Improving Mental Health Account must be used to expand mental health services and fund inpatient psychiatric services. The department must use the account money for supplemental payments tied to psychiatric inpatient days in licensed acute care and acute psychiatric hospitals.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.119. Improving Mental Health Account (a) (1) Moneys in the Improving Mental Health Account shall be used for the purpose of expanding access to mental health programs and services as set forth in this section. (2) Moneys in the account shall be used to provide additional funding for inpatient psychiatric services pursuant to subdivision (b). (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the account for the purpose of increasing the supply of mental health inpatient psychiatric beds by providing a supplemental payment for psychiatric inpatient days in licensed acute care hospitals and acute psychiatric hospitals. These payments shall: (1) Increase the net reimbursement levels paid to these hospitals with respect to those services above the existing net reimbursement levels in effect for those services as of January 1, 2024. (2) Not affect or supplant any other payments to these hospitals. (3) Be made to these hospitals irrespective of contracting status with a county mental health plan or with a Medi-Cal managed care plan or other managed care entity that is financially responsible for psychiatric inpatient hospital services under contract with the department, as applicable. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  91. 14199.120.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The department must use Health Care Workers Account money for health workforce goals, split the funds 75/25 between two subaccounts, and begin certain grant activity no earlier than 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.120. Health Care Workers Account (a) The department shall, subject to the stakeholder input requirements of Section 14199.121, use the moneys in the Health Care Workers Account for the purpose of attracting, retaining, and expanding the pool of health care workers available to treat Medi-Cal patients as set forth in this section. (b) Seventy-five percent of the moneys in the account shall be deposited in the Graduate Medical Education Subaccount, which is hereby created in the Health Care Workers Account. Moneys in this subaccount shall be transferred to the University of California for the administration and expenditure to other qualified entities to expand graduate medical education in order to achieve the goal of increasing the number of physician and surgeon residency slots and expanding the number of locations offering physician and surgeon residency programs, as compared to the number of residency slots and program locations in place on December 31, 2023. For the purposes of this section, all allopathic and osteopathic residency programs accredited by federally recognized accrediting organizations and located in California shall be eligible to apply to receive funding to support resident education in California. No later than January 1, 2027, the department may seek federal approval for the programs created or expanded pursuant to this subdivision. However, the graduate medical education programs are not contingent upon federal approval and federal financial participation. (c) Twenty-five percent of the moneys in the account shall be deposited in the Medi-Cal Workforce Subaccount, which is hereby created in the Health Care Workers Account. The department may enter into an interagency agreement with another state government agency or entity to administer and implement a grant program funded by the Medi-Cal Workforce Subaccount as set forth in this subdivision. (1) (A) No sooner than January 1, 2027, the department or its designated state government agency or entity shall issue grants pursuant to this subdivision with available moneys in the Medi-Cal Workforce Subaccount to strengthen and support the development and retention of the Medi-Cal workforce through bona fide labor-management cooperation committees. (B) Criteria shall be established, pursuant to the stakeholder input requirements of Section 14199.121, for grants to bona fide labor-management cooperation committees to support the development of high-quality workforce development programs. (2) The criteria for grant awards may include, but is not limited to, the following: (A) Implementing workforce training programs to promote patient safety, improve quality outcomes, and advance employee career opportunities. (B) Developing and supporting health care workforce apprenticeship and preapprenticeship programs. (C) Recruiting and retaining workforce. (D) Funding for training organizations such as Taft-Hartley training funds, to support the development of the workforce. (E) Additional investments in workforce capacity. (3) In issuing grants pursuant to this subdivision, the department or its designated state government agency or entity may give preference to a bona fide labor-management cooperation committee that is organized on a multiemployer basis and involves multiple labor organizations. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  92. 14199.120.5.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Clinic Quality Account money must be used to reward clinics that improve quality and access for Medi-Cal patients, and the department must develop and seek federal approval for an enhanced payment program for qualifying clinics.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.120.5. Clinic Quality Account (a) Moneys in the Clinic Quality Account shall be used for the purpose of providing monetary incentives for clinics that demonstrate improved quality and increased access to care for Medi-Cal patients as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, develop and seek federal approval for a directed payment program, alternative payment methodology, or other enhanced payment methodology for clinics that meet one or more of the following objectives: (1) Increasing appointment availability or access to health care services, including specialty services. (2) Meeting improved quality measures. (3) Improving data quality and reporting. (4) Enhancing care coordination. (c) Any funding methodology developed pursuant to this section shall be for enhanced payments to participating clinics on or after January 1, 2025, and moneys provided pursuant to this section shall not be used to supplant, in whole or in part, funding for any prior payment methodologies developed and submitted to the federal Centers for Medicare and Medicaid Services before December 31, 2024. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  93. 14199.120.6.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    Money in the Improved Dental Services Account must be used to improve access to specialty and restorative dental care for 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.120.6. Improved Dental Services Account (a) Moneys in the Improved Dental Services Account shall be used for the purpose of providing enhanced access to Medi-Cal patients for specialty and restorative dental care as set forth in this section. (b) The department shall, subject to the stakeholder input requirements of Section 14199.121, develop and seek federal approval for a payment methodology, rate augmentation, directed payment or other financial incentives to general dentists and dental specialists such as oral and maxillofacial surgeons, endodontists, periodontists, orthodontists, prosthodontists, and pediatric dentists. (c) The department may also use moneys in this account, subject to the stakeholder input requirements of Section 14199.121, for the purpose of supporting practice transformation activities in dental provider offices that treat Medi-Cal patients. Practice transformation activities include, but are not limited to, value-based payments, use or enhanced use of electronic medical records, care coordination with primary and specialty care providers, and training and retention of dental staff and clinicians. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  94. 14199.120.7.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Creates the Health Care Workforce Loan Repayment Account and related subaccounts, and requires the department to determine loan repayment eligibility and qualifications subject to stakeholder-input 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.120.7. Health Care Workforce Loan Repayment Account (a) The Health Care Workforce Loan Repayment Account is hereby created within the Improving Access to Health Care Subfund. Moneys in the Health Care Workforce Loan Repayment Account shall be used as set forth in this section. (b) Fifty percent of the moneys in the account shall be deposited in the Advanced Practice Clinicians and Allied Health Care Loan Repayment Subaccount, which is hereby created in the Health Care Workforce Loan Repayment Account. Moneys in this subaccount shall be used for the purpose of establishing an educational loan repayment program for advanced practice clinicians and allied health care professionals. The department shall, subject to the stakeholder input requirements of Section 14199.121, determine the eligibility and qualifications for loan repayment. (c) Fifty percent of the moneys in the account shall be deposited into the CalHealthCares Subaccount, which is hereby created in the Health Care Workforce Loan Repayment Account. Moneys in this subaccount shall be used for the purpose of providing increased funding for educational loan repayment for physicians and dentists through the CalHealthCares Program. (d) (1) On and after January 1, 2030, the maximum allowable balance of unencumbered moneys in this account shall be one hundred twenty-eight million dollars ($128,000,000). As long as this account is at or above one hundred twenty-eight million dollars ($128,000,000), moneys otherwise required to be deposited in this account shall instead be deposited on a pro rata basis into the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) which are not at or above their maximum allowable balance. (2) This subdivision does not apply if this account is at or above one hundred twenty-eight million dollars ($128,000,000) as a result of the department violating its nondiscretionary ministerial duty set forth in subdivision (b) of Section 14199.106, or if the accounts described in paragraphs (1) to (8), inclusive, and (11) to (13), inclusive, of subdivision (d) are all simultaneously at or above their maximum allowable balance. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  95. 14199.120.9.

    ## 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Money in the Medi-Cal Access and Support Account must be used to support the Medi-Cal program and keep access to necessary health 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 4. Protecting Access to Health Care [14199.109 - 14199.120.9] ( Article 4 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.120.9. Medi-Cal Access and Support Account (a) Moneys in the Medi-Cal Access and Support Account shall be used as set forth in this section. (b) Moneys in this account shall be used by the department to provide overall support to the Medi-Cal program and maintain access to necessary health care services. (c) Section 14199.107 does not apply to moneys in this account. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  96. 14199.121.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 5. Input, Approvals, and Adjustments [14199.121 - 14199.122] ( Article 5 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department, and any other state agency or entity implementing this chapter, must consult with and get written input from the stakeholder advisory committee on the chapter’s development and implementation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 5. Input, Approvals, and Adjustments [14199.121 - 14199.122] ( Article 5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.121. Stakeholder Input (a) (1) The department, or any other state government agency or entity that implements any part of this chapter, shall consult with, and obtain written input from, the stakeholder advisory committee regarding the development and implementation of the components of this chapter. (2) Examples of matters for which the department shall consult with, and obtain written input from, the committee shall include, but are not limited to, the following: (A) A proposal for, or the development of, a payment rate, supplemental payment, directed payment, or other payment methodology or methodologies. (B) The establishment of the criteria or eligibility for increased payments or grants. (C) The issuance of provider bulletins, all-plan letters, or other similar instructions or departmental guidance. (b) Before proposing a new payment methodology or a change to an existing payment methodology pursuant to this chapter, the department shall consult with, and obtain written input from, the stakeholder advisory committee. (c) An express reference elsewhere in this chapter to obtaining stakeholder committee input does not imply that stakeholder committee input is not required for other parts of this chapter where an express reference does not exist. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  97. 14199.122.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 5. Input, Approvals, and Adjustments [14199.121 - 14199.122] ( Article 5 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must seek needed federal approvals and try to maximize federal funding to implement 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 5. Input, Approvals, and Adjustments [14199.121 - 14199.122] ( Article 5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.122. Implementation; Federal Financial Participation; Modifications and Adjustments Necessary for Federal Approval (a) The department shall seek any federal approvals that are necessary to implement this chapter. (b) The department shall, wherever possible and to the extent feasible, seek to obtain the maximum amount of federal financial participation in implementing this chapter. (c) (1) The department may modify or make adjustments to the payment provisions set forth in Article 4 (commencing with Section 14199.109) to the extent necessary to accomplish any of the following: (A) Meet the requirements of federal statutes or regulations. (B) Obtain or maintain federal approval. (C) Ensure federal financial participation is available or is not otherwise jeopardized. (2) Any payment provision modification or adjustment described in paragraph (1) shall be subject to all of the following conditions: (A) The modification or adjustment does not otherwise conflict with the purposes of this chapter. (B) The modification or adjustment is consistent with the purpose of increasing payments and access to services pursuant to this chapter. (C) The department shall comply with the stakeholder input requirements of Section 14199.121. (d) (1) Payments made pursuant to Article 4 (commencing with Section 14199.109) shall be effective for dates of service on and after January 1, 2027. To the extent consistent with the purposes of this chapter, and unless otherwise specified in Article 4 (commencing with Section 14199.109), the department may, subject to the stakeholder input requirements of Section 14199.121, extend one or more payment methodologies used for the targeted payment increases for the 2026 calendar year pursuant to Section 14105.202 for purposes of implementing the increased payments pursuant to Article 4 (commencing with Section 14199.109) in the 2027 calendar year and subsequent calendar years as applicable. (2) Unless otherwise specified in Article 4 (commencing with Section 14199.109), payments made pursuant to Article 4 (commencing with Section 14199.109) may be implemented using one or more of the following: (A) Medi-Cal provider rate increases, including increases in rates paid in the Medi-Cal fee-for-service delivery system, or establishing or raising the level of minimum fee schedules in Medi-Cal managed care, or both. (B) New or expanded supplemental payments for Medi-Cal providers. (C) New or expanded directed payments for Medi-Cal providers. (D) Other forms of increased reimbursement for Medi-Cal providers, consistent with the provisions and intent of this chapter. (e) The department may require Medi-Cal managed care plans and providers of the applicable services to submit information the department deems necessary to implement and monitor compliance with this chapter, at the times and in the form and manner specified by the department. (f) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code but subject to the stakeholder input requirements of Section 14199.121, the department may implement this chapter by means of provider bulletins, all-plan letters, or other similar instructions, without taking further regulatory action. The department shall provide notification to the Department of Finance, the Joint Legislative Budget Committee, and to the Legislature’s relevant fiscal and policy committees at least five working days before taking action. (2) If the department enters into an interagency agreement with another state government agency or entity to administer and implement a portion of this chapter, that other agency or department shall be covered by paragraph (1). (g) For purposes of implementing this chapter, the department or its designated state government agency or entity 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 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, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, the State Contracting Manual, and shall be exempt from the review or approval of any division of the Department of General Services. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  98. 14199.123.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    California continues a managed care organization provider tax and assigns the department to implement and administer 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.123. Continued Imposition of Tax (a) It is the intent of the people of the State of California to permanently continue in existence a managed care organization provider tax upon the expiration of the tax imposed by Section 14199.84. (b) Therefore, upon the expiration of the tax imposed pursuant to Article 7.1 (commencing with Section 14199.80) of Chapter 7, a managed care organization provider tax shall hereby continue to be imposed on and after January 1, 2027, as provided in this article. (c) The department shall implement and administer the tax as set forth in this article. (d) To the extent permitted by federal law, the models and methodologies developed for Chapter 13 of the Statutes of 2023 shall be substantially utilized by the department in implementing the tax imposed by this article. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  99. 14199.124.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must implement the tax under Section 14199.123 subject to federal compliance, approval, and notice rules, and it cannot exceed the stated 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.124. Implementation of Tax (a) In implementing the tax imposed by subdivision (b) of Section 14199.123, the department shall adhere to all of the following: (1) The tax shall not exceed the limits set forth in Section 14199.126. (2) The models and methodologies utilized by the department shall be substantially similar to those relied upon for imposition of the tax set forth in Article 7.1 (commencing with Section 14199.80) of Chapter 7. (3) The tax shall comply with federal Medicaid requirements applicable to permissible health care-related taxes, including, but not limited to, Section 433.68 of Title 42 of the Code of Federal Regulations. (4) Consistent with the limits set forth in Section 14199.126, the department shall attempt to maximize the amount of federal matching funds. (b) (1) Except as provided in paragraph (2), if the requirements set forth in Section 433.68 of Title 42 of the Code of Federal Regulations, or any other provision of federal law with which the tax imposed by this article must comply, are replaced by amended or successor requirements, the department shall ensure the tax imposed pursuant to this article complies with those amended or successor requirements. (2) Notwithstanding paragraph (1), the limits set forth in Section 14199.126 shall not be exceeded. (c) (1) Commencing on the effective date of this chapter, the department shall be required to seek federal renewal and reauthorization as necessary to continue the imposition of the tax imposed by this article. (2) The department shall request approval from the federal Centers for Medicare and Medicaid Services as is necessary to implement this article. The department shall not impose or collect the tax imposed pursuant to this article until the department receives approval from the federal Centers for Medicare and Medicaid Services that the tax is a permissible health care-related tax in accordance with Section 433.68 of Title 42 of the Code of Federal Regulations and is eligible for federal financial participation. (d) (1) Consistent with the limits set forth in Section 14199.126, the department may, upon consultation with affected taxpayers, modify or make minor adjustments to any methodology, tax amount, taxing tier, or other provision specified in this article to the extent it is reasonably necessary to meet the requirements of federal statute or regulations, to obtain or maintain federal approval, or to ensure federal financial participation is available or is not otherwise jeopardized. (2) When making, or considering making, any adjustment described in paragraph (1), the department shall share with affected taxpayers and the stakeholder advisory committee relevant information, proposals, drafts, and any information affecting tax liability at least 90 calendar days in advance of seeking federal approval for the adjustment. The department shall provide notice of any final adjustment in tax liability to affected taxpayers at least 45 calendar days before the adjustment takes effect. (e) In implementing this article, the department may establish a specific calendar year as the base year and use the base data source to determine for each health plan each of the enrollment totals described in paragraphs (1) to (6), inclusive, of subdivision (a) of Section 14199.83, as that section read in Chapter 13 of the Statutes of 2023. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  100. 14199.125.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

    Verify source ↗

    The department must calculate annual tax liability and set tax tiers, per-enrollee amounts, and collection procedures for the tax, including notices, late-payment interest, penalties, and refunds.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.125. Tax Computation and Collection (a) Before each applicable calendar year or years, the department shall compute the annual tax liability for each taxpayer subject to the tax imposed by Section 14199.123. (b) For each tax period, the department shall establish all of the following: (1) The Medi-Cal taxing tiers based on countable Medi-Cal enrollees in a health plan. (2) The Medi-Cal per enrollee tax amount for each Medi-Cal taxing tier. (3) Subject to the limits in Section 14199.126, the other taxing tiers based on countable other enrollees in a health plan. (4) Subject to the limits in Section 14199.126, the other per enrollee tax amount for each other taxing tier. (c) The procedures for collection and payment of the tax, providing notices, interest charges not to exceed 10 percent per annum for late payments, penalties, refunds, and tax liability after a transfer of health plan responsibility shall be established by the department consistent with the applicable provisions of Article 7.1 (commencing with Section 14199.80) of Chapter 7 unless otherwise specified in this chapter. (d) (1) The director may correct any identified material or significant error in the data, including, but not limited to, the overall cumulative enrollment, Medicare cumulative enrollment, Medi-Cal cumulative enrollment, plan-to-plan cumulative enrollment, cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382), and other cumulative enrollment. The director’s determination as to whether to exercise discretion under this subdivision and any determination made by the director under this subdivision shall not be subject to judicial review, except that a health plan may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department in correcting that health plan’s data when that correction results in a greater tax amount for that health plan. (2) The authority granted to the director by this subdivision does not permit the limits set forth in Section 14199.126 to be exceeded. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  101. 14199.126.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section caps certain managed care organization provider tax amounts, allows inflation-based increases by the department, and lets the department exceed the caps by up to 10% in limited federal-renewal situations.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.126. Limits on Tax Amounts (a) Notwithstanding any other provision of this chapter or any other law, and except as provided in subdivisions (b) and (c), the tax imposed by this article shall comply with both of the following: (1) The other per enrollee tax amount for any other taxing tier shall not exceed two dollars and fifty cents ($2.50) per month. (2) The total aggregate tax amount imposed on, or through, all other taxing tiers shall not exceed thirty-six million dollars ($36,000,000) in a single calendar year. (b) The dollar amounts set forth in paragraph (1) and paragraph (2) of subdivision (a) may be increased by the department quinquennially to reflect any increase in inflation as measured by the Consumer Price Index for All Urban Consumers (CPI-U) beginning on January 1, 2030. At the request of the department, the Controller’s office shall calculate and publish the adjustments permitted by this subdivision. (c) When seeking federal renewal and reauthorization for calendar years commencing on or after January 1, 2027, the department may exceed either of the following by not more than 10 percent if doing so is necessary to comply with federal statute or regulations, ensure federal financial participation, or otherwise obtain federal approval: (1) The limits set forth in subdivision (a), as modified pursuant to subdivision (b). (2) The limits set forth in subdivision (a), as modified pursuant to subdivision (b), and including the amount of any prior adjustments made pursuant to this subdivision. (d) Except as provided by subdivisions (b) and (c), all other changes to the limits set forth in subdivision (a) shall only be made pursuant to Section 14199.134. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  102. 14199.127.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section says the article stops operating if required federal approval is not obtained or a final determination says the tax cannot be implemented, and the director must then carry out wind-down and refund 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 6. Continuation of Managed Care Organization Provider Tax [14199.123 - 14199.127] ( Article 6 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.127. Operation (a) This article shall be inoperative during any portion of a calendar year for which the department does not obtain the necessary federal approvals for the tax imposed pursuant to Section 14199.123. (b) This article shall cease to be operative for any affected tax period or periods upon a final determination of a court of competent jurisdiction, the United States Department of Health and Human Services, or the federal Centers for Medicare and Medicaid Services that the tax imposed pursuant to this article cannot be implemented for the affected tax period or periods. (c) Upon a failure to obtain federal approval as described in subdivision (a), or a final determination as described in subdivision (b), the director shall implement a plan for conducting all appropriate wind-down and closeout activities, including issuance of any refunds, in consultation with the Department of Finance and the stakeholder advisory committee. (d) This chapter does not change, alter, or abrogate the department’s legal and fiscal responsibility under state and federal law to monitor provider participation and beneficiary access to entitled services under California’s Medicaid State Plan or federally approved waivers. The department continues to have full legal and fiscal responsibility to adjust rates, payment methodologies, and authorization processes for programs, providers, or benefits within this chapter, as well as those not specifically mentioned herein. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  103. 14199.128.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 7. Definitions [14199.128- 14199.128.] ( Article 7 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section defines terms used in Chapter 7.5, including “department,” “base year,” “clinic,” and several Medi-Cal-related terms.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 7. Definitions [14199.128- 14199.128.] ( Article 7 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.128. Definitions For purposes of this chapter, as used in both the singular and plural form, the following definitions shall apply: (a) “Abortion” has the same meaning as set forth in subdivision (a) of Section 123464 of the Health and Safety Code. (b) “Acute psychiatric hospital” has the same meaning as set forth in subdivision (b) of Section 1250 of the Health and Safety Code. (c) “Advanced practice clinicians and allied health care professionals” shall be defined by the department, subject to the stakeholder input requirements of Section 14199.121, to include appropriate health profession careers. (d) “Article 7.1” means Article 7.1 (commencing with Section 14199.80) of Chapter 7, as added by Chapter 13 of the Statutes of 2023. (e) “Base data source” means the most recent available quarterly financial statement filings or annual enrollment data submitted by health plans to the Department of Managed Health Care for that updated base year, retrieved by the department, and supplemented by, as necessary, Medi-Cal enrollment data for the updated base year as maintained by the department, and as modified by the department to account for known or anticipated contracting changes that will affect Medi-Cal enrollment. (f) “Base year” means a 12-month period running from January 1 through December 31 of a calendar year selected by the department. The department may elect to update the base year to the extent it deems necessary to meet the requirements of federal statute or regulations, to obtain or maintain federal approval, or to ensure federal financial participation is available or is not otherwise jeopardized. (g) “Bona fide labor-management cooperation committee” or “bona fide LMCC” means a joint labor-management committee that is established pursuant to the federal Labor Management Cooperation Act of 1978 (29 U.S.C. Sec. 175a) and meets the following criteria: (1) The bona fide LMCC is not involved in the governance of a health care entity but exists to promote worker training, workforce expansion, and support for workers during training. (2) The bona fide LMCC has the following composition: (A) Fifty percent of the committee consists of representatives of organized labor unions that represent health workers in the state. (B) Fifty percent of the committee consists of representatives of health care employers that primarily serve Medi-Cal patients located in the state. (h) “CalHealthCares Program” means the Medi-Cal Physicians and Dentists Loan Repayment Program Act established pursuant to Section 14114. (i) “California Affordable Drug Manufacturing Act of 2020” means the program established pursuant to Chapter 10 (commencing with Section 127690) of Part 2 of Division 107 of the Health and Safety Code. (j) “Clinic” means any of the following: (1) Federally qualified health centers (FQHC), including FQHC look-alike clinics designated by the federal Health Resources and Services Administration as meeting FQHC program requirements as set forth in Sections 1395x(aa)(4)(B) and 1396d(1)(2)(B) of Title 42 of the United States Code. (2) Rural health clinics (RHC) meeting the definition set forth in Section 1396d(l)(1) of Title 42 of the United States Code. (3) Clinics licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code. (4) Tribal clinics exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code. (5) Intermittent clinics exempt from licensure pursuant to subdivision (h) of Section 1206 of the Health and Safety Code. (6) Clinics exempt from licensure pursuant to subdivision (b) of Section 1206 of the Health and Safety Code. If clinics exempt from licensure pursuant to subdivision (b) of Section 1206 of the Health and Safety Code choose to participate in a directed payment program described in Section 14199.120.5, the directed payment program will use the “classes of provider” functionality at a minimum to create a tier for those clinics and allow for payments to those clinics to be based on an amount allocated to their class’s pool. (7) Indian health clinics that provide services in California pursuant to the Indian Health Program, as set forth in Chapter 4 (commencing with Section 124575) of Part 4 of Division 106 of the Health and Safety Code. (k) “Committee” or “stakeholder advisory committee” means the Protect Access to Health Care Act Stakeholder Advisory Committee established pursuant to Section 14199.129. (l) “Community-based organization” means a nonprofit organization of demonstrated effectiveness that is representative of a community or significant segments of a community and promotes access to, or provides physical or mental health or related services to, individuals in the community. (m) “Community health worker” shall have the same meaning as defined in paragraph (1) of subdivision (b) of Section 14132.36. (n) “Community provider” means a holder of a certificate described in Section 2050 of the Business and Professions Code who serves Medi-Cal patients. (o) “Comprehensive clinical family planning services” means the services set forth in subdivision (aa) of Section 14132. (p) “Countable enrollee” means an individual enrolled in a health plan during a month of the base year according to the base data source. “Countable enrollee” does not include an individual enrolled in a Medicare plan, a plan-to-plan enrollee, or an individual enrolled in a health plan pursuant to the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) to the extent the imposition of the tax under Article 6 (commencing with Section 14199.123) of this chapter or Article 7.1 (commencing with Section 14199.80) of Chapter 7 is preempted pursuant to Section 8909(f) of Title 5 of the United States Code. (q) “County mental health plan” means an entity or local agency that contracts with the department to provide covered specialty mental health services pursuant to Section 14184.400 and Chapter 8.9 (commencing with Section 14700). (r) “Department” means the State Department of Health Care Services. (s) “Designated public hospital system” means a designated public hospital as defined in paragraph (1) of subdivision (f) of Section 14184.10 and its affiliated governmental providers and contracted governmental and nongovernmental entities that constitute a hospital and health care system. A single designated public hospital system may include multiple designated public hospitals under common government ownership. (t) (1) “Directed payment” means a payment arrangement whereby the department directs certain expenditures made by a Medi-Cal managed care plan that is approved by the federal Centers for Medicare and Medicaid Services as described in Section 438(c) of Title 42 of the Code of Federal Regulations, established pursuant to Section 438(c) of Title 42 of the Code of Federal Regulations, or otherwise required by the Medi-Cal managed care plan contract, and documented in a rate certification approved by the federal Centers for Medicare and Medicaid Services as applicable. (2) References in this subdivision to Section 438(c) of Title 42 of the Code of Federal Regulations shall include any subsequent amendments thereto. (u) “Director” means the director of the State Department of Health Care Services. (v) “Emergency air ambulance transport” means emergency medical transportation by air, as described in paragraph (1) of subdivision (c) of Section 51323 of Title 22 of the California Code of Regulations, by air ambulance, as defined in Section 100280 of Title 22 of the California Code of Regulations. (w) “Family PACT” means the Family Planning, Access, Care, and Treatment Program established pursuant to subdivision (aa) of Section 14132. (x) “Family planning services and family planning-related services in the Medi-Cal program” means the services covered by the Medi-Cal program pursuant to subdivision (n) of Section 14132. (y) “Family planning services in the State-Only Family Planning Program” means the services covered by that program pursuant to Division 24 (commencing with Section 24000). (z) “Fund” means the Protect Access to Health Care Fund established in the State Treasury pursuant to Section 14199.103. (aa) “General acute care hospital” has the same meaning as in subdivision (a) of Section 1250 of the Health and Safety Code. (ab) “Ground emergency medical transports” means emergency medical transports, as defined in Section 14129, that originate from a 911 call center or equivalent public safety answering point. (ac) “Health care service plan” or “health plan” means a health care service plan, other than a plan that provides only specialized or discount services, that is licensed by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or a Medi-Cal managed care plan contracted with the department to provide full-scope Medi-Cal services. (ad) “Medi-Cal patient” means a Medi-Cal beneficiary as defined in Section 14252. (ae) “Medi-Cal enrollee” means an individual enrolled in a health plan, as defined in subdivision (ac), who is a Medi-Cal patient for whom the department directly pays the health plan a capitated payment. (af) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal patients pursuant to this chapter or Chapter 8 (commencing with Section 14200). (ag) “Medi-Cal per enrollee tax amount” means the amount of tax assessed per countable Medi-Cal enrollee within a Medi-Cal taxing tier. (ah) “Medi-Cal taxing tier” means a range of cumulative enrollment of countable Medi-Cal enrollees for the base year. (ai) “Net reimbursement” or “net reimbursement levels” means the total payments to Medi-Cal providers for the applicable services and procedures received as of January 1, 2024, less any amounts financed by Medi-Cal providers as the nonfederal share of those payments via provider taxes or fees, certified public expenditures, or intergovernmental transfers. (aj) “Network provider” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (ak) “Other enrollee” means an individual enrolled in a health plan who is not a Medi-Cal enrollee. (al) “Other per enrollee tax amount” means the amount of tax assessed per countable other enrollee within an other taxing tier. (am) “Other taxing tier” means a range of cumulative enrollment of countable other enrollees for the base year. (an) “Plan-to-plan enrollee” means an individual who receives their health care services through a health plan pursuant to a subcontract from another health plan. (ao) “Primary care” has the same meaning as in Section 51170.5 of Title 22 of the California Code of Regulations. (ap) “Private ground emergency medical transport provider” means a provider of ground emergency medical transports that does not meet the definition of paragraph (1) of subdivision (a) of Section 14105.945. (aq) “Qualified family planning provider” means a Medi-Cal provider that meets all of the following conditions: (1) Is a community clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code. (2) Is enrolled in the Family PACT program, as described in subdivision (aa) of Section 14132. (3) Provides both abortion and contraception services. (ar) “Specialist” means a physician or surgeon or other licensee pursuant to the Medical Practice Act (Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code) or the Osteopathic Act (Chapter 8 (commencing with Section 3600) of Division 2 of the Business and Professions Code) who delivers to Medi-Cal patients health care services, treatment, or procedures at least some of which do not qualify as primary care. (as) “Specialty care” means health care services provided by a specialist. (at) “State-Only Family Planning Program” means the program established pursuant to Division 24 (commencing with Section 24000). (au) “Tax period” means a period of not more than 12 months for which the tax imposed pursuant to Article 6 (commencing with Section 14199.123) is assessed. (Amended by Stats. 2025, Ch. 21, Sec. 114. (AB 116) Effective June 30, 2025.)
  104. 14199.129.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section creates the Stakeholder Advisory Committee and sets rules for who may serve, how it functions, how often it meets, and staffing support from 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.129. Stakeholder Advisory Committee Established (a) The Protect Access to Health Care Act Stakeholder Advisory Committee is hereby established within the department. (b) An individual holding federal, state, tribal, or local elected or appointed office or an officer or official of a political party is not eligible for appointment to the committee. (c) Six members of the committee constitute a quorum for purposes of voting and conducting business of the committee. (d) The committee shall elect a chairperson from among its membership. The chairperson shall serve in that capacity for two years and is eligible for reelection. The chairperson shall preside at all meetings and shall have all the powers and privileges of other committee members. (e) The committee shall meet not less than biennially, and may hold additional regular and special meetings at the call of the committee or the chairperson. (f) At least two employees of the department shall be assigned full-time to staffing and supporting the committee. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  105. 14199.130.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section sets the membership and appointment rules for the stakeholder advisory committee.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.130. Committee Membership (a) The committee shall be composed of 10 members as follows: (1) One member that represents both primary and specialty physicians on a statewide basis. (2) One member that represents both public and private hospitals, regardless of licensure type, on a statewide basis. (3) One member that represents a private emergency ambulance provider that performs 500,000 or more emergency medical ground transports per calendar year in this state. (4) One member that represents family planning and reproductive health providers on a statewide basis. (5) One member that represents commercial, nongovernmental Medi-Cal managed care plans on a statewide basis. (6) One member that represents clinics on a statewide basis. (7) One member that represents public, nonprofit Medi-Cal managed care plans on a statewide basis. (8) One member that represents dentists on a statewide basis. (9) One member that represents organized labor groups on a statewide basis. (10) One member that represents a private emergency air ambulance transport provider that bills for more than 2,000 emergency ambulance transports per year in this state. (b) Committee members shall be appointed as follows: (1) The Governor shall appoint the members described in paragraphs (1) to (6), inclusive, of subdivision (a). (2) The Speaker of the Assembly shall appoint the members described in paragraphs (7) and (8) of subdivision (a). (3) The Senate President Pro Tempore shall appoint the members described in paragraphs (9) and (10) of subdivision (a). (c) An entity or organization shall not have more than one employee, officer, or director from that entity or organization appointed to the committee at any given time. (d) Each member of the committee shall either be a citizen and resident of the United States or satisfy the requirements of subdivision (b) of Section 1020 of the Government Code. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  106. 14199.131.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section sets deadlines for appointing committee members, starts initial terms on day 45, limits removal to misconduct or neglect of duty, and requires written notice and replacement when a category-representative member can no longer serve.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.131. Committee Member Terms (a) Each appointing authority described in subdivision (b) of Section 14199.130 shall make their initial appointments not later than 30 calendar days after the effective date of this chapter. (b) The term of initial appointees to the committee shall begin on the 45th calendar day after the effective date of this chapter. The terms of initial appointees to the committee shall be as follows: (1) The Governor’s initial appointees described in paragraphs (1) to (4), inclusive, of subdivision (a) of Section 14199.130 shall serve for a term of four years. (2) The Governor’s initial appointees described in paragraphs (5) and (6) of subdivision (a) of Section 14199.130 shall serve for a term of three years. (3) The Assembly Speaker’s initial appointee described in paragraph (7) of subdivision (a) of Section 14199.130 shall serve for a term of three years. (4) The Assembly Speaker’s initial appointee described in paragraph (8) of subdivision (a) of Section 14199.130 shall serve for a term of two years. (5) The Senate President Pro Tempore’s initial appointees shall serve for a term of two years. (c) After the initial terms, the term of each appointed or reappointed committee member shall be four years. Each member of the committee shall serve until a successor is appointed. (d) A member of the committee shall not be removed by the appointing authority except for malfeasance in office or neglect of duty. A member shall not be removed unless the reasons for removal are presented in writing to the member. (e) (1) A member of the committee appointed to represent a specific category described in paragraphs (1) to (10), inclusive, of subdivision (a) of Section 14199.130 shall notify in writing their appointing authority if they no longer represent that specific category or are otherwise unable to continue serving as a member of the committee. The notice required by this paragraph shall be provided within 15 calendar days of the changed circumstance. (2) Upon receipt of the written notice by the appointing authority, the member’s position on the committee shall be deemed vacant. Within 30 calendar days of receipt of the written notice, the appointing authority shall appoint a successor to serve the remainder of the former member’s term. Upon expiration of the unexpired term, the successor may be appointed to a full term. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  107. 14199.132.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The committee is advisory only, must give written advice and recommendations to the department, and may investigate, report, post materials, create subcommittees, and delegate tasks.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.132. Powers and Duties of the Committee (a) (1) The committee is advisory only and does not possess decisionmaking authority. The committee is established for the sole purpose of researching and analyzing approaches and best practices for the development and implementation of the components of this chapter, including by preparing reports or recommendations and providing advice thereon for submission to the department. The department has sole and final decisionmaking authority under this chapter. (2) The committee shall advise and make written recommendations to the department with respect to implementing this chapter and achieving the objectives set forth in Sections 14199.101 and 14199.102. (b) The committee is authorized, but not limited, to do any of the following: (1) Undertake investigations or studies. (2) Issue written reports. (3) Post any report or recommendation on the department’s internet website under the committee’s own link on the internet website. (c) Any member of the committee may request, and the Controller and department shall provide, any written accounting or record of deposits into, transfers between, or expenditures out of, any fund, subfund, account, or subaccount established or created by this chapter. (d) The committee may establish subcommittees consisting of one or more of its members, and may delegate to a subcommittee any right or responsibility bestowed upon the committee, including the right or responsibility of providing advice and written input to the department on a given subject. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  108. 14199.133.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    Committee members serve without compensation, but they may get reimbursement for necessary expenses if the department approves 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 8. Stakeholder Advisory Committee [14199.129 - 14199.133] ( Article 8 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.133. Compensation Members of the committee shall serve without compensation, but shall receive reimbursement for necessary expenses, subject to approval by the department. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  109. 14199.134.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    The Legislature may amend this chapter only if it follows the stated vote and publication 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.134. Amendment of Chapter (a) The Legislature may amend this chapter by a statute passed in each house of the Legislature by rollcall vote entered into the journal, three-fourths of the membership concurring, provided that the statute is consistent with, and furthers the purpose of, this chapter. (b) A bill seeking to amend this chapter after the effective date of this chapter shall not be passed or ultimately become a statute unless the bill has been printed and distributed to members, and published on the Internet, in its final form, for at least 10 business days before its passage in either house of the Legislature. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  110. 14199.135.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    This section says the chapter is severable, should be read liberally to carry out its purpose, uses certain outside statutes as they existed on July 1, 2023, and takes effect on the next January 1 after voter 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 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.135. Construction of Chapter (a) Severability. The provisions of this chapter are severable. If any portion, section, subdivision, paragraph, subparagraph, clause, subclause, sentence, phrase, word, or application of this chapter is for any reason held to be invalid by a decision of any court of competent jurisdiction, that decision shall not affect the validity of the remaining portions of this chapter. The people of the State of California hereby declare that they would have adopted this chapter and each and every portion, section, subdivision, paragraph, subparagraph, clause, subclause, sentence, phrase, word, and application not declared invalid or unconstitutional without regard to whether any part of this chapter or application thereof would be subsequently declared invalid. (b) Liberal Construction. This chapter is an exercise of the initiative power of the people of the State of California pursuant to Article II and Article IV of the Constitution, and shall be liberally construed to effectuate the purposes set forth in this chapter. (c) Statutory References. Unless otherwise stated, all references contained in this chapter to statutes codified outside of this chapter refer to those statutes as they existed on July 1, 2023. (d) Effective Date. This chapter shall take effect on the next January 1 following its approval by the voters of California. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election.)
  111. 14199.136.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. )

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    If California does not defend this chapter’s constitutionality, another state or local government agency may intervene in the case to defend it. The Department of Justice must promptly pay the reasonable defense fees and costs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7.5. Protect Access to Health Care Act of 2024 [14199.100 - 14199.136] ( Chapter 7.5 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## ARTICLE 9. Amendments, Construction, Standing [14199.134 - 14199.136] ( Article 9 added November 5, 2024, by initiative Proposition 35, Sec. 1. ) ## 14199.136. Standing to Defend Chapter Notwithstanding any other law, if the State of California or any of its officers or officials fail to defend the constitutionality of this chapter, following its approval by the voters, any other state or local government agency of this state shall have the authority to intervene on behalf of the State of California or the department in a court action challenging the constitutionality of this chapter for the purpose of defending its constitutionality, whether that action is in state or federal trial court, on appeal, or on discretionary review by the Supreme Court of California or the Supreme Court of the United States. The reasonable fees and costs of defending the action by the other state or local government agency shall be a charge on funds appropriated to the Department of Justice, which shall be satisfied promptly. (Added November 5, 2024, by initiative Proposition 35, Sec. 1. Effective December 18, 2024. Approved in Proposition 35 at the November 5, 2024, election. Operative January 1, 2025, pursuant to Section 14199.135.)
  112. 14199.2.

    ## 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 6.6. Medicaid Expansion Under The Federal Affordable Care Act [14199.1 - 14199.2] ( Article 6.6 added by Stats. 2013, Ch. 24, Sec. 2. )

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    Medi-Cal managed care plans must pay county public hospital health systems at least their cost for certain services, and related reporting and contract-certification duties apply.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 6.6. Medicaid Expansion Under The Federal Affordable Care Act [14199.1 - 14199.2] ( Article 6.6 added by Stats. 2013, Ch. 24, Sec. 2. ) ## 14199.2. (a) Subject to subdivision (e), Medi-Cal managed care plans serving newly eligible beneficiaries, as defined in subdivision (s) of Section 17612.2, shall pay county public hospital health systems, as defined in subdivision (f) of Section 17612.2, for services provided to newly eligible beneficiaries in amounts that are no less than the cost of providing those services, including the cost of network and out-of-network services that are charged to or paid for by county public hospital health systems. For purposes of this requirement, the cost of providing services shall mean the amounts, including the federal and nonfederal share of all allowable costs, determined in a manner consistent with the cost claiming protocols developed for the federal Medicaid demonstration project authorized under Section 1115 of the Social Security Act entitled the “Bridge to Health Care Reform” (waiver number 11-W-00193/9), including protocols pending federal approval, and under Section 14166.8. (b) Consistent with federal law, the capitation rates paid to Medi-Cal managed care plans for newly eligible beneficiaries shall be determined to reflect the obligations imposed by subdivision (a). (c) (1) Prior to the execution of a change order or contract amendment between the department and a Medi-Cal managed care plan providing for coverage of newly eligible beneficiaries, the Medi-Cal managed care plan shall demonstrate and certify that it has contracts or other arrangements in place with county public hospital health systems that provide for payments for services meeting the requirements of subdivision (a). (2) Each year, each Medi-Cal managed care plan shall provide to the department an accounting of the payments made to demonstrate compliance with subdivision (a). To the extent a Medi-Cal managed care plan is not compliant with any of the requirements of this section, the department shall reduce the default assignment into the Medi-Cal managed care plan with respect to all Medi-Cal beneficiaries by 25 percent, as long as the other Medi-Cal managed care plan or plans in the county have the capacity to receive the additional default membership. (d) A Medi-Cal managed care plan shall not impose a fee or retention amount, or reduce other payments to a county public hospital health system, that would result in a direct or indirect reduction to the amounts required to be paid under subdivision (a). (e) (1) If a nonfederal share is necessary with respect to the capitation rates described in subdivision (b), a county public hospital health system or affiliated governmental entity shall have the right to voluntarily provide intergovernmental transfers for the nonfederal share of expenditures for the capitation rates described in subdivision (b) with respect to the requirements in subdivision (a). Only if the county public hospital health system or affiliated governmental entity so chooses, the requirements in this section shall apply. Notwithstanding any other law, the state shall not assess the fee described in subdivision (d) of Section 14301.4, or any other similar fee. Nothing in this section shall be construed to require a county public hospital health system to provide the nonfederal share for expenditures for purposes other than those described in subdivision (a), or for expenditures that are otherwise for Medi-Cal managed care beneficiaries who do not receive services in the county public hospital health system. (2) Within 12 months following the end of each fiscal year, a county public hospital system shall submit data to the department demonstrating the payments received from Medi-Cal managed care plans as required under subdivision (a). If the amount of the applicable intergovernmental transfer provided by a county public hospital system does not equal the nonfederal share of those payments, the county hospital system and the department shall adjust the amount of the intergovernmental transfer accordingly. (Added by Stats. 2013, Ch. 24, Sec. 2. (AB 85) Effective June 27, 2013.)
  113. 14199.70.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

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    The Legislature states that qualified clinics are important to California’s health care safety net and that retention payments will help keep health care workers in clinic jobs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.70. The Legislature finds and declares all of the following: (a) Qualified clinics, as defined in this article, are fundamental to the California health care safety net, as their mission is to provide primary and preventive care to low-income and underserved populations. (b) Stability in the California qualified clinic workforce will further the Legislature’s efforts to manage the COVID-19 pandemic and address other public health issues that face Californians. (c) Retention payments will help retain qualified health care workers, in particular registered nurses, licensed vocational nurses, licensed clinical social workers, licensed mental health workers, medical assistants, and advanced practice professionals. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  114. 14199.71.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

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    This section defines terms used in the Clinic Workforce Stabilization Retention Payment 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.71. For purposes of this article, the following definitions apply: (a) “Date of record” means a date determined by the department on which eligible employees are deemed to qualify for a retention payment, which shall be no later than 90 calendar days after the effective date of the act that added this article. (b) “Department” means the State Department of Health Care Services. (c) “Eligible employee” means a person who is employed by an eligible qualified clinic as of the date of record and is not a manager or supervisor, as defined in this article. (d) “HCAI” means the Department of Health Care Access and Information. (e) “Manager or supervisor” means a qualified clinic employee who meets all of the following criteria: (1) Whose duties and responsibilities involve the management of the enterprise in which they are employed or of a customarily recognized department or subdivision thereof. (2) Who customarily and regularly directs the work of two or more other employees of the enterprise in which they are employed or of a customarily recognized department or subdivision of that enterprise. (3) Who has the authority to hire or fire other employees, or their suggestions and recommendations as to the hiring or firing and as to the advancement and promotion or any other change of status of other employees will be given particular weight. (4) Who customarily and regularly exercises discretion and independent judgment. (5) Who is primarily engaged in duties that meet the test of the exemption. The activities constituting exempt work and nonexempt work shall be construed in the same manner as those items are construed in the following regulations under the Fair Labor Standards Act effective as of the date of this section: Sections 541.102, 541.104-111, and 541.115-116 of Title 29 of the Code of Federal Regulations. Exempt work shall include, for example, all work that is directly and closely related to exempt work and work that is properly viewed as a means for carrying out exempt functions. The work actually performed by the employee during the course of the workweek shall, first and foremost, be examined and the amount of time the employee spends on that work, together with the employer’s realistic expectations and the realistic requirements of the job, shall be considered in determining whether the employee satisfies this requirement. (6) Who must earn a monthly salary equivalent to no less than two times the state minimum wage for full-time employment. “Full-time employment” is defined in subdivision (c) of Section 515 of the Labor Code as 40 hours per week. (f) “Qualified clinic” means, and is inclusive of, FQHCs, FQHC look-alikes, free clinics, Indian health clinics, intermittent clinics, and rural health clinics, as defined in this subdivision. A qualified clinic shall be located in the State of California, with the exception of Tribal FQHCs and Indian health clinics, as specified in the definitions of FQHC and Indian health clinic set forth in this subdivision. (1) “Federally qualified health center” or “FQHC” means any community or public federally qualified health center, including Tribal FQHCs, as defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code, as well as FQHC look-alikes. This definition also covers Tribal FQHCs on tribal land adjacent to California in a neighboring state that provides services to American Indians and their families who reside in California. (2) “FQHC look-alike” means an organization that does not receive an FQHC award, but is designated by the United States Health Resources and Services Administration as meeting FQHC program requirements, as set forth in Sections 1395x(aa)(4)(B) and 1396d(l)(2)(B) of Title 42 of the United States Code. For the purposes of this article, an FQHC look-alike is considered an FQHC and all references to FQHCs apply with equal force to FQHC look-alikes. (3) “Free clinic” means a facility meeting the definition set forth in subparagraph (B) of paragraph (1) of subdivision (a) of Section 1204 of the Health and Safety Code. (4) “Indian health clinic” means a health clinic that provides services to American Indians and their families who reside in California pursuant to the Indian Health Program, as set forth in Chapter 4 (commencing with Section 124575) of Part 4 of Division 106 of the Health and Safety Code, and Chapter 3.1 (commencing with Section 1500) of Division 1 of Title 17 of the California Code of Regulations. This definition also covers Indian health clinics on tribal land adjacent to California in a neighboring state that provides services to American Indians and their families who reside in California. (5) “Intermittent clinic” means a facility meeting the definition set forth in subdivision (h) of Section 1206 of the Health and Safety Code that has been added to the provider master file pursuant to Section 14043.15 under the license of a clinic defined in paragraphs (1) to (4), inclusive. (6) “Rural health clinic” or “RHC” means a facility meeting the definition set forth in Section 1396d(l)(1) of Title 42 of the United States Code. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  115. 14199.72.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

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    The department must create a clinic retention payment program if funds are appropriated, and qualified clinics must report information, pay eligible employees, and return any unused funds on time.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.72. (a) Upon appropriation by the Legislature of funds for this purpose, the department shall establish a clinic workforce stabilization retention payment program to provide funds to eligible qualified clinics to make retention payments to their eligible employees for the public purposes specified in Section 14199.70. (b) The department shall determine the conditions and data reporting requirements for qualified clinics to be eligible to receive funds. Within 90 days of the effective date of the act that added this article, the department shall notify all qualified clinics of those conditions and requirements, as well as the relevant portions of this article, including, but not limited to, the date of record set by the department, the information qualified clinics are required to submit pursuant to subdivision (c), the methodology for calculation of funds to be distributed pursuant to subdivision (d), how to pay retention payments pursuant to subdivision (e), and the consequences of noncompliance pursuant to Section 14199.74. (c) (1) Each qualified clinic that intends to request funding shall submit the following information to the department no later than 30 days after the date of record: (A) The name and mailing address of each eligible employee. (B) The employee’s professional license, certification, or registration, if applicable. (C) Any other information as required by the department for purposes of implementing this article. (2) The possession of a professional license, certification, or registration is not required for an employee to be eligible for a payment. All eligible employees, as defined in subdivision (c) of Section 14199.71, are eligible to receive payments. (3) The information required by this section shall include an attestation, made under penalty of perjury, that the qualified clinic employee did not receive funds pursuant to the Hospital and Skilled Nursing Facility COVID-19 Retention Pay program set forth in Part 4.6 (commencing with Section 1490) of Division 2 of the Labor Code. (d) The department shall distribute funds to each eligible qualified clinic based on the total number of eligible employees reported pursuant to subdivision (c). The amount of the payment shall be up to one thousand dollars ($1,000) per eligible employee, subject to available funding, and reduced on a pro rata basis if the requests exceed the amount of funds available. The department may distribute these funds to eligible qualified clinics using the existing Medi-Cal Checkwrite system. (e) Within 60 days of receipt of funds from the department, a qualified clinic shall pay eligible employees a retention payment in the amount of up to one thousand dollars ($1,000) if no pro rata reduction is made pursuant to subdivision (d), or the pro rata reduced amount if a pro rata reduction is made pursuant to subdivision (d). An eligible employee who leaves employment between the date of record and the date a qualified clinic pays retention payments shall not be eligible for retention payments. Each qualified clinic that receives funds shall attest, in a form and manner specified by the department, and under penalty of perjury, that all funding received pursuant to this section, with the exception of any funding requested for eligible employees who left employment after the date of record, was provided to eligible employees within 60 days of receipt from the department. Each qualified clinic that receives funds shall immediately return to the department any funding received pursuant to this section that is not distributed within the timeline set forth in this subdivision, including funds that the department provided for eligible employees who left employment after the date of record. (f) The department shall post on its internet website the amount each clinic site received, and the total number of eligible employees reported by each clinic pursuant to subdivision (c). (g) A qualified clinic shall not use retention payment funding to supplant other payments from the qualified clinic to eligible employees. (Amended by Stats. 2024, Ch. 40, Sec. 72. (SB 159) Effective June 29, 2024.)
  116. 14199.73.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

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    This section exempts certain article payments from Medi-Cal adjustments and deductions, lets the department contract and issue implementation instructions, and requires HCAI to publish reporting guidance for qualified clinics.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.73. (a) (1) Except as required by federal law, any payment made pursuant to this article shall be exempt from any adjustments or deductions made to Medi-Cal payments to qualified clinics, including, but not limited to, provider withholds or provider payment reductions. (2) Payments made pursuant to this article to qualified clinics shall not be considered payments for patient care or medical services. (3) The HCAI, in consultation with appropriate stakeholders, shall release guidance to instruct qualified clinics how to report this revenue through the established clinical annual utilization reports, as required under Section 1216 of the Health and Safety Code. (b) The department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis for purposes of implementing this article. A contract 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 from the State Administrative and State Contracting manuals, and shall be exempt from the review or approval of any division of the Department of General Services. (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 article, in whole or in part, by means of information notices or other similar instructions, without taking any further regulatory action. (d) This article is a state law within the meaning of Section 1621(d) of Title 8 of the United States Code. (e) This article shall be implemented only to the extent that the department determines that federal financial participation under the Medi-Cal program is not jeopardized. (f) Funds distributed to qualified clinics and payments made by those qualified clinics pursuant to this article shall not be factored into any reconciliation process or prospective payment system (PPS) rate calculation, including, but not limited to, the reconciliation process detailed in Section 14132.100 of this code and subdivision (bb) of Section 1396a of Title 42 of the United States Code, to the maximum extent permissible by law. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  117. 14199.74.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

    Verify source ↗

    This section lets an eligible employee or the employee’s labor organization request review of a retention-payment dispute, requires the qualified clinic to respond within 30 days, and allows further complaint or court action if the issue is not resolved.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.74. (a) In the event of a dispute as to the status of an employee as an eligible employee, the retention payment amount, or a qualified clinic’s failure to make a retention payment, an eligible employee or a labor organization that represents the employee may write to the qualified clinic and request a review of the employee’s eligibility status, retention payment amount, or the qualified clinic’s failure to make a retention payment. The qualified clinic shall have 30 days to review the request, disclose to the employee the amount received from the department subject to the methodology described in subdivision (e) of Section 14199.72, and cure any alleged deficiency. In the event the qualified clinic cures a deficiency alleged by an employee, the employee shall not be entitled to any further damages or other relief. (b) If the qualified clinic does not conclude the review described in subdivision (a) within 30 days of receipt of the review request, or does not cure the alleged deficiency within 30 days of receipt of the review request, the employee may file a complaint with the Labor Commissioner as provided in Section 98 of the Labor Code, or the employee may file an action in court to recover the deficiency. If the court finds that the qualified clinic is liable for failing to make a required retention payment, or to designate an employee for a retention payment, the qualified clinic shall be ordered to make full payment of the unpaid amount, plus interest at the rate of interest specified in subdivision (b) of Section 3289 of the Civil Code, which shall accrue from the date that the retention payment funds were transmitted to the qualified clinic by the department as provided in Section 14199.72, or from the date the qualified clinic should have designated the employee for the retention payment. A claim before the small claims court is not subject to joinder pursuant to Section 378 of the Code of Civil Procedure. (c) Notwithstanding any other law, the department shall not be liable for any payment, interest, damages, or attorney’s fees and costs awarded to an employee pursuant to this section, and shall not be required to indemnify a qualified clinic for any liability the qualified clinic incurs pursuant to this section. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  118. 14199.75.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

    Verify source ↗

    Qualified clinics act as part of a state program when handling retention payments, and the article limits certain lawsuits and damages tied to those payments.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.75. (a) In serving as a conduit for payments under this article, qualified clinics are carrying out a state program. This article does not create a private right of action in any civil litigation against qualified clinics regarding the administration of the retention payment program and in the receipt and transmittal of retention payment program funds except as set forth in Section 14199.74. (b) This article does not create a private right of action in any civil litigation or administrative proceeding against the state or the department or any other state agency or department. (c) Notwithstanding any other law, retention payments paid out pursuant to Section 14199.72 are not wages as defined in Section 200 of the Labor Code. (d) Except as provided in Sections 1493 and 1494 of the Labor Code, and notwithstanding any other law, qualified clinics, the state, and the department and any other state agency or department shall not be liable for damages awarded under Section 3294 of the Civil Code or Sections 2698 to 2699.5, inclusive, of the Labor Code, or other damages imposed primarily for the sake of example and by way of punishing the defendant, in any civil litigation related to the payments described in this article. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  119. 14199.76.

    ## 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 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. )

    Verify source ↗

    This section says the article is severable.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7. Clinic Workforce Stabilization Retention Payment Program [14199.70 - 14199.76] ( Article 7 added by Stats. 2022, Ch. 738, Sec. 19. ) ## 14199.76. The provisions of this article are severable. If any provision of this article or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application. (Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 2022.)
  120. 14199.80.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

    Verify source ↗

    The section states legislative findings and an intent that the department implement a managed care organization provider tax.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.80. The Legislature finds and declares all of the following: (a) The Legislature continues to recognize that an enrollment-based managed care organization provider tax is an essential and necessary source of nonfederal funding for maintaining and improving access to care and reimbursement levels under, and maximizing federal financial participation for, the Medi-Cal program. (b) The Legislature recognizes how the previous iterations of the managed care organization provider tax, in effect nearly continuously from July 1, 2016, enabled the state to provide ongoing funding for health care and prevention, while minimizing the need for any new reductions to the Medi-Cal program during the time periods when the tax was in effect. (c) Implementation of a new managed care organization provider tax at the earliest possible effective date allowable under federal law will best position the state to maintain and improve access to care, maximize federal financial participation, and minimize the need for any new reductions to the Medi-Cal program. (d) In furtherance of subdivisions (a) to (c), inclusive, it is the intent of the Legislature that the department implement a managed care organization provider tax effective April 1, 2023, to meet all of the following goals: (1) Generate an amount of nonfederal funds for the Medi-Cal program that is greater than the nonfederal funds generated by the tax imposed pursuant to Article 6.8 (commencing with Section 14199.60). (2) Comply with federal Medicaid requirements applicable to permissible health care-related taxes, including, but not limited to, Section 433.68 of Title 42 of the Code of Federal Regulations. (3) Provide funding to support the health care delivery system with an emphasis on the impact to the Medi-Cal program. (4) Minimize, to the extent possible, the need for any new reductions to the Medi-Cal program. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  121. 14199.81.

    ## 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 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

    Verify source ↗

    This section defines terms used for the managed care organization provider tax article.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.81. The following definitions shall apply for purposes of this article: (a) “Base data source” means the quarterly financial statement filings or annual enrollment data submitted by health plans to the Department of Managed Health Care retrieved by the department no later than June 30, 2023, and supplemented by, as necessary, Medi-Cal enrollment data for the base year as maintained by the department and retrieved no later than June 30, 2023, and as modified by the department to account for known or anticipated changes that will affect Medi-Cal enrollment on or after January 1, 2024. However, if the department elects to update the base year pursuant to subdivision (b), “base data source” means the most recently available quarterly financial statement filings or annual enrollment data submitted by health plans to the Department of Managed Health Care for that updated base year, retrieved by the department, and supplemented by, as necessary, Medi-Cal enrollment data for the updated base year as maintained by the department, and as modified by the department to account for known or anticipated changes that will affect Medi-Cal enrollment. (b) “Base year” means the 12-month period of January 1, 2022, through December 31, 2022. However, the department may elect to update the base year to the extent that 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. (c) “Countable enrollee” means an individual enrolled in a health plan, as defined in subdivision (f), during a month of the base year according to the base data source. “Countable enrollee” does not include an individual enrolled in a Medicare plan, a plan-to-plan enrollee, as defined in subdivision (m), or an individual enrolled in a health plan pursuant to the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) to the extent the imposition of the tax under this article is preempted pursuant to Section 8909(f) of Title 5 of the United States Code. (d) “Department” means the State Department of Health Care Services. (e) “Director” means the Director of Health Care Services. (f) “Health care service plan” or “health plan” means a health care service plan, other than a plan that provides only specialized or discount services, that is licensed by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or a managed care plan contracted with the State Department of Health Care Services to provide full-scope Medi-Cal services. (g) “Medi-Cal enrollee” means an individual enrolled in a health plan, as defined in subdivision (f), who is a Medi-Cal beneficiary for whom the department directly pays the health plan a capitated payment. (h) “Medi-Cal per enrollee tax amount” means the amount of tax assessed per countable Medi-Cal enrollee within a Medi-Cal taxing tier. (i) “Medi-Cal taxing tier” means a range of cumulative enrollment of countable Medi-Cal enrollees for the base year. (j) “Other enrollee” means an individual enrolled in a health plan, as defined in subdivision (f), who is not a Medi-Cal beneficiary. (k) “Other per enrollee tax amount” means the amount of tax assessed per countable other enrollee within an “other taxing tier.” (l) “Other taxing tier” means a range of cumulative enrollment of countable other enrollees for the base year. (m) “Plan-to-plan enrollee” means an individual who receives their health care services through a health plan pursuant to a subcontract from another health plan. (n) “Tax period” means a period of not more than 12 months for which the tax authorized by this article is assessed, in accordance with the requirements described in Section 14199.84. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  122. 14199.82.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

    Verify source ↗

    This section creates the Managed Care Enrollment Fund and directs related tax revenues and earnings into it, sets how the money may be used, requires reporting to health plans, and allows the Controller limited cashflow-loan use of the 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 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.82. (a) The Managed Care Enrollment Fund is hereby created in the State Treasury. (b) All revenues, less refunds, derived from the taxes provided for in this article shall be deposited in the State Treasury to the credit of the Managed Care Enrollment Fund. (c) Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on moneys in the Managed Care Enrollment Fund shall be retained in the fund and used solely for the purpose specified in subdivision (d). (d) Funds deposited in the Managed Care Enrollment Fund pursuant to this article shall, upon appropriation by the Legislature, be available to the department for the purpose of funding all of the following subcomponents to support the Medi-Cal program: (1) The nonfederal share of increased capitation payments to Medi-Cal managed care plans accounting for their projected tax obligation pursuant to this article for the applicable fiscal year or years. (2) The nonfederal share of Medi-Cal managed care rates for health care services furnished to children, adults, seniors and persons with disabilities, and persons dually eligible for the Medi-Cal program and the Medicare Program. (3) Transfers to the Medi-Cal Provider Payment Reserve Fund established pursuant to Section 14105.200. (e) The department shall provide an annual report to all health plans accounting for the funds deposited in, and expended from, the Managed Care Enrollment Fund, in a time and manner as deemed appropriate by the director. The report shall identify the taxes imposed on each health plan pursuant to this article and shall provide an itemized accounting of expenditures from the fund. (f) Effective December 31, 2023, the Health Care Services Special Fund in the State Treasury, created pursuant to Section 14199.62, is hereby abolished. All moneys in the fund or moneys designated to be deposited to the fund shall be transferred to the Managed Care Enrollment Fund created pursuant to subdivision (a). Any remaining balance, assets, liabilities, and encumbrances of the Health Care Services Special Fund as of December 31, 2023, shall be transferred to, and become part of, the Managed Care Enrollment Fund. (g) Notwithstanding any other law, the Controller may use the funds in the Managed Care Enrollment Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Inoperative on date prescribed by Section 14199.103. Repealed one year after inoperative date, pursuant to Section 14199.103.)
  123. 14199.83.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

    Verify source ↗

    The department must calculate specified enrollment totals for each health plan, and the director may correct identified material or significant data errors.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.83. (a) The department shall determine for each health plan, using the base data source, all of the following: (1) Total cumulative enrollment for the base year. (2) Total Medicare cumulative enrollment for the base year. (3) Total Medi-Cal cumulative enrollment for the base year. (4) Total plan-to-plan cumulative enrollment for the base year. (5) Total cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) for the base year. (6) Total other cumulative enrollment for the base year that is not otherwise counted in paragraphs (2) to (5), inclusive. (b) Notwithstanding any other provision in this article, the director may correct any identified material or significant error in the data, including, but not limited to, the overall cumulative enrollment, Medicare cumulative enrollment, Medi-Cal cumulative enrollment, plan-to-plan cumulative enrollment, cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382), and other cumulative enrollment. The director’s determination as to whether to exercise discretion under this section and any determination made by the director under this section shall not be subject to judicial review, except that a health plan may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department in correcting that health plan’s data when that correction results in a greater tax amount for that health plan pursuant to Section 14199.85. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  124. 14199.84.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

    Verify source ↗

    A managed care organization provider tax is imposed on each health plan, but the department cannot collect it until federal approval is received.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.84. (a) A managed care organization provider tax shall be imposed on each health plan. The tax shall be imposed for the following tax periods: (1) April 1, 2023, through December 31, 2023. (2) 2024 calendar year. (3) 2025 calendar year. (4) 2026 calendar year. (b) (1) The department shall compute the annual tax for each health plan subject to the tax during each applicable calendar year pursuant to Section 14199.85. (2) The computed tax for the tax period of April 1, 2023, through December 31, 2023, shall be equal to three-fourths of the amount that would otherwise be computed for a 12-month period, as determined by the department. (c) The department shall collect the tax for each health plan in quarterly installments and shall determine the amount due for each installment in the applicable tax period by dividing the total tax for a tax period by the number of calendar quarters in the respective tax period. (d) The department shall not collect the tax imposed pursuant to this article until the department receives approval from the federal Centers for Medicare and Medicaid Services that this tax is a permissible health care-related tax in accordance with Section 433.68 of Title 42 of the Code of Federal Regulations and is eligible for federal financial participation. (1) Within 10 business days following the date the department receives all necessary federal approvals for the tax pursuant to this article, the director shall certify in writing that federal approval has been received, and the department shall post the certification on its internet website and send a copy of the certification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (2) Within 30 business days following the date the department receives all necessary federal approvals for the tax pursuant to this article, the department shall send a notice to each health plan subject to the tax that shall contain the following information: (A) The tax due for each tax period. (B) The dates on which the installment tax payments are due for each tax period. (3) A health plan shall pay the tax for each tax period in installments as calculated pursuant to Section 14199.85, based on a schedule developed by the department. The department shall establish the date that each tax payment is due, provided that the first tax payment shall be due no earlier than 20 calendar days following the date the department sends the notice pursuant to paragraph (2), and the tax payments shall be paid at least one month apart, but no more than one quarter apart. (4) A health plan shall pay the taxes that are due, if any, in the amounts and at the times set forth in the notice unless superseded by a subsequent notice issued by the department. (e) The tax assessed pursuant to this article shall be paid by each health plan subject to the tax to the department for deposit in the Managed Care Enrollment Fund created pursuant to Section 14199.82. (f) (1) Interest shall be assessed on an applicable health plan for any amount of the managed care organization provider taxes that are not paid on the date due at a rate of 10 percent per annum. Interest shall begin to accrue the day after the date the tax payment was due and shall be deposited in the Managed Care Enrollment Fund created pursuant to Section 14199.82. (2) If a tax payment is more than 60 days overdue, a penalty equal to the total accrued interest charge described in paragraph (1) shall also be assessed on the applicable health plan and due for each month for which the tax payment is not received after 60 days. (g) (1) Subject to paragraph (2), the director may waive a portion or all of either the interest or penalties, or both, assessed under this article if the director determines, in their sole discretion, that the health plan has demonstrated that imposition of the full amount of the tax pursuant to the timelines applicable under this article has a high likelihood of creating an undue financial hardship for the health plan or creates a significant financial difficulty in providing needed services to Medi-Cal beneficiaries. (2) Waiver of some or all of the interest or penalties pursuant to this subdivision shall be conditioned on the health plan’s agreement to make tax payments on an alternative schedule developed by the department that takes into account the financial situation of the health plan and the potential impact on the delivery of services to Medi-Cal beneficiaries. (h) In the event of a merger, acquisition, establishment, or any other similar transaction that results in the transfer of health plan responsibility for all countable enrollees under this article from a health plan to another health plan or similar entity, and that occurs at any time during which this article is operative, the resultant health plan or similar entity shall be responsible for paying the full tax amount as provided in this article that would have been the responsibility of the health plan to which that full tax amount was assessed upon the effective date of any such transaction. If a merger, acquisition, establishment, or any other similar transaction results in the transfer of health plan responsibility for only some of a health plan’s countable enrollees under this article but not all countable enrollees, the full tax amount as provided in this article shall remain the responsibility of that health plan to which that full tax amount was assessed. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  125. 14199.85.

    ## 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 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

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    This section sets Medi-Cal provider tax tiers and per-enrollee tax amounts for specified periods, and gives the department authority to make federal-compliance adjustments.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.85. (a) For each tax period, the Medi-Cal taxing tiers shall be as follows: (1) Medi-Cal taxing tier I shall consist of all countable Medi-Cal enrollees in a health plan from zero to 1,250,000, inclusive. (2) Medi-Cal taxing tier II shall consist of all countable Medi-Cal enrollees in a health plan from 1,250,001 to 4,000,000, inclusive. (3) Medi-Cal taxing tier III shall consist of all countable Medi-Cal enrollees in a health plan greater than 4,000,000. (b) For each tax period, the other taxing tiers shall be as follows: (1) Other taxing tier I shall consist of all countable other enrollees in a health plan from zero to 1,250,000, inclusive. (2) Other taxing tier II shall consist of all countable other enrollees in a health plan from 1,250,001 to 4,000,000, inclusive. (3) Other taxing tier III shall consist of all countable other enrollees in a health plan greater than 4,000,000. (c) For the period of April 1, 2023, through December 31, 2023, the Medi-Cal per enrollee tax amount for each Medi-Cal taxing tier shall be as follows: (1) The Medi-Cal per enrollee tax for Medi-Cal taxing tier I shall be zero dollars ($0). (2) The Medi-Cal per enrollee tax for Medi-Cal taxing tier II shall be one hundred eighty-two dollars and fifty cents ($182.50). (3) The Medi-Cal per enrollee tax for Medi-Cal taxing tier III shall be zero dollars ($0). (d) For the period of April 1, 2023, through December 31, 2023, the other per enrollee tax amount for each other taxing tier shall be as follows: (1) The other per enrollee tax for the other taxing tier I shall be zero dollars ($0). (2) The other per enrollee tax for the other taxing tier II shall be one dollar and seventy-five cents ($1.75). (3) The other per enrollee tax for the other taxing tier III shall be zero dollars ($0). (e) For the 2024 calendar year, the Medi-Cal per enrollee tax amount for each Medi-Cal taxing tier shall be as follows: (1) The Medi-Cal per enrollee tax for Medi-Cal taxing tier I shall be zero dollars ($0). (2) The Medi-Cal per enrollee tax for Medi-Cal taxing tier II shall be two hundred seventy-four dollars ($274). (3) The Medi-Cal per enrollee tax for Medi-Cal taxing tier III shall be zero dollars ($0). (f) For the 2024 calendar year, the other per enrollee tax amount for each other taxing tier shall be as follows: (1) The other per enrollee tax for the other taxing tier I shall be zero dollars ($0). (2) The other per enrollee tax for the other taxing tier II shall be one dollar and seventy-five cents ($1.75). (3) The other per enrollee tax for the other taxing tier III shall be zero dollars ($0). (g) For the 2025 calendar year, the Medi-Cal per enrollee tax amount for each Medi-Cal taxing tier shall be as follows: (1) The Medi-Cal per enrollee tax for Medi-Cal taxing tier I shall be zero dollars ($0). (2) The Medi-Cal per enrollee tax for Medi-Cal taxing tier II shall be two hundred seventy-four dollars ($274). (3) The Medi-Cal per enrollee tax for Medi-Cal taxing tier III shall be zero dollars ($0). (h) For the 2025 calendar year, the other per enrollee tax amount for each other taxing tier shall be as follows: (1) The other per enrollee tax for the other taxing tier I shall be zero dollars ($0). (2) The other per enrollee tax for the other taxing tier II shall be two dollars ($2). (3) The other per enrollee tax for the other taxing tier III shall be zero dollars ($0). (i) For the 2026 calendar year, the Medi-Cal per enrollee tax amount for each Medi-Cal taxing tier shall be as follows: (1) The Medi-Cal per enrollee tax for Medi-Cal taxing tier I shall be zero dollars ($0). (2) The Medi-Cal per enrollee tax for Medi-Cal taxing tier II shall be two hundred seventy-four dollars ($274). (3) The Medi-Cal per enrollee tax for Medi-Cal taxing tier III shall be zero dollars ($0). (j) For the 2026 calendar year, the other per enrollee tax amount for each other taxing tier shall be as follows: (1) The other per enrollee tax for the other taxing tier I shall be zero dollars ($0). (2) The other per enrollee tax for the other taxing tier II shall be two dollars and twenty-five cents ($2.25). (3) The other per enrollee tax for the other taxing tier III shall be zero dollars ($0). (k) (1) The department may modify or make adjustments to any methodology, tax amount, taxing tier, or other provision specified in this article to the extent that 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, provided the modification or adjustment does not otherwise conflict with the purposes of this article, or result in an increase in the aggregate tax amounts projected to be collected under this article that the department, in its sole discretion, determines is significant. (2) If the department identifies that modification or adjustment is necessary in accordance with paragraph (1), the department shall consult with affected health plans, to the extent practicable, to implement that modification or adjustment. (3) In the event of a modification or adjustment made pursuant to this subdivision, the department shall notify affected health plans, the Department of Finance, the Joint Legislative Budget Committee, the Senate Committees on Appropriations, Budget and Fiscal Review, and Health, and the Assembly Committees on Appropriations, Budget, and Health within 10 business days of that modification or adjustment. (l) The department shall request approval from the federal Centers for Medicare and Medicaid Services as is necessary to implement this article. In making that request, the department may seek, as it deems necessary, a request for waiver of the broad-based requirement, waiver of the uniformity requirement, or both, pursuant to Section 433.68(e)(1) and (2) of Title 42 of the Code of Federal Regulations, or a request for waiver of any other federal law or regulation necessary to implement this article. (m) 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 article by means of provider bulletins, all-plan letters, or other similar instructions, without taking any further regulatory action. The department shall provide notification to the Department of Finance, the Joint Legislative Budget Committee, the Senate Committees on Appropriations, Budget and Fiscal Review, and Health, and the Assembly Committees on Appropriations, Budget, and Health within 10 business days after the above-described action is taken. (Amended by Stats. 2024, Ch. 39, Sec. 1. (AB 160) Effective June 29, 2024. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  126. 14199.86.

    ## 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 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

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    This section makes the provider tax effective only after the stated date and federal approval, and it requires the director to post or send notices and to end the program if certain determinations are made.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.86. (a) The tax assessed under this article shall become effective and operative on April 1, 2023, or the effective date, certified in writing by the director, of the federal approval necessary for receipt of federal financial participation, whichever occurs later. The director shall post the certification of federal approval on the department’s internet website and send a copy of the certification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (b) This article, except for Section 14199.82 to the extent not in conflict with federal law, shall cease to be operative the first day of the calendar year beginning on or after the date the director, in consultation with the Director of Finance, determines that the taxes have not met the intent as outlined in Section 14199.80, or the department has not obtained the federal approval necessary for receipt of federal financial participation. The director shall post the determination on the department’s internet website and send a copy of the determination to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (c) This article, except for Section 14199.82 to the extent not in conflict with federal law, shall cease to be operative for any affected tax period or periods upon a final judicial determination made by any court of appellate jurisdiction or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that the tax assessed pursuant to this article cannot be implemented for the affected tax period or periods, and any amount of the tax paid under this article with respect to the affected tax period or periods shall be refunded. The director shall post a notification of that final judicial or federal administrative determination on the department’s internet website and provide this notification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (d) Notwithstanding this section, any tax and any applicable interest and penalties imposed under this article shall continue to be due and payable to the department until the tax and any applicable interest and penalties are fully paid. (e) Upon execution of the declaration described in subdivision (b) or (c), the director shall implement a plan, in consultation with the Department of Finance, to end the program consistent with the purpose of the article, including the recoupment of payments made under this article if required by a final judicial determination made by any court of appellate jurisdiction or a final determination made by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
  127. 14199.87.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. )

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    This section sets when the article starts, when most of it becomes inoperative and repealed, and confirms that unpaid tax, interest, and penalties remain collectible until fully paid.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.1. Managed Care Organization Provider Tax [14199.80 - 14199.87] ( Article 7.1 added by Stats. 2023, Ch. 13, Sec. 2. ) ## 14199.87. (a) This article shall become operative on the effective date, certified in writing by the director, of the federal approval necessary for receipt of federal financial participation, as described in subdivision (a) of Section 14199.86 for purposes of assessing the tax under this article. (b) (1) All sections in this article, except for Section 14199.82 to the extent not in conflict with federal law, shall become inoperative on January 1, 2027, or on a date as specified in subdivision (b) or (c) of Section 14199.86, whichever occurs first. All sections in this article, except for Section 14199.82, are repealed on January 1, 2028. (2) Notwithstanding paragraph (1), any tax and any applicable interest and penalties imposed under this article shall continue to be due and payable to the department until the tax and any applicable interest and penalties are fully paid. (Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Repealed as of January 1, 2028, by its own provisions. Repeal affects Article 7.1, commencing with 14199.80, except Section 14199.82.)
  128. 14199.90.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

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    The Legislature declares that a continued managed care organization provider tax is needed to fund Medi-Cal, maintain access to care and reimbursement, and comply with federal Medicaid 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.90. The Legislature finds and declares all of the following: (a) The Legislature continues to recognize that an enrollment-based managed care organization (MCO) provider tax is an essential and necessary source of nonfederal funding for maintaining and improving access to care and reimbursement levels under, and maximizing federal financial participation for, the Medi-Cal program. (b) The Legislature recognizes how the previous iterations of the MCO provider tax, in effect nearly continuously from July 1, 2016, enabled the state to provide ongoing funding for health care and prevention, while minimizing the need for any new reductions to the Medi-Cal program during the time periods when the tax was in effect. (c) The current MCO provider tax, set forth in Article 7.1 (commencing with Section 14199.80), expires on December 31, 2026. (d) Article 6 (commencing with Section 14199.123) of Chapter 7.5 requires the department to submit an application for a continued, permanent MCO provider tax, utilizing substantially similar models and methodologies as those for the MCO provider tax authorized in Article 7.1 (commencing with Section 14199.80), to the federal Centers for Medicare and Medicaid Services (CMS), to be effective on January 1, 2027. (e) The passage of federal H.R. 1 (Public Law 119-21) in 2025, and the publication of the CMS Final Rule on February 2, 2026, titled “Preserving Medicaid Funding for Vulnerable Populations-Closing a Health Care-Related Tax Loophole” (91 FR 4794), materially changed the standards by which CMS may approve applications for a waiver from the broad-based and uniformity requirements for health care-related taxes under Section 433.68(e) of Title 42 of the Code of Federal Regulations. (f) These new federal requirements may result in a denial of federal approval for the MCO provider tax authorized in Article 6 (commencing with Section 14199.123) of Chapter 7.5. (g) The CMS Final Rule described in subdivision (e) provided the state with a transition period through December 31, 2026, to bring the state’s MCO provider tax into compliance with the new requirements under Section 433.68(e) of Title 42 of the Code of Federal Regulations. (h) Implementation of a continued federally approvable MCO provider tax at the earliest possible effective date allowable under federal law, with an application for any necessary federal approvals submitted to CMS before the end of the state’s transition period on December 31, 2026, will best position the state to maintain and improve access to care and reimbursement levels, to maximize federal financial participation, and to minimize the need for any new reductions to the Medi-Cal program. (i) In furtherance of subdivisions (a) to (h), inclusive, it is the intent of the Legislature that the department implement an MCO provider tax effective on January 1, 2027, that is not subject to Chapter 7.5 (commencing with Section 14199.100), in order to meet all of the following goals: (1) Generate an amount of funds for the Medi-Cal program that is sufficient to fund the purposes specified in paragraphs (1) to (3), inclusive, of subdivision (d) of Section 14199.92 in full and the purpose specified in paragraph (4) of subdivision (d) of Section 14199.92 in the amount of at least two billion dollars ($2,000,000,000) annually. (2) Comply with federal Medicaid requirements applicable to permissible health care-related taxes, including, but not limited to, Section 433.68 of Title 42 of the Code of Federal Regulations. (3) Provide funding to support the Medi-Cal program. (4) Minimize, to the extent possible, the need for any new reductions to the Medi-Cal program. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Conditionally inoperative on or before January 1, 2031, as prescribed by Sections 14199.96 and 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  129. 14199.91.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

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    This section defines terms used for the managed care organization provider tax article, including the base data source, base year, countable enrollee, department, director, health plan, plan-to-plan enrollee, tax amount, and tax period.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.91. For purposes of this article, the following definitions apply: (a) “Base data source” means the quarterly financial statement filings or annual enrollment data submitted by health plans to the Department of Managed Health Care retrieved by the department no later than June 30, 2026, and supplemented by, as necessary, Medi-Cal enrollment data for the base year as maintained by the department and retrieved no later than June 30, 2026, and as modified by the department to account for known or anticipated changes that will affect Medi-Cal enrollment on or after January 1, 2027. However, if the department elects to update the base year pursuant to subdivision (b), “base data source” means the most recently available quarterly financial statement filings or annual enrollment data submitted by health plans to the Department of Managed Health Care for that updated base year, retrieved by the department, and supplemented by, as necessary, Medi-Cal enrollment data for the updated base year as maintained by the department, and as modified by the department to account for known or anticipated changes that will affect Medi-Cal enrollment. (b) “Base year” for the 2027 calendar year tax period means either the 12-month period of January 1, 2024, through December 31, 2024, or the 12-month period of January 1, 2025, through December 31, 2025, as determined by the department. For subsequent tax periods, the department may elect to update the base year to the extent that it deems such action to be consistent with the requirements of federal law or regulations, or necessary to obtain or maintain federal approval or to ensure that federal financial participation is available or is not otherwise jeopardized. (c) “Countable enrollee” means an individual enrolled in a health plan, as described in subdivision (f), during a month of the base year according to the base data source. “Countable enrollee” does not include an individual enrolled in a Medicare plan, a plan-to-plan enrollee, as defined in subdivision (h), or an individual enrolled in a health plan pursuant to the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) to the extent that the imposition of the tax under this article is preempted pursuant to Section 8909(f) of Title 5 of the United States Code. (d) “Department” means the State Department of Health Care Services. (e) “Director” means the Director of Health Care Services. (f) “Enrollee” means an individual enrolled in a health plan, as defined in subdivision (g), unless otherwise specified. (g) “Health care service plan” or “health plan” means a health care service plan, other than a plan that provides only specialized or discount services, that is licensed by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or a managed care plan contracted with the State Department of Health Care Services to provide full-scope Medi-Cal services. (h) “Plan-to-plan enrollee” means an individual who receives their health care services through a health plan pursuant to a subcontract from another health plan. (i) “Tax amount” means the amount of tax assessed per countable enrollee. (j) “Tax period” means a period of not more than 12 months for which the tax authorized by this article is assessed, in accordance with the requirements described in Section 14199.94. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Conditionally inoperative on or before January 1, 2031, as prescribed by Sections 14199.96 and 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  130. 14199.92.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

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    This section creates the Medi-Cal Stability Fund in the State Treasury and directs how money in it must be 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.92. (a) The Medi-Cal Stability Fund is hereby created in the State Treasury. (b) All revenues, less refunds, derived from the taxes provided for in this article shall be deposited in the State Treasury to the credit of the Medi-Cal Stability Fund. (c) Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on moneys in the Medi-Cal Stability Fund shall be retained in the fund and used solely for the purpose specified in subdivision (d). (d) Notwithstanding Section 13340 of the Government Code or any other law, funds deposited in the Medi-Cal Stability Fund pursuant to this article are continuously appropriated, without regard to fiscal year, to the department for the purpose of funding all of the following subcomponents to support the Medi-Cal program, in the following order of priority: (1) The department’s administrative costs in an amount not to exceed four million dollars ($4,000,000) annually. (2) The nonfederal share of increased capitation payments to Medi-Cal managed care plans accounting for their projected tax obligation pursuant to this article for the applicable tax period or periods. (3) The nonfederal share of the payments described in Section 14105.201. (4) The nonfederal share of Medi-Cal managed care rates for health care services furnished to children, adults, seniors and persons with disabilities, and persons dually eligible for the Medi-Cal program and the federal Medicare Program, in the amount of at least two billion dollars ($2,000,000,000) annually. (e) Notwithstanding any other law, the Controller may use the funds in the Medi-Cal Stability Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97.)
  131. 14199.93.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

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    The department must calculate specified enrollment totals for each health plan using the base data source, and the director may correct material or significant data errors.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.93. (a) The department shall determine for each health plan, using the base data source, all of the following: (1) Total cumulative enrollment for the base year. (2) Total Medicare cumulative enrollment for the base year. (3) Total Medi-Cal cumulative enrollment for the base year. (4) Total plan-to-plan cumulative enrollment for the base year. (5) Total cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) for the base year. (6) Total other cumulative enrollment for the base year that is not otherwise counted in paragraphs (2) to (5), inclusive. (b) Notwithstanding any other provision in this article, the director may correct any identified material or significant error in the data, including, but not limited to, the total cumulative enrollment, Medicare cumulative enrollment, Medi-Cal cumulative enrollment, plan-to-plan cumulative enrollment, cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382), and other cumulative enrollment. The director’s determination as to whether to exercise discretion under this section and any determination made by the director under this section shall not be subject to judicial review, except that a health plan may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department in correcting that health plan’s data when that correction results in a greater tax amount for that health plan pursuant to Section 14199.95. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Conditionally inoperative on or before January 1, 2031, as prescribed by Sections 14199.96 and 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  132. 14199.94.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

    Verify source ↗

    This section imposes a managed care organization provider tax on each health plan and sets how the department must compute, collect, notice, and enforce 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.94. (a) A managed care organization provider tax shall be imposed on each health plan. The tax shall be imposed for the 2027, 2028, and 2029 calendar years. The tax shall be imposed for all periods within a calendar year that the tax is effective and operative as set forth in Section 14199.96. (b) The department shall compute the annual tax for each health plan subject to the tax during each applicable calendar year pursuant to Section 14199.95. (c) The department shall collect the tax for each health plan in quarterly installments and shall determine the amount due for each installment in the applicable tax period by dividing the total tax for a tax period by the number of calendar quarters in the respective tax period. (d) The department shall not collect the tax imposed pursuant to this article until one of the following conditions is met: (1) The director certifies in writing that the tax imposed pursuant to this article is a federally permissible health care-related tax that meets the broad-based and uniformity requirements under subdivisions (b) through (d) of Section 433.68 of Title 42 of the Code of Federal Regulations and complies with federal hold-harmless requirements under Section 1396b(w)(4) of Title 42 of the United States Code and Section 433.68(f) of Title 42 of the Code of Federal Regulations. The department shall post the certification on its internet website and shall send a copy of the certification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (2) (A) The department receives written approval from the federal Centers for Medicare and Medicaid Services that this tax is a permissible health care-related tax in accordance with Section 433.68 of Title 42 of the Code of Federal Regulations. (B) Within 10 business days following the date the department receives all necessary federal approvals for the tax pursuant to this article, the director shall certify in writing that federal approval has been received, and the department shall post the certification on its internet website and shall send a copy of the certification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (e) Within 30 business days following the date the director issues a certification as set forth in paragraph (1) of subdivision (d) or the date the department receives all necessary federal approvals for the tax pursuant to this article as set forth in paragraph (2) of subdivision (d), the department shall send a notice to each health plan subject to the tax that shall contain the following information: (1) The tax due for the 2027 calendar year tax period and the estimated tax due for subsequent tax periods. (2) The dates on which the installment tax payments are due for the 2027 calendar year tax period and the estimated dates on which the installment tax payments are due for subsequent tax periods. (f) (1) A health plan shall pay the tax for each tax period in installments as calculated pursuant to Section 14199.95, based on a schedule developed by the department. The department shall establish the date that each tax payment is due, provided that the first tax payment shall be due no earlier than 20 calendar days following the date the department sends the notice pursuant to subdivision (e), and the tax payments shall be paid at least one month apart. (2) A health plan shall pay the taxes that are due, if any, in the amounts and at the times set forth in the notice unless superseded by a subsequent notice issued by the department. (g) The tax assessed pursuant to this article shall be paid by each health plan subject to the tax to the department for deposit in the Medi-Cal Stability Fund created pursuant to Section 14199.92. (h) (1) Interest shall be assessed on an applicable health plan for any amount of the managed care organization provider taxes that are not paid on the date due at a rate of 10 percent per annum. Interest shall begin to accrue the day after the date the tax payment was due and shall be deposited in the Medi-Cal Stability Fund created pursuant to Section 14199.92. (2) If a tax payment is more than 60 days overdue, a penalty equal to the total accrued interest charge described in paragraph (1) shall also be assessed on the applicable health plan and due for each month for which the tax payment is not received after 60 days. (i) (1) Subject to paragraph (2), the director may waive a portion or all of either the interest or penalties, or both, assessed under this article if the director determines, in their sole discretion, that the health plan has demonstrated that imposition of the full amount of the tax pursuant to the timelines applicable under this article has a high likelihood of creating an undue financial hardship for the health plan or creates a significant financial difficulty in providing needed services to Medi-Cal members. (2) Waiver of some or all of the interest or penalties pursuant to this subdivision shall be conditioned on the health plan’s agreement to make tax payments on an alternative schedule developed by the department that takes into account the financial situation of the health plan and the potential impact on the delivery of services to Medi-Cal members. (j) In the event of a merger, acquisition, establishment, or any other similar transaction that results in the transfer of health plan responsibility for all countable enrollees under this article from a health plan to another health plan or similar entity, and that occurs at any time during which this article is operative, the resultant health plan or similar entity shall be responsible for paying the full tax amount as provided in this article that would have been the responsibility of the health plan to which that full tax amount was assessed upon the effective date of any such transaction. If a merger, acquisition, establishment, or any other similar transaction results in the transfer of health plan responsibility for only some of a health plan’s countable enrollees under this article but not all countable enrollees, the full tax amount as provided in this article shall remain the responsibility of that health plan to which that full tax amount was assessed. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Conditionally inoperative on or before January 1, 2031, as prescribed by Sections 14199.96 and 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  133. 14199.95.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

    Verify source ↗

    This section sets the managed care organization provider tax amount for health plans and gives the department power to adjust, implement, and seek federal approval for 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.95. (a) (1) For each calendar year in which the managed care organization provider tax authorized by this article is in effect, the tax amount for each health plan shall be eight dollars and eighty-five cents ($8.85) per countable enrollee per month, unless modified in accordance with paragraph (2) or (3) or with subdivision (b). (2) (A) The department may calculate and impose an alternative tax amount upon a determination by the department, in its sole discretion, that the tax amount in paragraph (1) is projected to generate revenues that are lower or materially higher than are needed to meet the goal described in paragraph (1) of subdivision (i) of Section 14199.90. (B) The alternative tax amount pursuant to subparagraph (A) shall not be higher or lower than the tax amount in paragraph (1) by more than 10 percent for the 2027 calendar year tax period and by more than 25 percent for subsequent tax periods. (3) (A) The department may establish taxing tiers consisting of discrete ranges of countable enrollees and may calculate and impose alternative tax amounts for these taxing tiers, but only to the extent consistent with the purposes of this article and necessary to achieve legitimate public policy goals. (B) (i) The average of the alternative tax amounts pursuant to subparagraph (A), weighted according to the applicable number of countable enrollees, shall not exceed the limits specified in subparagraph (B) of paragraph (2). (ii) The alternative tax amounts pursuant to subparagraph (A) shall not result in an increase in the aggregate tax amounts projected to be collected from any health plan under this article that the department, in its sole discretion, determines is significant. (b) The department may modify or make adjustments to any methodology, tax amount, taxing tier, or other provision specified in this article to the extent that it deems necessary to meet the requirements of federal law or regulations, to obtain or maintain federal approval, or to ensure that federal financial participation is available or is not otherwise jeopardized, provided the modification or adjustment does not otherwise conflict with the purposes of this article, or result in an increase in the aggregate tax amounts projected to be collected under this article that the department, in its sole discretion, determines is significant. (c) (1) If the department calculates and imposes an alternative tax amount or amounts in accordance with paragraph (2) or (3) of subdivision (a) or identifies that modification or adjustment is necessary in accordance with subdivision (b), the department shall consult with affected health plans, to the extent practicable, to implement that alternative tax amount or amounts or modification or adjustment, as applicable. (2) In the event of imposition of an alternative tax amount or amounts in accordance with paragraph (2) or (3) of subdivision (a) or a modification or adjustment made pursuant to subdivision (b), the department shall notify affected health plans, the Department of Finance, the Joint Legislative Budget Committee, the Senate Committees on Appropriations, Budget and Fiscal Review, and Health, and the Assembly Committees on Appropriations, Budget, and Health within 10 business days of taking the applicable action. (d) The department shall request approval from the federal Centers for Medicare and Medicaid Services as is necessary to implement this article. In making that request, the department may seek, as it deems necessary, a request for waiver of the broad-based requirement, waiver of the uniformity requirement, or both, pursuant to Section 433.68(e) of Title 42 of the Code of Federal Regulations, or a request for waiver of any other federal law or regulation necessary to implement this article. (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 article by means of provider bulletins, all-plan letters, or other similar instructions, without taking any further regulatory action. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Conditionally inoperative on or before January 1, 2031, as prescribed by Sections 14199.96 and 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  134. 14199.96.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

    Verify source ↗

    This section sets when the managed care organization provider tax becomes operative, and when the article must stop operating if federal approval, compliance, or implementation problems arise.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.96. (a) The tax assessed under this article shall become effective and operative on January 1, 2027, or the effective date, certified in writing by the director, of federal approval if such approval is necessary, whichever occurs later. When such federal approval is necessary and is secured, the director shall post the certification of federal approval on the department’s internet website and shall send a copy of the certification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, and the Executive Officer of the Franchise Tax Board. (b) This article, except for Section 14199.92 to the extent not in conflict with federal law, shall cease to be operative the first day of the calendar year beginning on or after the date the director, in consultation with the Director of Finance, determines that the tax has not met the intent as outlined in Section 14199.90 or that the tax was rejected where federal approval was necessary or found out of compliance with federal law by the federal Centers for Medicare and Medicaid Services and the director determines that it is not feasible to modify the tax to achieve such federal approval or compliance. The director shall post the determination on the department’s internet website and shall send a copy of the determination to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, the Department of Finance, and the Executive Officer of the Franchise Tax Board. (c) This article, except for Section 14199.92 to the extent not in conflict with federal law, shall cease to be operative for any affected tax period or periods upon a final judicial determination made by any court of appellate jurisdiction, or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services, that the tax assessed pursuant to this article cannot be implemented for the affected tax period or periods, and any amount of the tax paid under this article with respect to the affected tax period or periods shall be refunded. The director shall post a notification of that final judicial or federal administrative determination on the department’s internet website and shall provide this notification to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, the State Board of Equalization, the Department of Insurance, the Department of Finance, and the Executive Officer of the Franchise Tax Board. (d) Notwithstanding this section, any tax and any applicable interest and penalties imposed under this article shall continue to be due and payable to the department until the tax and any applicable interest and penalties are fully paid. (e) Upon execution of the declaration described in subdivision (b) or (c), the director shall implement a plan, in consultation with the Department of Finance, to end the program consistent with the purpose of the article, including the recoupment of payments made under this article if required by a final judicial determination made by any court of appellate jurisdiction or a final determination made by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Operative July 1, 2026, pursuant to Section 14199.97. Repealed as of January 1, 2032, pursuant to Section 14199.97.)
  135. 14199.97.

    ## 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 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. )

    Verify source ↗

    This section sets when Article 7.2 starts, when most of it becomes inoperative, when most of it is repealed, and says taxes, interest, and penalties imposed under the article remain due until fully paid.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 7.2. Continuation of Managed Care Organization Provider Tax [14199.90 - 14199.97] ( Article 7.2 added by Stats. 2026, Ch. 24, Sec. 2. ) ## 14199.97. (a) This article shall become operative on July 1, 2026, or the date on which the act that added this article is chaptered, whichever is later. (b) (1) All sections in this article, except for Section 14199.92 to the extent not in conflict with federal law, shall become inoperative on January 1, 2031, or on a date as specified in subdivision (b) or (c) of Section 14199.96, whichever occurs first. All sections in this article, except for Section 14199.92, are repealed on January 1, 2032. (2) Notwithstanding paragraph (1), any tax and any applicable interest and penalties imposed under this article shall continue to be due and payable to the department until the tax and any applicable interest and penalties are fully paid. (Added by Stats. 2026, Ch. 24, Sec. 2. (SB 125) Effective June 29, 2026. Repealed as of January 1, 2032, by its own provisions. Note: Repeal affects Article 7.2, commencing with Section 14199.90, except Section 14199.92.)
  136. 14200.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This chapter is named the Waxman-Duffy Prepaid Health Plan Act and may be cited by that name.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14200. This chapter shall be known and may be cited as the Waxman-Duffy Prepaid Health Plan Act. (Added by Stats. 1972, Ch. 1366.)
  137. 14200.1.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section states that the chapter’s purpose is to let eligible persons enroll as regular subscribers in prepaid health plans, without regard to marital status or characteristics listed in Government Code Section 11135.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14200.1. The purpose of this chapter is to afford persons eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part the opportunity to enroll as regular subscribers in prepaid health plans, without reference to marital status or any characteristic listed or defined in Section 11135 of the Government Code. (Amended by Stats. 2008, Ch. 682, Sec. 11. Effective January 1, 2009.)
  138. 14201.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section states the Legislature’s intent to make prepaid health plans available to certain public assistance and medically indigent persons, and to improve Medi-Cal care delivery and costs.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14201. The intent of the Legislature is to provide, to the extent feasible, through the provisions of this chapter and the necessarily related provisions of Chapter 7 (commencing with Section 14000) of this part, recipients of public assistance and medically indigent aged and other persons with the opportunity to enroll in prepaid health plans. It is further intended that this legislation is to benefit the people of the State of California by: (a) Encouraging the development of more efficient delivery of health care to Medi-Cal recipients. (b) Reducing the inflationary costs of health care. (c) Improving the quality of medical services rendered to those eligible enrollees as defined in this chapter and Chapter 7 (commencing with Section 14000) of this part. (d) Reducing administrative costs of operating the Medi-Cal Act by allowing prepaid health plans to assume substantial costs of administration and utilization controls that are now assumed by the State Department of Health Services. (Amended by Stats. 1977, Ch. 1252.)
  139. 14203.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    The department has power to administer this chapter and related Chapter 7, and may adopt regulations, including emergency regulations, to ensure compliance.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14203. (a) For purposes of administering this chapter and Chapter 7 (commencing with Section 14000) of this part, the department is hereby designated as the single or appropriate state agency with full power to administer and adopt regulations in order to secure full compliance with applicable provisions of state and federal laws. (b) The department may adopt regulations implementing this chapter 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. Initial regulations to implement this chapter may be adopted as emergency regulations. The adoption of these initial emergency regulations shall be considered by the Office of Administrative Law as necessary for the immediate preservation of the public peace, health, and safety, or general welfare. Initial emergency regulations adopted pursuant to this section shall remain in effect for no more than 180 days. (c) This section shall become operative on January 1, 1995. (Repealed (in Sec. 5) and added by Stats. 1993, Ch. 573, Sec. 6. Effective September 28, 1993. Section operative January 1, 1995, by its own provisions.)
  140. 14204.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

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    The department may contract with prepaid health plans and certain children’s hospitals, and contracts under this chapter can be awarded on a bid or nonbid basis; contracts under this chapter are exempt from a Public Contract Code chapter, and the department must amend certain dental health plan contracts for Medi-Cal dental 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14204. (a) Pursuant to the provisions of this chapter, the department may contract with one or more prepaid health plans in order to provide the benefits authorized under this chapter and Chapter 7 (commencing with Section 14000) of this part. The department may contract with one or more children’s hospitals on an exclusive basis for a specified population in a specified geographic area. Contracts entered into pursuant to this chapter may be awarded on a bid or nonbid basis. (b) In order to achieve maximum cost savings the Legislature hereby determines that expedited contract process for contracts under this chapter is necessary. Therefore, contracts under this chapter shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (c) The department shall amend contracts with dental health plans in effect on the date the act that added this subdivision and Section 14459.6 become effective to provide Medi-Cal dental services authorized under this chapter and Chapter 7 (commencing with Section 14000) to Medi-Cal beneficiaries who reside in a specified geographic area to meet the requirements of Sections 14089.09 and 14459.6. (Amended by Stats. 2012, Ch. 23, Sec. 112. (AB 1467) Effective June 27, 2012.)
  141. 14205.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    Chapter 7’s general provisions apply to Chapter 8 prepaid plans, unless context requires otherwise or a specific exception is authorized.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14205. Except where the context otherwise requires, or where specific exceptions are authorized, all provisions of Chapter 7 (commencing with Section 14000) of this part shall be applicable to the provisions of this chapter and the violation of the provisions of this chapter or any rule or regulation adopted pursuant thereto shall be deemed to be a violation of Chapter 7. (Added by Stats. 1977, Ch. 1036.)
  142. 14206.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    Prepaid health plans and pilot programs are not treated as transacting insurance or being subject to the Insurance Code because they enter into or perform contracts under this chapter, and the director may require security for such contracts.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 1. General Provisions [14200 - 14206] ( Article 1 added by Stats. 1972, Ch. 1366. ) ## 14206. (a) No prepaid health plan or pilot program shall be deemed to transact insurance or to be subject to any provision of the Insurance Code by virtue of negotiating, executing, or performing a prepaid health plan or pilot program contract under this chapter, or by virtue of compliance with the provisions of such a prepaid health plan or pilot program contract, including, but not limited to, creation, segregation, or maintenance of security to protect or safeguard the performance of such a prepaid health plan or pilot program contract. The director may require such security in respect to any such contract including, but not limited to, securities, surety bonds, or evidences of governmental debt, of the kinds, in the manner, and to the extent provided by the prepaid health plan or pilot program contract. (b) Prepaid health plans or pilot programs to which the state is a party under the provisions of this chapter, and contracts and arrangements embodying such plans or programs shall not be subject to the provisions of law prescribing the forms of hospital or medical service or insurance contracts or requiring approval thereof or of the form thereof, by any state officer or agency except the director or the department. This exemption applies, but is not limited to: (1) Chapter 4 (commencing with Section 10270) of Part 2 of Division 2 of the Insurance Code, (2) Section 11069 of the Insurance Code, and (3) Section 11513 of the Insurance Code. However, the exemption provided for in this section shall not exempt any insurer subject to taxation under Part 7 (commencing with Section 12001) of Division 2 of the Revenue and Taxation Code from the tax imposed under such part on gross premiums derived from contracts under this chapter. (Added by Stats. 1977, Ch. 1036.)
  143. 14250.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section says the article’s definitions control how this chapter is read unless the context 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14250. Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter. (Added by Stats. 1972, Ch. 1366.)
  144. 14251.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “prepaid health plan” and lets the State Director of Health Care Services waive certain chapter provisions for a fiscal intermediary at risk, except the licensure requirement.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14251. (a) (1) “Prepaid health plan” means a plan that meets all of the following criteria: (A) Is licensed as a health care service plan by the Director of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), other than a plan organized and operating pursuant to Section 10810 of the Corporations Code that substantially indemnifies subscribers or enrollees for the cost of provided services, or has an application for licensure pending and was registered under the Knox-Mills Health Plan Act prior to its repeal. (B) Meets the requirements for participation in the Medicaid program (Title XIX of the Social Security Act) on an at-risk basis. (C) Agrees with the State Department of Health Care Services to furnish directly or indirectly health services to Medi-Cal beneficiaries on a predetermined periodic rate basis. (2) “Prepaid health plan” includes any organization that is licensed as a plan pursuant to the Knox-Keene Health Care Service Plan Act of 1975 and is subject to regulation by the Department of Managed Health Care pursuant to that act, and that contracts with the State Department of Health Care Services solely as a fiscal intermediary at risk. (b) (1) Except for the requirement of licensure pursuant to the Knox-Keene Health Care Service Plan Act of 1975, the State Director of Health Care Services may waive any provision of this chapter that the director determines is inappropriate for a fiscal intermediary at risk. An exemption or waiver shall be set forth in the fiscal intermediary at-risk contract with the State Department of Health Care Services. (2) “Fiscal intermediary at risk” means any entity that entered into a contract with the State Department of Health Care Services on a pilot basis pursuant to subdivision (f) of Section 14000, as in effect June 1, 1973, in accordance with which the entity received capitated payments from the state and reimbursed providers of health care services on a fee-for-service or other basis for at least the basic scope of health care services, as defined in Section 14256, provided to all beneficiaries covered by the contract residing within a specified geographic region of the state. The fiscal intermediary at risk shall be at risk for the cost of administration and utilization of services or the cost of services, or both, for at least the basic scope of health care services, as defined in Section 14256, provided to all beneficiaries covered by the contract residing within a specified geographic region of the state. The fiscal intermediary at risk may share the risk with providers or reinsuring agencies or both. Eligibility of beneficiaries shall be determined by the State Department of Health Care Services and capitation payments shall be based on the number of beneficiaries so determined. (Amended by Stats. 2015, Ch. 455, Sec. 53. (SB 804) Effective January 1, 2016.)
  145. 14252.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Medi-Cal beneficiary” means a person eligible to receive benefits under Chapter 7 (starting with Section 14000) of this part.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14252. “Medi-Cal beneficiary” means a person who is eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part. (Added by Stats. 1972, Ch. 1366.)
  146. 14253.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “subcontract” for a prepaid health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14253. “Subcontract” means an agreement entered into by the prepaid health plan with any of the following: (a) A provider of health care services who agrees to furnish such services to Medi-Cal beneficiaries enrolled in the prepaid health plan. (b) A marketing organization. (c) Any other person or organization who agrees to perform any administrative function or service for the operation of the prepaid health plan specifically related to securing or fulfilling its contractual obligations with the department. (Added by Stats. 1974, Ch. 983.)
  147. 14254.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “primary care physician” and describes the responsibilities of primary care physicians and supervised nonphysician medical practitioners.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14254. (a) “Primary care physician” is a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. (b) A nonphysician medical practitioner, as defined in subdivision (c) of Section 14088, who is supervised by a primary care physician, has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. (Amended by Stats. 2013, Ch. 684, Sec. 5. (SB 494) Effective January 1, 2014.)
  148. 14255.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Specialist” means a physician who is board certified or board eligible in the specialty of medical care 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14255. “Specialist” means a physician who is board certified or board eligible in the specialty of medical care provided. (Amended by Stats. 1974, Ch. 983.)
  149. 14256.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “basic scope of health care benefits” to include physician’s services, hospital outpatient services, laboratory and X-ray, prescription drugs, hospital inpatient care, and skilled nursing facility 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14256. The “basic scope of health care benefits” means: (a) Physician’s services; (b) Hospital outpatient services; (c) Laboratory and X-ray; (d) Prescription drugs; (e) Hospital inpatient care; (f) Skilled nursing facility care. (Amended by Stats. 1974, Ch. 1240.)
  150. 14257.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    The director is not barred from contracting with licensed specialized health care service plans that provide only dental, pharmaceutical, optometric, or psychological services, if the contract follows department 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14257. Nothing in this act shall preclude the director from contracting with licensed specialized health care service plans which provide only dental, pharmaceutical, optometric, or psychological services in accordance with regulations issued by the department. (Amended by Stats. 1977, Ch. 1036.)
  151. 14258.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Service area” means the area designated by the department where a prepaid health plan must provide health care services and where eligible Medi-Cal beneficiaries live for enrollment.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14258. “Service area” means a geographical area designated by the department within which a prepaid health plan shall provide health care services and within which the Medi-Cal beneficiaries eligible for enrollment in the prepaid health plan reside. (Added by Stats. 1974, Ch. 983.)
  152. 14259.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “Director” as the State Director of Health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14259. “Director” means the State Director of Health Services. (Amended by Stats. 1977, Ch. 1252.)
  153. 14260.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Department” means the State Department of Health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14260. “Department” means the State Department of Health Services. (Amended by Stats. 1977, Ch. 1252.)
  154. 14261.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Vendor” is defined as a person who provides services or supplies to a prepaid health plan or its subcontractor, and who does not have the specified subcontract.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14261. “Vendor” means any person who provides services or supplies to a prepaid health plan or a subcontractor of a prepaid health plan and who does not have a subcontract as defined by Section 14253 with either the prepaid health plan or its subcontractors. (Repealed and added by Stats. 1977, Ch. 1036.)
  155. 14263.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “marketing” for prepaid health plans.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14263. “Marketing” means any activity conducted by or on behalf of a prepaid health plan where information regarding the services offered by a prepaid health plan is disseminated in order to persuade Medi-Cal beneficiaries to enroll or accept any application for enrollment in the prepaid health plan. Marketing shall also include any similar activity to procure the endorsement of the prepaid health plan from any individual or organization. (Amended by Stats. 1977, Ch. 1036.)
  156. 14264.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    “Marketing organization” means a subcontractor that agrees to provide marketing services for a prepaid health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14264. “Marketing organization” means any subcontractor who agrees to provide marketing services for a prepaid health plan. (Amended by Stats. 1977, Ch. 1036.)
  157. 14265.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. )

    Verify source ↗

    This section defines “marketing representative” as a person who markets for a marketing organization or the prepaid health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 2. Definitions [14250 - 14265] ( Article 2 added by Stats. 1972, Ch. 1366. ) ## 14265. “Marketing representative” means any person who engages in marketing activities on behalf of a marketing organization or the prepaid health plan. (Added by Stats. 1974, Ch. 983.)
  158. 14300.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must give at least 60 days’ notice before an initial or renewed contract, publish the notice in local newspapers in the prepaid health plan’s service area, and cannot sign the contract until it decides the plan can fully meet its obligations.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14300. The department shall publish a notice of intent to contract at least 60 days prior to the effective date of any initial or renewed contract. The notice shall appear in local newspapers circulated in the service areas of the prepaid health plan. The notice shall announce the department’s intent to contract and any person affected by the contract shall have the opportunity to request that a public hearing be held. The request for public hearing shall be accompanied by an explanation of the reason for the request and a description of problems or questions regarding the plan’s ability to meet its contractual obligations. A hearing shall be held by the department if the director determines that the request is reasonable and warrants a full public hearing. A request shall be considered reasonable if there is a question regarding the plan’s ability to meet its contractual obligations. No contract shall be signed by the department until the department determines that the plan has the ability to fully comply with its contractual obligations. (Amended by Stats. 1984, Ch. 1338, Sec. 4.)
  159. 14301.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must set prepaid health plan per-capita payment rates using actuarial methods and an actuary, and the contract must state the rates and the actuarial basis 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301. (a) The department shall determine, by actuarial methods, prospective per capita rates of payment for services provided under this chapter for Medi-Cal beneficiaries enrolled in a prepaid health plan. The rates of payment shall be determined annually, shall be effective no later than either the first day of July each year, or another date chosen by the department, and shall not exceed the total per capita amount (including cost of administration) which the department estimates (with appropriate adjustments to provide actuarial equivalence) would be payable for all services and requirements covered under the prepaid health plan contract if all such services and requirements were to be furnished to Medi-Cal beneficiaries under the fee-for-service Medi-Cal program provided for by Chapter 7 (commencing with Section 14000). In the event that there is any delay in the payment of the new annual rates determined pursuant to this subdivision, continued payment to the prepaid health plan of the rate in effect at the time the delay occurred shall be interim payment only, and shall be subject to increase or decrease, as the case may be, to the level of the new annual rates effective as of either the first day of July or the date chosen by the department. Notwithstanding the foregoing provision, in the event that a contract amendment providing for the new annual rates has been executed by the department and a prepaid health plan, but has not yet received the approval of all required control agencies and departments by the end of the first month following the effective date of the new rate, payment of the new annual rates shall commence no later than the first day of the second month following the effective date of the new rate. Contract amendments providing for the new annual rates shall provide that the prepaid health plan contractor agrees that by accepting payment of the new annual rates prior to final approval, such contractor stipulates to a confession of judgment for any amounts received in excess of the final approved rate. If the final approved rates differ from the rates set forth in such amendments, any underpayment by the state shall be paid by the department to the prepaid health plan within 30 days after final approval of such rates. Any overpayment by the state shall be recaptured by the state withholding the amount due from the prepaid health plan’s next capitation check. If the amount to be withheld from subsequent capitation checks exceeds 25 percent of the appropriate capitation payment for that month, amounts up to 25 percent shall be withheld from each successive monthly capitation payment until such deficiencies are recovered by the state. The contract shall provide the specific per capita rates, to be determined by sound actuarial methods on the basis of age, sex, and aid categories, which the state shall pay the prepaid health plan each month for each beneficiary enrolled in the prepaid health plan, a detailed description of the specific actuarial method or methods and assumptions used in determining per capita rates, and a summary of the data base, including costs and inflation assumptions and utilization rates, which was used to determine per capita rates. In addition, the director shall engage and rely upon the services of an actuary or consulting actuary in determining prospective per capita rates. (b) Any prepaid health plan with an operating experience and scale of operation deemed by the department to be insufficient to justify the application of an actuarially determined per capita rate, shall be reimbursed on a cost basis up to the fee-for-service maximum for services provided until such time as the director determines that a per capita method is reasonable, but not to exceed a period of one year. For purposes of this section, costs shall be net of intercompany profits in those circumstances where any of the following persons have a substantial financial interest, as defined by Section 14478, in any vendor to the prepaid health plan or any vendor to a subcontractor of the plan: (1) Any person also having a substantial financial interest in the plan. (2) Any director, officer, partner, trustee or employee of the plan. (3) Any member of the immediate family of any person designated in paragraph (1) or (2). (c) The obligations of a prepaid health plan shall be changed only by contract or contract amendment. Any such change may be made during a contract term or at the time of contract renewal, where there is a change in obligations required by federal or state law or regulation, or required by a change in the interpretation or implementation of any such law or regulation. If any such change in obligations occurs which affects the cost to a prepaid health plan of performing under the terms of its contract, then the per capita rates under the contract may be redetermined in the manner provided by subdivision (a) to reflect such change. During such period of time as is required to redetermine the per capita rates, payment to a prepaid health plan of the per capita rates in effect at the time such change occurred shall be considered interim payments and shall be subject to increase or decrease, as the case may be, effective as of the date on which such change is effective. (d) The obligations of a prepaid health plan shall be changed only by contract or contract amendment wherein payment for the changes, whether payment results in an increase or decrease in the prior per capita rates paid to a prepaid health plan, shall be determined in accordance with this section and paid to affected prepaid health plans. (e) Nothing contained in this section shall be construed as removing from a prepaid health plan the risk of beneficial or adverse effects, including inflation, which normally result from contracting to furnish health services. (f) Per capita rates of payment for services provided to Medi-Cal beneficiaries enrolled in prepaid health plans or Medi-Cal managed care plans contracting in areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3 or contracting under Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96, 14089, and 14089.05 shall be paid by the state effective the date a beneficiary’s enrollment takes effect. A primary care provider or clinic contracting with a prepaid health plan or a Medi-Cal managed care plan on a capitation basis and whose assignment to or selection by a beneficiary has been confirmed by the plan shall be paid capitation payments effective the date of the beneficiary’s enrollment. However, a primary care provider whose assignment to or selection by a beneficiary was not confirmed by the plan on the date of the beneficiary’s enrollment, but is later confirmed by the plan, shall be paid capitation payments effective no later than 30 days after the beneficiary’s enrollment. The prepaid health plan or Medi-Cal managed care plan shall be financially responsible for all Medi-Cal services covered under the contract with the department for any newly enrolled beneficiary until that beneficiary has a confirmed assignment to a primary care provider or clinic. This subdivision shall not apply when a beneficiary requests a change in primary care provider after initial selection or assignment. (Amended by Stats. 1995, Ch. 859, Sec. 7. Effective January 1, 1996.)
  160. 14301.1.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

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    The department must set and pay Medi-Cal managed care capitation rates using actuarial methods, and health plans must provide financial and utilization data for rate 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.1. (a) For rates established on or after August 1, 2007, the department shall pay capitation rates to health plans participating in the Medi-Cal managed care program using actuarial methods and may establish health-plan- and county-specific rates. Notwithstanding any other law, this section shall apply to any managed care organization, licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), that has contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS for rates established on or after July 1, 2012. The department shall utilize a county- and model-specific rate methodology to develop Medi-Cal managed care capitation rates for contracts entered into between the department and any entity pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), and Article 2.91 (commencing with Section 14089) of Chapter 7 that includes, but is not limited to, all of the following: (1) Health-plan-specific encounter and claims data. (2) Supplemental utilization and cost data submitted by the health plans. (3) Fee-for-service data for the underlying county of operation or other appropriate counties as deemed necessary by the department. (4) Department of Managed Health Care financial statement data specific to Medi-Cal operations. (5) Other demographic factors, such as age, gender, or diagnostic-based risk adjustments, as the department deems appropriate. (b) To the extent that the department is unable to obtain sufficient actual plan data, it may substitute plan model, similar plan, or county-specific fee-for-service data. (c) The department shall develop rates that include administrative costs, and may apply different administrative costs with respect to separate aid code groups. (d) The department shall develop rates that shall include, but are not limited to, assumptions for underwriting, return on investment, risk, contingencies, changes in policy, and a detailed review of health plan financial statements to validate and reconcile costs for use in developing rates. (e) The department may develop rates that pay plans based on performance incentives, including quality indicators, access to care, and data submission. (f) The department may develop and adopt condition-specific payment rates for health conditions, including, but not limited to, childbirth delivery. (g) (1) Before finalizing Medi-Cal managed care capitation rates, the department shall provide health plans with information on how the rates were developed, including rate sheets for that specific health plan, and provide the plans with the opportunity to provide additional supplemental information. (2) For contracts entered into between the department and any entity pursuant to Article 2.8 (commencing with Section 14087.5) of Chapter 7, the department, by June 30 of each year, or, if the budget has not passed by that date, no later than five working days after the budget is signed, shall provide preliminary rates for the upcoming fiscal year. (h) For the purposes of developing capitation rates through implementation of this ratesetting methodology, Medi-Cal managed care health plans shall provide the department with financial and utilization data in a form and substance as deemed necessary by the department to establish rates. These data shall be considered proprietary and shall be exempt from disclosure as official information pursuant to Section 7927.705 of the Government Code as contained in the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code). (i) Notwithstanding any other law, on and after the effective date of the act adding this subdivision, the department may apply this section to the capitation rates it pays under any managed care health plan contract. (j) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may set and implement managed care capitation rates, and interpret or make specific this section and any applicable federal waivers and state plan amendments by means of plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. (k) (1) The department shall report, upon request, to the fiscal and policy committees of the respective houses of the Legislature regarding implementation of this section. (2) The department shall publish on its public internet website a description of the rate methodology, data used for rate development, and core actuarial assumptions and adjustments in each year that the department develops rates pursuant to this section. (l) Before October 1, 2011, the risk-adjusted countywide capitation rate shall comprise no more than 20 percent of the total capitation rate paid to each Medi-Cal managed care plan. (m) (1) It is the intent of the Legislature to preserve the policy goal to support and strengthen traditional safety net providers who treat high volumes of uninsured and Medi-Cal patients when Medi-Cal enrollees are defaulted into Medi-Cal managed care plans. (2) As the department adds additional factors, such as managed care plan costs, to the Medi-Cal managed care plan default assignment algorithm, it shall consult with the Auto Assignment Performance Incentive Program stakeholder workgroup to develop cost factor disregards related to intergovernmental transfers and required wraparound payments that support safety net providers. (n) (1) The department shall develop and pay capitation rates to entities contracted pursuant to Chapter 8.75 (commencing with Section 14591), using actuarial methods and in a manner consistent with this section, except as provided in this subdivision. (2) (A) The department may develop capitation rates using a standardized rate methodology across managed care plan models for comparable populations. The specific rate methodology applied to PACE organizations shall address features of PACE that distinguishes it from other managed care plan models. (B) The rate methodology shall be consistent with actuarial rate development principles and shall provide for all reasonable, appropriate, and attainable costs for each PACE organization within a region. (3) The department may develop statewide rates and apply geographic adjustments, using available data sources deemed appropriate by the department. Consistent with actuarial methods, the primary source of data used to develop rates for each PACE organization shall be its Medi-Cal cost and utilization data or other data sources as deemed necessary by the department. (4) Rates developed pursuant to this subdivision shall reflect the level of care associated with the specific populations served under the contract. (5) The rate methodology developed pursuant to this subdivision shall contain a mechanism to account for the costs of high-cost drugs and treatments. (6) Rates developed pursuant to this subdivision shall be actuarially certified before implementation. (7) The department shall consult with those entities contracted pursuant to Chapter 8.75 (commencing with Section 14591) in developing a rate methodology according to this subdivision. (8) Consistent with the requirements of federal law, the department shall calculate an upper payment limit for payments to PACE organizations. In calculating the upper payment limit, the department shall correct the applicable data as necessary and shall consider the risk of nursing home placement for the comparable population when estimating the level of care and risk of PACE participants. (9) The department shall pay the entity at a rate within the certified actuarially sound rate range developed with respect to that entity, to the extent consistent with federal requirements and subject to paragraph (11), as necessary to mitigate the impact to the entity of the methodology developed pursuant to this subdivision. (10) During the first two years in which a new PACE organization or existing PACE organization enters a previously unserved area, the department shall pay at a rate within the certified actuarially sound rate range developed with respect to that entity, to the extent consistent with federal requirements and subject to paragraph (11), to reflect the lower enrollment and higher operating costs associated with a new PACE organization relative to a PACE organization with higher enrollment and more experience providing managed care interventions to its beneficiaries. (11) This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available. (12) This subdivision shall apply for rates implemented no earlier than January 1, 2017. (o) (1) Notwithstanding any other law, as a component of the CalAIM Initiative authorized pursuant to Article 5.51 (commencing with Section 14184.100) of Chapter 7, and any successor waiver, demonstration, or state plan amendment authorizing the Medi-Cal managed care program, the department may establish capitation rates to contracted health plans on a regional basis in lieu of health plan and county-specific rates. (2) Before initially implementing regional-based capitation rates under this subdivision, the department shall report to the Legislature on the process for developing those regional rates and determining the regional groups. (3) The department shall provide a briefing to providers and stakeholders, including, but not limited to, physicians, hospitals, and consumer advocates, that describes the actuarial assumptions and rate methodologies used by the department following submission of rates to the federal government for approval that initially implement regional-based capitation rates under this subdivision. This publicly noticed meeting to providers and other stakeholders shall occur no more than 60 days after submission of the capitation rates to the federal government for approval. The meeting shall be for explanatory purposes and shall not otherwise impact the methodology and data provided to the federal government for approval. (4) The department shall consult with affected contracted health plans in developing the regional groups and rate methodologies, consistent with applicable federal requirements, actuarial methods, and the CalAIM Terms and Conditions as defined in subdivision (c) of Section 14184.101 prior to implementing this subdivision. In developing and implementing any methodology pursuant to this subdivision, the department shall seek to incentivize improved quality and outcomes for Medi-Cal managed care enrollees. (5) This subdivision shall be implemented only to the extent that the department obtains any necessary federal approvals, and that federal financial participation is available and not otherwise jeopardized. (p) (1) It is the intent of the Legislature that both affected contracted health plans and the state have appropriate actuarial protections against the risk of either significant overpayments or significant underpayments in capitation rates developed and paid pursuant to this section that are associated with the changes to the Medi-Cal managed care program described in Article 5.51 (commencing with Section 14184.100) of Chapter 7, as identified by the department. (2) (A) Notwithstanding any other law, as a component of the CalAIM initiative authorized pursuant to Article 5.51 (commencing with Section 14184.100) of Chapter 7, and any successor waiver, demonstration, or state plan amendment authorizing the Medi-Cal managed care program, the department may develop and implement appropriate actuarial methods to prevent significant overpayments or significant underpayments as described in paragraph (1), subject to paragraph (4). This may include, but need not be limited to, one or more of the following: (i) A medical or profit and loss risk corridor. (ii) Blended capitation rates based on projected member risk. (iii) Other prospective or retrospective shared savings or risk models. (B) The methods or models described in subparagraph (A) shall seek to encourage quality improvement and promote appropriate utilization incentives, including, but not limited to, reduced rehospitalization and shorter lengths of institutional stay. (3) The department shall consult with affected contracted health plans in implementing this subdivision. (4) This subdivision shall be implemented only to the extent that the department obtains any necessary federal approvals, and that federal financial participation is available and not otherwise jeopardized. (Amended by Stats. 2022, Ch. 28, Sec. 163. (SB 1380) Effective January 1, 2023.)
  161. 14301.11.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

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    The department must develop, pay, and adjust Medi-Cal managed care capitation rates and may use a risk corridor and other adjustments tied to the COVID-19 public health emergency, subject to federal approvals and specified 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.11. (a) Notwithstanding any law, and subject to subdivisions (e) and (f), in order to account for the impacts of the COVID-19 public health emergency on Medi-Cal managed care capitation rates, the department shall develop and pay capitation rates and capitation increments under any Medi-Cal managed care plan contract pursuant to this section. (b) In consultation with affected Medi-Cal managed care plans, the department shall develop and implement a risk corridor that is symmetrical to risk and profit to limit the financial risk of either significant capitation rate overpayments or underpayments, pursuant to both of the following: (1) The risk corridor shall apply to those capitation increments, services and populations, as determined by the department. (2) The risk corridor shall apply from July 1, 2019, to December 31, 2020, inclusive. The department may continue to apply the risk corridor for rating periods starting on or after January 1, 2021, if the department determines that the continuation of the risk corridor is actuarially appropriate and necessary to account for the impacts of the COVID-19 public health emergency. (c) To the extent the department determines appropriate, the department shall reduce applicable capitation rate increments by up to 1.5 percent pursuant to subsection (c)(3) of Section 438.7 of Title 42 of the Code of Federal Regulations for capitation rates associated with the July 1, 2019, to December 31, 2020 rating period. The department may apply this reduction to rating periods starting on or after January 1, 2021, if the department determines that the continued reduction is actuarially appropriate and necessary to account for the impacts of the COVID-19 public health emergency. (d) The department shall evaluate the impact of the COVID-19 public health emergency on capitation rates it develops and pays under Medi-Cal managed care plan contracts, and shall make any adjustments it determines are necessary to ensure capitation rates are actuarially appropriate. (e) (1) 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. (2) The department shall seek any federal approvals it deems necessary to implement the adjustments described in this section, subject to subdivision (f). If federal approval is unavailable with respect to one or more of the adjustments described in this section, or if one or more of the adjustments is held to be invalid or unconstitutional by a decision of a court of competent jurisdiction, the department shall implement the remaining adjustments for which any necessary federal approvals are obtained. (f) The department, in consultation with the Department of Finance, may modify the requirements of this section, or modify any application of this section with respect to certain capitation rate increments, certain Medi-Cal managed care enrollee categories and subcategories of aid, or certain categories or subcategories of medical assistance provided under a Medi-Cal managed care plan contract, if the department determines necessary to meet federal requirements, to obtain or maintain federal approval, or to maximize federal financial participation. (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 by means of all-county letters, plan letters, provider bulletins, or other similar instructions, without taking any further regulatory action. (h) For purposes of this section, the following definitions apply: (1) “COVID-19 public health emergency” means the Public Health Emergency declared by the federal Secretary of Health and Human Services on January 31, 2020 pursuant to Section 247d of Title 42 of the United States Code (entitled “Determination that a Public Health Emergency Exists Nationwide as the Result of the 2019 Novel Coronavirus”), and any subsequent renewal of such declaration. (2) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or this chapter. (Added by Stats. 2020, Ch. 12, Sec. 68. (AB 80) Effective June 29, 2020.)
  162. 14301.2.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

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    The director may defer certain Medi-Cal and fee-for-service payments that are due in the final month of the state fiscal year, if doing so is consistent with 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.2. (a) The director may defer fee-for-service payments or payments to Medi-Cal managed care health plans contracting with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), Article 2.9 (commencing with Section 14088), or Article 2.91 (commencing with Section 14089) of this chapter, or Chapter 8 (commencing with Section 14200) or Chapter 8.75 (commencing with Section 14591), the Senior Care Action Network Health Plan, and Medi-Cal managed care health plan providers, as applicable, which are payable during the final month of the state fiscal year. This section may be implemented only to the extent consistent with federal law. (b) Notwithstanding subdivisions (c) and (d) of Section 34 of Chapter 37 of the Statutes of 2013, this section shall not be made inoperative as a result of any determination made by the Director of Finance pursuant to Section 34 of Chapter 37 of the Statutes of 2013. (Amended by Stats. 2017, Ch. 52, Sec. 76. (SB 97) Effective July 10, 2017.)
  163. 14301.3.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

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    The department must ensure Medi-Cal managed care plans can meet Section 14132.195 obligations, and it may adjust capitation rates at its discretion to improve outcomes.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.3. The department shall ensure that Medi-Cal managed care plans demonstrate ongoing ability and readiness to perform the obligations set forth in Section 14132.195. The department shall, as may be appropriate and in its discretion, adjust the capitation rate of a Medi-Cal managed care plan to promote improved outcomes through value-based purchasing payment protocols to create improved incentives for outcomes. (Added by Stats. 2019, Ch. 387, Sec. 4. (AB 1004) Effective January 1, 2020.)
  164. 14301.4.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

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    This section lets a transferring entity choose to make an intergovernmental transfer, requires certification to the department, and imposes a 20% fee on covered transfers, with stated 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.4. (a) It is the intent of the Legislature, to the extent federal financial participation is not jeopardized and consistent with federal law, that the intergovernmental transfers described in this section provide support for the nonfederal share of risk-based payments to managed care health plans to enable those plans to compensate providers designated by the transferring entity for Medi-Cal health care services and for support of the Medi-Cal program. (b) For the purposes of this section, the following definitions apply: (1) “Intergovernmental transfer” or “IGT” means the transfer of public funds by the transferring entity to the state in accordance with the requirements of this section. (2) “Managed care health plan” means a Medi-Cal managed care plan contracting with the department under this chapter or Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.81 (commencing with Section 14087.96), or Article 2.91 (commencing with Section 14089) of Chapter 7. (3) “Public provider” means any provider that is able to certify public expenditures under state and federal Medicaid law. (4) “Rate range increases” means increases to risk-based payments to managed care health plans to increase the payments from the lower bound of the range determined to be actuarially sound to the upper bound of that range, as determined by the department’s actuaries to take into account the variations in underwriting, risk, return on investment, and contingencies. (5) “Transferring entity” means a public entity, which may be a city, county, special purpose district, or other governmental unit in the state, regardless of whether the unit of government is also a health care provider, except as prohibited by federal law. (c) To the extent permitted by federal law, a transferring entity may elect to make an intergovernmental transfer to the state, and the department may accept all intergovernmental transfers from a transferring entity, for the purposes of providing support for the nonfederal share of risk-based payments to managed care health plans to enable those plans to compensate providers designated by the transferring entity for Medi-Cal health care services and for the support of the Medi-Cal program. The transferring entity shall certify to the department that the funds it proposes to transfer satisfy the requirements of this section and are in compliance with all federal rules and regulations. (d) (1) Pursuant to paragraphs (2), (3), and (4), the state shall, upon acceptance of the IGT described in subdivision (c), assess a fee of 20 percent on each IGT subject to this section to reimburse the department for the administrative costs of operating the IGT program pursuant to this section and for the support of the Medi-Cal program. (2) The IGTs subject to the fee shall be limited to those made by a transferring entity to provide the nonfederal share of rate range increases. (3) The 20-percent assessment shall not apply to IGTs designated for increases to risk-based payments to managed care health plans intended to increase reimbursement for designated public providers for purposes of equaling the amount of reimbursement the public provider would have received through certified public expenditures under the fee-for-service payment methodology. (4) The 20-percent assessment shall not apply to IGTs authorized pursuant to Sections 14168.7 and 14182.15. (e) Participation in the intergovernmental transfers pursuant to this section is voluntary on the part of the transferring entities for the purposes of all applicable federal laws. (f) The director shall seek any necessary federal approvals for the implementation of this section. (g) To the extent that the director determines that the payments made pursuant to this section do not comply with the federal Medicaid requirements, the director retains the discretion to return the IGTs or not accept the IGTs. (h) This section shall be implemented only to the extent that federal financial participation is not jeopardized. (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 section by means of policy letters or similar instructions, without taking further regulatory action. (j) This section shall be implemented on July 1, 2011, or the date on which all necessary federal approvals have been received, whichever is later. (Added by Stats. 2011, Ch. 29, Sec. 19. (AB 102) Effective June 29, 2011.)
  165. 14301.5.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must pay certain Medi-Cal managed care plan rate range increases, and plans must pass those amounts through to county public hospital health systems under specified 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14301.5. (a) (1) To the extent federal financial participation is not jeopardized and consistent with federal law, and subject to the conditions set forth in subdivision (b), the department shall pay Medi-Cal managed care plans rate range increases, as defined by paragraph (4) of subdivision (b) of Section 14301.4, at a minimum level of 75 percent of the rate range available with respect to all enrollees who are newly eligible beneficiaries for purposes of this section. If a nonfederal share is necessary to fund the rate range increases, a county public hospital health system as defined in subdivision (f) of Section 17612.2 or affiliated governmental entity may voluntarily provide intergovernmental transfers for the nonfederal share. (2) The increased payments to Medi-Cal managed care plans that would be paid consistent with actuarial certification and enrollment in the absence of this section, including, but not limited to, payments described in Section 14182.15, shall not be reduced as a consequence of payment under this section. (b) Payments to Medi-Cal managed care plans pursuant to subdivision (a) are conditioned on all of the following: (1) The Medi-Cal managed care plan shall pay all of the rate range increases provided under this section as additional payments to county public hospital health systems for providing and making available services to Medi-Cal enrollees of the plan. (2) The Medi-Cal managed care plan shall demonstrate that it has a contract or other arrangement in place with county public hospital health systems to provide additional payments to county public hospital health systems for services rendered to Medi-Cal beneficiaries that meet the requirements of paragraph (1). The existence of those agreements or arrangements shall be reported to the department by the county public hospital health system. (3) Additional payments described in paragraph (1) shall not supplant amounts that would otherwise be payable by Medi-Cal managed care plans to county public hospital health systems. A Medi-Cal managed care plan shall not impose a fee or retention amount, or reduce other payments to a county public hospital health system, that would result in a direct or indirect reduction to these payments. (4) The county public hospital health system or affiliated governmental entity voluntarily provides an intergovernmental transfer of public funds to the state for use as the nonfederal share, if any, of the increased capitation rates. Notwithstanding any other provision of law, the department shall not assess the fee described in subdivision (d) of Section 14301.4, or any other similar fee. (c) To the extent a Medi-Cal managed care plan is not compliant with any of the requirements imposed upon it pursuant to this section, the department shall reduce by 25 percent the default assignment into the Medi-Cal managed care plan with respect to all Medi-Cal beneficiaries, as long as the other Medi-Cal managed care plan or plans in that county have the capacity to receive the additional default membership. (Added by Stats. 2013, Ch. 24, Sec. 3. (AB 85) Effective June 27, 2013.)
  166. 14302.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Initial contracts under this chapter may run for up to one year, and renewed contracts for up to five years, except as provided in Section 14490.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14302. Except as provided in Section 14490, the duration of initial contracts entered into pursuant to this chapter shall be for a maximum of one year and of renewed contracts for a maximum of five years. (Amended by Stats. 1979, Ch. 1061.)
  167. 14302.1.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    If a prepaid health plan contract is being renewed, the state agency must draft and submit a contract extension on set deadlines, and the extension cannot take effect without 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14302.1. (a) (1) Once it is determined that a contract shall be renewed pursuant to this chapter with a prepaid health plan, by the state agency responsible for negotiating these contracts, the agency shall, no later than 25 working days prior to the expiration date of the existing contract or immediately, if that date has passed, draft an extension of the existing contract for a period not to exceed two calendar months. A contract extension shall contain the same terms as the prior existing contract except for the contract’s expiration date. The contract extension shall be for a period of time not to exceed two months from the termination date of the original contract. (2) The state agency responsible for negotiating the contract shall simultaneously submit to each federal and state agency required to approve a contract extension, a draft of the contract for extension no later than 20 working days prior to the expiration date of the prior existing contract. (3) Each state agency to which an extension for contract has been submitted shall approve or disapprove the extension no later than 10 working days after receipt of the contract. (4) In the course of any contract negotiations, the responsible state agency shall encourage the participation of other involved state and federal agencies in the negotiation process and shall cooperate with those agencies and with the contractor, or proposed contractor, to seek the resolution of any obstacles to contractual agreement. (5) No extension shall become effective until and unless federal approval is received indicating that federal funds will be available for services provided under the Medi-Cal program during the period of the contract extension. (6) These contract extensions shall remain in force and effect until such time as: (A) The contract expires because the extension date has been reached. (B) The contract for renewal is entered into and is in force and effect. (C) The state agency responsible for negotiating the contract determines not to contract or renew a contract with the provider and notifies the provider in writing to that effect. (D) The state agency responsible for negotiating the contract terminates the contract in accordance with Section 14197.7. (b) When contract renewals are entered into, the effective date of the contract shall be the termination date of the prior contract, not the ending date of any contract extension. The state agency responsible for negotiating the contract, once a new contract is finalized, shall retroactively make adjustments in any amounts paid under the contract extension to reflect the new terms and rates of reimbursements as provided in the new contract. (c) It is the intent of the Legislature to provide for the payment of services provided for under this chapter in a timely and efficient manner. Nothing in this chapter shall be construed as to hinder, prohibit, or interfere with the negotiating and contract process of the responsible state agency and provider. (d) This section shall apply only to those instances in which both parties have reason to believe that their contract renewal process will not be completed by the termination date of the contract. (Amended by Stats. 2019, Ch. 465, Sec. 7. (AB 1642) Effective January 1, 2020.)
  168. 14303.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A contract between the department and a prepaid health plan cannot be amended without public notice, and sometimes a public hearing, when the amendment makes certain listed changes.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14303. No contract between the department and the prepaid health plan shall be amended without the public notice and if necessary the holding of a public hearing as required in Section 14300 if such amendments make any of the following changes in the contract: (a) Reduction in the scope or availability of services. (b) Enlargement of the service area. (c) Increase in the maximum enrollment permitted under the contract. (d) Any other change in the plan’s organization, operation, or delivery of services which the director determines will have a substantial impact on the ability of enrollees to obtain health care services. (Amended by Stats. 1980, Ch. 1073, Sec. 3.)
  169. 14303.1.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department may amend a prepaid health plan contract when a merger meets 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14303.1. The department shall have authority to amend a prepaid health plan contract in accordance with the terms of a merger of a prepaid health plan with another organization or organizations other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, provided the surviving organization meets the following conditions: (a) The surviving organization assures the continued and accessible delivery of health care services to enrollees. (b) The plans concerned have satisfactorily demonstrated the fiscal and administrative soundness of the newly proposed organization. (c) The enrollees of the plans concerned are informed of the impending merger, any resulting changes in the service area or delivery of health care services, and such other information required by subdivision (a) of Section 14406 at least 30 days in advance of the merger. (d) The enrollees of the plans concerned are given the option of disenrolling for any cause within 60 days following the effective date of the merger. (e) Public notice is given and if necessary a public hearing is held as required by Section 14300. (f) The organization meets such other requirements as deemed necessary by the department in order to carry out the purpose of this chapter. (Amended by Stats. 1980, Ch. 1073, Sec. 4.)
  170. 14303.2.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department may amend a prepaid health plan contract when a plan is reorganized or merged, if stated service, soundness, notice, and enrollee-option 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14303.2. The department shall have authority to amend a prepaid health plan contract in accordance with the terms of the reorganization of a prepaid health plan or a merger of the plan with its subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, provided the following conditions are met: (a) The resulting or surviving organization assures the continued and accessible delivery of health care services to enrollees. (b) The plan has satisfactorily demonstrated the fiscal and administrative soundness of the newly proposed organization. (c) If the proposed reorganization or merger results in any change of the plan’s service area or delivery of health care services, or if the director otherwise deems it to be appropriate, the following additional conditions shall be met: (1) Public notice is given and if necessary a public hearing is held as required by Section 14300. (2) The enrollees of the plan are informed of the impending reorganization or merger, any resulting changes in the service area or delivery of health care services, and such other information required by subdivision (a) of Section 14406 at least 30 days in advance of the reorganization or merger. (3) The enrollees of the plan are given the option of disenrolling for any cause within 60 days following the effective date of the reorganization or merger. (d) The plan meets such other requirements as deemed necessary by the department in order to carry out the purpose of this chapter. (Amended by Stats. 1980, Ch. 1073, Sec. 5.)
  171. 14303.3.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must renew a contract unless there is good cause not to renew 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14303.3. The department shall renew a contract unless good cause is shown for nonrenewal. (Added by Stats. 1980, Ch. 1073, Sec. 6.)
  172. 14304.5.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans must provide at least the basic scope of health care benefits. The director sets service scope and duration and can approve or require certain additional service arrangements.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14304.5. Each prepaid health plan shall provide directly or through subcontractors, not less than the basic scope of health care benefits as defined in Section 14256. The director shall establish the scope and duration of such services and may require other services listed in Section 14053 be provided on a risk or nonrisk basis. The director shall encourage the prepaid health plan to provide all of the services enumerated in Section 14053 on a prepaid basis. When mutually agreeable to the prepaid health plan, the department, and the hospital involved, and provided that the confidentiality of the selected hospital contracting rates negotiated pursuant to Chapter 7 (commencing with Section 14081) is maintained by all parties, contracts entered into by the department pursuant to this chapter may provide for alternative arrangements in any or all of a prepaid health plan’s Medi-Cal service area for the payment of inpatient hospital services using Medi-Cal hospital inpatient rates. Subject to prior approval by the director, any additional services other than those listed in Section 14053 may be provided at reasonable cost to Medi-Cal enrollees, provided the enrollees are notified of services for which they will be charged and the amount of the charge prior to rendering such services. (Amended by Stats. 1988, Ch. 1348, Sec. 14.)
  173. 14305.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department may limit prepaid health plan benefits to exclude care for illness or injury caused or worsened by a catastrophic occurrence, including war, if the occurrence happens after enrollment.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14305. The department may limit the scope of health care benefits provided by a prepaid health plan under this chapter to exclude the care of illness or injury which results from or is greatly aggravated by, a catastrophic occurrence, including, but not limited to, an act of war, declared or undeclared, and which occurs subsequent to enrollment in the prepaid health plan. (Repealed and added by Stats. 1974, Ch. 983.)
  174. 14308.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans must provide the director with required information and reports, and the director may require additional reports or statistical information by regulation.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14308. (a) Each prepaid health plan shall furnish to the director such information and reports as required by Title XIX of the federal Social Security Act. (b) The director may require a prepaid health plan to provide the director with information and reports that are furnished by the prepaid health plan to the Director of the Department of Managed Health Care pursuant to the provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, the Knox-Keene Health Care Service Plan Act of 1975. (c) The director may, by regulation, require plans to furnish statistical information to the extent the information is necessary for the department to establish rates of payment pursuant to Section 14301.1 and to provide reports pursuant to Section 14313. The department shall, to the extent feasible, accept this information in a form which is consistent with reports required to be provided pursuant to the Knox-Keene Health Care Service Plan Act of 1975. In the case of a hospital based plan that is a health maintenance organization qualified pursuant to Title XIII of the federal Public Health Service Act, and that has more than one million enrollees, of whom less than 10 percent are Medi-Cal enrollees, information required pursuant to this subdivision shall consist of reports required to be made to the United States Department of Health and Human Services pursuant to Title XIII of the federal Public Health Service Act. (Amended by Stats. 2023, Ch. 266, Sec. 3. (AB 614) Effective January 1, 2024.)
  175. 14309.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must study care quality and services under this chapter and produce surveys and reports on prepaid health plans. It may also hire professional organizations to do related studies and reports for plans contracted under the 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14309. The department shall provide for a continuing study of the quality of care and services resulting from the operation of this chapter and for surveys and reports on prepaid health plans. With respect to such plans contracted for under this chapter, the department may contract with professional organizations for studies and reports of the experience of such plans as to the standards of care available to eligible persons, gross and net costs, administrative costs, benefits, utilization of benefits, the portion of actual personal expenditures of eligible persons for health care which are being met by prepaid benefits, and the methods of evaluating and improving the quality of, and controlling the costs of, health care provided under such contracts. However, this section shall not be construed to require any prepaid health plan to provide accounting data or statistical data not required by regulations adopted by the director. (Amended by Stats. 1977, Ch. 1036.)
  176. 14311.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans and related services are not subject to certain service limitations, and the director must still provide specified 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14311. Prepaid health plans, the services they provide, and the persons receiving these services shall not be subject to the limitations on services set forth in Section 14133, 14133.1, 14133.25, or 14133.3 or subdivisions (c), (d), and (e) of Section 14120, or subdivision (c) of Section 14105. Notwithstanding this section, the requirements set forth in Section 14301 for the determination of prospective per capita rates of payment for services provided under this chapter to Medi-Cal beneficiaries enrolled in a prepaid health plan shall remain unchanged. Nothing in this section or in Article 7 (commencing with Section 14490) shall relieve the director of his responsibility to provide the benefits provided for in Section 14132. Where a contract between the department and a prepaid health plan does not require the prepaid health plan to provide a benefit to which a Medi-Cal recipient is otherwise entitled, the recipient shall be entitled to receive such benefit pursuant to Chapter 7 (commencing with Section 14000) of this part. (Amended by Stats. 1984, Ch. 780, Sec. 1.)
  177. 14312.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The director must adopt necessary rules and regulations for this chapter, guided by eligible persons’ needs and current prepaid health care practices, unless federal law or this part 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14312. The director shall adopt all necessary rules and regulations to carry out the provisions of this chapter. In adopting such rules and regulations, the director shall be guided by the needs of eligible persons as well as prevailing practices in the delivery of health care on a prepaid basis. Except where otherwise required by federal law or by this part, the rules and regulations shall be consistent with the requirements of the Knox-Keene Health Care Service Plan Act of 1975. (Amended by Stats. 2014, Ch. 442, Sec. 38. (SB 1465) Effective September 18, 2014.)
  178. 14314.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The director may recover a due and payable overpayment made to a prepaid health 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14314. The director may recover a due and payable overpayment made to a prepaid health plan by means of a repayment agreement executed between such prepaid health plan and the director, and by any other means available at law. (Amended by Stats. 1979, Ch. 373.)
  179. 14315.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    If a prepaid health plan has received an overpayment that is due and payable, the director may recover it by offsetting amounts currently owed to the 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14315. When it has been determined that a prepaid health plan has received an overpayment which is due and payable, the director may recover such overpayment by offset against any amount currently due to the prepaid health plan under the provisions of this chapter or Chapter 7 (commencing with Section 14000) of this part. (Added by Stats. 1977, Ch. 1046.)
  180. 14316.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Contracts with plans under this article may include rate-adjustment, guaranteed capitation payment, and extra-benefit provisions, subject to stated 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 3. Administration [14300 - 14316] ( Article 3 repealed and added by Stats. 1974, Ch. 983. ) ## 14316. Notwithstanding any other provisions of law, contracts with plans which are entered into, renewed, or amended pursuant to this article may include one or more of the following: (1) A provision to the effect that if the rate for a plan is less than 90 percent of the estimated Medi-Cal fee-for-service cost, the plan’s rate shall be increased by one-half the difference between the rate fixed and 90 percent of the estimated fee-for-service cost. The rate shall not, however, be less than 85 percent of the estimated fee-for-service costs. (2) Guaranteed capitation payments for Medi-Cal beneficiaries, who are entitled to benefits under Title IV of the Social Security Act, for a period of six months or less, even if the eligibility for benefits of such beneficiaries terminates prior to the end of the guaranteed payment period. Each guaranteed payment period shall be calculated beginning on the date a beneficiary’s enrollment takes effect. (3) Benefits in addition to those listed under Section 14132, as long as the provision of such additional services permits plans to remain more cost effective than fee-for-service reimbursement. (Added by Stats. 1982, Ch. 328, Sec. 45. Effective June 30, 1982.)
  181. 14400.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans must hold an open enrollment period at least once a year and accept eligible Medi-Cal beneficiaries during that period, subject to capacity, contract limits, and any restrictions required by the director.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14400. Every prepaid health plan shall have an open enrollment period at least once every year. During the open enrollment period the plan shall accept up to the limit of its capacity or the limit of its contract, without restrictions, other than those which may be required by the director, Medi-Cal beneficiaries who are eligible to enroll in such plans. Eligible enrollees shall be accepted in the order in which they apply for enrollment. (Amended by Stats. 1977, Ch. 1036.)
  182. 14401.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A Medi-Cal beneficiary may not be enrolled in a prepaid health plan until the required contract is signed by the department and the plan is approved by the appropriate state 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14401. No Medi-Cal beneficiary shall be enrolled in a prepaid health plan prior to the time a contract under this chapter is signed by the department and such prepaid health plan is approved by the appropriate state agencies. (Added by Stats. 1974, Ch. 983.)
  183. 14402.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans may enroll only Medi-Cal beneficiaries in their contract service area, must use a department-prescribed standard application form, and the department may approve certain enrollee transfers despite voluntary-enrollment 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14402. The prepaid health plan shall enroll only those Medi-Cal beneficiaries who reside within the contract service area. Prepaid health plans shall use a standard application form prescribed by the department which is readily understandable to the enrollees. A beneficiary shall be enrolled in the prepaid health plan when the beneficiary voluntarily signs the enrollment application agreeing to utilize the health services provided by the prepaid plan and his eligibility for enrollment in that plan is verified by validation of the application by the department. Notwithstanding the provisions of this section requiring voluntary enrollment, the department may approve the transfer of the enrollees of one or more prepaid health plans to another prepaid health plan in accordance with the terms of a merger or reorganization approved by the department pursuant to the conditions set forth in Sections 14303.1 and 14303.2. (Amended by Stats. 1977, Ch. 1036.)
  184. 14403.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A Medi-Cal beneficiary may not be enrolled in more than one prepaid health plan at the same time.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14403. No Medi-Cal beneficiary shall be enrolled in more than one prepaid health plan at any time. (Added by Stats. 1974, Ch. 983.)
  185. 14406.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A prepaid health plan must give new enrollees written enrollment and service information within 7 days, update and resend it annually and after service changes, and give at least 14 days’ notice before non-unforeseeable changes.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14406. (a) Within seven days after the effective date of enrollment, the prepaid health plan shall provide in writing the following information to a new enrollee or the family unit of the new enrollee: (1) An appropriate document identifying the enrollee and authorizing the services or benefits to which that person is entitled under the plan subject to verification of eligibility. (2) A description of all services and benefits provided by the plan. (3) An explanation of the procedure for obtaining these services and benefits, including in the case of medical foundations or independent practice associations, the address and telephone number of each primary care physician, dentist, optometrist, psychologist, and in the case of other plans, the address and telephone number of each service site and the location of primary care physicians, dentists, optometrists and psychologists, and in the case of all prepaid health plans, the address and telephone numbers of each hospital, pharmacy, and skilled nursing facility where health care benefits may be obtained. In addition, the explanation shall state the hours and days where each of these facilities are open and the services and benefits available. (4) The location, telephone number, and procedure for securing 24-hour emergency care and an explanation of and procedure for obtaining out-of-area emergency coverage. (5) Information setting forth the term of enrollment in the prepaid health plan including the causes for which an enrollee shall lose eligibility in the prepaid health plan. (6) The procedure for processing and resolving any grievance by enrollees. Such information shall include the name, address, and telephone number of the person responsible for resolving grievances or initiating a grievance procedure. (7) The procedure by which enrollees may request disenrollment. (8) Any other information essential to the use of the prepaid health plan as may be required by the department. (b) The information made available under this section shall be revised and distributed annually to each enrollee or enrollee’s family unit and whenever there is a change in the services provided or the location where they may be obtained. Except for a change which is unforeseeable, all enrollees affected by the change in service or the location of services shall be notified at least 14 days prior to such a change. (Amended by Stats. 1979, Ch. 1061.)
  186. 14407.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Enrollment in a prepaid health plan must be voluntary, and the plan may not use false ads or false statements to get people to enroll.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14407. Enrollment in a prepaid health plan shall be voluntary and a prepaid health plan shall not use false advertising or false statements to induce enrollment. No solicitation of enrollees shall include the granting or offering of any monetary or other valuable consideration for enrollment. (Amended by Stats. 1977, Ch. 1036.)
  187. 14407.1.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Medi-Cal managed care contractors may offer nonmonetary incentives for good health practices, but not before written approval from 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14407.1. (a) A contractor that has entered into a contract with the department under this chapter, or under another Medi-Cal managed care contracting authority, may offer nonmonetary incentives to promote good health practices by its existing Medi-Cal enrollees. (b) No Medi-Cal managed care contractor may offer an incentive to promote good health practices by its Medi-Cal enrollees prior to written approval by the department. In the absence of other countervailing considerations, the department shall approve, to the extent permitted by federal law, the use by health plans of nonmonetary incentives to enhance health education program efforts to increase member participation, learning, and motivation to do any of the following: (1) Effectively use managed health care services, including preventive and primary care services, obstetric care, and health education services. (2) Modify personal health behaviors, achieving and maintaining healthy lifestyles and treatment therapies and positive health outcomes. (3) Follow self-care regimens and treatment therapies for existing medical conditions, chronic diseases, or health conditions. (c) If a contractor is a publicly operated entity, the offering of a department-approved, nonmonetary incentive to promote good health practices by enrollees shall not constitute a gift of public funds. (d) Violations of this section shall be subject to the requirements and penalties set forth in Sections 14408 and 14409, and any regulations adopted by the department pursuant to this article. (e) The department shall develop and publish written guidelines for the appropriate use of nonmonetary incentives that may be offered to Medi-Cal enrollees. (Amended by Stats. 2008, Ch. 179, Sec. 248. Effective January 1, 2009.)
  188. 14407.6.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department must establish a minimum enrollment period for Medi-Cal beneficiaries in managed care plans, subject to federal law and any federal waivers it may obtain. During that period, disenrollment is allowed only for good cause 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14407.6. (a) Notwithstanding Section 14407.5, the department shall, to the extent permitted by federal law or under federal waivers which the department may obtain, establish a minimum enrollment period for Medi-Cal beneficiaries enrolling in managed care plans under any of the following: (1) This chapter. (2) Any of the following provisions of Chapter 7 (commencing with Section 14000): (A) Article 2.7 (commencing with Section 14087.3). (B) Article 2.9 (commencing with Section 14088). (C) Article 2.91 (commencing with Section 14089). (b) (1) Except as otherwise required by federal law, disenrollment during the minimum enrollment period shall only be for good cause. (2) For purposes of this section, the meaning of “good cause” shall be as defined in subdivision (b) of Section 14407.8, and shall include “good cause” as defined by federal laws or regulations governing Medi-Cal managed care contracting. (Added by Stats. 1991, Ch. 95, Sec. 12. Effective June 30, 1991.)
  189. 14408.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans and related marketers must get department approval before marketing, and some marketing practices are prohibited.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14408. (a) Except as otherwise prohibited by law, a contractor that has entered into a contract with the department pursuant to this chapter may make the benefits known to potential enrollees by methods approved by the department. (b) No prepaid health plan, marketing representative, or marketing organization shall engage in marketing activities prior to written submittal to and approval by the department. All marketing activities, procedures, methods, and places in which any activities will be conducted shall be explicitly described in a marketing plan and approved by the department prior to being used by a prepaid health plan, marketing representative, or marketing organization. The marketing plan shall be updated and submitted for renewed approval on an annual basis. The department may approve, disapprove, or withdraw approval of any marketing activity or procedure. The department shall require the discontinuance of any marketing activity or procedure for which the department withdraws approval. The conduct of activities or procedures not included in an approved marketing plan shall constitute a violation of this article and be subject to sanctions in accordance with Section 14409. The prepaid health plan shall be responsible for all presentations by its marketing representatives and for their ethical and professional conduct. The department may withdraw certification for participation in the program from, and impose marketing sanctions specified in Section 14409, as applicable, on marketing representatives. (c) The marketing plan shall meet the standards established by the department. The marketing plan shall include, but not be limited to, an explicit description of the specific marketing activities, the method of identifying individual enrollments by marketing representative, and formal measures to monitor performance of marketing representatives and verify both of the following: (1) The prepaid health plan’s marketing activities and practices do not violate subdivision (a) of Section 14409. (2) Beneficiaries receive complete and accurate information about the benefits and limitations of receiving health care services through the prepaid plan in a manner that considers the beneficiary’s level of comprehension. (d) Each time a marketing representative presents information about the benefits of prepaid health plan enrollment to a beneficiary in order to encourage the beneficiary to enroll, the marketing representative shall leave with the beneficiary printed information identifying the marketing representative by name and prepaid health plan represented. (e) All printed or illustrated material prepared by the prepaid health plan for dissemination to enrollees or to prospective enrollees shall be submitted to the department prior to dissemination. The department shall acknowledge receipt of the printed or illustrated material within five days, and shall approve or disapprove the material for dissemination within 60 days after the date of notification that the material has been received. The department may withdraw approval of the material previously approved and order its dissemination discontinued. If the department notifies the prepaid health plan of its disapproval or withdrawal of approval, the prepaid health plan shall have the right to meet and confer with the director or his or her designee and demonstrate the purpose and reasonable basis for the distribution of the material to enrollees and potential enrollees. (f) (1) Any form of door-to-door or in-person marketing that coerces or misleads beneficiaries or selectively enrolls beneficiaries on the basis of their health status is unlawful. In addition, on or after July 1, 1996, door-to-door solicitation of Medi-Cal enrollees shall not be permitted. (2) On or after July 1, 1996, the health care options presentation required by Sections 14016.5 and 14016.6 or the health care options information required by Sections 14087.305 and 14089 shall be fully operational in counties specified by the director for expansion of the Medi-Cal managed care program or in counties where prepaid health plans are contracting with the department pursuant to Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96, 14089, and 14089.05. In these counties, on or after July 1, 1996, no enrollment of beneficiaries by prepaid health plans shall occur during in-person marketing activities or during health fairs pursuant to paragraph (5) of subdivision (f). Enrollment shall be exclusively performed and transmitted pursuant to the program required by Sections 14016.5, 14016.6, 14087.305, and 14089. (3) In the event the health care options presentation required by Sections 14016.5 and 14016.6 is not fully operational or the health care options information required by Sections 14087.305 and 14089 is not fully available, as specified in paragraph (2) of subdivision (f), the department shall perform the enrollment-only functions until the health care options presentation or information is fully operational or available. (4) Nothing in this section shall preclude a prepaid health plan from responding to inquiries initiated by beneficiaries or potential beneficiaries. (5) Until July 1, 1996, a prepaid health plan may participate in an organized community or neighborhood health fair in a public place only if two or more prepaid health plans are participating, or if the plan is invited by the sponsor of the fair. If there are not two or more prepaid health plans providing services to Medi-Cal beneficiaries in a prepaid health plan’s service area, this subdivision shall not apply. On or after July 1, 1996, a prepaid health plan may participate in an organized community or neighborhood health fair in a public place for marketing purposes. (g) Any prepaid health plan, marketing representative, or marketing organization that violates subdivision (f) shall be subject to the sanctions set forth in subdivision (b) of Section 14409 and shall be guilty of a misdemeanor and subject to a fine of five hundred dollars ($500) or imprisonment in a county jail for six months, or both, for each violation. (h) The department shall certify each marketing representative prior to participation in the program in accordance with standards established by the department. Continuing certification for participation in the program shall be contingent upon compliance with this article, as well as guidelines and standards adopted by the department, and may be withdrawn upon their violation, as determined by the department. The department may temporarily decertify any marketing representative when that action is necessary to protect the public welfare or the interests of the Medi-Cal program. Temporary decertification shall be effective immediately upon written notice to the marketing representative and the managed care contractor, and shall remain in effect until the department has made a determination on the merits. Temporary decertification shall be canceled unless the department acts to permanently withdraw certification within 60 days. (i) No prepaid health plan shall employ in any capacity relating to the marketing operations of the plan a marketing representative whose certification has been withdrawn. Marketing representatives shall not be recertified for participation until the cause for withdrawal of certification has been corrected to the satisfaction of the department. Proof of correction shall be the sole responsibility of the marketing representative. (Amended by Stats. 2004, Ch. 183, Sec. 389. Effective January 1, 2005.)
  190. 14408.5.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A prepaid health plan contracting with Medi-Cal managed care or the Healthy Families Program may provide application assistance during eligibility redetermination.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14408.5. A prepaid health plan that contracts with Medi-Cal managed care or contracts with the Healthy Families Program may provide application assistance pursuant to Section 12693.325 of the Insurance Code during the eligibility redetermination process in order to allow persons to retain coverage. (Added by Stats. 2000, Ch. 93, Sec. 97. Effective July 7, 2000.)
  191. 14409.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans, marketing representatives, and marketing organizations must not misrepresent themselves, the plans, or the Medi-Cal 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14409. (a) No prepaid health plan, marketing representative, or marketing organization shall in any manner misrepresent itself, the plans it represents, or the Medi-Cal program. A violation of this section shall include, but is not limited to, all of the following: (1) False or misleading claims that marketing representatives are employees or representatives of the state, county, or anyone other than the prepaid health plan or the organization by whom they are reimbursed. (2) False or misleading claims that the prepaid health plan is recommended or endorsed by any state or county agency, or by any other organization which has not certified its endorsement in writing to the prepaid health plan. (3) False or misleading claims that the state or county recommends that a Medi-Cal beneficiary enroll in a prepaid health plan. (4) Claims that a Medi-Cal beneficiary will lose their benefits under the Medi-Cal program or any other health or welfare benefits to which they are legally entitled, if they do not enroll in a prepaid health plan. (b) Violations of this article or regulations adopted by the department pursuant to this article shall result in one or more of the following sanctions that are appropriate to the specific violation, considering the nature of the offense and frequency of occurrence within the prepaid health plan: (1) Revocation of one or more permitted methods of marketing. (2) Termination of authorization for a plan to provide application assistance. (3) Refusal of the department to accept new enrollments for a period specified by the department. (4) Refusal of the department to accept enrollments submitted by a marketing representative or organization. (5) Forfeiture by the plan of all or part of the capitation payments for persons enrolled as a result of such violations. (6) Requirement that the prepaid health plan in violation of this article personally contact each enrollee enrolled to explain the nature of the violation and inform the enrollee of their right to disenroll. (7) Application of sanctions as provided in Section 14197.7. (8) Temporarily suspend capitation payments for beneficiaries enrolled in violation of this article, or regulations adopted thereunder, until the prepaid health plan is in substantial compliance with the statutory and regulatory requirements. (c) Any marketing representative who violates subdivision (a) while engaged in door-to-door solicitation is guilty of a misdemeanor, and shall be subject to a fine of five hundred dollars ($500) or imprisonment in a county jail for six months, or both. (Amended by Stats. 2019, Ch. 465, Sec. 9. (AB 1642) Effective January 1, 2020.)
  192. 14410.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A prepaid health plan or marketing representative may not use procedures to identify prospective enrollees with medical or psychiatric problems for the purpose of excluding them from enrollment, except for conditions specifically excluded by the 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14410. No prepaid health plan or marketing representative shall adopt or utilize any procedure to identify prospective enrollees with medical or psychiatric problems in order to exclude them from enrollment in the prepaid health plan, other than medical conditions specifically excluded from coverage by the contract. (Added by Stats. 1974, Ch. 983.)
  193. 14411.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans and marketing organizations generally may not solicit prospective enrollees on county or state premises, unless one of the listed agreement-and-approval exceptions applies.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14411. (a) No prepaid health plan or marketing organization shall solicit prospective enrollees on county premises for benefits or services available pursuant to this chapter except under any one of the following conditions: (1) Such marketing activities are performed by a county employee under an agreement between the county and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department. (2) Such marketing activities are performed by a state employee under an agreement between the department, county, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department. (3) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the county, the prepaid health plan and the department, and all marketing presentations and materials to be used have been approved by the department. (b) No prepaid health plan or marketing organization shall solicit prospective enrollees on state premises for benefits or services available pursuant to this chapter, except under any one of the following conditions: (1) Such marketing activities are performed by a state employee under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department. (2) Such marketing activities are performed by a marketing representative of a prepaid health plan under an agreement between the department, the Department of General Services, and the prepaid health plan, and all marketing presentations and materials to be used have been approved by the department. (Amended by Stats. 1977, Ch. 1036.)
  194. 14412.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A Medi-Cal beneficiary’s enrollment in a prepaid health plan cannot be ended except for loss of eligibility, good cause determined by the department, or the beneficiary’s request.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14412. (a) The enrollment of a Medi-Cal beneficiary in the prepaid health plan shall not be terminated except for loss of eligibility, for good cause as determined by the department, or at the request of the beneficiary. (b) Enrollment shall be terminated at the request of the Medi-Cal beneficiary, to the extent required by federal law. (c) Any Medi-Cal beneficiary enrolled in a prepaid health plan who would remain eligible for Medi-Cal program benefits for three additional months pursuant to Section 14005.8 shall remain enrolled in the prepaid health plan and shall not receive a Medi-Cal card unless disenrollment is requested by the beneficiary, and the request is submitted in accordance with state and federal law. (d) It is the intent of the Legislature that the department shall develop such policies and procedures to maximize continuity of care for persons enrolled in prepaid health plans and to insure that the eligibility determination or redetermination process does not unnecessarily interfere with such enrollment or create gaps in the delivery of health services. (Amended by Stats. 1983, Ch. 822, Sec. 1.)
  195. 14413.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Disenrollment requests must be made to the prepaid health plan or the department, and most requests must go through the plan’s grievance procedure.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 4. Enrollment and Disenrollment [14400 - 14413] ( Article 4 added by Stats. 1974, Ch. 983. ) ## 14413. (a) Requests for disenrollment shall be made to an authorized representative of the prepaid health plan or to the department. All requests for disenrollment, except those submitted pursuant to subdivision (c) of Section 14303.1, subdivision (c) of Section 14303.2, or paragraph (6) of subdivision (b) of Section 14409, or for other good cause as determined by the director, shall be processed through the prepaid health plan’s grievance procedure as approved by the department. Disenrollment requests received by the prepaid health plan shall be submitted to the department, on standard disenrollment forms prescribed by the department, within a reasonable time following the date of such signed request, as determined by the director, to permit the department to terminate enrollment effective the beginning of the first calendar month following a full calendar month after the request is made. (b) All applications for disenrollment shall be processed by the department, and where Medi-Cal eligibility continues or Medi-Cal coverage is extended under Section 14005.8, a Medi-Cal card shall be issued effective not later than the beginning of the first calendar month following a full calendar month after the request for disenrollment is made. Submittal of a request for disenrollment for processing through the grievance procedure of a prepaid health plan shall not be deemed to infringe on this entitlement. (Amended by Stats. 2020, Ch. 370, Sec. 287. (SB 1371) Effective January 1, 2021.)
  196. 14450.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    This section sets conditions for approving or renewing prepaid health plan contracts and requires grievance procedures, disclosures, marketing plans, and financial showings.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. ) ## 14450. (a) No contract between the department and a prepaid health plan shall be approved or renewed unless the providers and the facilities of the prepaid health plan meet the Medi-Cal program standards for participation as established by the director. In addition, a prepaid health plan shall meet the standards required pursuant to the provisions of the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), standards specifically required by federal law, and the following requirements: (1) Each prepaid health plan shall establish a grievance procedure under which enrollees may submit their grievances. The procedure shall be approved by the department prior to the approval of the contract. The department shall establish standards for the procedures to insure adequate consideration and rectification of enrollee grievances. A prepaid health plan shall make a finding of fact in the case of each grievance processed, a copy of which shall be transmitted to the enrollee. If the enrollee has an unresolved grievance, the fair hearing provided in Chapter 7 (commencing with Section 10950) of Part 2 shall be available to resolve all grievances regarding care and administration by the prepaid health plan. The findings and recommendations of the department, based on the decision of the hearing officer, shall be binding upon the prepaid health plan. Any changes in a proposed health plan’s grievance procedure must be approved by the department before the changes take effect. (2) (A) Medi-Cal enrollees shall have the same responsibilities and shall be entitled to the same rights as other enrollees with regard to any requirements for arbitration as a condition of membership in a health plan. (B) Arbitration requirements shall be clearly disclosed in all of the contractor’s Medi-Cal marketing presentations, materials and brochures, enrollment agreements, evidence of coverage, and disclosure forms. (3) The prepaid health plan shall provide the director, for their approval, a plan for marketing its services to Medi-Cal beneficiaries which relates the proposed service to the need for services, and the size of the potential population to be served in the proposed service area. (4) The prepaid health plan shall demonstrate to the department that it has adequate financial resources, administrative abilities and soundness of program design to carry out its contractual obligations. (b) The requirements of this section shall apply to all managed care plan contracts entered into under any of the following: (1) The act that added this subdivision. (2) Any of the following provisions of Chapter 7 (commencing with Section 14000). (A) Article 2.7 (commencing with Section 14087.3). (B) Article 2.9 (commencing with Section 14088). (C) Article 2.91 (commencing with Section 14490). (3) Article 7 of Chapter 8 (commencing with Section 14490). (Amended by Stats. 2023, Ch. 266, Sec. 4. (AB 614) Effective January 1, 2024.)
  197. 14450.5.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    The department may not approve or renew certain prepaid health plan contracts unless Section 1374.16 standards 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. ) ## 14450.5. (a) No contract between the department and a prepaid health plan that is contracting with, or that is governed, owned, or operated by, a county board of supervisors, shall be approved or renewed unless the standards set forth in Section 1374.16 of the Health and Safety Code are met. The treatment plan developed pursuant to Section 1374.16 of the Health and Safety Code shall be consistent with federal and state medicaid requirements. Nothing in Section 1374.16 of the Health and Safety Code is intended to alter or abrogate any other requirements of federal or state law with regard to medicaid. (b) The requirements of this section shall apply to all managed care plan contracts entered into under any of the following: (1) The act that added this subdivision. (2) Any of the following provisions of Chapter 7 (commencing with Section 14000). (A) Article 2.7 (commencing with Section 14087.3). (B) Article 2.9 (commencing with Section 14088). (C) Article 2.91 (commencing with Section 14089). (3) Article 7 of Chapter 8 (commencing with Section 14490). (Added by Stats. 1998, Ch. 31, Sec. 2. Effective January 1, 1999.)
  198. 14451.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Services under a prepaid health plan contract must be provided in accordance with the Knox-Keene Health Care Service Plan Act of 1975.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. ) ## 14451. Services under a prepaid health plan contract shall be provided in accordance with the requirements of the Knox-Keene Health Care Service Plan Act of 1975. (Amended by Stats. 2014, Ch. 442, Sec. 39. (SB 1465) Effective September 18, 2014.)
  199. 14451.5.

    ## 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    A prepaid health plan contractor cannot use subcontracts if that would shift away a significant share of the risk for covered services. The plan may buy reinsurance, but the reinsurance cannot reduce liability below $5,000 per enrollee for any 12-month period, with stated exceptions for certain emergency-service and high-cost coverage.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. ) ## 14451.5. (a) A prepaid health plan contractor may not enter into subcontracts when such an action would remove from the contractor his obligation to bear a significant portion of the risk encountered in providing the covered services. (b) The prepaid health plan may obtain reinsurance for the cost of providing covered services. Such reinsurance shall not limit the contractor’s liability below five thousand dollars ($5,000) per enrollee for any one 12-month period, except that the contractor may also obtain reinsurance for the total cost of services provided to enrollees by noncontractor emergency service providers, and for 90 percent of all costs exceeding 115 percent of its income during any contractor fiscal year. (Added by Stats. 1977, Ch. 1036.)
  200. 14452.

    ## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. )

    Verify source ↗

    Prepaid health plans must put subcontracts in writing, send copies to the department, include compensation terms, and in some cases submit subcontracts for department 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 8. Prepaid Plans [14200 - 14499.77] ( Chapter 8 added by Stats. 1972, Ch. 1366. ) ## ARTICLE 5. Standards for Prepaid Health Plans [14450 - 14464] ( Article 5 added by Stats. 1974, Ch. 983. ) ## 14452. (a) (1) All subcontracts shall be entered into pursuant to the requirements of the Knox-Keene Health Care Service Plan Act of 1975 and federal law. All subcontracts shall be in writing, a copy of which shall be transmitted to the department. (2) Each subcontract shall contain the amount of compensation or other consideration that the subcontractor will receive under the terms of the subcontract with the prepaid health plans. These provisions shall not apply to a provider who is employed or salaried by the prepaid health plan. Unless the department objects, a prepaid health plan may enter into a subcontract in which consideration is determined by a percentage of the primary contractor’s payment from the department. This subdivision shall not be construed to prohibit any subcontract in which consideration is determined on a capitation basis. (3) Subcontracts between a prepaid health plan and the subcontractor shall be public records on file with the department. The names of the officers and owners of the subcontractor, stockholders owning more than 10 percent of the stock issued by the subcontractor, and major creditors holding more than 5 percent of the debt of the subcontractor shall be submitted by each prepaid health plan to the department and shall be public records on file with the department. (b) A prepaid health plan that is not a qualified health maintenance organization pursuant to Title XIII of the federal Public Health Service Act shall submit all provider and management subcontracts to the department for approval prior to the subcontract taking effect. (c) Each subcontract shall require that the subcontractor make all of its books and records pertaining to the goods and services furnished under the terms of the subcontract available for inspection, examination, or copying by the department during normal working hours at the subcontractor’s place of business, or another mutually agreeable location in California. (Amended by Stats. 2023, Ch. 266, Sec. 5. (AB 614) Effective January 1, 2024.)

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