Welfare and Institutions Code

Part 8 of 35 · provisions 1,401–1,600

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

Jurisdiction: United States — California
Instrument: Code
Citation: WIC
Version: Undated source snapshot
Language: en
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Complete work: View statute overview

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

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Provisions of Welfare and Institutions Code

Showing 200 of 6,925

14018.1.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must tell a Medi-Cal managed care plan the date of a beneficiary’s regularly scheduled annual redetermination in covered disabled-aid cases.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14018.1. The department shall prospectively notify a Medi-Cal managed care plan of the date of the regularly scheduled annual redetermination of a Medi-Cal beneficiary in a disabled aid category, who is enrolled in that plan and where eligibility redetermination is the responsibility of the department. Nothing in this section shall provide a beneficiary with additional Medi-Cal coverage due to the department’s failure to provide this notice. (Added by Stats. 2001, Ch. 742, Sec. 1. Effective January 1, 2002.)
14018.2.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medi-Cal providers cannot be denied reimbursement just because a proof-of-eligibility label is missing, and providers and beneficiaries have specific information-sharing and identity-verification duties.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14018.2. (a) Reimbursement shall not be denied to any qualified health care provider for care rendered to an eligible Medi-Cal beneficiary for the sole reason that a proof of eligibility label does not accompany the bill. Proof of eligibility labels may, however, continue to be used as such and shall be made available to an eligible Medi-Cal beneficiary through the local office which has determined the person’s eligibility or through the department. The provider may submit machine-reproduced copies of the beneficiary Medi-Cal card for billing purposes as long as the copy is made from the original unaltered Medi-Cal card under circumstances controlled by the provider, for example, on the premises of the provider with copying equipment controlled by the provider. (b) It shall remain the responsibility of a Medi-Cal beneficiary to provide information and evidence of Medi-Cal eligibility, restrictions on the eligibility, and non-Medi-Cal health coverage, to that person’s health care providers, if this information is requested by those providers prior to rendering services to that beneficiary. (c) It shall be the responsibility of the provider prior to rendering Medi-Cal reimbursable services to persons presenting themselves as Medi-Cal beneficiaries to make a good faith effort to verify the person’s identity, if the person is not known to the provider, by matching the name and signature on his or her Medi-Cal card against the signature on a valid California driver’s license, or California identification card issued by the Department of Motor Vehicles, or another type of picture identification card or other credible document of identification. When the provider verifies the beneficiary’s identity with a signed Medi-Cal card and one of the documents described above, the state will deem this to be a good faith effort. If the provider does not make a good faith effort of reasonable identification prior to rendering Medi-Cal reimbursable services and renders services to a presenting person who is ineligible for those Medi-Cal services, payment for those services may later be disallowed. This provision shall not apply to: (1) Persons 17 years of age and under. (2) Persons in long-term care. (3) Persons receiving emergency services. (d) Notwithstanding subdivision (b) of this section, county welfare departments may provide Medi-Cal eligibility information to other governmental agencies and their designated agents as necessary for proper administration of the Medi-Cal program. (e) If a hospital obtains proof of Medi-Cal eligibility for a patient subsequent to the date of service, it shall be the responsibility of the hospital to provide all information regarding that person’s Medi-Cal eligibility to all hospital-based providers, ambulance transportation services providers, providers that provide ambulance transportation services through the “911” emergency response system, and other hospital-based providers of professional services that bill separately for all services associated with the person’s treatment in the hospital rendered during the same time period for which the hospital is submitting a claim. The hospital may inform the provider that the person’s Medi-Cal eligibility is pending, before a final determination is made on the patient’s Medi-Cal application, to satisfy the requirements of this subdivision. If the provider or the provider’s agent obtains this information from the hospital, the requirement has been satisfied. (f) For purposes of this section, the following definitions apply: (1) “Hospital-based provider” means an anesthesiologist, radiologist, pathologist, emergency room physician, or other physician or a group of physicians providing medical services at the hospital. (2) “Hospital-based professional services” means services performed for a patient while at a hospital, related to the patient’s hospital stay, and known to the hospital, including, but not limited to, diagnostic, laboratory, therapeutic, and radiologic services. (Amended by Stats. 2009, Ch. 511, Sec. 1. (AB 1142) Effective January 1, 2010.)
14018.4.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Hospitals, licensed primary care clinics, and long-term health care facilities cannot be denied reimbursement just because a proof-of-eligibility label is missing if they have other eligibility documentation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14018.4. (a) Reimbursement shall not be denied to any hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code for care rendered to an eligible Medi-Cal beneficiary for the sole reason that a proof of eligibility label does not accompany the bill, so long as the claim includes other appropriate documentation of eligibility. (b) The director shall require county welfare departments to issue, upon the request of a hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code providing care to an eligible Medi-Cal beneficiary, replacement Medi-Cal proof of eligibility labels or other appropriate documentation of eligibility to the requester, if all of the following conditions are met: (1) The hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code attempted to obtain a label from the beneficiary at the time the service was provided. (2) The hospital, licensed primary care clinic, or long-term health care facility as defined in Section 1326 of the Health and Safety Code made a subsequent attempt to obtain a label or other appropriate documentation from the beneficiary. (c) Notwithstanding subdivision (a), the director shall require that the replacement proof of eligibility label or other appropriate documentation of eligibility provided pursuant to subdivision (b) accompany the bill of the hospital, the licensed primary care clinic, or the long-term health care facility as defined in Section 1326 of the Health and Safety Code. (d) This section shall remain in effect only until both the Secretary of the Senate and the Chief Clerk of the Assembly have received certification by registered mail from the Director of Health Services, that the automated eligibility verification system required by Section 14042 is operative for all counties and has been demonstrated to be accurate for each county at the 97-percent level as required by Section 14042 and as of that date is repealed. (Amended by Stats. 1987, Ch. 1161, Sec. 3. Repealed as of date prescribed by its own provisions.)
14018.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Civil Code section 3275 does not apply to Medi-Cal reimbursement or prior authorization.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14018.5. Notwithstanding any other provision of law, Section 3275 of the Civil Code does not apply to Medi-Cal reimbursement or prior authorization. (Added by Stats. 1999, Ch. 146, Sec. 36. Effective July 22, 1999.)
14018.7.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section creates a conflict-of-interest exception for certain commission and advisory panel members if specific appointment, disclosure, abstention, recordkeeping, and good-faith voting 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14018.7. (a) Notwithstanding any other provision of law, neither a member of the governing body of the commission nor a member of any advisory panel to the governing body shall be deemed to be interested in a contract entered into by the commission within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all of the following apply: (1) The board of supervisors or the governing body appointed the individual to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations. (2) The contract authorizes the individual or the organization the individual represents to provide services under the local initiative. (3) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the individual was appointed to represent. (4) The individual does not influence or attempt to influence any advisory panel, the governing body, or any member of the governing body to enter into the contract. (5) The individual discloses the interest to the governing body and the advisory panel, if applicable, and abstains from voting on the contract. (6) The governing body and the advisory panel, if applicable, notes the disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for that purpose without counting the vote of the individual. (b) (1) For purposes of this section, “commission” means a nonprofit corporation established in Kern County to operate the local health plan and other health care programs owned by, or operated in, Kern County. (2) The commission shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code. (c) For purposes of this section, “governing body” means the board of directors of the nonprofit corporation established in Kern County, and “board of supervisors” means the Kern County Board of Supervisors. (d) The commission may enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. (Amended by Stats. 2004, Ch. 228, Sec. 10.3. Effective August 16, 2004.)
14019.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medi-Cal eligibility can authorize payment for certain health care services for up to three months before an application, with narrower lookback periods for applications made on or after the first quarter after December 31, 2026. The department may implement the section by guidance, and later application rules depend on a director finding, federal approval, and available federal financial participation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019. (a) (1) Notwithstanding Section 14018, except as provided in Section 14019.6, Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law, during any of the three months immediately prior to the month in which application was made, and for which such person would have otherwise been eligible. (2) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by an applicant described in Section 1396a(a)(10)(A)(i)(VIII) of Title 42 of the United States Code, or by an applicant for state-funded Medi-Cal coverage who meets the same criteria described in that federal provision, Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during the month immediately prior to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018. (3) For an application made on or after the first day of the first quarter that begins after December 31, 2026, by any applicant except those described in paragraph (2), Medi-Cal eligibility shall be authorization for payment for health care services rendered, under conditions prescribed by the director and to the extent required by federal law during either of the two months immediately prior to the month the application was made, and for which that person would have otherwise been eligible, notwithstanding Section 14018. (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action. (c) (1) Paragraphs (2) and (3) of subdivision (a) shall be implemented only after the director determines, and communicates in writing to the Department of Finance, that systems have been programmed for implementation of this section. (2) Paragraphs (2) and (3) of subdivision (a) shall be implemented only to the extent that any necessary federal approvals are obtained and that federal financial participation is available and not otherwise jeopardized. (Amended by Stats. 2026, Ch. 27, Sec. 81. (SB 164) Effective June 29, 2026.)
14019.3.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section lets certain Medi-Cal beneficiaries get refunds or direct reimbursement for qualifying covered care payments, and requires providers and the department to process claims and repayments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019.3. (a) A beneficiary or any person on behalf of a beneficiary who has paid for medically necessary health care services, otherwise covered by the Medi-Cal program, received by the beneficiary shall be entitled to a return from a provider or directly from the department of any part of the payment that meets all of the following: (1) Was rendered during the 90-day period prior to application for, his or her Medi-Cal card, or after application for but prior to the issuance of, his or her Medi-Cal card, for which the card authorizes payment under Section 14018 or 14019, or was charged to the beneficiary as excess copayment during the period after issuance of his or her Medi-Cal card. (2) Is not payable by a third party under contractual or other legal entitlement. (3) Was not used to satisfy his or her paid or obligated liability for health care services or to establish eligibility. (b) To the extent permitted by federal law, whether or not a facility actually evicts a beneficiary, a beneficiary who may validly be evicted pursuant to Section 1439.7 of the Health and Safety Code, and who has received and paid for health care services otherwise covered by the Medi-Cal program shall not be entitled to the return from a provider of any part of the payment for which service was rendered during any period prior to the date upon which knowledge is acquired by a provider of the application of a beneficiary for Medi-Cal or the date of application for Medi-Cal, whichever is later. (c) Upon presentation of the Medi-Cal card or other proof of eligibility, a provider shall submit a Medi-Cal claim for reimbursement, subject to the rules and regulations of the Medi-Cal program. (d) Notwithstanding subdivision (c), payment received from the state in accordance with Medi-Cal fee structures shall constitute payment in full, except that a provider, after making a full refund to the department of any Medi-Cal payments received for services, may recover all provider fees to the extent that any other contractual entitlement, including, but not limited to, a private group or indemnification insurance program, is obligated to pay the charges for the care provided a beneficiary. (e) A provider shall return any and all payments made by a beneficiary, or any person on behalf of a beneficiary, other than a third party obligated to pay charges by reason of a beneficiary’s other contractual or legal entitlement for Medi-Cal program covered services upon receipt of Medi-Cal payment. (f) To the extent permitted by federal law, the department shall waive overpayments made to a pharmacy provider that would otherwise be reimbursable to the department for prescription drugs returned to a pharmacy provider from a nursing facility upon discontinuation of the drug therapy or death of a beneficiary. (g) The department shall ensure payment to a beneficiary from a provider. A provider shall be notified in writing by the department when a beneficiary has submitted a claim to the department for reimbursement of services provided during the periods specified in paragraph (1) of subdivision (a). If a provider is not currently enrolled in the Medi-Cal program, the department shall assist in that enrollment. Enrollment in the Medi-Cal program may be made retroactive to the date the service was rendered. (h) If a provider fails or refuses to reimburse a beneficiary for services provided during the periods specified in paragraph (1) of subdivision (a), within 90 days of receipt by the department of a written request by a beneficiary or a representative of a beneficiary, the department may take enforcement action that may include, but shall not be limited to, any or all of the following: (1) Withholding of future provider payments. (2) Suspension of a provider from participation in the Medi-Cal program. (3) Recoupment of funds from a provider. (i) If a provider fails or refuses to reimburse a beneficiary within 90 days after receipt by the department of a written request from a beneficiary or a representative of a beneficiary, the department shall directly reimburse a beneficiary for medically necessary health care expenses incurred during the periods specified in paragraph (1) of subdivision (a). The department shall reimburse a beneficiary only to the extent that federal financial participation is available and only when the claim meets all of the following criteria: (1) The service was a covered benefit under the Medi-Cal program. (2) The provider was an enrolled Medi-Cal provider at the time the service was rendered. (3) The service was ordered by a health care provider, within the scope of his or her practice. (4) The beneficiary is eligible for reimbursement, as specified in subdivision (a). (5) The reimbursement shall be the amount paid by the beneficiary, not to exceed the rate established for that service under the Medi-Cal program. (j) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of the Government Code, this section may be implemented with a provider bulletin or similar notification, without any further regulatory action. (Amended by Stats. 2003, Ch. 230, Sec. 58. Effective August 11, 2003.)
14019.4.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Health care providers using Medi-Cal eligibility proof must not bill the patient for covered services, must give a receipt in certain over-$500 claims, and must notify collectors and the patient when covered bills are sent to collections.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019.4. (a) A provider of health care services who obtains a label or copy from the Medi-Cal card or other proof of eligibility pursuant to this chapter shall not seek reimbursement nor attempt to obtain payment for the cost of those covered health care services from the eligible applicant or recipient, or a person other than the department or a third-party payor who provides a contractual or legal entitlement to health care services. (b) Whenever a service or set of services rendered to a Medi-Cal beneficiary results in the submission of a claim in excess of five hundred dollars ($500), and the beneficiary has given the provider proof of eligibility to receive the service or services, the provider shall issue the beneficiary a receipt to document that appropriate proof of eligibility has been provided. The form and content of those receipts shall be determined by the provider but shall be sufficient to comply with the intent of this subdivision. Nursing facilities and all categories of intermediate care facilities for the developmentally disabled are exempt from the requirements of this subdivision. (c) In addition to being subject to applicable sanctions set forth in law or regulation, a provider of health care services who obtains a label from, or copy of, the Medi-Cal card or other proof of eligibility pursuant to this chapter, and who subsequently pursues reimbursement or payment for the cost of covered services from the beneficiary or fails to cease collection efforts against the beneficiary for covered services as required by subdivision (d), may be subject to a penalty, payable to the department, not to exceed three times the amount payable by the Medi-Cal program. In implementing this subdivision, mitigating circumstances, which include, but are not limited to, clerical error and good faith mistake, shall be considered when assessing the penalty. Providers subject to penalties under this subdivision shall have the right to appeal the assessed penalty, consistent with department procedures. (d) When a Medi-Cal provider receives proof of a patient’s Medi-Cal eligibility and that provider has previously referred an unpaid bill for services rendered to the patient to a debt collector, the Medi-Cal provider shall promptly notify the debt collector of the patient’s Medi-Cal coverage, instruct the debt collector to cease collection efforts on the unpaid bill for the covered services, and notify the patient accordingly. (e) If a patient provides proof of Medi-Cal eligibility to a debt collector, and the debt collector fails to notify the provider of this proof, the provider shall not be responsible for ensuring that collection efforts against the patient cease pursuant to subdivision (d) until either the patient or the debt collector provides the provider with proof of the patient’s Medi-Cal eligibility. (f) A Medi-Cal provider or debt collector shall be deemed to be in violation of subdivision (a) of Section 1785.25 of the Civil Code if more than 30 days after receiving proof of Medi-Cal coverage the provider or debt collector does either of the following: (1) Furnishes information regarding the rendering of the Medi-Cal covered services to a consumer credit reporting agency. (2) Fails to provide corrections of, or instructions to delete, as appropriate, information regarding Medi-Cal covered services previously furnished by that Medi-Cal provider or debt collector to a consumer reporting agency. (g) This section shall not apply to the Medi-Cal spend down of excess income owed by a Medi-Cal beneficiary, unless the beneficiary’s spend down of excess income has been met for the month in which services were rendered. (h) For purposes of this section, “debt collector” includes any person who regularly engages in debt collection, as defined by Section 1788.2 of the Civil Code, but does not include the original Medi-Cal provider. (Amended by Stats. 2023, Ch. 42, Sec. 118. (AB 118) Effective July 10, 2023.)
14019.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Facilities must comply with reasonable certification standards to participate in the 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019.5. Nothing in this chapter shall be construed as imposing any control over the management of any medical or health care facility, except that each such facility shall be required to comply with reasonable standards for certification to participate in the program provided by this chapter. (Amended by Stats. 1971, Ch. 577.)
14019.6.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A person whose property reserve exceeds the property limit may not establish eligibility for the retroactive eligibility period by spending down the excess property.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019.6. Notwithstanding any other provision of law, no person, whose property reserve exceeds the property limit, may establish eligibility for the applicable retroactive eligibility period described in Section 14019, by spenddown of such excess property. (Amended by Stats. 2026, Ch. 27, Sec. 82. (SB 164) Effective June 29, 2026.)
14019.7.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A relative may pay extra to a skilled nursing facility for certain noncovered services or extra bed-hold days, but the facility must disclose specified bed-hold information before taking that payment and may not make admission depend on the relative’s ability to pay.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14019.7. (a) Notwithstanding Section 14019.4 and if permitted by federal law, a relative of a skilled nursing facility resident who is a beneficiary under this chapter may pay an additional amount to the facility to enable the resident to obtain requested noncovered services, such as a private room, telephone, or television, or for bed hold days that exceed a period paid for under the state plan. (b) The additional charge for requested noncovered services shall not exceed the amount charged to private pay residents. The additional charge for bed hold days shall not exceed the rate paid for by the Medi-Cal program for a covered bed hold day. The additional charge for a private room shall not exceed the difference between the private pay rate for a semiprivate room and a private room. (c) Prior to accepting supplemental payment for holding a bed for a resident in a facility, a facility shall disclose to the relative the resident’s right under federal law to be readmitted without charge upon the first availability of a bed in a semiprivate room in that facility, other state and federal laws regarding bed hold rights, the average number of bed vacancies at that facility for the past month, and the current number of bed vacancies. Written information regarding bed vacancies shall be provided to the relative at the first available opportunity. (d) The ability of a resident’s relative to pay an additional amount for noncovered services shall not be a condition of admission. (Added by Stats. 2004, Ch. 661, Sec. 2. Effective January 1, 2005.)
1402.
## Welfare and Institutions Code - WIC ## DIVISION 2. CHILDREN [100 - 1500] ( Division 2 enacted by Stats. 1937, Ch. 369. ) ## PART 1. DELINQUENTS AND WARDS OF THE JUVENILE COURT [100 - 1459] ( Part 1 enacted by Stats. 1937, Ch. 369. ) ## CHAPTER 4. The Interstate Compact for Juveniles [1400 - 1402] ( Repealed and added by Stats. 2009, Ch. 268, Sec. 2. )
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The executive director must convene a steering committee, and the Corrections Standards Authority must present the committee’s final report to the Legislature by January 1, 2011.

## Welfare and Institutions Code - WIC ## DIVISION 2. CHILDREN [100 - 1500] ( Division 2 enacted by Stats. 1937, Ch. 369. ) ## PART 1. DELINQUENTS AND WARDS OF THE JUVENILE COURT [100 - 1459] ( Part 1 enacted by Stats. 1937, Ch. 369. ) ## CHAPTER 4. The Interstate Compact for Juveniles [1400 - 1402] ( Repealed and added by Stats. 2009, Ch. 268, Sec. 2. ) ## 1402. The executive director of the Corrections Standards Authority shall convene an executive steering committee to review and make recommendations regarding the Interstate Compact for Juveniles and whether permanent membership in the compact would be the most effective and prudent means by which California can achieve the purpose set forth in Section 1400 compared to other alternatives. The Corrections Standards Authority shall present the executive steering committee’s final report, including recommendations for legislative action, if necessary, to the appropriate committees of the Legislature by January 1, 2011. The report shall be concise and may be produced and submitted solely in electronic format. (Added by Stats. 2009, Ch. 268, Sec. 2. (AB 1053) Effective January 1, 2010.)
14020.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This chapter stays in operation only while grants-in-aid are available to the state under a federally approved medical assistance state plan.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14020. All sections of this chapter shall remain in operation during such times as grants-in-aid are provided or made available to the state on the basis of a state plan approved by the federal government for medical assistance pursuant to provisions of the Federal Social Security Act, as amended. (Amended by Stats. 1969, Ch. 21.)
14021.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Health care includes specified mental health and substance use disorder services, subject to several payment 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021. Notwithstanding any other provision of this chapter, health care shall include the following mental health and substance use disorder services: (a) Mental health services provided by a county or a city. (b) Mental health services provided in a community mental health service or in a community mental health center organized under the federal Community Mental Health Centers Act of 1963. No amount shall be paid for that portion of the total costs of care and services in a federally funded community mental health center which may be compensated by the United States government under the federal Community Mental Health Centers Act of 1963. No amount shall be paid to a community mental health service or a federally funded community mental health center unless the community mental health service or the federally funded community mental health center participates in a county or city mental health performance contract pursuant to Section 5650. (c) Drug Medi-Cal outpatient substance use disorder services under the jurisdiction of the department provided by a county provider certified under this chapter or a private provider certified under this chapter which has an approved contract with the county or with the department to provide covered substance use disorder services. (d) Inpatient hospital services in an institution for mental diseases to persons of all ages, provided that the institution for mental diseases is certified as a psychiatric hospital under Title XVIII of the federal Social Security Act and regulations issued thereunder. Notwithstanding Section 14157, no money in the State Health Care Deposit Fund shall be expended for the purposes of this section unless the Legislature specifically appropriates money for the purposes of this section. The amendment of this subdivision enacted at the 1972 Regular Session of the Legislature does not constitute a change in, but is declaratory of, the preexisting law. (e) (1) Other diagnostic, screening, preventive, or remedial rehabilitative services for the maximum restoration of an individual to the best possible functional level. (2) Paragraph (1) includes any medical or remedial services provided in a facility, home, or other setting, that are recommended by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law. (Amended by Stats. 2012, Ch. 36, Sec. 72. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.2.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must develop a proposal for a federal demonstration program, use appropriated funds to support that proposal, and, if selected, report specified information to the Legislature by March 1, 2017.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.2. (a) The department shall develop a proposal for the United States Secretary of Health and Human Services for selection as a participating state in the time-limited demonstration program pursuant to Section 223 of the federal Protecting Access to Medicare Act of 2014 (Public Law 113-93) in order to improve mental health services furnished by certified community behavioral health clinics to Medi-Cal beneficiaries. (b) The department shall use the funds appropriated in the act that added this section to pay any costs that will support the development of a competitive proposal, including, but not limited to, establishing actuarially sound rates and providing technical assistance to counties. (c) If the state is selected as a participating state in the time-limited demonstration program described in subdivision (a), the department, by March 1, 2017, shall provide an update to the Legislature that includes, to the extent it is available, the following information: (1) The names of the participating counties. (2) The estimated amount of additional funding each county is expected to receive under the demonstration program. (3) The proposed uses of the additional funds and the county funds no longer required to be used as the federal match. (4) A description of the improved partnerships between certified community behavioral health clinics and veterans organizations, primary care providers, health plans, educational agencies, and other organizations that the demonstration program includes. (5) Other identified benefits from the demonstration program funding and planning process, and recommendations on any components of the demonstration program that could be extended to other counties. (Amended by Stats. 2016, Ch. 283, Sec. 2. (AB 168) Effective January 1, 2017.)
14021.3.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The Medicaid state plan must include targeted case management services as a Medi-Cal specialty mental health benefit.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.3. The state plan for medical assistance under Medicaid pursuant to Section 1915(g) of Title 19 of the federal Social Security Act, as amended by Public Law 99-272 (42 U.S.C. Section 1396n(g)), shall include targeted case management services as a benefit under the specialty mental health services Medi-Cal program. (Amended (as added by Stats. 1987, Ch. 1385, Sec. 1) by Stats. 2012, Ch. 34, Sec. 222. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
14021.30.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section transfers Drug-Medi-Cal administration to the State Department of Health Care Services and requires transition activities and quarterly update 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.30. (a) It is the intent of the Legislature to transfer to the State Department of Health Care Services, no later than July 1, 2012, the administration of the Drug Medi-Cal program from the State Department of Alcohol and Drug Programs. It is further the intent of the Legislature that this transfer should happen efficiently and effectively, with no unintended interruptions in service delivery. This transfer is intended to do all of the following: (1) Improve access to alcohol and drug treatment services, including a focus on recovery and rehabilitation services. (2) More effectively integrate the financing of services, including the receipt of federal funds. (3) Improve state accountability and outcomes. (4) Provide focused, high-level leadership for behavioral health services. (b) Effective July 1, 2012, the administrative functions for the Drug Medi-Cal program that were previously performed by the State Department of Alcohol and Drug Programs are transferred to the department. (c) Notwithstanding subdivision (b), the department and the State Department of Alcohol and Drug Programs may conduct transition activities prior to July 1, 2012, that are necessary to ensure the efficient and effective transfer of Drug Medi-Cal program functions by that date in accordance with the transition plan described in Section 14021.31. (d) After July 1, 2012, and through the quarter ending June 30, 2014, the department shall provide quarterly updates to the Legislature, key stakeholders, and the public on the steps foreseen, planned, and completed for the Drug Medi-Cal transfer, noting areas of concern, delay, or disruption, as the program fully transitions to the State Department of Health Care Services. These updates shall include information on continuity of care for beneficiaries and any access issues to care that arise as a result of or within the Drug Medi-Cal transfer. The State Department of Health Care Services shall convene meetings with interested stakeholders, including legislative representatives, either in preparation for or at the release of these quarterly updates. The first of these quarterly updates shall be released no later than October 1, 2012. (Amended by Stats. 2012, Ch. 36, Sec. 73. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.31.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must work with the State Department of Alcohol and Drug Programs to create a transition plan for moving Drug-Medi-Cal to the department and to consult stakeholders during the process.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.31. The department, in collaboration with the State Department of Alcohol and Drug Programs, shall develop an administrative and programmatic transition plan to guide the transfer of the Drug Medi-Cal program to the department effective July 1, 2012. (a) Commencing no later than July 15, 2011, the department, together with the State Department of Alcohol and Drug Programs, shall convene stakeholders to receive input from consumers, family members, providers, counties, and representatives of the Legislature concerning the transfer of the administration of Drug Medi-Cal functions currently performed by the State Department of Alcohol and Drug Programs to the department. This consultation shall inform the creation of an administrative and programmatic transition plan that shall include, but is not limited to, the following components: (1) Plans for how to review monthly billing from counties to monitor and prevent any disruptions of service to Drug Medi-Cal beneficiaries during and immediately after the transition, and a description of how the department intends to approach the longer-term development of measures for access and quality of service. (2) A detailed description of the Drug Medi-Cal administrative functions currently performed by the State Department of Alcohol and Drug Programs. (3) Explanations of the operational steps, timelines, and key milestones for determining when and how each of these functions will be transferred. These explanations shall also be developed for the transition of position and staff serving the Drug Medi-Cal program and how these will relate to and align with positions for the Medi-Cal program at the department. The department shall consult with the Department of Human Resources in developing this aspect of the transition plan. (4) A list of any planned or proposed changes or efficiencies in how the functions will be performed, including the anticipated fiscal and programmatic impacts of the changes. (5) A detailed organization chart that reflects the planned staffing at the department, taking into account the requirements of subparagraphs (A) to (C), inclusive, and includes focused, high-level leadership for behavioral health issues. (6) A description of how stakeholders were included in the initial planning process to formulate the transition plan, and a description of how their feedback will be taken into consideration after transition activities are underway. (b) The department, together with the State Department of Alcohol and Drug Programs, shall convene and consult with stakeholders at least once following production of a draft of the transition plan and before submission of that plan to the Legislature. Continued consultation with stakeholders shall occur in accordance with the requirement in subparagraph (F) of paragraph (1). (Amended by Stats. 2018, Ch. 903, Sec. 22. (SB 1504) Effective January 1, 2019.)
14021.33.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A qualifying Drug Medi-Cal Treatment Program regulation or order stays in force and enforceable until the department readopts, amends, or repeals it, or it expires on its own 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.33. A regulation or order concerning the Drug Medi-Cal Treatment Program adopted by the State Department of Alcohol and Drug Programs pursuant to former Chapter 3.4 (commencing with Section 11758.40) of Part 1 of Division 10.5 of the Health and Safety Code, as in effect preceding the effective date of the act that added this section, shall remain in effect and shall be fully enforceable, unless and until the readoption, amendment, or repeal of the regulation or order by the department, or until it expires by its own terms. (Added by Stats. 2012, Ch. 36, Sec. 74. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must seek federal approval for Drug-Medi-Cal implementation and then define covered services, set qualifying standards, and develop reimbursement rates.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.35. (a) The department shall prepare and submit amendments to the Medicaid state plan and apply for any necessary waivers in order to obtain federal financial participation to implement Drug Medi-Cal Treatment Program provisions contained in Section 14124.24. (b) Upon federal approval for federal financial assistance, the department, in consultation with the State Department of Alcohol and Drug Programs, shall define the Drug Medi-Cal services, as needed, shall establish the standards under which those services qualify as Drug Medi-Cal reimbursable services, and shall develop appropriate rates of reimbursement for those services, subject to utilization controls. (Amended by Stats. 2012, Ch. 36, Sec. 75. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.4.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section directs the department to revise quality assurance standards for Medi-Cal mental health services and limits rehabilitative-option services to certified specialty mental 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.4. (a) California’s plan for federal Medi-Cal grants for medical assistance programs, pursuant to Subchapter XIX (commencing with Section 1396) of Title 42 of the United States Code, shall accomplish the following objectives: (1) Expansion of the location and type of therapeutic services offered to persons with mental illnesses under Medi-Cal by the category of “other diagnostic, screening, preventative, and rehabilitative services” that is available to states under the federal Social Security Act and its implementing regulations (42 U.S.C. Sec. 1396d(a)(13); 42 C.F.R. 440.130). (2) Expansion of federal financial participation in the costs of specialty mental health services provided by local mental health plans or under contract with the mental health plans. (3) Expansion of the location where reimbursable specialty mental health services can be provided, including home, school, and community-based sites. (4) Expansion of federal financial participation for services that meet the rehabilitation needs of persons with mental illnesses, including, but not limited to, medication management, functional rehabilitation assessments of clients, and rehabilitative services that include remedial services directed at restoration to the highest possible functional level for persons with mental illnesses and maximum reduction of symptoms of mental illness. (5) Improvement of fiscal systems and accountability structures for specialty mental health services, costs, and rates, with the goal of achieving federal fiscal requirements. (b) The department’s state plan revision shall be completed with review and comments by the County Behavioral Health Directors Association of California and other appropriate groups. (c) Services under the rehabilitative option shall be limited to specialty mental health plans certified to provide Medi-Cal under this option. (d) It is the intent of the Legislature that the rehabilitation option of the state Medicaid plan be implemented to expand and provide flexibility to treatment services and to increase the federal participation without increasing the costs to the General Fund. (e) The department shall review and revise the quality assurance standards and guidelines required by Section 14725 to ensure that quality services are delivered to the eligible population. Any reviews shall include, but not be limited to, appropriate use of mental health professionals, including psychiatrists, in the treatment and rehabilitation of clients under this model. The existing quality assurance standards and guidelines shall remain in effect until the adoption of the new quality assurance standards and guidelines. (f) Consistent with services offered to persons with mental illnesses under the Medi-Cal program, as required by this section, it is the intent of the Legislature for the department to include care and treatment of persons with mental illnesses who are eligible for the Medi-Cal program in facilities with a bed capacity of 16 beds or less. (Amended by Stats. 2015, Ch. 455, Sec. 51. (SB 804) Effective January 1, 2016.)
14021.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must issue emergency regulations on claims submission and on how reimbursement rates and the rate-setting method are determined for certain Medi-Cal mental health and substance use disorder services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.5. (a) Notwithstanding any other provision of law, rates for reimbursing specialty mental health and substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall continue to be based on the upper limits allowable under federal law and regulations for services provided prior to July 1, 1980, on the lower of reasonable cost and customary charges for services provided July 1, 1980, through June 30, 1982, and on the lowest of reasonable cost, customary charges, and rates paid by the Medi-Cal program for services provided July 1, 1982, through June 30, 1984. (b) The Legislature hereby states and declares that this section does not constitute a change in, but is declaratory of, existing law and that rates for reimbursing specialty mental health and substance use disorder services to Medi-Cal beneficiaries under the Medi-Cal program in previous fiscal years were based upon the lower of reasonable costs or customary charges. (c) The department shall promulgate emergency regulations relating to claims submission and establishing rates and a ratesetting methodology for determining reimbursement of specialty mental health and substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries. The methodology and rates shall reflect the most recently completed cost reports and shall be effective commencing July 1, 1984. (d) Notwithstanding any other law, rates for reimbursing specialty mental health services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall be effective from July 1 through June 30 of the fiscal year in which these rates are established. (e) Notwithstanding any other law, rates for reimbursing substance use disorder services allowable under the Medi-Cal program and rendered to Medi-Cal beneficiaries shall be effective from July 1 through June 30 of the fiscal year in which these rates are established. (Amended by Stats. 2012, Ch. 34, Sec. 224. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
14021.51.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must set a methadone dosing fee and adopt implementing regulations; reimbursement for narcotic treatment program services is tightly limited and rate-based.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.51. (a) For purposes of this section, “narcotic treatment program services” includes, but is not limited to, all of the following: (1) Admission, physical evaluation, and diagnosis. (2) Drug screening. (3) Pregnancy tests. (4) Narcotic replacement therapy dosing. (5) Any medication approved under Section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), and all biological products licensed under Section 351 of the Public Health Service Act (42 U.S.C. 262) to treat opioid use disorders. (6) (A) Intake assessment, treatment planning, and counseling services. (B) The frequency of counseling, behavioral therapy, or medical psychotherapy, outcomes, and rates shall be addressed through guidance issued by the department pursuant to subdivision (k). For purposes of this paragraph, these services include substance use services to pregnant and postpartum Medi-Cal beneficiaries. (b) (1) The department shall establish a narcotic replacement therapy dosing fee for methadone. (2) In addition to the narcotic replacement therapy dosing fee specified in paragraph (1), a narcotic treatment program shall be reimbursed for the ingredient costs of methadone dispensed to a Medi-Cal beneficiary. These costs may be determined on an average daily dose of methadone, as set forth by the department. (c) Reimbursement for narcotic treatment program services shall be based on a per capita uniform statewide daily reimbursement rate for each individual patient, as established by the department. The uniform statewide daily reimbursement rate for narcotic treatment program services shall be based upon, if available and appropriate, all of the following: (1) The outpatient rates for the same or similar services under the fee-for-service Medi-Cal program. (2) Cost report data. (3) Other data deemed reliable and relevant by the department. (4) The rate studies completed pursuant to Section 54 of Chapter 197 of the Statutes of 1996. (d) The uniform statewide daily reimbursement rate for ancillary services shall not exceed, for individual services or in the aggregate, the outpatient rates for the same or similar services under the fee-for-service Medi-Cal program. (e) The uniform statewide daily reimbursement rate shall be established after consultation with narcotic treatment program providers and county alcohol and drug program administrators. (f) Reimbursement for narcotic treatment program services shall be limited to those services specified in state law and any authorized federally approved Medicaid state plan amendments or waivers related to the Drug Medi-Cal program, and shall be provided in accordance with federal and state law governing the licensing and administration of narcotic treatment programs. (g) Reimbursement under this section shall be limited to claims for narcotic treatment program services at the uniform statewide daily reimbursement rate for these services. These rates shall be exempt from the requirements of Section 14021.6. (h) (1) Reimbursement to a narcotic treatment program provider shall be limited to the lower of the uniform statewide daily reimbursement rate, pursuant to subdivision (c), or the provider’s usual and customary charge to the general public for the same or similar service. (2) (A) Reimbursement paid by a county to a narcotic treatment program provider for services provided to any person subject to Section 1210.1 or 3063.1 of the Penal Code, and for which the individual client is not liable to pay, is not a usual and customary charge to the general public for the purposes of this section. (B) Subparagraph (A) is not a change in, but is declaratory of, existing law. (i) A program shall not be reimbursed for services or medications not rendered to or received by a patient of a narcotic treatment program. (j) Reimbursement for narcotic treatment program services shall be administered by the department and any county electing to participate in the program. Utilization and payment for these services shall be subject to federal Medicaid and state utilization and audit requirements. (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, in whole or in part, by means of bulletins or similar instructions, until the time that any necessary regulations are adopted. (l) The department shall adopt regulations necessary to implement this section by July 1, 2023. (m) This section shall be implemented to the extent that any necessary federal approval of state plan amendments or other federal approvals, including waivers, are obtained, and federal financial participation is available and not otherwise jeopardized. (Amended by Stats. 2020, Ch. 12, Sec. 50. (AB 80) Effective June 29, 2020.)
14021.52.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A licensed narcotic treatment program provider serving low-income non-Drug-Medi-Cal clients must use a sliding indigency scale that meets listed documentation and fee 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.52. (a) (1) The Legislature finds and declares all of the following: (A) Medical treatment for indigent patients who are not eligible for Medi-Cal is essential to protecting the public health. (B) The Legislature supports the adoption of standardized and simplified forms and procedures in order to promote the drug treatment of indigent patients who are not eligible for Medi-Cal. (C) Providers should not be required by the state to subsidize the medical treatment provided to indigent patients who are not eligible for Medi-Cal. (D) The Legislature supports the therapeutic value of indigent patients who are not eligible for Medi-Cal contributing some level of fees for drug treatment services in order to support the goals of those drug treatment services. (2) It is the intent of the Legislature in enacting this section to encourage narcotic treatment program providers to serve indigent patients who are not eligible for Medi-Cal. It is also the intent of the Legislature that the department allow narcotic treatment program providers to charge therapeutic fees for providing drug treatment to indigent patients who are not eligible for Medi-Cal if the providers establish a fee scale that complies with the documentation requirements established pursuant to this section and federal law. (b) (1) The Legislature recognizes that narcotic treatment program providers are reimbursed for controlled substances provided under the Drug Medi-Cal Treatment Program, also known as Drug Medi-Cal, and pursuant to federal law at a rate that is the lower of the per capita uniform statewide daily reimbursement or Drug Medi-Cal rate, or the provider’s usual and customary charge to the general public for the same or similar services. (2) It furthers the intent of the Legislature to ensure that narcotic treatment programs in the state are able to serve indigent clients and that there is an exception to the reimbursement requirements described in paragraph (1), as the federal law has been interpreted by representatives with the federal Centers for Medicare and Medicaid Services. Pursuant to this exception, if a narcotic treatment program provider that is serving low-income non-Drug Medi-Cal clients complies with a federal requirement for the application of a sliding indigency scale, the reduced charges under the sliding indigency scale shall not lower the provider’s usual and customary charge determination for purposes of Medi-Cal reimbursement. (c) A licensed narcotic treatment program provider that serves low-income non-Drug Medi-Cal clients shall be deemed in compliance with federal and state law, for purposes of the application of the exception described in paragraph (2) of subdivision (b), and avoid audit disallowances, if the provider implements a sliding indigency scale that meets all of the following requirements: (1) The maximum fee contained in the scale shall be the provider’s full nondiscounted, published charge and shall be at least the rate that Drug Medi-Cal would pay for the same or similar services provided to Drug Medi-Cal clients. (2) The sliding indigency scale shall provide for an array of different charges, based upon a client’s ability to pay, as measured by identifiable variables. These variables may include, but need not be limited to, financial information and the number of dependents of the client. (3) Income ranges shall be in increments that result in a reasonable distribution of clients paying differing amounts for services based on differing abilities to pay. (4) A provider shall obtain written documentation that supports an indigency allowance under the sliding indigency scale established pursuant to this section, including a financial determination. In cases where this written documentation cannot be obtained, the provider shall document at least three attempts to obtain this written documentation from a client. (5) The provider shall maintain all written documentation that supports an indigency allowance under this section, including, if used, the financial evaluation form set forth in Section 14021.53. (6) Written policies shall be established and maintained that set forth the basis for determining whether an indigency allowance may be granted under this section and establish what documentation shall be requested from a client. (d) In developing the sliding indigency scale, a narcotic treatment program provider shall consider, but need not include, any or all of the following components: (1) Vertically, the rows would reflect increments of family or household income. There would be a sufficient number of increments to allow for differing charges, such as a six hundred dollar ($600) increase per interval. (2) Horizontally, the columns would provide for some other variable, such as family size, in which case, the columns would reflect the number of people dependent on the income, including the client. (3) Each row, except the first and last rows, would contain at least two different fee amounts and each of the columns, four or more in number, would contain at least six different fee amounts. (4) The cells would contain an array of fees so that no fee would be represented in more than 25 percent of the cells. (e) A narcotic treatment program provider that uses the financial evaluation form instructions and financial form set forth in Section 14021.53 in obtaining written documentation that supports an indigency allowance as required under paragraph (4) of subdivision (c) shall be deemed in compliance with that paragraph. (Added by Stats. 2012, Ch. 36, Sec. 77. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.53.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A narcotic treatment program provider may use the listed financial evaluation form instructions to comply with Section 14021.52, and must provide a reason if it changes a client’s sliding-scale fee. The provider must also make at least three documented attempts to collect documentation from the client.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.53. A narcotic treatment program provider may use the following instructions and financial evaluation form to comply with the requirements of paragraph (4) of subdivision (c) of Section 14021.52: ## FINANCIAL EVALUATION FORM INSTRUCTIONS MONTHLY INCOME DATA—This data should specify the source and the amount and be supported by sufficient documentation. Income data may include, but are not limited to, income received as a paid employee, unemployment benefits, disability benefits, pension payments, family income, savings income, or other sources. MONTHLY EXPENSES DATA—This data is not required unless there is no evidence or documentation of income data. Expense data may include, but are not limited to, any known expenses related to the following: (1) Court-ordered payments, such as child support, fines, debts, restitution, or other payments. (2) Housing-related expenses, such as rent, mortgage, insurance, utilities, or other obligations. (3) Transportation costs, such as any related expenses, including automobile payments or automobile insurance payments. (4) Insurance coverage should also be noted if it produces either an expense or benefit to the client. CLIENT MONTHLY TREATMENT FEE—The following applies to this data: (1) The amount box indicates the client’s fee according to his or her location on the sliding scale. (2) The adjusted client monthly fee box is to be filled only if the fee to be charged differs from the fee indicated by the client’s location on the sliding scale. (3) If the fee is adjusted from what the sliding scale would indicate, a reason for the adjustment must be provided. (Valid reasons might include extraordinary medical expenses for a client suffering from HIV/AIDS, etc.) PLEASE NOTE—The documentation for this form requires that the provider make at least three documented attempts to collect documentation from a client. Any questions on this form may be directed to the department at (____). (Added by Stats. 2012, Ch. 36, Sec. 78. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14021.6.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section sets how the Drug Medi-Cal Treatment Program’s maximum allowable rates are calculated and gives the department rulemaking, reporting, and rate-setting duties.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.6. (a) For the fiscal years prior to the 2004–05 fiscal year, and subject to the requirements of federal law, the maximum allowable rates for the Drug Medi-Cal Treatment Program shall be determined by computing the median rate from available cost data by modality from the fiscal year that is two years prior to the year for which the rate is being established. (b) (1) For the 2007–08 fiscal year, and subsequent fiscal years, and subject to the requirements of federal law, the maximum allowable rates for the Drug Medi-Cal Treatment Program shall be determined by computing the median rate from the most recently completed cost reports, by specific service codes that are consistent with the federal Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Sec. 300gg). (2) For the 2005–06 and 2006–07 fiscal years, if the State Department of Health Care Services determines that reasonably reliable and complete cost report data are available, the methodology specified in this subdivision shall be applied to either or both of those years. If reasonably reliable and complete cost report data are not available, the State Department of Health Care Services shall establish rates for either or both of those years based upon the usual, customary, and reasonable charge for the services to be provided, as the department may determine in its discretion. This subdivision does not modify subdivision (h) of Section 14124.24, which requires certain providers to submit performance reports. (c) Notwithstanding subdivision (a), for the 1996–97 fiscal year, the rates for nonperinatal outpatient methadone maintenance services shall be set at the rate established for the 1995–96 fiscal year. (d) Notwithstanding subdivision (a), the maximum allowable rate for group outpatient drug free services shall be set on a per person basis. A group shall consist of a minimum of 2 and a maximum of 12 individuals, at least one of which shall be a Medi-Cal eligible beneficiary. For groups consisting of two individuals, if one of the individuals is ineligible for Medi-Cal, the individual who is ineligible for Medi-Cal shall be receiving outpatient drug free services for a substance use disorder diagnosed by a physician. (e) The department shall develop individual and group rates for extensive counseling for outpatient drug free treatment, based on a 50-minute individual or a 90-minute group hour, not to exceed the total rate established for subdivision (d). (f) (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 by means of bulletins or similar instructions until the time any necessary regulations are adopted. The department shall adopt regulations by July 1, 2020, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act that added this paragraph, and notwithstanding Section 10231.5 of the Government Code, the department shall, on a semiannual basis and in compliance with Section 9795 of the Government Code, provide a status report to the Legislature until the regulations have been adopted. (2) Notwithstanding paragraph (1) and Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may annually establish and update the statewide maximum allowable reimbursement rates specified in this section by means of bulletins or similar instructions. (g) Bills for services under the Drug Medi-Cal Treatment Program shall be submitted no later than 12 months from the date of service. (Amended by Stats. 2023, Ch. 42, Sec. 119. (AB 118) Effective July 10, 2023.)
14021.7.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must amend the Medi-Cal state plan to add targeted case management services for specified pregnant and parenting adolescents and their children, then submit the amended plan for federal approval by April 1, 1991.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.7. (a) The department shall amend the state plan for medical assistance under the Medicaid program pursuant to subdivision (g) of Section 1396n of Title 42 of the United States Code, to add targeted case management services for those pregnant and parenting adolescents and their children, targeted by the department, in those localities served on January 1, 1991, by the Adolescent Family Life Program (Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106 of the Health and Safety Code), as a covered benefit under the Medi-Cal program. The department shall submit the amended plan for federal approval by April 1, 1991. (b) For purposes of this section, the term “targeted case management services” shall be defined as those services provided to pregnant and parenting adolescents pursuant to Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106 of the Health and Safety Code. (c) Upon federal approval for federal financial assistance, the department shall establish the standards under which targeted case management services qualify as a Medi-Cal reimbursable service, subject to the availability of funding through the budget process, and shall develop an appropriate rate of reimbursement, subject to utilization controls. (Amended by Stats. 1996, Ch. 1023, Sec. 469. Effective September 29, 1996.)
14021.8.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must not use whether a beneficiary’s psychiatric inpatient admission was voluntary or involuntary when deciding eligibility for Medi-Cal claim reimbursement.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.8. The department may not utilize any information regarding whether a beneficiary’s psychiatric inpatient admission was made on a voluntary or involuntary basis for the purpose of determining eligibility for Medi-Cal claim reimbursement. (Added by Stats. 2001, Ch. 506, Sec. 10. Effective January 1, 2002.)
14021.9.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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For specified fiscal years, Drug-Medi-Cal service rates are reduced or capped at the lower of two calculations, and the 2009–10 reduction applies retroactively to July 1, 2009.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14021.9. (a) Notwithstanding any other law, for the 2009–10 fiscal year, a 10-percent reduction shall be applied to rates for Drug Medi-Cal services developed by the State Department of Alcohol and Drug Programs pursuant to Section 11758.42 of the Health and Safety Code and Sections 14021.35, 14021.5, and 14021.6. (b) For the 2010–11 and 2011–12 fiscal years, rates for Drug Medi-Cal services shall be the lower of the following: (1) The rates developed by the State Department of Alcohol and Drug Programs pursuant to Section 11758.42 of the Health and Safety Code and Sections 14021.35, 14021.5, and 14021.6. (2) The rates applicable in the 2009–10 fiscal year pursuant to subdivision (a), adjusted for the cumulative growth in the Implicit Price Deflator for the Costs of Goods and Services to Governmental Agencies, as reported by the Department of Finance. (c) For the 2012–13 fiscal year and each fiscal year thereafter, rates for Drug Medi-Cal reimbursable services shall be the lower of the following: (1) The rates developed pursuant to Sections 14021.35, 14021.51, and 14021.6. (2) The rates applicable in the 2009–10 fiscal year pursuant to subdivision (a), adjusted for the cumulative growth in the Implicit Price Deflator for the Costs of Goods and Services to Governmental Agencies, as reported by the Department of Finance. (d) The rate reductions applicable for the 2009–10 fiscal year pursuant to subdivision (a) shall be applied retroactively to July 1, 2009. (Amended by Stats. 2012, Ch. 36, Sec. 79. (SB 1014) Effective June 27, 2012. Operative July 1, 2012, by Sec. 83 of Ch. 36.)
14022.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medi-Cal payments may not be made for certain referral-related services unless a statement about the relevant interest is on file with the director and the Advisory Health Council.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14022. (a) This section shall be known as the “Medi-Cal Conflict of Interest Law.” It is the intent of the Legislature that provisions be made for disclosure of the interests of providers of service in the services, facilities and organizations to which they refer Medi-Cal recipients so that it is possible to determine the extent to which conflicts of interests may exist because of such referrals. (b) As used in this section, the term “referral” means (1) the referral of a recipient by a provider of service to any other provider of service; (2) the placement of a recipient by a provider of service in any facility; or (3) the obtaining, requesting, ordering or prescribing of services or supplies by a provider of service on behalf of a recipient from any other provider of service. As used in this section, the term “immediate family” includes the spouse and children of the provider of service, the parents of the provider of service and his spouse, and the spouses of the children of the provider of service. (c) A payment under this chapter shall not be made to a provider of service or to any facility or organization in which he or his immediate family has a significant beneficial interest, for services rendered in connection with any referral of a recipient, unless there is on file with the director and the Advisory Health Council a statement of the nature and extent of such interest. (d) This section shall become operative only upon the date of which Section 1902(a)(4)(C) of the federal Social Security Act, as added by Public Law 95-559 is repealed, held invalid by a court of appeal, or otherwise made inoperative. (Amended by Stats. 2015, Ch. 303, Sec. 606. (AB 731) Effective January 1, 2016. Section conditionally operative by its own provisions. Note: Until this section is operative, see related provisions in Article 1.6, commencing with Section 14047.)
14022.1.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Covered facilities must give the department complete ownership and officer/director/partner information, and promptly report changes that affect accuracy.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14022.1. Any nursing facility or any category of intermediate care facility for the developmentally disabled participating in the Medi-Cal program shall supply to the department full and complete information as to the identity (a) of each person having, directly or indirectly, an ownership interest of 10 percent or more in the facility, or, who is owner, in whole or part, of any mortgage, deed of trust, note, or other obligation secured, in whole or part, by the facility, or any of the property or assets of the facility, (b) in case a facility is organized as a corporation, of each officer and director of the corporation, and (c) in case a facility is organized as a partnership, of each partner; and shall promptly report any changes which would affect the current accuracy of the information so required to be supplied. (Amended by Stats. 1990, Ch. 1329, Sec. 13. Effective September 26, 1990.)
14022.3.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Long-term health care facilities must tell applicants, before admission, whether they participate in Medi-Cal and when the law allows an involuntary transfer of a Medi-Cal recipient.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14022.3. Long-term health care facilities shall reveal to applicants for admission, or their designated representatives, orally and in writing and prior to admission, whether the facility participates in the Medi-Cal program, and the circumstances under which the law permits a Medi-Cal recipient to be transferred involuntarily. (Added by Stats. 1985, Ch. 11, Sec. 19. Effective March 6, 1985.)
14022.4.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Certain Medi-Cal-participating nursing and intermediate care facilities cannot voluntarily withdraw unless they file notice, protect existing residents, and give new admissions oral and written notice.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14022.4. (a) Any nursing facility or any category of intermediate care facility for the developmentally disabled currently certified to participate in the Medi-Cal program may not voluntarily withdraw from the program unless all of the following conditions are met: (1) The facility shall file with the department a notice of intent to withdraw from the Medi-Cal program. (2) Except for patients to be transferred or discharged only for medical reasons, or for patients’ welfare or that of other patients, or for nonpayment for his or her stay, the facility shall not subsequently evict any Medi-Cal recipient or private pay patient residing in the facility at the time the notice of intent to withdraw from the Medi-Cal program is filed. (3) Patients admitted to the facility on or after the date of the notice of intent to withdraw from the Medi-Cal program shall be advised orally and in writing of both the following: (A) That the facility intends to withdraw from the Medi-Cal program. (B) That notwithstanding Section 14124.7, the facility is not required to keep a new resident who converts from private pay to Medi-Cal. (b) Subdivision (a) shall not apply to facilities that have filed, prior to May 1, 1987, a notice of intent to withdraw from the Medi-Cal program. (c) The department shall notify the appropriate substate ombudsmen monthly as to which facilities have filed a notice of intent to withdraw from the Medi-Cal program. This information shall also be made available to the public and noted in facility files available in each district office. (d) The facility may formally withdraw from the Medi-Cal program when all patients residing in the facility at the time the facility filed the notice of intent to withdraw from the Medi-Cal program no longer reside in the facility. (e) If a facility that has withdrawn as a Medi-Cal provider pursuant to this section subsequently reapplies to the department to become a Medi-Cal provider, the department shall require as a condition of becoming a Medi-Cal provider that the facility enter into a five-year Medi-Cal provider contract with the department. (f) This section shall be inoperative in the event federal law or federal or state appellate judicial decisions prohibit implementation or invalidate any part of this section. (g) (1) This section does not apply to any facility which ceases operations entirely. (2) For purposes of this subdivision, “ceases operations entirely” means not being in operation for a period of not less than 12 months. (Amended by Stats. 2012, Ch. 728, Sec. 198. (SB 71) Effective January 1, 2013. Conditionally inoperative as provided in subd. (f).)
14022.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must share specified dental-services data with certain legislative committees by April 1, 2003, in cooperation with the State Department of Developmental Services and in consultation with the California Dental Association.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14022.5. (a) It is the intent of the Legislature to recognize the challenges and unique dental treatment needs of the developmentally disabled population that cannot be addressed within the current structure of benefits, frequency of allowable procedures, and treatment authorization procedures for assistance programs relating to dental benefits. (b) The department shall work in cooperation with the State Department of Developmental Services, and in consultation with the California Dental Association, to provide existing data directly to the fiscal and policy committees of the Legislature specified in subdivision (c), by April 1, 2003, describing the characteristics of dental services received by Medi-Cal beneficiaries who are eligible to receive dental services under the Lanterman Developmental Disability Services Act (Division 4.5 (commencing with Section 4500)), who can be easily identified, including, but not limited to, the frequency of utilization of dental procedures and services, and types of dental procedures and services. (c) The committees to whom the data shall be provided include all of the following: (1) The Senate Committee on Health and Human Services. (2) The Senate Budget Subcommittee Number 3 on Health, Human Services, Labor, and Veterans Affairs. (3) The Assembly Committee on Health. (4) The Assembly Committee on Human Services. (5) The Assembly Budget Subcommittee Number 1 on Health and Human Services. (d) It is the intent of the Legislature that the information described in subdivision (b) will be used to identify possible program modifications that are more appropriate to serve the population described in subdivision (b), and that are more efficient and more effective in serving this population, while remaining cost-neutral. (Added by Stats. 2002, Ch. 522, Sec. 1. Effective January 1, 2003.)
14023.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Applicants and eligible persons must disclose or report other health-care entitlements, use them first, and applicants are deemed to have assigned certain benefits to 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14023. (a) Any applicant for coverage under this chapter who at the time of application has any other contractual or legal entitlement to any health care service defined in Section 14053, and who willfully fails at that time to disclose the fact of such other entitlement, or falsely represents that he or she does not have such other entitlement, is guilty of a misdemeanor. (b) Any person eligible under this chapter who, subsequent to the date of application for such assistance or coverage under this chapter, acquires any other contractual or legal entitlement to any health care service defined in Section 14053, and willfully fails or refuses to give notice thereof to his county welfare department within 10 days of such acquisition, is guilty of a misdemeanor. (c) Any person eligible under this chapter who has any other contractual or legal entitlement to any health care service defined in Section 14053, and who knowing that he or she must use such entitlement first, obtains any such service under Medi-Cal without first having utilized and exhausted his or her other contractual or legal entitlement thereto or therefor, is guilty of a misdemeanor. (d) Any applicant shall by virtue of becoming eligible under this chapter have irrevocably assigned the benefits of any contractual or legal entitlement for health care to the State Director of Health Services to the extent that the services were paid for under this chapter. (Amended by Stats. 1985, Ch. 1354, Sec. 14.)
14023.7.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Providers seeking payment for covered health care services must first try to collect from available private or public health insurance before billing the department. If the insurer has not paid within 90 days of billing, the provider may submit the claim to the department.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14023.7. Any provider of service seeking payment for health care services for a person eligible for these services under this chapter shall first seek to obtain payment from any private or public health insurance coverage to which the person is entitled, where the provider is aware of this coverage and to the extent the coverage extends to these services, prior to submitting a claim to the department for the payment of any unpaid balance for these services. In the event that a claim submitted to a private or public health insurer has not been paid within 90 days of billing by the provider, a claim may be submitted to the department. (Added by Stats. 1983, Ch. 323, Sec. 125.4. Effective July 1, 1983.)
14024.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The director may recover certain amounts when a person receiving health care services has another legal or contractual entitlement, and providers must report potential third-party liability and disclose Medi-Cal status in certain claims.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14024. When health care services are provided to a person under this chapter who at the time the service is provided has any other contractual or legal entitlement to such services, the director shall have the right to recover from the person, corporation, or partnership who owes such entitlement, the amount which would have been paid to the person entitled thereto, or to a third party in his behalf, or the value of the service actually provided, if the person entitled thereto was entitled to services. The Attorney General may, to recover under this section, institute and prosecute legal proceedings against the person, corporation, or partnership owing such entitlement in the appropriate court in the name of the director. To the extent permitted by federal law and subject to the director’s prior right to recover upon any contractual or legal entitlement or other third-party liability for the cost incurred in rendering care, the provider of services shall remain entitled to recover remaining unpaid charges to the extent that any third party is obligated to pay the charges by reason of the beneficiary’s other contractual entitlement. Any claim shall not be permitted to the extent that the claim would reduce the director’s right to recover pursuant to Section 14124.78. The provider of services shall be required to notify the department of any potential contractual or legal entitlement or other third-party liability within 60 days of discovery. A provider who has obtained proof of Medi-Cal eligibility and who makes a claim for payment by any third party shall disclose in the claim that the patient is a Medi-Cal beneficiary. (Amended by Stats. 1985, Ch. 776, Sec. 3.)
14025.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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It is a criminal offense for any person to buy, sell, or barter Medi-Cal cards, labels, or beneficiary identification numbers, with a narrow exception for certain peace officers and people working under their direction during fraud or related-crime investigations.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14025. (a) Any person who buys or sells a Medi-Cal card, Medi-Cal label, or Medi-Cal beneficiary identification number is guilty of a public offense punishable by imprisonment in the county jail for not more than one year, or in the state prison, or by a fine not exceeding five thousand dollars ($5,000), or by both the fine and imprisonment. (b) Any person who barters for the purpose of resale or commercial exchange a Medi-Cal card, Medi-Cal label, or Medi-Cal beneficiary identification number is guilty of a public offense punishable by imprisonment in the county jail for not more than one year, or in the state prison, or by a fine not exceeding five thousand dollars ($5,000), or by both the fine and imprisonment. (c) This section shall not apply to any peace officer or any other person working under the peace officer’s immediate direction, supervision, or instruction while investigating Medi-Cal fraud or other related crimes in the performance of his or her official duties. (Added by Stats. 1989, Ch. 1267, Sec. 1.)
14026.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medi-Cal beneficiaries and other persons may not hand over or use a Medi-Cal card unlawfully; violations are misdemeanors.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14026. (a) It is a misdemeanor for a Medi-Cal beneficiary to furnish, give, or lend his Medi-Cal card or labels to any person other than a provider of service as required under Medi-Cal regulations. (b) It is a misdemeanor for any person to use a Medi-Cal card other than the one which was issued to him or her to obtain health care services. This subdivision shall not apply to the use of a Medi-Cal card of a family member by another family member if the person using the card is, in fact, eligible under this chapter. (c) This section shall not apply to any peace officer while investigating Medi-Cal fraud or other crimes in performance of his official duties or to any person working under the peace officer’s immediate direction, supervision, or instruction when such peace officer has been issued a Medi-Cal card pursuant to Section 14026.5. (Amended by Stats. 1984, Ch. 752, Sec. 1.)
14026.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The State Director of Health Services may issue Medi-Cal cards to fraud investigators, and must do so in some cases involving a complaint and a magistrate’s order. The department must also report to the Legislature every six months starting June 1, 1981.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14026.5. (a) The State Director of Health Services may issue Medi-Cal cards to Medi-Cal fraud investigators for the purpose of conducting investigations of Medi-Cal fraud, or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code upon written request to the State Director of Health Services, or his or her designee, from the head of the requesting agency stating the purpose of the investigation. The request shall be based upon a specific complaint or information alleging Medi-Cal fraud. The request shall be based upon a specific complaint or information from an outside agency pursuant to its standard procedure for referring cases to another agency where there is suspicion of Medi-Cal fraud. (b) (1) Upon a complaint by any individual alleging information creating a reasonable suspicion that any person is engaging in Medi-Cal fraud, the State Director of Health Services shall issue Medi-Cal cards for the purpose of conducting investigations of Medi-Cal fraud, or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, upon an order of a magistrate issued upon a showing of reasonable suspicion that the person being investigated has committed or is committing Medi-Cal fraud or a violation of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (2) For purposes of this section, “reasonable suspicion” means that a peace officer subjectively entertains such a suspicion and that it is objectively reasonable for him or her to do so. The facts shall be those that would cause any reasonable peace officer in a like position drawing when appropriate on his or her training and experience, to suspect the same criminal activity and the same involvement by the person in question. A showing of reasonable suspicion may be made either by written statement under penalty of perjury or by oral statement taken under oath, recorded and transcribed. (c) Nothing in this section shall be construed to mean that it is the exclusive method for conducting investigations for Medi-Cal fraud or for violations of the Medical Practice Act as set forth in Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. (d) The State Department of Health Services shall report to the Legislature every six months commencing June 1, 1981, on the utilization of Medi-Cal cards issued pursuant to this section. The report shall include, among other matters, a description of the types of criminal investigations conducted pursuant thereto. (Amended by Stats. 2004, Ch. 193, Sec. 238. Effective January 1, 2005.)
14027.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department may designate participating county health service agencies to provide home nursing services if licensing and certification requirements are met, and a designated county must pass all Medi-Cal reimbursements through to the licensed individuals providing the nursing services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14027. (a) The department may designate participating county health service agencies as health care service providers of home nursing services, subject to appropriate statutory licensing and certification requirements. (b) Any county designated as a health care provider of home nursing services pursuant to subdivision (a) shall act as a fiscal intermediary for the provision of home nursing services and pass through to the licensed individuals rendering those nursing services, in total, all Medi-Cal reimbursements received for those nursing services. (c) The Medi-Cal reimbursement rate applicable to nursing services reimbursed through a designated county health service agency shall be the current Medi-Cal rate applicable to those services. (d) For purposes of this section, “designated provider of home nursing services” means any participating county health services agency designated as a provider of home nursing services pursuant to subdivision (a). (Added by Stats. 1988, Ch. 1161, Sec. 1.)
14028.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section requires state agencies to share deidentified psychotropic-medication data with the Medical Board of California, and requires the Board to review prescribing patterns for certain foster children.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14028. (a) (1) In order to ensure appropriate oversight of psychotropic medications prescribed for children, pursuant to Section 2245 of the Business and Professions Code, the department and the State Department of Social Services, pursuant to a data-sharing agreement that shall meet the requirements of all applicable state and federal laws and regulations, shall provide the Medical Board of California with information regarding Medi-Cal physicians and their prescribing patterns of psychotropic medications and related services for individuals described in subparagraphs (B) and (C) of paragraph (1) of subdivision (c). The data concerning psychotropic medications and related services shall be drawn from existing data sources maintained by the departments. Every five years, the Medical Board of California, the department, and the State Department of Social Services shall consult and revise the methodology, if determined to be necessary. (2) At minimum, the department, on an annual basis, shall share with the Medical Board of California data, including, but not limited to, pharmacy claims data for all foster children who are or have been on three or more psychotropic medications for 90 days or more. Prior to the release of this data, personal identifiers such as name, date of birth, address, and social security number shall be removed and a unique identifier shall be submitted. For each foster child who falls into these categories, the department shall submit the following information to the board: (A) A list of the psychotropic medications prescribed. (B) The start and stop dates, if any, for each psychotropic medication prescribed. (C) The prescriber’s name and contact information. (D) The child’s or adolescent’s year of birth. (E) Any other information that is deidentified and necessary to the Medical Board of California to allow the board to exercise its statutory authority as an oversight entity. (F) The unit and quantity of the medication and the number of days’ supply of the medication. (b) The Medical Board of California shall contract for consulting services from, if available, a psychiatrist who has expertise and specializes in pediatric care for the purpose of reviewing the data provided to the board pursuant to subdivision (a). The consultant shall consider the treatment guidelines published by the department and the State Department of Social Services when assessing prescribing patterns. (c) The Medical Board of California, pursuant to subdivision (a), shall analyze prescribing patterns by population for both of the following: (1) Children adjudged as dependent children under Section 300 and placed in foster care. (2) A minor adjudged a ward of the court under Section 601 or 602 who has been removed from the physical custody of the parent and placed into foster care. (d) This section shall remain in effect only until January 1, 2027, and as of that date is repealed, unless a later enacted statute, that is enacted before January 1, 2027, deletes or extends that date. (Added by Stats. 2016, Ch. 840, Sec. 3. (SB 1174) Effective January 1, 2017. Repealed as of January 1, 2027, by its own provisions.)
14029.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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A transfer of a child to the home setting must be made only after consulting the child’s California Children’s Services program case manager, when the request involves services under Section 14132 and the child is case-managed by that 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14029. Whenever a request for services authorized pursuant to subdivision (s), (t), or (v) of Section 14132 is made to the department for a child who is being case-managed by the California Children’s Services program, any decision to transfer the child to the home setting shall be made only in consultation with the California Children’s Services program case manager for the child. (Added by Stats. 1997, Ch. 294, Sec. 59. Effective August 18, 1997.)
14029.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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County juvenile detention facilities must send certain ward information to the county welfare department, and the welfare department must start Medi-Cal eligibility processing for the ward.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14029.5. (a) (1) Commencing January 1, 2008, immediately following the issuance of an order of the juvenile court, pertaining to the disposition of a ward of the county, committing that ward to a juvenile hall, camp, or ranch for 30 days or longer, the county juvenile detention facility shall provide the appropriate county welfare department with the ward’s name, his or her scheduled or actual release date, any known information regarding the ward’s Medi-Cal status prior to disposition, and sufficient information, when available, for the county welfare department to begin the process of determining the ward’s eligibility for benefits under this chapter, including, if the ward is a minor, contact information for the ward’s parent or guardian, if available. (2) If the ward is a minor, prior to providing information to the county welfare department pursuant to paragraph (1), the county juvenile detention facility shall notify the parent or guardian, in writing, of its intention to submit the information required by that paragraph to the county welfare department. The parent or guardian shall be given a reasonable time to opt out of the Medi-Cal eligibility determination provided for under this section, in which case the county juvenile detention facility shall not comply with paragraph (1). (3) For purposes of this section, “ward” means a person in the custody of a county juvenile detention facility. (b) (1) Upon receipt of the information described in paragraph (1) of subdivision (a), and pursuant to the protocols and procedures developed pursuant to subdivision (c), the county welfare department shall initiate an application for any ward not already enrolled in the Medi-Cal program, and determine the individual’s eligibility for benefits under the Medi-Cal program. If the ward is a minor, the county welfare department shall promptly contact the parent or guardian to arrange for completion of the application. If the cooperation of the minor’s parent or guardian is necessary to complete the application, but the parent or guardian fails to cooperate in completing the application, the county welfare department shall deny the application in accordance with due process requirements. The county shall expedite the application of a ward who, according to the information provided pursuant to paragraph (1) of subdivision (a), is scheduled to be released in fewer than 45 days. (2) If the county welfare department determines that the ward does not meet the eligibility requirements for the Medi-Cal program, the county welfare department, with the consent of the ward’s parent or guardian, if the ward is a minor, shall forward the ward’s information to the appropriate entity to determine eligibility for the Healthy Families Program, or other appropriate health coverage program, as determined by the department. (3) If the county welfare department determines that a ward meets eligibility requirements for the Medi-Cal program, the county shall provide sufficient documentation to enable the ward to obtain necessary medical care upon his or her release from custody. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of all-county letters or similar instructions, without taking any further regulatory action. Thereafter, the department shall adopt regulations, as necessary, to implement this section 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. (d) The department shall seek any federal waivers necessary for the implementation of this section. (Amended by Stats. 2008, Ch. 546, Sec. 2. Effective January 1, 2009.)
14029.8.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Section 124260 of the Health and Safety Code does not apply when a person receives Medi-Cal benefits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14029.8. Section 124260 of the Health and Safety Code shall not apply to the receipt of benefits under the Medi-Cal program. (Added by Stats. 2010, Ch. 503, Sec. 2. (SB 543) Effective January 1, 2011.)
14029.91.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Managed care plans must provide language assistance to LEP Medi-Cal beneficiaries, including 24-hour oral interpretation, translation services, and required notices.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14029.91. (a) The department shall require all managed care plans contracting with the department to provide Medi-Cal services to provide language assistance services to limited-English-proficient (LEP) Medi-Cal beneficiaries who are mandatorily enrolled in managed care in the following manner: (1) (A) Oral interpretation services shall be provided in any language on a 24-hour basis at key points of contact. (B) Oral interpretation services shall be provided by an interpreter that, at a minimum, meets all of the following qualifications: (i) Demonstrated proficiency in speaking and understanding both spoken English and the language spoken by the LEP beneficiary. (ii) The ability to interpret effectively, accurately, and impartially, both receptively and expressly, to and from the language spoken by the LEP beneficiary and English, using any necessary specialized vocabulary, terminology, and phraseology. (iii) Adherence to generally accepted interpreter ethics principles, including client confidentiality. (C) A managed care plan shall not require an LEP beneficiary to provide the beneficiary’s own interpreter or rely on a staff member who does not meet the qualifications described in subparagraph (B) to communicate directly with the LEP beneficiary. (D) A managed care plan shall not rely on an adult or minor child accompanying the LEP beneficiary to interpret or facilitate communication except under either of the following circumstances: (i) In an emergency, as defined by the department, and an interpreter who meets the qualifications described in subparagraph (A) is not immediately available for the LEP beneficiary. (ii) If the LEP beneficiary specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide that assistance, and reliance on that accompanying adult for that assistance is appropriate under the circumstances. (2) Translation services shall be provided to the language groups identified by the department. (3) Written notice of the availability of free language assistance services shall be provided in English and in the top 15 languages spoken by LEP individuals in California, as determined by the department, and consistent with the requirements identified in Part 92 of Title 45 of the Code of Federal Regulations and Section 1557 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18116). (b) The department shall determine when an LEP population meets the requirement for translation services using one of the following numeric thresholds: (1) A population group of at least 3,000 or 5 percent of the beneficiary population, whichever is fewer, mandatory managed care Medi-Cal beneficiaries, residing in the service area, who indicate their primary language as other than English. (2) A population group of mandatory managed care Medi-Cal beneficiaries, residing in the service area, who indicate their primary language as other than English, and that meet a concentration standard of 1,000 beneficiaries in a single ZIP Code or 1,500 beneficiaries in two contiguous ZIP Codes. (c) The department shall make this determination if any of the following occurs: (1) A nonmanaged care county becomes a new managed care county. (2) A new population group becomes a mandatory Medi-Cal managed care beneficiary population. (3) A period of three years has passed since the last determination. (d) The department shall instruct managed care plans, by means of incorporating the requirement into plan contracts, all-plan letters, or similar instructions, of the language groups that meet the numeric thresholds. (e) A managed care plan shall notify beneficiaries, prospective beneficiaries, and members of the public of all of the following information: (1) The availability of language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner, when those services are necessary to provide meaningful access to health care programs or activities to LEP beneficiaries. (2) The availability of appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities. (3) A managed care plan does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. (4) The availability of a grievance procedure and how to file a grievance, including identification of, and contact information for, the designated managed care plan representative. (5) How to file a discrimination complaint with the United States Department of Health and Human Services Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. (f) (1) The information described in paragraph (3) of subdivision (a) and subdivision (e) shall be provided in the following manner: (A) In the evidence of coverage. (B) Posted in conspicuous physical locations where the managed care plan interacts with the public. (C) On the internet website published and maintained by the managed care plan in a manner that allows a beneficiary, prospective beneficiary, and members of the public to easily locate the information. (2) To the extent the information described in paragraph (3) of subdivision (a) and subdivision (e) is not included in existing informational notices, a managed care plan shall add this information at the time of the next regularly scheduled update of the applicable publication. (g) The amendments made to this section by the act that added this subdivision shall be implemented by the department only to the extent that federal financial participation is available and is not otherwise jeopardized. (h) This section does not apply to mental health plans contracting with the department pursuant to Section 14712. (i) For purposes of this section, a person is “limited-English-proficient” if the person speaks English less than very well. (Amended by Stats. 2019, Ch. 497, Sec. 314. (AB 991) Effective January 1, 2020.)
14029.92.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must give Medi-Cal-related notices about language access, disability aids, nondiscrimination, grievances, and discrimination complaints to beneficiaries, prospective beneficiaries, and the public.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14029.92. (a) The department shall notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public of all of the following information: (1) The availability of language assistance services, including oral interpretation and translated written materials, free of charge and in a timely manner, when those services are necessary to provide meaningful access to individuals with limited English proficiency. (2) The availability of appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when those aids and services are necessary to ensure an equal opportunity to participate for individuals with disabilities. (3) The department does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. (4) The availability of the grievance procedure and how to file a grievance, including identification of, and contact information for, the designated department representative. (5) How to file a discrimination complaint with the United States Department of Health and Human Services Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. (b) Written notice of the availability of free language assistance services shall be provided in English and in the top 15 languages spoken by limited-English-proficient individuals in California, as determined by the department, and consistent with the requirements identified in Part 92 of Title 45 of the Code of Federal Regulations and Section 1557 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 18116). (c) (1) The information described in subdivisions (a) and (b) shall be provided in the following manner: (A) In the department’s Medi-Cal informational publications. (B) Posted in conspicuous physical locations where the department interacts with the public. (C) On the department’s Internet Web site, in a manner that allows beneficiaries, prospective beneficiaries, and members of the public to easily locate the information. (2) To the extent the information described in subdivisions (a) and (b) is not included in existing informational notices, the department shall add this information at the time of the next regularly scheduled update of the applicable publication. (d) This section shall be implemented only to the extent that federal financial participation is available and is not otherwise jeopardized. (Amended by Stats. 2018, Ch. 92, Sec. 235. (SB 1289) Effective January 1, 2019.)
14040.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section lets providers use electronic claims transmission where practicable, requires department approval of the transmission method and format, and sets rules for standards, retention, and claim completeness.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14040. (a) Each contract for fiscal intermediary services shall allow, to the extent practicable, providers to utilize electronic means for transmitting claims to the fiscal intermediary contractor. Means of transmission, and the manner and format used, shall be approved by the director. In determining which electronic means are acceptable, the director shall consider magnetic tape, computer-to-computer via telephone, diskettes, and any other methods which may become available through technological advancements. (b) A provider, as defined in Section 14043.1, may assign signature authority for transmission of claims to the provider’s authorized representative or the registered billing agent of the provider identified to the department pursuant to subdivision (c) of Section 14040.5. (c) The department shall develop reasonable standards for participation and continued participation by providers and billing agents in the use of claims transmission methods utilized pursuant to this section. These standards shall be designed to ensure that providers and billing agents submit technically complete claims and to reduce the potential for fraud and abuse. The department shall notify providers and billing agents of any planned changes to the claims transmission standards prior to the implementation of the changes. A “technically complete claim” means any billing request for payment from a provider or the billing agent of the provider, including an original claim, claim inquiry, or appeal, that is submitted on the correct Medi-Cal claim form or electronic billing format, is fully and accurately completed, and includes all information and documentation required to be submitted on or with the claim pursuant to Medi-Cal billing and documentation requirements. (d) To the extent required by federal and state law, the fiscal intermediary shall retain claim data submitted by providers or the billing agent of the provider pursuant to this section. The department shall, however, return to a provider or the billing agent of the provider original tapes, diskettes, and any other similar devices that are used by the provider or the billing agent of the provider pursuant to this section. (e) In order to reduce the amount of paperwork or attachments which are required to be completed by a provider or the billing agent of the provider submitting a claim for reimbursement under this chapter to the fiscal intermediary, the department shall direct the fiscal intermediary to investigate and develop the means to incorporate as much information as possible on the electronic format. (f) Each provider and billing agent submitting claims shall be responsible for ensuring that each claim submitted for reimbursement for services, goods, supplies, or merchandise rendered or supplied by the provider to a Medi-Cal beneficiary or under the Medi-Cal program meets the standards established by the department pursuant to this section. (Amended by Stats. 2000, Ch. 322, Sec. 13. Effective January 1, 2001.)
14040.1.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “billing agent” and requires the department to set registration standards; unregistered billing agents may not submit claims after the standards’ time period begins, and applicants must provide a surety bond of at least $50,000.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14040.1. (a) “Billing agent” or “billing agent of the provider” means any individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of any partnership, group, association, corporation, institution, or entity, that submits claims on behalf of the provider, as defined in Section 14043.1, for reimbursement for services, goods, supplies, or merchandise rendered or provided directly or indirectly to a Medi-Cal beneficiary or under the Medi-Cal program. As used in this section a billing agent shall not include an authorized representative of a provider billing solely for that provider, a provider wholly owned entity billing solely for the provider, or a clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code when preparing and submitting claims for services provided on behalf of the clinic. For purposes of this subdivision, an authorized representative shall be either an individual who is an employee of the provider or an individual with a familial relationship to the provider. For purposes of this section and Section 14040.5, an authorized representative, a provider wholly owned entity billing solely for the provider, or a clinic that is licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or exempt from licensure pursuant to subdivision (c) of Section 1206 of the Health and Safety Code, when preparing and submitting claims for services provided on behalf of the clinic, shall be considered a provider. (b) The department shall establish standards for the registration or continued registration of each billing agent. The standards shall establish time periods, no longer than a year from the date the standards become effective, after which, no billing agent shall submit a claim on behalf of a provider, as defined in Section 14043.1, for reimbursement for services, goods, supplies, or merchandise rendered or provided directly or indirectly by the provider to a Medi-Cal beneficiary or under the Medi-Cal program, unless that billing agent has been registered with the department. The department shall establish the standards for the registration or continued registration of billing agents pursuant to this subdivision, in consultation with interested parties, by the adoption of emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The adoption of these emergency regulations or readoption of the regulations shall be deemed to be an emergency necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding Chapter 3.5 (commencing with Section 11340 of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted or readopted pursuant to this subdivision shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this subdivision shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations. (c) The department may complete a background check on applicants for registration or continued registration as a billing agent, for the purpose of verifying the accuracy of information provided by an applicant for registration or continued registration as a billing agent or in order to prevent fraud and abuse. The background check may include, but not be limited to, onsite inspection, review of business records, and data searches. (d) As a condition of registration, or continued registration, as a billing agent, an applicant for registration as a billing agent shall provide to the department a surety bond of not less than fifty thousand dollars ($50,000). This subdivision shall become operative only if the director executes a declaration, that shall be retained by the director, stating that the surety bonds described in this paragraph are commercially offered throughout the state and by more than one vendor. (Added by Stats. 2000, Ch. 322, Sec. 14. Effective January 1, 2001.)
14040.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Providers may use billing agents for Medi-Cal claims if they use a written contract and give advance notice; billing agents must register, get a unique identifier, and include it on claims.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14040.5. (a) A provider may, by written contract, do either of the following: (1) Authorize a billing agent to submit claims, including electronic claims, on behalf of the provider for reimbursement for services, goods, supplies, or merchandise provided by the provider to the Medi-Cal program or a Medi-Cal beneficiary. (2) Assign signature authority for transmission of the claims by the authorized billing agent. (b) If a contract as described in subdivision (a) is entered into, the contract shall meet the requirements of Section 447.10 of Title 42 of the Code of Federal Regulations or shall have been approved by the federal Health Care Financing Administration for purposes of the Medicare program. (c) Any provider intending to use a billing agent to submit claims for reimbursements to the Medi-Cal program shall provide, at least 30 days prior to the submission of any claims for reimbursement by the billing agent, written notification to the director of the name, including known legal and any known fictitious or “doing business as” names used by the billing agent, the address, and the telephone number of the billing agent. (d) Billing agents shall register with the director and shall obtain a unique identifier prior to submitting any claims for reimbursement. This unique identifier shall be part of each claim for reimbursement submitted by the billing agent. (e) (1) Any Medi-Cal claim submitted by a billing agent or provider failing to comply with the requirements of this section or Section 14040 or 14040.1, or the regulations adopted pursuant to these sections, shall be subject to denial by the director. (2) The director may deny, suspend, or revoke the registration or continued registration of a billing agent based upon any of the following grounds: (A) Failure of the billing agent to comply with this section or Section 14040.1 or the regulations adopted under these sections. (B) Involvement of a billing agent in illegal submission of claims. (C) The billing agent is under investigation for fraud or abuse, as defined in Section 14043.1, by the department or any federal, state, or local law enforcement agency. (3) The director may immediately revoke or suspend the registration or continued registration of a billing agent upon the involvement of that billing agent in the filing of false or misleading information on claims submitted for services allegedly rendered, or when a billing agent has demonstrated a pattern of filing claims that are not technically complete claims as defined in subdivision (c) of Section 14040. The director shall not take action to revoke or suspend a billing agent’s registration or continued registration when the falsity or misleading nature of the information was the result of the provider’s actions and not the billing agent’s. (4) Proceedings for suspension or revocation of the registration or continued registration of a billing agent pursuant to this section shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, except that hearings may be conducted by departmental hearing officers appointed by the director. The director may periodically contract with the Office of Administrative Hearings to conduct these hearings. (5) The director shall provide written notification outlining the reasons for the proposed action to the billing agent 30 days in advance of a proposed suspension or revocation and shall allow the billing agent to demonstrate within those 30 days by comment why the suspension or revocation notice should not be issued. (6) If after consideration of the billing agent’s comment, the director determines that the suspension or revocation is nonetheless warranted, the director shall notify the billing agent of the suspension or revocation and the effective date thereof and at the same time shall serve the billing agent with an accusation. In addition, the director shall send each provider utilizing the services of the billing agent written notice of the suspension or revocation of the billing agent. The suspension or revocation of the billing agent shall take effect 15 days from the date of the notification of the billing agent and service of the accusation. To the extent allowed by federal law, the director may waive any claims submission requirement to assist a provider in submitting or resubmitting claims to the Medi-Cal program when they are delayed because of a billing agent’s suspension or revocation. Upon receipt of a notice of defense by the billing agent, the director shall set the matter for hearing within 30 days of the receipt of the notice. The suspension or revocation shall remain in effect until the hearing is completed and the director has made a final determination on the merits. The suspension or revocation shall, however, be deemed vacated if the director fails to make a final determination on the merits within 60 days of the completion of the original hearing. (7) Paragraph (4) of this subdivision shall not apply where the suspension or revocation of a billing agent is based upon the conviction for any crime involving fraud, abuse of the Medi-Cal program, or suspension from the federal Medicare or medicaid programs, or where the billing agent has entered into a settlement in lieu of conviction for fraud or abuse in any government program, within the previous 10 years. In those instances, suspension or revocation shall be automatic and not subject to administrative appeal or hearing. In those instances, the director shall send each provider utilizing the services of the billing agent written notice of the automatic suspension or revocation of the billing agent. To the extent allowed by federal law, the director may waive any claims submission requirement to assist a provider in submitting or resubmitting claims to the Medi-Cal program when they are delayed because of a billing agent’s automatic suspension or revocation. (8) Notwithstanding Section 100171 of the Health and Safety Code, proceedings for the denial of the registration of a billing agent pursuant to this section shall be conducted in accordance with Section 14043.65. This subdivision shall not apply where the denial is based upon conviction of any crime involving fraud or abuse of the Medi-Cal program or the federal medicaid or Medicare programs, or exclusion by the federal government from the medicaid or Medicare programs. In this case, the denial shall be automatic and not subject to administrative appeal or hearing. (f) For purposes of this section, “billing agent” has the same meaning as defined in Section 14040.1. (g) As used in this section “provider” has the same meaning as defined in Section 14043.1. (Amended by Stats. 2000, Ch. 322, Sec. 15. Effective January 1, 2001.)
14041.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The director must create and carry out standards for timely processing and payment of each claim type.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14041. (a) The director shall develop and implement standards for the timely processing and payment of each claim type. The standards shall be sufficient to meet minimal federal requirements for the timely processing of claims. (b) It is the intent of the Legislature that claim forms for use by physicians and hospitals be the same as claim forms in general use by other payors, including Medicare, to the extent compatible with the following: (1) Requirements for maximum federal matching funds. (2) The reasonable needs of the mechanized claims processing system. (3) Maximum billing efficiency. (4) The convenience of providers. (Amended by Stats. 1987, Ch. 996, Sec. 1.)
14041.1.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department may temporarily hold certain Medi-Cal-related payments for one month.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14041.1. (a) Notwithstanding any other provision of law, and to the extent not otherwise conflicting with federal law, the department may hold for a period of one month, or direct the medical fiscal intermediary for the Medi-Cal program to hold for a period of one month, payments to providers or their designated agents for health care services that are provided pursuant to this chapter, and payments to entities that contract with the department pursuant to this chapter, Chapter 8 (commencing with Section 14200) and Chapter 8.75 (commencing with Section 14591) for the delivery of health care services. (b) The authority described in subdivision (a) shall be limited to payments for one month only, and only for a month ending prior to June 30, 2009. (Amended by Stats. 2011, Ch. 367, Sec. 9. (AB 574) Effective January 1, 2012.)
14041.5.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must develop, update, and share Medi-Cal claims processing software, consult provider groups, report a plan, provide technical help, and start giving the software to physician providers by January 1, 1991.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14041.5. (a) The department shall develop, disseminate, and update, on a periodic basis, claims preparation and processing software programs that may be used on computers at individual provider or billing service sites. The software shall be made available, to the extent feasible, for the most common computers used in the provider community for use, on an optional basis, by clerical or billing personnel to facilitate the preparation and submission of Medi-Cal claims for services rendered. (b) The software programs specified in subdivision (a) shall, to the extent possible: (1) Contain all necessary validity edits utilized by the fiscal intermediary. (2) Be designed to reasonably reduce common submission and billing errors. (3) Contain features that provide options for the provider to use provider-developed files to reduce data entry requirements and improve reporting accuracy. (4) Provide, at the provider’s discretion, for the electronic or paper transmission of claims to the Medi-Cal fiscal intermediary. (c) The department shall consult with affected provider groups prior to developing, disseminating, and updating claims preparation and processing software pursuant to this section. (d) The department shall report to the Chairpersons of the Senate Health and Human Services Committee and Assembly Health Committee by April 1, 1990, on a plan and timetable for implementing this section. The plan and timetable shall identify provider groups for which the department plans to develop, disseminate, and update claims preparation and processing software. (e) Notwithstanding the plan and timetable required by subdivision (d), the department shall develop and begin disseminating claims processing software programs to physician providers no later than January 1, 1991. (f) The department shall, as part of implementing this section, provide technical assistance to providers, including, but not limited to, a user hotline and appropriate training materials. These materials shall cover the installation of the programs, use of the software to enter Medi-Cal claims data, and submission procedures. (g) The software programs for the submission of Medi-Cal claims shall be made available to all interested parties for a reasonable initial fee, plus an annual subscription fee for updates, maintenance, and support provided to users. Fees shall be set so as to recover, as nearly as possible, the development, distribution, and ongoing support costs of software programs, instructional materials, or subsequent updates. (h) Third-party vendors may obtain and enhance these programs for resale and provisions of value-added services to Medi-Cal providers. However, the state or any of its officials, employees, or agents shall bear no liability for software provided through any third party that has been altered or misused by any third party. (i) Neither the state nor any of its officials, employees, or agents shall be responsible for any of the following: (1) A provider’s failure to meet Medi-Cal documentation and billing requirements, including timely billing pursuant to Section 14115. (2) Alteration or misuse of the software in the submission of claims to the Medi-Cal program. (3) Use of the software for any purpose other than the submission of claims to the Medi-Cal program. (4) This subdivision shall not apply to any failure to meet Medi-Cal documentation and billing requirements that is substantiated as resulting from the use of software that is directly provided by the department and that contains proven flaws or defects that significantly contribute to the failure to meet those requirements. (j) A provider or third party’s eligibility to bill claims electronically by using software programs made available pursuant to this section shall be governed by Section 14040 and Section 14040.5, and any rules and regulations adopted by the director pursuant to these sections. (Amended by Stats. 2004, Ch. 193, Sec. 239. Effective January 1, 2005.)
14042.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Contracts must provide automated Medi-Cal eligibility verification, providers must include the eligibility identifier on payment claims, and the department must test the system and report to the Legislature.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14042. Each contract for fiscal intermediary services shall provide for an automated system for verifying the eligibility of Medi-Cal recipients. The automated eligibility verification system shall provide the health care provider with a unique method of identifying the eligibility of the beneficiary. The provider shall include the eligibility identifier on the claim for payment. Where a recipient’s eligibility has been verified by the automated system and the provider provides a unique identifier on the claim form, the director may not require any label, card impression, or any other evidence to establish the recipient’s eligibility. The automated system for eligibility verification shall provide for the continuous updating of recipient eligibility determination. The department shall periodically test the automated system for verifying recipient eligibility for completeness and accuracy, and report the findings of such testing to the Legislature. Unless and until the automated system for verifying recipient eligibility is accurate in at least 97 percent of the cases tested, the director shall provide for the issuance of proof-of-eligibility labels, or identity cards from which an identifying impression may be taken, or other evidence of eligibility to be used as a secondary recipient eligibility verification system. Notwithstanding the inability to provide verification of a recipient’s eligibility through use of the automated system for eligibility verification, presentation of a claim for service with evidence of recipient eligibility as is provided for by the secondary system shall conclusively establish the recipient’s eligibility. On-line access shall be available to providers, at their discretion, upon the payment of a reasonable fee. The department shall establish the amount of the fees charged to providers for on-line access, which shall be based upon the costs of providing on-line access to providers. (Added by Stats. 1982, Ch. 1508, Sec. 1.)
14042.1.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must create and run a medically tailored meals pilot program, serve eligible Medi-Cal participants, and report results to the Legislature.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14042.1. (a) No earlier than January 1, 2018, the State Department of Health Care Services shall establish a Medically Tailored Meals Pilot Program to operate for a period of four years from the date the program is established, or until funding is no longer available for the program, whichever date is earlier. (1) The department shall determine the number of eligible participants and providers in the program and shall use data from the Medi-Cal program to identify eligible beneficiaries for participation in the program. (2) The program shall provide medically tailored meal intervention services to Medi-Cal participants with one or more of the following health conditions: congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease. (3) The department may establish additional eligibility requirements based on acuity and other selection criteria. Each participant in the program shall receive a standard intervention, as determined by the department, of up to 21 meals per week for 12 to 24 weeks. The provided meals shall be medically tailored and designed to meet the specific nutritional needs of the participant’s specific illness. (4) The program shall be conducted in the Counties of Alameda, Los Angeles, Marin, San Diego, San Francisco, San Mateo, Santa Clara, and Sonoma. (5) (A) At the conclusion of the program, the department shall use the data from the Medi-Cal program on the program participants to evaluate what impact, to the extent it can be determined, the program had on hospital readmissions, decreased admissions to long-term care facilities, and emergency room utilization. (B) The department shall send a report containing its evaluation to the Legislature within 12 months after the end of the four-year program. (C) The legislative report submitted pursuant to subparagraph (B) shall be submitted in compliance with Section 9795 of the Government Code. (b) For the purposes of this section, “medically tailored meals” means a specifically tailored diet to address the participant’s specific medical condition and associated symptoms. (c) The department shall develop a methodology for reimbursing contractors, or other entities, as applicable, for services or activities provided pursuant to this section based on, and not to exceed, the aggregate amount of funds allocated per year for purposes of the program. The department may use up to 20 percent of the funds allocated per year for the program to support its administration and evaluation. (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 policy letters, all-county letters, plan letters, or other similar instructions, without taking regulatory action. (e) 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. (f) The department shall seek any federal approvals necessary to implement this section, including any waivers it deems necessary to obtain federal financial participation for the program, and shall claim federal financial participation to the full extent permitted by law. If federal financial participation is unavailable, the department shall implement the program using available state-only funds, subject to annual appropriation by the Legislature. (g) (1) For the 2021–2022 fiscal year, in addition to the Medically Tailored Meals Pilot Program specified under subdivisions (a) to (f), inclusive, the department shall implement the Short-Term Medically Tailored Meals Intervention Services Program to award funds to qualified entities providing medically tailored meals intervention services to eligible Medi-Cal beneficiaries who reside in a county identified in paragraph (4) with one or more of the following health conditions described in subparagraphs (A) to (H), inclusive, when meal services are unavailable under the Medically Tailored Meals Pilot Program: (A) Diabetes. (B) Chronic obstructive pulmonary disease. (C) Renal disease. (D) Chronic kidney disease. (E) Cancer. (F) Malnutrition. (G) Human immunodeficiency virus or acquired immune deficiency syndrome. (H) Congestive heart failure. (2) The Short-Term Medically Tailored Meals Intervention Services Program shall cease to be operative when the funding allocated under the Budget Act of 2021 has been exhausted, or on June 30, 2022, whichever is sooner. (3) (A) To the extent funding is available, an eligible Medi-Cal beneficiary shall receive medically tailored meals intervention services as specified in subparagraph (B). (B) (i) For the 2021–2022 fiscal year, medically tailored meals intervention services shall be available to an eligible Medi-Cal beneficiary, and they shall receive up to 21 meals per week for 12 to 52 weeks, for a maximum of 52 weeks, depending on the medical diagnosis and need. The meals shall be medically tailored and designed to meet the specific nutritional needs of the Medi-Cal beneficiary’s specific health condition. (ii) To the extent funding is available, the medically tailored meals intervention services shall include medical nutrition therapy or counseling for the program’s participants. (C) The department may implement, as specified in subdivision (d), and in consultation with medically tailored meals providers, additional eligibility requirements for individuals to receive services under the Short-Term Medically Tailored Meals Intervention Services Program, based on acuity and other selection criteria. (4) Funds appropriated for the Short-Term Medically Tailored Meals Intervention Services Program shall be awarded based on a methodology developed by the department to nonprofit and community-based organizations that have expertise as medically tailored meals providers in the Counties of Alameda, Contra Costa, Fresno, Kings, Los Angeles, Madera, Marin, San Diego, San Francisco, San Mateo, Santa Clara, Santa Cruz, Sonoma, and Tulare. (5) Providers that are awarded funding to provide short-term medically tailored meals intervention services shall monitor and document the impacts of the Short-Term Medically Tailored Meals Intervention Services Program, including, but not limited to, the effect of this program on hospital readmissions, emergency room utilization, and health outcomes, to the extent data is available, and shall provide that information to the department upon request, and in a form and manner specified by the department. This information shall not be included in the data considered in evaluating the Medically Tailored Meals Pilot Program, as described in paragraph (5) of subdivision (a). (6) The department shall develop a methodology for reimbursing contractors or other entities, as applicable, for services or activities provided pursuant to this subdivision based on, and not to exceed, the aggregate amount of funds allocated for purposes of this subdivision. The department shall allocate 5 percent of the funds to a nonprofit organization fiscal sponsor that shall coordinate the program to support its administration. The fiscal sponsor shall work with nonprofit members in relevant regions. (7) To the extent permitted under applicable federal and state law, the department may use data from the Medi-Cal program to identify Medi-Cal beneficiaries eligible to receive services under the Short-Term Medically Tailored Meals Intervention Services Program. (8) This subdivision shall be implemented only to the extent the department determines that federal financial participation under the Medi-Cal program is not jeopardized. (h) This section shall remain in effect until the department submits its report containing its evaluation of the Medically Tailored Meals Pilot Program to the Legislature pursuant to subparagraph (B) of paragraph (5) of subdivision (a), or 12 months after the end of the Medically Tailored Meals Pilot Program or the Short-Term Medically Tailored Meals Intervention Services Program, whichever occurs last, and as of that date is repealed. (Amended by Stats. 2021, Ch. 143, Sec. 368. (AB 133) Effective July 27, 2021. Section repealed on date prescribed by its own provisions.)
14042.2.
## 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 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The State Department of Health Care Services must file quarterly reports on calls handled by the Medi-Cal Managed Care Ombudsman and post the report online.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1. General Provisions [14000 - 14042.2] ( Article 1 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14042.2. (a) The Legislature finds and declares the following: (1) The Medi-Cal Managed Care Ombudsman helps resolve issues between Medi-Cal managed care members and health plans, assists members with managed care related questions and problems, and answers questions from members. (2) A pattern of inquiries, complaints, and grievances may be indicators of systemic problems regarding coverage and problems with access to care and warrant consideration. (b) On a quarterly basis, the State Department of Health Care Services shall report on calls received by the Medi-Cal Managed Care Ombudsman. At a minimum, the report shall include the following: (1) The number of contacts received, separated by inquiries and complaints. (2) The average wait time for callers to answer. (3) The number of calls abandoned. (4) The result of contacts, including destination of referred calls, when possible. (5) The average call time. (6) Complaints, by issue type. (7) The number of calls referred to another area of the department or to the Department of Managed Health Care for resolution. (c) All data collected and reported shall include demographic information of beneficiaries, including race, ethnicity, age, gender, preferred language, language members were assisted in, and county of residence, and health plans of beneficiaries, to the extent known to the department at the time of the call. The department shall request, but not require, this information from members during the calls. (d) The quarterly report shall include contacts from county mental health plan beneficiaries, as defined in Section 14700, including the requirements of subdivisions (a) and (b). (e) The quarterly report shall be posted on the department’s internet website. (f) The fourth quarterly report issued each year also shall include information pertaining to the following: (1) Training protocols for staff, including cultural and linguistic competency. (2) Assessment of contacts trends and actions taken by the State Department of Health Care Services as a result of contacts received. (3) Consumer assistance protocols, procedures, and referral tools. (Added by renumbering Section 14043.1 (as added by Stats. 2017, Ch. 52, Sec. 23) by Stats. 2019, Ch. 497, Sec. 320. (AB 991) Effective January 1, 2020.)
14043.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Applicants and providers covered by Section 14043.1 must comply with this article’s 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043. In order to ensure the proper and efficient administration of the Medi-Cal program, every applicant, as defined in subdivision (b) of Section 14043.1, and every provider, as defined in subdivision (o) of Section 14043.1, shall be subject to the requirements of this article. (Amended by Stats. 2010, Ch. 192, Sec. 1. (AB 1783) Effective January 1, 2011. Note: Sections 14040 to 14042 are located following Section 14029.91, at the end of Article 1.)
14043.1.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section defines key terms used in the article, including “abuse,” “applicant,” “provider,” “fraud,” and related Medi-Cal enrollment 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.1. As used in this article: (a) “Abuse” means either of the following: (1) Practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to the federal Medicaid and Medicare programs, the Medi-Cal program, another state’s Medicaid program, or other health care programs operated, or financed in whole or in part, by the federal government or a state or local agency in this state or another state. (2) Practices that are inconsistent with sound medical practices and result in reimbursement by the federal Medicaid and Medicare programs, the Medi-Cal program or other health care programs operated, or financed in whole or in part, by the federal government or a state or local agency in this state or another state, for services that are unnecessary or for substandard items or services that fail to meet professionally recognized standards for health care. (b) “Applicant” means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the department for enrollment as a provider in the Medi-Cal program. (c) “Application or application package” means a completed and signed application form, signed under penalty of perjury or notarized pursuant to Section 14043.25, a disclosure statement, a provider agreement, and all attachments or changes in the form, statement, or agreement. (d) “Appropriate volume of business” means a volume that is consistent with the information provided in the application and any supplemental information provided by the applicant or provider, and is of a quality and type that would reasonably be expected based upon the size and type of business operated by the applicant or provider. (e) “Business address” means the location where an applicant or provider provides services, goods, supplies, or merchandise, directly or indirectly, to a Medi-Cal beneficiary. A post office box or commercial box is not a business address. The business address for the location of a vehicle or vessel owned and operated by an applicant or provider enrolled in the Medi-Cal program and used to provide services, goods, supplies, or merchandise, directly or indirectly, to a Medi-Cal beneficiary shall either be the business address location listed on the provider’s application as the location where similar services, goods, supplies, or merchandise would be provided or the applicant’s or provider’s pay to address. (f) “Convicted” means any of the following: (1) A judgment of conviction has been entered against an individual or entity by a federal, state, or local court, regardless of whether there is a posttrial motion, an appeal pending, or the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed. (2) A federal, state, or local court has made a finding of guilt against an individual or entity. (3) A federal, state, or local court has accepted a plea of guilty or nolo contendere by an individual or entity. (4) An individual or entity has entered into participation in a first offender, deferred adjudication, or other program or arrangement where judgment of conviction has been withheld. (g) “Debt due and owing” means 60 days have passed since a notice or demand for repayment of an overpayment or another amount resulting from an audit or examination, for a penalty assessment, or for another amount due to the department was sent to the provider, regardless of whether the provider is an institutional provider or a noninstitutional provider and regardless of whether an appeal is pending. (h) “Enrolled or enrollment in the Medi-Cal program” means authorized under any processes by the department or its agents or contractors to receive, directly or indirectly, reimbursement for the provision of services, goods, supplies, or merchandise to a Medi-Cal beneficiary. (i) “Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. (j) “Location” means a street, city, or rural route address or a site or place within a street, city, or rural route address, and the city, county, state, and nine-digit ZIP Code. (k) “Not currently enrolled at the location for which the application is submitted” means either of the following: (1) The provider is changing location and moving to a different location than that for which the provider was issued a provider number. (2) The provider is adding a business address. (l) (1) “Individual dentist practice” means a dentist licensed by the Dental Board of California enrolled or enrolling in Medi-Cal as an individual provider who is a sole proprietor of his or her practice or is a corporation owned solely by the individual dentist and the only dentist practitioner is the owner. An individual dentist practice may include nondentist allied dental health professionals employed and supervised by the dentist. (2) “Individual physician practice” means a physician and surgeon licensed by the Medical Board of California or the Osteopathic Medical Board of California enrolled or enrolling in Medi-Cal as an individual provider who is sole proprietor of his or her practice or is a corporation owned solely by the individual physician and the only physician practitioner is the owner. An individual physician practice may include nonphysician medical practitioners employed and supervised by the physician. (m) “Preenrollment period” or “preenrollment” includes the period of time during which an application package for enrollment, continued enrollment, or for the addition of or change in a location is pending. (n) “Professionally recognized standards of health care” means statewide or national standards of care, whether in writing or not, that professional peers of the individual or entity whose provision of care is an issue recognize as applying to those peers practicing or providing care within a state. When the United States Department of Health and Human Services has declared a treatment modality not to be safe and effective, practitioners that employ that treatment modality shall be deemed not to meet professionally recognized standards of health care. This subdivision shall not be construed to mean that all other treatments meet professionally recognized standards of care. (o) “Provider” means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to a Medi-Cal beneficiary and that has been enrolled in the Medi-Cal program. (p) “Resolution of an investigation for fraud or abuse” means there is no documentation to indicate either that a charge or accusation has been filed against the provider and either (1) the investigation has not been active at any time during the previous 12 months or (2) the department has made a documented good faith effort and has been unable, for a period of 12 months, to contact an investigator or responsible representative of any agency investigating the provider. (q) “Unnecessary or substandard items or services” means those that are either of the following: (1) Substantially in excess of the provider’s usual charges or costs for the items or services. (2) Furnished, or caused to be furnished, to patients, whether or not covered by Medicare, Medicaid, or any of the state health care programs to which the definitions of applicant and provider apply, and which are substantially in excess of the patient’s needs, or of a quality that fails to meet professionally recognized standards of health care. The department’s determination that the items or services furnished were excessive or of unacceptable quality shall be made on the basis of information, including sanction reports, from the following sources: (A) The professional review organization for the area served by the individual or entity. (B) State or local licensing or certification authorities. (C) Fiscal agents or contractors or private insurance companies. (D) State or local professional societies. (E) Any other sources deemed appropriate by the department. (Amended by Stats. 2015, Ch. 271, Sec. 1. (SB 299) Effective September 4, 2015.)
14043.15.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may set certification rules for Medi-Cal applicants and providers, but some licensed natural persons do not need certification. Certain applicants and providers must comply with Section 14043.26 and enroll in specified provider categories, while some enrolled providers and mobile optometric offices get limited enrollment or address-related exceptions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.15. (a) The department may adopt regulations for certification of each applicant and each provider in the Medi-Cal program. No certification shall be required for natural persons licensed or certificated under Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act. (b) (1) An applicant or provider who is a natural person, and is licensed or certificated pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, or is a professional corporation, as defined in subdivision (b) of Section 13401 of the Corporations Code, shall comply with Section 14043.26 and shall be enrolled in the Medi-Cal program as either an individual provider or as a rendering provider in a provider group for each application package submitted and approved pursuant to Section 14043.26, notwithstanding that the applicant or provider meets the requirements to qualify as exempt from clinic licensure under subdivision (a) or (m) of Section 1206 of the Health and Safety Code. (2) A provider enrolled in the Medi-Cal program pursuant to paragraph (1), who has disclosed in the application package for enrollment that the provider’s practice includes the rendering of services, goods, supplies, or merchandise solely at one, or at more than one, health facility, as defined in Section 1250 of the Health and Safety Code, or clinic, as defined in Section 1204 of the Health and Safety Code, or medical therapy unit, for purposes of Section 123950 of the Health and Safety Code, or residence of the provider’s patient, or office of a physician and surgeon involved in the care and treatment of the provider’s patients, shall not be required to enroll at each such health facility, clinic, medical therapy unit, patient’s residence, or physician and surgeon’s office location and may utilize the business addresses listed on the application for enrollment pursuant to paragraph (1) to claim reimbursement from the Medi-Cal program for services rendered by the provider to Medi-Cal beneficiaries at all of those health facilities, clinics, medical therapy units, residences, or physician offices. (3) This subdivision shall not be interpreted to allow the violation of any state or federal law governing fiscal intermediaries or Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act. This subdivision does not remove the requirement that each claim for reimbursement from the Medi-Cal program identify the place of service and the rendering, ordering, referring, and prescribing provider, where applicable. (c) An applicant or provider licensed as a clinic pursuant to Chapter 1 (commencing with Section 1200) of, or a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of, Division 2 of the Health and Safety Code may be enrolled in the Medi-Cal program as a clinic or a health facility and need not comply with Section 14043.26 if the clinic or health facility is certified by the department to participate in the Medi-Cal program. (d) An applicant or provider that meets the requirements to qualify as exempt from clinic licensure under subdivisions (b) to (l), inclusive, or subdivisions (n) to (p), inclusive, of Section 1206 of the Health and Safety Code shall comply with Section 14043.26 and may be enrolled in the Medi-Cal program as either a clinic or within any other provider category for which the applicant or provider qualifies. An applicant or provider to which any of the clinic licensure exemptions specified in this subdivision apply shall identify the licensure exemption category and document in its application package the legal and factual basis for the clinic license exemption claimed. (e) Notwithstanding subdivisions (a), (b), (c), and (d), an applicant or provider need not enroll in the Medi-Cal program as a separate provider and need not comply with Section 14043.26 if all of the following conditions are met: (1) The applicant or provider is one of the following: (A) An intermittent site that qualifies as exempt from clinic licensure under subdivision (h) of Section 1206 of the Health and Safety Code. (B) An affiliated mobile health care unit licensed or approved under Chapter 9 (commencing with Section 1765.101) of Division 2 of the Health and Safety Code, and qualifies as exempt from clinic licensure under subdivision (h) of Section 1206 of the Health and Safety Code. (2) The applicant or provider is operated by, and all staffing, protocols, equipment, supplies, and billing services are provided, directly or indirectly, by, one of the following: (A) A licensed primary care clinic. (B) A clinic exempt from licensure pursuant to subdivision (b) of Section 1206 of the Health and Safety Code. (3) The licensed primary care clinic or clinic exempt from licensure under subdivision (b) of Section 1206 of the Health and Safety Code operating the applicant, provider clinic, or mobile health care unit has notified the department of its separate locations, premises, intermittent sites, or mobile health care units. (f) A primary care clinic with (1) an additional physical plant added to its primary care clinic license under a consolidated license pursuant to subdivision (d) of Section 1212 of the Health and Safety Code, or (2) a physical plant that was added to an existing primary care clinic license by the State Department of Public Health, prior to January 1, 2017, whether by a regional district office or the centralized application unit, need not separately enroll the additional physical plant as a separate provider, and need not comply with Section 14043.26 if the primary care clinic has notified the department of its additional physical plant. (g) Notwithstanding any other law and to the extent permitted by federal law, an applicant or provider that meets the requirements to qualify as a mobile optometric office pursuant to Section 3070.2 of the Business and Professions Code and Section 14043.26 may be enrolled in the Medi-Cal program as either a mobile optometric office or within any other provider category for which the applicant or provider qualifies. (1) An applicant or provider to which Section 3070.2 of the Business and Professions Code applies shall demonstrate its compliance by providing proof of its nonprofit or charitable organization status pursuant to Section 501(c)(3) or 501(c)(4) of the Internal Revenue Code and a statement that it shall not accept payment for services other than those provided to Medi-Cal beneficiaries, even if the State Board of Optometry has not yet issued final regulations as required by Section 3070.2 of the Business and Professions Code or issued any registrations at the time of enrollment. (2) A mobile optometric office shall use the address of the owner and operator of the mobile optometric office as registered with the State Board of Optometry for its place of business address and shall not be required to comply with Section 51000.60 of Title 22 of the California Code of Regulations. (3) To the extent federal financial participation is available, a mobile optometric office shall be permitted to bill the Medi-Cal program for the professional optometry services provided by licensed optometrists. The licensed optometrists providing service at a mobile optometric office shall use the address of the owner and operator of the mobile optometric office as registered with the State Board of Optometry for its place of business address and shall not be required to comply with Section 51000.60 of Title 22 of the California Code of Regulations. (Amended by Stats. 2024, Ch. 448, Sec. 2. (SB 819) Effective January 1, 2025.)
14043.17.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department must notify the applicant within 30 calendar days that Medi-Cal enrollment is approved, and must enroll the affiliate primary care clinic retroactive to the certification 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.17. (a) Notwithstanding any other law, within 30 calendar days of receiving confirmation of certification for enrollment as a Medi-Cal provider for an affiliate primary care clinic that is licensed pursuant to Section 1218.1 of the Health and Safety Code, the department shall provide written notice to the applicant informing the applicant that its Medi-Cal enrollment is approved. (b) The department shall enroll the affiliate primary care clinic retroactive to the date of certification. (c) This section shall not be construed to limit the department’s authority pursuant to Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits. (Added by Stats. 2014, Ch. 356, Sec. 1. (AB 2051) Effective January 1, 2015.)
14043.2.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Providers and applicants may have to sign a provider agreement and must disclose and submit specified information to the department to enroll or stay enrolled.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.2. (a) Whether or not regulations for certification are adopted under Section 14043.15, in order to be enrolled as a provider, or for enrollment as a provider to continue, an applicant or provider may be required to sign a provider agreement and shall disclose all information as required in federal Medicaid regulations and any other information required by the department. Applicants, providers, and persons with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their date of birth and their social security number or numbers to the department, to the full extent allowed under federal law. Corporations with an ownership or control interest, as defined in federal Medicaid regulations, shall submit their taxpayer identification number and all business address locations and post office box addresses. The director may designate the form of a provider agreement by provider type. Failure to disclose the required information, or the disclosure of false information, shall result in denial of the application for enrollment or shall make the provider subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number or numbers, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program. (b) The director shall notify the provider of the temporary suspension and deactivation of the provider’s number or numbers, including all business addresses used by the provider, and the effective date thereof. Notwithstanding Section 100171 of the Health and Safety Code and Section 14123, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65. (Amended by Stats. 2012, Ch. 797, Sec. 6. (SB 1529) Effective January 1, 2013.)
14043.25.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Enrollment application forms, provider agreements, and related changes must be signed under penalty of perjury; some applications may also need notarization, and the department collects an enrollment fee subject to listed exemptions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.25. (a) The application form for enrollment, the provider agreement, and all attachments or changes to either, shall be signed under penalty of perjury. (b) The department may require that the application form for enrollment, the provider agreement, and all attachments or changes to either, submitted by an applicant or provider licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, be notarized. (c) Application forms for enrollment, provider agreements, and all attachments or changes to either, submitted by an applicant or provider not subject to subdivision (b) shall be notarized. This subdivision shall not apply with respect to providers under the In-Home Supportive Services program or any providers that choose to enroll electronically. (d) The department shall collect an application fee for enrollment, including continued enrollment or enrollment at a new location or a change in location. The application fee shall not be collected from individual physicians or nonphysician practitioners, from providers that are enrolled in Medicare or another state’s Medicaid program or Children’s Health Insurance Program, from providers that submit proof that they have paid the applicable fee to a Medicare contractor or to another state’s Medicaid program, or pursuant to an exemption or waiver pursuant to federal law. The application fee collected shall be in the amount calculated by the federal Centers for Medicare and Medicaid Services in effect for the calendar year during which the application for enrollment is received by the department. (Amended by Stats. 2015, Ch. 271, Sec. 3. (SB 299) Effective September 4, 2015.)
14043.26.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section requires Medi-Cal applicants and certain providers to file complete enrollment materials, and it sets deadlines for the department to acknowledge, review, and decide on applications.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.26. (a) (1) On and after January 1, 2004, an applicant that currently is not enrolled in the Medi-Cal program, or a provider applying for continued enrollment, upon written notification from the department that enrollment for continued participation of all providers in a specific provider of service category or subgroup of that category to which the provider belongs will occur, or, except as provided in subdivisions (b) and (e), a provider not currently enrolled at a location where the provider intends to provide services, goods, supplies, or merchandise to a Medi-Cal beneficiary, shall submit a complete application package for enrollment, continuing enrollment, or enrollment at a new location or a change in location. (2) Clinics licensed by the department pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section. (3) Health facilities licensed by the department pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section. (4) Adult day health care providers licensed pursuant to Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section. (5) Home health agencies licensed pursuant to Chapter 8 (commencing with Section 1725) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section. (6) Hospices licensed pursuant to Chapter 8.5 (commencing with Section 1745) of Division 2 of the Health and Safety Code and certified by the department to participate in the Medi-Cal program shall not be subject to this section. (b) A physician and surgeon licensed by the Medical Board of California or the Osteopathic Medical Board of California, or a dentist licensed by the Dental Board of California, practicing as an individual physician practice or as an individual dentist practice, as defined in Section 14043.1, who is enrolled and in good standing in the Medi-Cal program, and who is changing locations of that individual physician practice or individual dentist practice within the same county, shall be eligible to continue enrollment at the new location by filing a change of location form to be developed by the department. The form shall comply with all minimum federal requirements related to Medicaid provider enrollment. Filing this form shall be in lieu of submitting a complete application package pursuant to subdivision (a). (c) (1) Except as provided in paragraph (2), within 30 days after receiving an application package submitted pursuant to subdivision (a), the department shall provide written notice that the application package has been received and, if applicable, that there is a moratorium on the enrollment of providers in the specific provider of service category or subgroup of the category to which the applicant or provider belongs. This moratorium shall bar further processing of the application package. (2) Within 15 days after receiving an application package from a physician, or a group of physicians, licensed by the Medical Board of California or the Osteopathic Medical Board of California, or a change of location form pursuant to subdivision (b), the department shall provide written notice that the application package or the change of location form has been received. (d) (1) If the application package submitted pursuant to subdivision (a) is from an applicant or provider who meets the criteria listed in paragraph (2), the applicant or provider shall be considered a preferred provider and shall be granted preferred provisional provider status pursuant to this section and for a period of no longer than 18 months, effective from the date on the notice from the department. The ability to request consideration as a preferred provider and the criteria necessary for the consideration shall be publicized to all applicants and providers. An applicant or provider who desires consideration as a preferred provider pursuant to this subdivision shall request consideration from the department by making a notation to that effect on the application package, by cover letter, or by other means identified by the department in a provider bulletin. Request for consideration as a preferred provider shall be made with each application package submitted in order for the department to grant the consideration. An applicant or provider who requests consideration as a preferred provider shall be notified within 60 days whether the applicant or provider meets or does not meet the criteria listed in paragraph (2). If an applicant or provider is notified that the applicant or provider does not meet the criteria for a preferred provider, the application package submitted shall be processed in accordance with the remainder of this section. (2) To be considered a preferred provider, the applicant or provider shall meet all of the following criteria: (A) Hold a current license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California, which license shall not have been revoked, whether stayed or not, suspended, placed on probation, or subject to other limitation. (B) Be a current faculty member of a teaching hospital or a children’s hospital, as defined in Section 10727, accredited by the Joint Commission or the American Osteopathic Association, or be credentialed by a health care service plan that is 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) or county organized health system, or be a current member in good standing of a group that is credentialed by a health care service plan that is licensed under the Knox-Keene Act. (C) Have full, current, unrevoked, and unsuspended privileges at a Joint Commission or American Osteopathic Association accredited general acute care hospital. (D) Not have any adverse entries in the federal Healthcare Integrity and Protection Data Bank. (3) The department may recognize other providers as qualifying as preferred providers if criteria similar to those set forth in paragraph (2) are identified for the other providers. The department shall consult with interested parties and appropriate stakeholders to identify similar criteria for other providers so that they may be considered as preferred providers. (e) (1) If a Medi-Cal applicant meets the criteria listed in paragraph (2), the applicant shall be enrolled in the Medi-Cal program after submission and review of a short form application to be developed by the department. The form shall comply with all minimum federal requirements related to Medicaid provider enrollment. The department shall notify the applicant that the department has received the application within 15 days of receipt of the application. The department shall enroll the applicant or notify the applicant that the applicant does not meet the criteria listed in paragraph (2) within 90 days of receipt of the application. (2) Notwithstanding any other provision of law, an applicant or provider who meets all of the following criteria shall be eligible for enrollment in the Medi-Cal program pursuant to this subdivision, after submission and review of a short form application: (A) The applicant’s or provider’s practice is based in one or more of the following: a general acute care hospital, a rural general acute care hospital, or an acute psychiatric hospital, as defined in subdivisions (a) and (b) of Section 1250 of the Health and Safety Code. (B) The applicant or provider holds a current, unrevoked, or unsuspended license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California. An applicant or provider shall not be in compliance with this subparagraph if a license revocation has been stayed, the licensee has been placed on probation, or the license is subject to any other limitation. (C) The applicant or provider does not have an adverse entry in the federal Healthcare Integrity and Protection Data Bank. (3) An applicant shall be granted provisional provider status under this subdivision for a period of 12 months. (f) Except as provided in subdivision (g), within 180 days after receiving an application package submitted pursuant to subdivision (a), or from the date of the notice to an applicant or provider that the applicant or provider does not qualify as a preferred provider under subdivision (d), the department shall give written notice to the applicant or provider that any of the following applies, or shall on the 181st day grant the applicant or provider provisional provider status pursuant to this section for a period no longer than 12 months, effective from the 181st day: (1) The applicant or provider is being granted provisional provider status for a period of 12 months, effective from the date on the notice. (2) The application package is incomplete. The notice shall identify additional information or documentation that is needed to complete the application package. (3) The department is exercising its authority under Section 14043.37, 14043.4, or 14043.7, and is conducting background checks, preenrollment inspections, or unannounced visits. (4) The application package is denied for any of the following reasons: (A) Pursuant to Section 14043.2 or 14043.36. (B) For lack of a license necessary to perform the health care services or to provide the goods, supplies, or merchandise directly or indirectly to a Medi-Cal beneficiary, within the applicable provider of service category or subgroup of that category. (C) The period of time during which an applicant or provider has been barred from reapplying has not passed. (D) For other stated reasons authorized by law. (E) For failing to submit fingerprints as required by federal Medicaid regulations. (F) For failing to pay an application fee as required by federal Medicaid regulations. (5) The application package is withdrawn by request of the applicant or provider and the department’s review is canceled pursuant to subdivision (n). (g) Notwithstanding subdivision (f), within 90 days after receiving an application package submitted pursuant to subdivision (a) from a physician or physician group licensed by the Medical Board of California or the Osteopathic Medical Board of California, or from the date of the notice to that physician or physician group that does not qualify as a preferred provider under subdivision (d), or within 90 days after receiving a change of location form submitted pursuant to subdivision (b), the department shall give written notice to the applicant or provider that either paragraph (1), (2), (3), (4), or (5) of subdivision (f) applies, or shall on the 91st day grant the applicant or provider provisional provider status pursuant to this section for a period no longer than 12 months, effective from the 91st day. (h) (1) If the application package that was noticed as incomplete under paragraph (2) of subdivision (f) is resubmitted with all requested information and documentation, and received by the department within 60 days of the date on the notice, the department shall, within 60 days of the resubmission, send a notice that any of the following applies: (A) The applicant or provider is being granted provisional provider status for a period of 12 months, effective from the date on the notice. (B) The application package is denied for any other reasons provided for in paragraph (4) of subdivision (f). (C) The department is exercising its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits. (D) The application package is withdrawn by request of the applicant or provider and the department’s review is canceled pursuant to subdivision (n). (2) (A) If the application package that was noticed as incomplete under paragraph (2) of subdivision (f) is not resubmitted with all requested information and documentation and received by the department within 60 days of the date on the notice, the application package shall be denied by operation of law. The applicant or provider may reapply by submitting a new application package that shall be reviewed de novo. (B) If the failure to resubmit is by a currently enrolled provider as defined in Section 14043.1, including providers applying for continued enrollment, the failure may make the provider also subject to deactivation of the provider’s number and all of the business addresses used by the provider to provide services, goods, supplies, or merchandise to Medi-Cal beneficiaries. (C) Notwithstanding subparagraph (A), if the notice of an incomplete application package included a request for information or documentation related to grounds for denial under Section 14043.2 or 14043.36, the applicant or provider shall not reapply for enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department or its agents or contractors for a period of three years. (i) (1) If the department exercises its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits, the applicant or provider shall receive notice, from the department, after the conclusion of the background check, preenrollment inspection, or unannounced visit of either of the following: (A) The applicant or provider is granted provisional provider status for a period of 12 months, effective from the date on the notice. (B) Discrepancies or failure to meet program requirements, as prescribed by the department, have been found to exist during the preenrollment period. (2) (A) The notice shall identify the discrepancies or failures, and whether remediation can be made or not, and if so, the time period within which remediation must be accomplished. Failure to remediate discrepancies and failures as prescribed by the department, or notification that remediation is not available, shall result in denial of the application by operation of law. The applicant or provider may reapply by submitting a new application package that shall be reviewed de novo. (B) If the failure to remediate is by a currently enrolled provider as defined in Section 14043.1, including providers applying for continued enrollment, the failure may make the provider also subject to deactivation of the provider’s number and all of the business addresses used by the provider to provide services, goods, supplies, or merchandise to Medi-Cal beneficiaries. (C) Notwithstanding subparagraph (A), if the discrepancies or failure to meet program requirements, as prescribed by the director, included in the notice were related to grounds for denial under Section 14043.2 or 14043.36, the applicant or provider shall not reapply for three years. (j) If provisional provider status or preferred provisional provider status is granted pursuant to this section, a provider number shall be used by the provider for each business address for which an application package has been approved. This provider number shall be used exclusively for the locations for which it was approved, unless the practice of the provider’s profession or delivery of services, goods, supplies, or merchandise is such that services, goods, supplies, or merchandise are rendered or delivered at locations other than the provider’s business address and this practice or delivery of services, goods, supplies, or merchandise has been disclosed in the application package approved by the department when the provisional provider status or preferred provisional provider status was granted. (k) Except for providers subject to subdivision (c) of Section 14043.47, a provider currently enrolled in the Medi-Cal program at one or more locations who has submitted an application package for enrollment at a new location or a change in location pursuant to subdivision (a), or filed a change of location form pursuant to subdivision (b), may submit claims for services, goods, supplies, or merchandise rendered at the new location until the application package or change of location form is approved or denied under this section, and shall not be subject, during that period, to deactivation, or be subject to any delay or nonpayment of claims as a result of billing for services rendered at the new location as herein authorized. However, the provider shall be considered during that period to have been granted provisional provider status or preferred provisional provider status and be subject to termination of that status pursuant to Section 14043.27. A provider that is subject to subdivision (c) of Section 14043.47 may come within the scope of this subdivision upon submitting documentation in the application package that identifies the physician providing supervision for every three locations. If a provider submits claims for services rendered at a new location before the application for that location is received by the department, the department may deny the claim. (l) An applicant or a provider whose application for enrollment, continued enrollment, or a new location or change in location has been denied pursuant to this section, may appeal the denial in accordance with Section 14043.65. (m) (1) Upon receipt of a complete and accurate claim for an individual nurse provider, the department shall adjudicate the claim within an average of 30 days. (2) During the budget proceedings of the 2006–07 fiscal year, and each fiscal year thereafter, the department shall provide data to the Legislature specifying the timeframe under which it has processed and approved the provider applications submitted by individual nurse providers. (3) For purposes of this subdivision, “individual nurse providers” are providers authorized under certain home- and community-based waivers and under the state plan to provide nursing services to Medi-Cal recipients in the recipients’ own homes rather than in institutional settings. (n) (1) Except as provided in paragraph (2), an applicant or provider may request to withdraw an application package submitted pursuant to this section at any time, at which point the department’s review shall be canceled. (2) The department’s review shall not be canceled if, at the time the applicant or provider requests to withdraw the application package, the department has already initiated its review under Section 14043.37, 14043.4, or 14043.7. (o) (1) For the period beginning on July 1, 2026, and ending on June 30, 2027, an applicant or provider shall not be granted provisional or preferred provisional enrollment status in the Medi-Cal program as a result of the department’s failure to act within any of the following statutory timeframes: (A) The 90-day determination period described in subdivision (e). (B) The 90-day determination period described in subdivision (g). (C) The 180-day extended determination period described in subdivision (f). (D) The 60-day determination period for supplemental information described in subdivision (h). (2) During the period described in paragraph (1), the department’s failure to issue a determination within the applicable timeframe shall not result in approval by default, and the application shall remain pending unless and until the department issues a written determination consistent with all applicable state and federal Medicaid screening requirements. (3) Nothing in this subdivision limits the department’s authority to deny, terminate, or otherwise act upon an application under this article during the review period. (4) This subdivision shall become inoperative on July 1, 2027. (Amended by Stats. 2026, Ch. 27, Sec. 83. (SB 164) Effective June 29, 2026.)
14043.27.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department must end provisional provider status or preferred provisional provider status when specified grounds arise, and termination can include deactivation and Medi-Cal enrollment removal.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.27. (a) If an applicant or provider is granted provisional provider status or preferred provisional provider status pursuant to Section 14043.26 and, if at any time during the provisional provider status period or preferred provisional provider status period, the department conducts any announced or unannounced visits or any additional inspections or reviews pursuant to this chapter or Chapter 8 (commencing with Section 14200), or the regulations adopted thereunder, or pursuant to Section 100185.5 of the Health and Safety Code, and discovers or otherwise determines the existence of any ground to deactivate the provider’s number and business addresses or suspend the provider from the Medi-Cal program pursuant to this chapter or Chapter 8 (commencing with Section 14200), or the regulations adopted thereunder, or pursuant to Section 100185.5 of the Health and Safety Code, or if any of the circumstances listed in subdivision (c) occur, the department shall terminate the provisional provider status or preferred provisional provider status of the provider, regardless of whether the period of time for which the provisional provider status or preferred provisional provider status was granted under Section 14043.26 has elapsed. (b) Termination of provisional provider status or preferred provisional provider status shall include deactivation of the provider’s number, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program and removal of the provider from enrollment in the Medi-Cal program, except where the termination is based upon a ground related solely to a specific location for which provisional provider status was granted. Termination of provisional provider status based upon grounds related solely to a specific location may include failure to have an established place of business, failure to possess the business or zoning permits or other approvals necessary to operate a business, or failure to possess the appropriate licenses, permits, or certificates necessary for the provider of service category or subcategory identified by the provider in its application package. Where the grounds relate solely to a specific location, the termination of provisional provider status shall include only deactivation of the specific locations that the grounds apply to and shall include removal of the provider from enrollment in the Medi-Cal program only if, after deactivation of the specific locations, the provider does not have any business address that is not deactivated. (c) The following circumstances are grounds for termination of provisional provider status or preferred provisional provider status: (1) The provider, persons with an ownership or control interest in the provider, or persons who are directors, officers, or managing employees of the provider have been convicted of any felony, or convicted of any misdemeanor involving fraud or abuse in any government program, related to neglect or abuse of a patient in connection with the delivery of a health care item or service, or in connection with the interference with, or obstruction of, any investigation into health care related fraud or abuse, or have been found liable for fraud or abuse in any civil proceeding, or have entered into a settlement in lieu of conviction for fraud or abuse in any government program within 10 years of the date of the application package. (2) There is a material discrepancy in the information provided to the department, or with the requirements to be enrolled, that is discovered after provisional provider status or preferred provisional provider status has been granted and that cannot be corrected because the discrepancy occurred in the past. (3) The provider has provided material information that was false or misleading at the time it was provided. (4) The provider failed to have an established place of business at the business address for which the application package was submitted at the time of any onsite inspection, announced or unannounced visit, or any additional inspection or review conducted pursuant to this article or a statute or regulation governing the Medi-Cal program, unless the practice of the provider’s profession or delivery of services, goods, supplies, or merchandise is such that services, goods, supplies, or merchandise are rendered or delivered at locations other than the business address and this practice or delivery of services, goods, supplies, or merchandise has been disclosed in the application package approved by the department when the provisional provider status or preferred provisional provider status was granted. (5) The provider meets the definition of a clinic under Section 1200 of the Health and Safety Code, but is not licensed as a clinic pursuant to Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code and fails to meet the requirements to qualify for at least one exemption pursuant to Section 1206 or 1206.1 of the Health and Safety Code. (6) The provider performs clinical laboratory tests or examinations, but it or its personnel do not meet CLIA, and the regulations adopted thereunder, and the state clinical laboratory law, do not possess valid CLIA certificates and clinical laboratory registrations or licenses pursuant to Chapter 3 (commencing with Section 1200) of Division 2 of the Business and Professions Code, or are not exempt from licensure as a clinical laboratory under Section 1241 of the Business and Professions Code. (7) The provider fails to possess either of the following: (A) The appropriate licenses, permits, certificates, or other approvals needed to practice the profession or occupation, or provide the services, goods, supplies, or merchandise the provider identified in the application package approved by the department when the provisional provider status or preferred provisional provider status was granted and for the location for which the application was submitted. (B) The business or zoning permits or other approvals necessary to operate a business at the location identified in its application package approved by the department when the provisional provider status or preferred provisional provider status was granted. (8) The provider, or if the provider is a clinic, group, partnership, corporation, or other association, any officer, director, or shareholder with a 10 percent or greater interest in that organization, commits two or more violations of the federal or state statutes or regulations governing the Medi-Cal program, and the violations demonstrate a pattern or practice of fraud, abuse, or provision of unnecessary or substandard medical services. (9) The provider commits any violation of a federal or state statute or regulation governing the Medi-Cal program or of a statute or regulation governing the provider’s profession or occupation and the violation represents a threat of immediate jeopardy or significant harm to any Medi-Cal beneficiary or to the public welfare. (10) The provider submits claims for payment that subject a provider to suspension under Section 14043.61. (11) The provider submits claims for payment for services, goods, supplies, or merchandise rendered at a location other than the business address or addresses listed on the application for enrollment, unless the practice of the provider’s profession or delivery of services, goods, supplies, or merchandise is such that services, goods, supplies, or merchandise are rendered or delivered at locations other than the business address and this practice or delivery of services, goods, supplies, or merchandise has been disclosed in the application package approved by the department when the provisional provider status was granted. (12) The provider has not paid its fine, or has a debt due and owing, including overpayments and penalty assessments, to any federal, state, or local government entity that relates to Medicare, medicaid, Medi-Cal, or any other federal or state health care program, and has not made satisfactory arrangements to fulfill the obligation or otherwise been excused by legal process from fulfilling the obligation. (d) If, during a provisional provider status period or a preferred provisional provider status period, the department conducts any announced or unannounced visits or any additional inspections or reviews pursuant to this chapter or Chapter 8 (commencing with Section 14200), or the regulations adopted thereunder, and commences an investigation for fraud or abuse, or discovers or otherwise determines that the provider is under investigation for fraud or abuse by any other state, local, or federal government law enforcement agency, the provider shall be subject to termination of provisional provider status or preferred provisional provider status, regardless of whether the period of time for which the provisional provider status or preferred provisional provider status was granted under Section 14043.26 has elapsed. (e) A provider whose provisional provider status or preferred provisional provider status has been terminated pursuant to this section may appeal the termination in accordance with Section 14043.65. (f) Any department-recovered fine or debt due and owing, including overpayments, that are subsequently determined to have been erroneously collected shall be promptly refunded to the provider, together with interest paid in accordance with subdivision (e) of Section 14171 and Section 14172.5. (Amended by Stats. 2007, Ch. 188, Sec. 41. Effective August 24, 2007.)
14043.28.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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If Medi-Cal enrollment is denied or provider status is terminated, the applicant or provider is barred from reapplying for a set period, and certain claims may not be 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.28. (a) (1) If an application package is denied under Section 14043.26 or provisional provider status or preferred provisional provider status is terminated under Section 14043.27, the applicant or provider shall be prohibited from reapplying for enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department or its agents or contractors for a period of three years from the date the application package is denied or the provisional provider status is terminated, except as provided otherwise in paragraph (2) of subdivision (h), or paragraph (2) of subdivision (i), of Section 14043.26 and as set forth in this section. (2) If the application is denied under paragraph (2) of subdivision (h) of Section 14043.26 because the applicant failed to resubmit an incomplete application package or is denied under paragraph (2) of subdivision (i) of Section 14043.26 because the applicant failed to remediate discrepancies, the applicant may resubmit an application in accordance with paragraph (2) of subdivision (h) or paragraph (2) of subdivision (i), respectively. (3) If the denial of the application package is based upon a conviction for any offense or for any act included in Section 14043.36 or termination of the provisional provider status or preferred provisional provider status is based upon a conviction for any offense or for any act included in paragraph (1) of subdivision (c) of Section 14043.27, the applicant or provider shall be prohibited from reapplying for enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department or its agents or contractors for a period of 10 years from the date the application package is denied or the provisional provider status or preferred provisional provider status is terminated. (4) If the denial of the application package is based upon two or more convictions for any offense or for any two or more acts included in Section 14043.36 or termination of the provisional provider status or preferred provisional provider status is based upon two or more convictions for any offense or for any two acts included in paragraph (1) of subdivision (c) of Section 14043.27, the applicant or provider shall be permanently barred from enrollment or continued enrollment in the Medi-Cal program or for participation in any health care program administered by the department or its agents or contractors. (5) The prohibition in paragraph (1) against reapplying for three years shall not apply if the denial of the application or termination of provisional provider status or preferred provisional provider status is based upon any of the following: (A) The grounds provided for in paragraph (4), or subparagraph (B) of paragraph (7), of subdivision (c) of Section 14043.27. (B) The grounds provided for in subdivision (d) of Section 14043.27, if the investigation is closed without any adverse action being taken. (C) The grounds provided for in paragraph (6) of subdivision (c) of Section 14043.27. However, the department may deny reimbursement for claims submitted while the provider was noncompliant with the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA) (42 U.S.C. Sec. 263a et seq.). (D) The grounds provided for in subdivision (b) of Section 14043.36 for being terminated or excluded under Medicare or under the Medicaid program or Children’s Health Insurance Program of any other state. (b) (1) If an application package is denied under subparagraph (A), (B), (D), or (E) of paragraph (4) of subdivision (f) of Section 14043.26, or with respect to a provider described in subparagraph (B) of paragraph (2) of subdivision (h), or subparagraph (B) of paragraph (2) of subdivision (i), of Section 14043.26, or provisional provider status or preferred provisional provider status is terminated based upon any of the grounds stated in subparagraph (A) of paragraph (7), or paragraphs (1), (2), (3), (5), and (8) to (12), inclusive, of subdivision (c) of Section 14043.27, all business addresses of the applicant or provider shall be deactivated and the applicant or provider shall be removed from enrollment in the Medi-Cal program by operation of law. (2) If the termination of provisional provider status is based upon the grounds stated in subdivision (d) of Section 14043.27 and the investigation is closed without any adverse action being taken, or is based upon the grounds in subparagraph (B) of paragraph (7) of subdivision (c) of Section 14043.27 and the applicant or provider obtains the appropriate license, permits, or approvals covering the period of provisional provider status, the termination taken pursuant to subdivision (c) of Section 14043.27 shall be rescinded, the previously deactivated provider numbers shall be reactivated, and the provider shall be reenrolled in the Medi-Cal program, unless there are other grounds for taking these actions. (c) Claims that are submitted or caused to be submitted by an applicant or provider who has been suspended from the Medi-Cal program for any reason or who has had its provisional provider status terminated or had its application package for enrollment or continued enrollment denied and all business addresses deactivated may not be paid for services, goods, merchandise, or supplies rendered to Medi-Cal beneficiaries during the period of suspension or termination or after the date all business addresses are deactivated. (Amended by Stats. 2015, Ch. 271, Sec. 4. (SB 299) Effective September 4, 2015.)
14043.29.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section says when provisional Medi-Cal provider status ends, when it must be granted to certain earlier applicants or providers, and how some applications received during a specific period must be handled.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.29. (a) If, at the end of the period for which provisional provider status or preferred provisional provider status was granted under Section 14043.26, all of the following conditions are met, the provisional status shall cease and the provider shall be enrolled in the Medi-Cal program without designation as a provisional provider: (1) The provider has demonstrated an appropriate volume of business. (2) The provisional provider status or preferred provisional provider status has not been terminated or if it has been terminated, the act of termination was rescinded. (3) The provider continues to meet the standards for enrollment in the Medi-Cal program as set forth in this article and Section 51000 and following of Title 22 of the California Code of Regulations. (b) (1) An applicant or a provider who applied for enrollment or continued enrollment in the Medi-Cal program, prior to May 1, 2003, and for whom the application has not been approved or denied, or who has not received a notice on or before January 1, 2004, that the department is exercising its authority under Section 14043.37, 14043.4, or 14043.7 to conduct background checks, preenrollment inspections, or unannounced visits, shall be granted provisional provider status effective on January 1, 2004. Applications from applicants or providers who have been so noticed prior to January 1, 2004, shall be processed in accordance with subdivision (h) of Section 14043.26. (2) Applications from applicants or providers that have been received by the department after May 1, 2003, but prior to January 1, 2004, shall be processed in accordance with Section 14043.26, except that these application packages shall be deemed to have been received by the department on January 1, 2004. (Amended by Stats. 2009, Ch. 298, Sec. 27. (AB 1540) Effective January 1, 2010.)
14043.3.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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A provider must repay Medi-Cal funds received during any period when material information was not reported or was reported falsely to the department.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.3. A provider shall be required to reimburse those Medi-Cal funds received during any period for which material information was not reported, or reported falsely, to the department. (Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
14043.34.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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A pharmacy participating in Medi-Cal must keep prescription drugs in stock and regularly dispense 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.34. (a) As a condition of a pharmacy’s participation in the Medi-Cal program, the pharmacy shall have in stock and regularly dispense prescription drugs. (b) For purposes of this section, “prescription drugs” means any drug unsafe for self use by a person, and includes either of the following: (1) Any drug that bears the legend: “Rx Only” or “Caution: federal law prohibits dispensing without prescription” or words of similar import. (2) Any other drug that by federal or state law can be lawfully dispensed by the prescription of a licensed physician and surgeon. (Added by Stats. 2000, Ch. 322, Sec. 18. Effective January 1, 2001.)
14043.341.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Certain providers must keep a signature-based record when dispensing or furnishing specified drugs or devices to Medi-Cal beneficiaries, or when obtaining biological specimens for clinical laboratory testing, subject to listed exceptions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.341. (a) Each provider that dispenses, as defined in Section 4024 of the Business and Professions Code, or that furnishes, as defined in Section 4026 of the Business and Professions Code, a controlled drug, a dangerous drug, or a dangerous device to a Medi-Cal beneficiary, or a drug or device requiring a written order or prescription for the drug or device to be covered under the Medi-Cal program, or who obtains a biological specimen from a Medi-Cal beneficiary for the performance of a clinical laboratory test or examination shall maintain a record of the signature of the person receiving the drug or device or from whom a biological specimen was obtained; the printed name of the recipient or person from whom the biological specimen was obtained; the date signed; for a drug or device, the prescription number or a description of the item or items dispensed or furnished; and if the recipient is not the beneficiary for whom the drug or device was ordered or prescribed or from whom a biological specimen was obtained, a notation of the recipient’s relationship to that beneficiary. The signature and printed name of the person from whom a biological specimen is obtained on the requisition provided to the clinical laboratory for performance of the test or examination for which the specimen was obtained shall be sufficient to comply with this section if a copy of the signed requisition is kept by the provider obtaining the biological specimen. Furthermore, no signature is required under this section where the biological specimen is obtained for the purpose of anatomical pathology examinations performed during the inpatient or outpatient surgery if a notation of the performance of the anatomical pathology examination appears in the medical record. (b) For purposes of this section: (1) “Biological specimen” shall have the same meaning as in Section 1206 of the Business and Professions Code. (2) “Clinical laboratory test or examination” shall have the same meaning as in Section 1206 of the Business and Professions Code. (3) “Controlled substance” shall mean any substance listed in Chapter 2 (commencing with Section 11053) of Division 10 of the Health and Safety Code. (4) “Dangerous drug” or “dangerous device” has the same meaning as in Section 4022 of the Business and Professions Code. (5) “Drug or device” means: (A) “Drug,” as defined in Section 4025 of the Business and Professions Code. (B) “Device,” as defined in Section 4023 of the Business and Professions Code. (C) Pharmaceuticals, medical equipment, medical supplies, orthotics and prosthetics appliances, and other product-like supplies or equipment. (c) Nothing in this section shall require a provider who dispenses or furnishes a complimentary sample of a dangerous drug to maintain the signature of the person receiving that drug, provided no charge is made to the patient, and an appropriate record is entered in the patient’s chart. (d) If the dispensing or furnishing of a drug or device occurs on a periodic basis within an established provider-patient relationship, the signature shall only be required upon the initial dispensing or furnishing of the drug, so long as an appropriate record of each dispensing or furnishing is entered in the patient’s chart. (e) If the obtaining of a biological specimen is required in order that a test or examination occur on a periodic basis within an established provider-patient relationship, the signature shall only be required upon obtaining the biological specimen necessary for the initial test or examination so long as an appropriate record of each test or examination is entered in the patient’s chart. (f) The requirement of this section to obtain a signature shall not apply to a licensed pharmacy or clinical laboratory that is owned and operated by a nonprofit health care service plan that has at least 3,500,000 enrollees or that is owned and operated by a nonprofit hospital corporation that has a mutually exclusive contract with a nonprofit health care service plan that has at least 3,500,000 enrollees, or to a licensed provider who practices within a physician organization that meets either of the requirements set forth in paragraph (2) of subdivision (g) of Section 1375.4 of the Health and Safety Code. (Added by Stats. 2003, Ch. 601, Sec. 8. Effective January 1, 2004.)
14043.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section says earlier sections do not limit the director’s authority or providers’ rights under Section 14123, and any action taken under Section 14123 must follow that 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.35. Sections 14043.2, 14043.25, and 14043.3 shall not limit the authority granted the director and the rights granted providers in Section 14123. Action taken under the authority granted in Section 14123 shall be taken in accordance with that section. (Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
14043.36.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department must refuse enrollment to applicants with certain fraud- or abuse-related convictions or civil findings from the last 10 years, and it may deny enrollment to applicants under fraud or abuse investigation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.36. (a) The department shall not enroll any applicant that has been convicted of any felony or misdemeanor involving fraud or abuse in any government program, or related to neglect or abuse of a patient in connection with the delivery of a health care item or service, or in connection with the interference with or obstruction of any investigation into health care related fraud or abuse or that has been found liable for fraud or abuse in any civil proceeding, or that has entered into a settlement in lieu of conviction for fraud or abuse in any government program, within the previous 10 years. In addition, the department may deny enrollment to any applicant that, at the time of application, is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse pursuant to Subpart A (commencing with Section 455.12) of Part 455 of Title 42 of the Code of Federal Regulations. The department shall not deny enrollment to an otherwise qualified applicant whose felony or misdemeanor charges did not result in a conviction solely on the basis of the prior charges. If it is discovered that a provider is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse, that provider shall be subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program. (b) If it is discovered that a provider has been terminated under Medicare or under the Medicaid program or Children’s Health Insurance Program in any other state, the provider shall not be enrolled in, or shall be subject to termination from, the Medi-Cal program, which shall include deactivation of the provider’s enrolled numbers and all business addresses used to obtain reimbursement from the Medi-Cal program. (c) The director shall notify in writing the provider of the temporary suspension and deactivation of the provider’s number, which shall take effect 15 days from the date of the notification. Notwithstanding Section 100171 of the Health and Safety Code, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65. (d) A temporary suspension may be lifted when a resolution of an investigation for fraud or abuse occurs. (Amended by Stats. 2015, Ch. 271, Sec. 5. (SB 299) Effective September 4, 2015.)
14043.37.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may do background checks on Medi-Cal enrollment applicants to verify information and prevent fraud and abuse.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.37. The department may complete a background check on applicants for the purpose of verifying the accuracy of the information provided to the department for purposes of enrolling in the Medi-Cal program and in order to prevent fraud and abuse. The background check may include, but is not limited to, the following: (a) Onsite inspection prior to enrollment. (b) Review of business records. (c) Data searches. (Amended by Stats. 2000, Ch. 322, Sec. 20. Effective January 1, 2001.)
14043.38.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section requires the department to use federal risk rules, designate certain providers or applicants as high categorical risk when specified conditions apply, and then require background checks and fingerprints for identified persons.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.38. (a) Provider types are designated as “limited,” “moderate,” or “high” categorical risk by the federal government in Section 424.518 of Title 42 of the Code of Federal Regulations. The department shall, at minimum, utilize the federal regulations in determining a provider’s or applicant’s categorical risk. (b) In accordance with Section 455.450 of Title 42 of the Code of Federal Regulations, the department shall designate a provider or applicant as a “high” categorical risk if any of the following occur: (1) The department imposes a payment suspension based on a credible allegation of fraud, waste, or abuse. (2) The provider or applicant has an existing Medicaid overpayment based on fraud, waste, or abuse. (3) The provider or applicant has been excluded by the federal Office of the Inspector General or another state’s Medicaid program within the previous 10 years. (4) The department or the federal Centers for Medicare and Medicaid Services lifted a temporary moratorium within the previous six months for the particular provider type submitting the application, the applicant would have been prevented from enrolling based on that previous moratorium, and the applicant applies for enrollment as a provider at any time within six months from the date the moratorium was lifted. (c) If the department designates a provider or applicant as a “high” categorical risk, the department or its designee shall do both of the following: (1) Conduct a criminal background check of the following persons: (A) The provider or applicant. If the provider or applicant is a nonprofit Drug Medi-Cal provider or applicant, the officers and executive director of the provider or applicant. (B) Any person with a 5-percent or greater direct or indirect ownership interest in the provider or applicant. (2) Require the following persons to submit a set of fingerprints within 30 days of the department’s request, in a manner determined by the department: (A) The provider or applicant. If the provider or applicant is a nonprofit Drug Medi-Cal provider or applicant, the officers and executive director of the provider or applicant. (B) Any person with a 5-percent or greater direct or indirect ownership interest in the provider or applicant. (d) (1) The department shall submit to the Department of Justice fingerprint images and related information required by the Department of Justice of Medi-Cal providers or applicants determined to be a “high” categorical risk pursuant to subdivision (a), and any person with a 5-percent or greater direct or indirect ownership interest in those providers and applicants, for the purposes of obtaining information as to the existence and content of a record of state or federal convictions and state or federal arrests and also information as to the existence and content of a record of state or federal arrests for which the Department of Justice establishes that the person is free on bail or on his or her recognizance pending trial or appeal. (2) When received, the Department of Justice shall forward to the Federal Bureau of Investigation requests for federal summary criminal history information received pursuant to this section. The Department of Justice shall review the information returned from the Federal Bureau of Investigation and compile and disseminate a response to the department. (3) The Department of Justice shall provide a state or federal level response to the department pursuant to paragraph (1) of subdivision (p) of Section 11105 of the Penal Code. (4) The department shall request from the Department of Justice subsequent notification service, as provided pursuant to Section 11105.2 of the Penal Code, for persons described in paragraph (1). (5) The Department of Justice shall charge a fee sufficient to cover the cost of processing the request described in this section. That fee shall be paid by the subject of the criminal background check. (e) For persons subject to the requirements of subdivision (a) of Section 15660, the procedure for obtaining and submitting fingerprints and notification by the Department of Justice of criminal record information set forth in subdivision (c) of Section 15660 shall apply instead of the procedure set forth in subdivision (d). (Amended by Stats. 2015, Ch. 271, Sec. 6. (SB 299) Effective September 4, 2015.)
14043.4.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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If preenrollment discrepancies are found, the department may do more inspections, and it may deactivate all of a provider’s business addresses if the discrepancies are material.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.4. If discrepancies are found to exist during the preenrollment period, the department may conduct additional inspections prior to enrollment. Failure of a provider to remediate discrepancies as prescribed by the director may result in denial of the application for enrollment. The department may deactivate all of the provider’s business addresses if the department determines that the discrepancies are material to the provider’s continued enrollment and the provider’s compliance with program requirements at the additional business addresses. (Amended by Stats. 2015, Ch. 271, Sec. 7. (SB 299) Effective September 4, 2015.)
14043.45.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may require applicants or providers to submit or use an NPI number, and it must notify and consult stakeholders before implementing or specifying 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.45. (a) Notwithstanding whether a National Provider Identification (NPI) number is required by the rules issued by the Centers for Medicare and Medicaid Services implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the department may require that an applicant or provider submit an NPI number. (b) For transactions not specifically identified as covered transactions under the HIPAA NPI rules, the department may require that a provider use a National Provider Identification number on those transactions, or the department may issue the provider a unique identification number or numbers that shall be used on all transactions. (c) Notwithstanding any other provisions of law, the department may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific this statute, including taking all of the following actions: (1) Notifying provider representatives of the proposed action or change. The notice shall occur at least 10 business days prior to the meeting provided for in paragraph (2). (2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the action or change. (3) Allowing for written input regarding the action or change. (4) Providing at least 30 days’ advance notice of the effective date of the action or change. (d) This section shall apply to any health care program administered by the department or its agents or contractors. (Repealed and added by Stats. 2007, Ch. 188, Sec. 45. Effective August 24, 2007.)
14043.46.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may impose a one-year moratorium on new adult day health care center certification and enrollment in Medi-Cal, subject to listed exemptions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.46. (a) Notwithstanding any other provision of law, on the effective date of the act adding this section, the department may implement a one-year moratorium on the certification and enrollment into the Medi-Cal program of new adult day health care centers on a statewide basis or within a geographic area. (b) The moratorium shall not apply to the following: (1) Programs of All-Inclusive Care for the Elderly (PACE) established pursuant to Chapter 8.75 (commencing with Section 14590). (2) An organization that currently holds a designation as a federally qualified health center as defined in Section 1396d(l)(2) of Title 42 of the United States Code. (3) An organization that currently holds a designation as a federally qualified rural health clinic as defined in Section 1396d(l)(1) of Title 42 of the United States Code. (4) An applicant with the physical location of the center in an unserved area, which is defined as a county having no licensed and certified adult day health care center within its geographic boundary. (5) Commencing May 1, 2006, an applicant for certification that meets all of the following: (A) Is serving persons discharged into community housing from a nursing facility operated by the City and County of San Francisco. (B) Has submitted, after December 31, 2005, but prior to February 1, 2006, an application for certification that has not been denied. (C) Meets all criteria for certification imposed under this article and is licensed as an adult day health care center pursuant to Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code. (6) An applicant that is requesting expansion or relocation, or both, that has been Medi-Cal certified as an adult day health care center for at least four years, is expanding or relocating within the same county, and that meets one of the following population-based criteria as reported in the California Long Term Care County Data Book, 2002: (A) The county is ranked number one or two for having the highest ratio of persons over 65 years of age receiving Medi-Cal benefits. (B) The county is ranked number one or two for having the highest ratio of persons over 85 years of age residing in the county. (C) The county is ranked number one or two for having the greatest ratio of persons over 65 years of age living in poverty. (7) An applicant for certification that is currently licensed and located in a county with a population that exceeds 9,000,000 and meets the following criteria: (A) The applicant has identified a special population of regional center consumers whose individual program plan calls for the specialized health and social services that are uniquely provided within the adult day health care center, in order to prevent deterioration of the special population’s health status. (B) The referring regional center submits a letter to the Director of Health Services supporting the applicant for certification as an adult day health care provider for this special population. (C) The applicant is currently providing services to the special population as a vendor of the referring regional center. (D) The participants in the center are clients of the referring regional center and are not residing in a health facility licensed pursuant to subdivision (c), (d), (g), (h), or (k) of Section 1250 of the Health and Safety Code. (c) The moratorium shall not prohibit the department from approving a change of ownership, relocation, or increase in capacity for an adult day health care center if the following conditions are met: (1) For an application to change ownership, the adult day health care center meets all of the following conditions: (A) Has been licensed and certified prior to the effective date of this section. (B) Has a license in good standing. (C) Has a record of substantial compliance with certification laws and regulations. (D) Has met all requirements for the change application. (2) For an application to relocate an existing facility, the relocation center must meet all of the conditions of paragraph (1) and both of the following conditions: (A) Must be located in the same county as the existing licensed center. (B) Must be licensed for the same capacity as the existing licensed center, unless the relocation center is located in an underserved area, which is defined as a county having 2 percent or fewer Medi-Cal beneficiaries over the age of 65 years using adult day health care services, based on 2002 calendar year Medi-Cal utilization data. (3) For an application to increase the capacity of an existing facility, the center must meet all of the conditions of paragraph (1) and must be located in an underserved area, which is defined as a county having 2 percent or fewer Medi-Cal beneficiaries over the age of 65 years using adult day health care services, based on 2002 calendar year Medi-Cal utilization data. (d) Following the first 180 days of the moratorium period, the department may make exceptions to the moratorium for new adult day health care centers that are located in underserved areas if the center’s application was on file with the department on or before the effective date of the act adding this section. In order to apply for this exemption, an applicant or licensee must meet all of the following criteria: (1) The applicant has control of a facility, either by ownership or lease agreement, that will house the adult day health care center, has provided to the department all necessary documents and fees, and has completed and submitted all required fingerprinting forms to the department. (2) The physical location of the applicant’s or licensee’s adult day health care center is in an underserved area, which is defined as a county having 2 percent or fewer Medi-Cal beneficiaries over the age of 65 years using adult day health care services, based on 2002 calendar year Medi-Cal utilization data. (e) During the period of the moratorium, a licensee or applicant that meets the criteria for an exemption as defined in subdivision (d) may submit a written request for an exemption to the director. (f) If the director determines that a new adult day health care licensee or applicant meets the exemption criteria, the director may certify the licensee or applicant, once licensed, for participation in the Medi-Cal program. (g) The director may extend this moratorium, if necessary, to coincide with the implementation date of the adult day health care waiver. (h) The authority granted in this section shall not be interpreted as a limitation on the authority granted to the department in any other section. (Amended by Stats. 2007, Ch. 188, Sec. 46. Effective August 24, 2007.)
14043.47.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Certain Medi-Cal providers must follow the applicable supervision rules, and some physician providers may not be enrolled at more than three business addresses unless the stated supervision ratio is 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.47. (a) A provider doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who utilizes nonphysician medical practitioners to provide services, goods, supplies, or merchandise to Medi-Cal beneficiaries shall meet the specific supervisory requirements applicable to such providers, pursuant to the Business and Professions Code or other state or federal law. (b) A provider doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who fails to comply with the requirements of this section is subject to temporary suspension from the Medi-Cal program and deactivation of the provider’s number, including all business addresses. (c) A physician doing business as a sole proprietorship, partnership, or professional corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group may not be enrolled at more than three business addresses unless there is a ratio of at least one physician providing supervision for every three locations. (d) A physician doing business as a sole proprietorship, partnership, or professional medical corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations Code or a rendering physician provider in a group who fails to comply with the requirements of this section is subject to temporary suspension from the Medi-Cal program and deactivation of all of his or her number, including all business addresses. (Amended by Stats. 2007, Ch. 188, Sec. 47. Effective August 24, 2007.)
14043.5.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may contract for consultant services or information technology, including software, data, and analytical methods, to help detect and prevent fraud or abuse.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.5. Subject to Article 4 (commencing with Section 19130) of Chapter 5 of Division 5 of Title 2 of the Government Code, the department may enter into contracts to secure consultant services or information technology including, but not limited to, software, data, or analytical techniques or methodologies for the purpose of fraud or abuse detection and prevention. Contracts under this section shall be exempt from the Public Contract Code. (Added by Stats. 1999, Ch. 146, Sec. 37. Effective July 22, 1999.)
14043.51.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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This section lets the department implement an electronic visit verification system and requires covered providers to follow department-set verification 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.51. (a) For purposes of this section, the following definitions apply: (1) “Department” means the State Department of Health Care Services. (2) “Electronic visit verification system” has the same meaning as that term is defined in subsection (l) of Section 1396b of Title 42 of the United States Code. (3) “Partners” means governmental entities, including, but not limited to, the State Department of Social Services, the State Department of Developmental Services, the State Department of Public Health, the California Department of Aging, and the Office of Technology and Solutions Integration. (4) “Provider” means a provider who is enrolled in the Medi-Cal program, as specified in subdivision (h) of Section 14043.1. (b) The department, as the single state agency for the Medicaid program in California, may undertake action, as determined by the director to be appropriate, to implement an electronic visit verification system for purposes of obtaining and maintaining federal approval or ensuring federal financial participation is available or not otherwise jeopardized. (c) The department may collaborate and contract with other governmental entities, including its partners, to comply with federal requirements relating to electronic visit verification. (d) (1) If a provider renders Medi-Cal services that are subject to electronic visit verification, they shall comply with requirements, as established by the department and its partners, relating to electronic verification of those services. (2) Except as provided in paragraph (3), if the department determines a provider has failed to comply with the established requirements, the department and its partners, as may be appropriate under the circumstances, may take any of the following action to address the noncompliance of the provider: (A) Provide technical assistance on compliance. (B) Require an approved corrective action plan. (C) Recover associated overpayments. (D) Impose enrollment or monetary sanctions. (E) Take any other remedial action, as deemed appropriate. (3) Individual providers of in-home supportive services, and individual providers of waiver personal care services, who are not employed by an agency, are not subject to the actions described in paragraph (2) for purposes of noncompliance with requirements established pursuant to paragraph (1), and are instead subject to the electronic visit verification system development and implementation principles set forth in Section 10836 and the provisions of Sections 12305.82 and 12305.83. (e) (1) The department and its partners may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis to implement this section and an electronic visit verification system. (2) In developing and implementing electronic visit verification, the department and its partners may continue to utilize services performed under existing contracts if those services involve planning, developing, or establishing an electronic visit verification protocol or system. (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department and its partners may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins, plan letters, or other similar instructions, without taking any further regulatory action. (Amended by Stats. 2023, Ch. 43, Sec. 68. (AB 120) Effective July 10, 2023.)
14043.55.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may impose a 180-day provider enrollment moratorium in some areas, and must match a federal moratorium when one is established, subject to stated exceptions and an access-to-care safeguard.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.55. (a) The department may implement a 180-day moratorium on the enrollment of providers in a specific provider of service category, on a statewide basis or within a geographic area, except that no moratorium shall be implemented on the enrollment of providers who are licensed as clinics under Section 1204 of the Health and Safety Code, health facilities under Chapter 2 (commencing with Section 1250) of the Health and Safety Code, clinics exempt from licensure under Section 1206 of the Health and Safety Code, or natural persons licensed or certified under Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, when the director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. This moratorium may be extended or repeated when the director determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. The authority granted in this section shall not be interpreted as a limitation on the authority granted to the department in Section 14105.3. (b) If the Secretary of the United States Department of Health and Human Services establishes a temporary moratorium on enrollment as described in federal regulations, the department shall establish a corresponding moratorium covering the same period and provider types, even if those provider types would not ordinarily be subject to a moratorium under this section, unless the department determines that the imposition of the moratorium will adversely impact beneficiaries access to medical assistance. A federal moratorium adopted under this subdivision shall not be subject to the director’s determinations regarding safeguards of public funds and program integrity or other prerequisites that are necessary to implement a state-initiated moratorium. (Amended by Stats. 2015, Ch. 271, Sec. 8. (SB 299) Effective September 4, 2015.)
14043.6.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department must automatically suspend Medi-Cal providers whose health care license or approval is revoked, suspended, lost, or surrendered in the stated circumstances, unless the subdivision (b) exception 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.6. (a) Except as provided in subdivision (b), the department shall automatically suspend, as a provider in the Medi-Cal program, any individual who, or any entity that, has a license, certificate, or other approval to provide health care, which is revoked or suspended by a federal, California, or another state’s licensing, certification, or approval authority, has otherwise lost that license, certificate, or approval, or has surrendered that license, certificate, or approval while a disciplinary hearing on that license, certificate, or approval was pending. The automatic suspension shall be effective on the date that the license, certificate, or approval was revoked, lost, or surrendered. (b) The department may elect to not suspend an individual or entity as a provider in the Medi-Cal program pursuant to subdivision (a) if the revocation, suspension, or loss of the individual or entity’s license, certification, or approval authority in another state or the pending disciplinary hearing during which the individual or entity surrendered the license, certification, or approval authority in another state is based solely on conduct that is not deemed to be unprofessional conduct under California law. The department shall seek any federal approvals it deems necessary to implement this subdivision. This subdivision shall be implemented only to the extent that the department obtains any necessary federal approvals and federal financial participation under the Medi-Cal program is available and not otherwise jeopardized. (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 subdivision (b), in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or similar written instructions. (Amended by Stats. 2023, Ch. 261, Sec. 4. (SB 487) Effective January 1, 2024.)
14043.61.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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A provider may be suspended if payment claims are made for services or goods tied to a suspended, excluded, or otherwise ineligible person or entity listed on the relevant provider lists.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.61. (a) A provider shall be subject to suspension if claims for payment are submitted for the services, goods, supplies, or merchandise provided, directly or indirectly, to a Medi-Cal beneficiary, by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi-Cal program and the individual or entity is listed on either the Suspended and Ineligible Provider List, published by the department, to identify suspended and otherwise ineligible providers, or any list published by the federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the federal Medicare and medicaid programs, to identify suspended, excluded, or otherwise ineligible providers. (b) Notwithstanding Section 100171 of the Health and Safety Code, the imposition of the sanction provided for in subdivision (a) shall be appealable in accordance with Section 14043.65. (Amended by Stats. 2007, Ch. 188, Sec. 48. Effective August 24, 2007.)
14043.62.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department must deactivate a provider’s number immediately, without prior notice, if mailed items are returned as undeliverable or if the provider has not filed a Medi-Cal reimbursement claim for one 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.62. (a) The department shall deactivate, immediately and without prior notice, the provider’s number, including all business addresses used by a provider to obtain reimbursement from the Medi-Cal program when warrants or documents mailed to a provider’s mailing address or its pay to address, if any, or its service or business address, are returned by the United States Postal Service as not deliverable or when a provider has not submitted a claim for reimbursement from the Medi-Cal program for one year. Prior to taking this action the department shall use due diligence in attempting to contact the provider at its last known telephone number and ascertain if the return by the United States Postal Service is by mistake or shall use due diligence in attempting to contact the provider by telephone or in writing to ascertain whether the provider wishes to continue to participate in the Medi-Cal program. If deactivation pursuant to this section occurs, the provider shall meet the requirements for reapplication as specified in this article or the regulations adopted thereunder. (b) For purposes of this section: (1) “Mailing address” means the address that the provider has identified to the department in its application for enrollment as the address at which it wishes to receive general program correspondence. (2) “Pay to address” means the address that the provider has identified to the department in its application for enrollment as the address at which it wishes to receive warrants. (3) “Service or business address” means the address that the provider has identified to the department in its application for enrollment as the address at which the provider will provide services to program beneficiaries. (Amended by Stats. 2007, Ch. 188, Sec. 49. Effective August 24, 2007.)
14043.65.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Some denied or suspended Medi-Cal providers, applicants, and billing agents may appeal in writing to the director or designee, but they must do so within 60 days and the appeal process has 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.65. (a) Notwithstanding any other law, any applicant whose application for enrollment as a provider or whose certification is denied; or any provider who is denied continued enrollment or certification, or denied enrollment for a new location, who has been temporarily suspended, who has had payments suspended, who has had one or more business addresses used to obtain reimbursement from the Medi-Cal program deactivated, or whose provisional provider status or preferred provisional provider status has been terminated pursuant to this article or Section 14107.11, or Section 100185.5 of the Health and Safety Code, or who has had a civil penalty imposed pursuant to subdivision (a) of Section 14123.25; or any billing agent, as defined in Section 14040, when the billing agent’s registration has been denied pursuant to subdivision (e) of Section 14040.5, may appeal this action by submitting a written appeal, including any supporting evidence, to the director or the director’s designee. If the appeal is of a suspension of payment pursuant to Section 14107.11, the appeal to the director or the director’s designee shall be limited to the credibility of the allegation supporting the payment suspension, as described in subdivision (d) of Section 14107.11, and shall not encompass investigation or adjudication of the allegation. The appeal procedure shall not include a formal administrative hearing under the Administrative Procedure Act and shall not result in reactivation of any deactivated provider numbers during appeal. An applicant, provider, or billing agent that files an appeal pursuant to this section shall submit the written appeal along with all pertinent documents and all other relevant evidence to the director or to the director’s designee within 60 days of the date of notification of the department’s action. The director or the director’s designee shall review all of the relevant materials submitted and shall issue a decision within 90 days of the receipt of the appeal. The decision may provide that the action taken should be upheld, continued, or reversed, in whole or in part. The decision of the director or the director’s designee shall be final. Any further appeal shall be required to be filed in accordance with Section 1085 of the Code of Civil Procedure. (b) No applicant whose application for enrollment as a provider has been denied pursuant to Section 14043.2, 14043.36, or 14043.4 may reapply for a period of three years from the date the application is denied. The three-year period shall commence upon the date of the denial notice. (Amended by Stats. 2012, Ch. 797, Sec. 20. (SB 1529) Effective January 1, 2013.)
14043.7.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may make unannounced visits to applicants or providers, and providers must allow access and show they have an appropriate business location. If access is refused or discrepancies are not fixed, the provider may be denied, suspended, deactivated, or removed from Medi-Cal 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.7. (a) The department may make unannounced visits to an applicant or to a provider for the purpose of determining whether enrollment, continued enrollment, or certification is warranted, or as necessary for the administration of the Medi-Cal program. If an unannounced site visit is conducted by the department for any enrolled provider, the provider shall permit access to any and all of their provider locations. If a provider fails to permit access for any site visit, the application shall be denied and the provider shall be subject to deactivation. At the time of the visit, the applicant or provider shall be required to demonstrate an established place of business appropriate and adequate for the services billed or claimed to the Medi-Cal program, as relevant to his or her scope of practice, as indicated by, but not limited to, the following: (1) Being open and available to the general public. (2) Having regularly established and posted business hours. (3) Having adequate supplies in stock on the premises. (4) Meeting all local laws and ordinances regarding business licensing and operations. (5) Having the necessary equipment and facilities to carry out day-to-day business for his or her practice. (b) An unannounced visit pursuant to subdivision (a) shall be prohibited with respect to clinics licensed under Section 1204 of the Health and Safety Code, clinics exempt from licensure under Section 1206 of the Health and Safety Code, health facilities licensed under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, and natural persons licensed or certified under Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, unless the department has reason to believe that the provider will defraud or abuse the Medi-Cal program or lacks the organizational or administrative capacity to provide services under the program. (c) (1) Failure to remediate significant discrepancies in information provided to the department by the provider or significant discrepancies that are discovered as a result of an announced or unannounced visit to a provider, for purposes of enrollment, continued enrollment, or certification pursuant to subdivision (a) shall make the provider subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program. The director shall notify in writing the provider of the temporary suspension and deactivation of provider numbers, which shall take effect 15 days from the date of the notification. Notwithstanding Section 100171 of the Health and Safety Code, proceedings after the imposition of sanctions in this subdivision shall be in accordance with Section 14043.65. (2) A notice of temporary suspension issued pursuant to paragraph (1) shall include the following: (A) A list of discrepancies required to be remediated. (B) The timeframe in which a provider may demonstrate to the department that the discrepancies identified pursuant to subparagraph (A) have been remediated. The timeframe in which a provider may remediate discrepancies shall not be less than 60 days from the date the notice of temporary suspension is issued. (3) If a provider who has received a notice of temporary suspension pursuant to paragraph (1) demonstrates to the department that the discrepancies identified pursuant to subparagraph (A) of paragraph (2) have been remediated and meets the standards of participation within the timeframe specified in subparagraph (B) of paragraph (2), the department shall lift the temporary suspension and shall notify the provider that the temporary suspension has been lifted and that he or she is eligible to receive Medi-Cal reimbursement for services provided after the date the temporary suspension was lifted. (4) If a provider has received a site visit pursuant to this section that results in a notice of temporary suspension pursuant to paragraph (1), and the provider fails to remediate the discrepancies identified pursuant to subparagraph (A) of paragraph (2) within the timeframe specified in subparagraph (B) of paragraph (2), the department shall send the provider a notice stating that the provider will be removed from enrollment as a provider in the Medi-Cal program by operation of law based on failure to remediate the discrepancies identified in the notice of temporary suspension. (Amended by Stats. 2014, Ch. 844, Sec. 1. (SB 1315) Effective January 1, 2015.)
14043.75.
## 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The director may adopt or change anti-fraud measures by regulation, and may also use provider bulletins to clarify certain sections. The department must notify and consult stakeholders when making those changes, with advance notice and a meeting opportunity.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14043.75. (a) The director may, in consultation with interested parties, by regulation, adopt, readopt, repeal, or amend additional measures to prevent or curtail fraud and abuse. Regulations adopted, readopted, repealed, or amended pursuant to this section shall be deemed emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). These emergency regulations shall be deemed necessary for the immediate preservation of the public peace, health and safety, or general welfare. Emergency regulations adopted, amended, or repealed pursuant to this section shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations. (b) Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific Sections 14043.15, 14043.25, 14043.26, 14043.27, 14043.28, 14043.29, 14043.341, and 14043.38 by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific those provisions described in this subdivision, including all of the following: (1) Notifying provider representatives of the proposed action or change. The notice shall occur at least 10 business days prior to the meeting provided for in paragraph (2). (2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the action or change. (3) Allowing for written input regarding the action or change. (4) Providing at least 30 days’ advance notice of the effective date of the action or change. (Amended by Stats. 2012, Ch. 797, Sec. 23. (SB 1529) Effective January 1, 2013.)
14044.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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The department may temporarily limit certain billing/reimbursement codes, and providers may appeal some limits within 45 days.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14044. (a) The department may limit, for 18 months or less, the American Medical Association’s Current Procedural Terminology Fourth Edition (CPT-4) codes, the National Drug Codes (NDC), the Healthcare Common Procedure Coding System (HCPCS) codes, or codes established under Title II of the Health Insurance Portability & Accountability Act of 1996 (42 U.S.C. Sec. 1320d et seq.) for which any provider may bill, or for which reimbursement to any person or entity may be made by, the Medi-Cal program or other health care programs administered by the department if either of the following conditions exist: (1) The department determines, by audit or other investigation, that excessive services or billings, or abuse, has occurred, which may include the department’s discovery or determination that a claim was submitted for reimbursement under the Medi-Cal program for a nerve conduction test, electromyography, or procedures, tests, examinations, or other medical services that the department has specified requires a certain residency or board certification, but the records did not contain, or the person or entity submitting the claim for reimbursement did not have, the certificate or diploma required by Section 14170.11. (2) The Medical Board of California or other licensing authority or a court of competent jurisdiction limits a licensee’s practice of medicine or the rendering of health care, and the limitation precludes the licensee from performing services that could otherwise be reimbursed by the Medi-Cal program or other health care programs administered by the department. (b) The department may impose a limitation pursuant to subdivision (a) for one or more codes or any combination of codes after giving the provider notice of the proposed limitation and, if applicable, the opportunity to appeal pursuant to subdivision (c). (c) (1) A provider who receives notice of a proposed limitation based on paragraph (1) of subdivision (a) shall have 45 days from the date of notice to appeal the limitation by providing to the department reliable evidence that excessive services or billings, or abuse, did not occur. (2) The department shall review the evidence and issue a decision within 45 days of receipt of the evidence. (d) If a limitation is imposed pursuant to paragraph (1) of subdivision (a), it shall take effect on the 46th day after notice of the proposed limitation was given or, if the limitation is timely appealed, 15 days after the department gives the provider notice of its decision to impose the limitation. If a limitation is imposed pursuant to paragraph (2) of subdivision (a), it shall take effect 15 days after notice of the proposed limitation was given. (e) If the department’s limitation could interfere with the provider’s or other prescriber’s ability to provide health care services to a beneficiary, the burden to transfer a patient’s care to another qualified person shall remain the responsibility of the licensee. (f) For purposes of this section, the following definitions apply: (1) “Abuse” has the same meaning as defined in Section 14043.1. (2) “Administered by the department” means administered by the department or its agents or contractors. (3) “Excessive services or billings” means an amount that is substantially in excess of what the department reasonably expects from the provider, based on data regarding the provider or other providers in the health care community who provide substantially similar services to a substantially similar patient population, that is available to the department from any source, including the department. (4) “Licensee” means a person licensed under Division 2 (commencing with Section 500) of the Business and Professions Code. (5) “Other prescriber” means that person who is not the primary or attending physician for a patient who is a beneficiary of the Medi-Cal program or other health care program administered by the department, and that person causes the department, or its agents or contractors, to provide reimbursement for a drug, device, medical service, or supply to the beneficiary. (6) “Provider” has the same meaning as defined in Section 14043.1. (Amended by Stats. 2004, Ch. 228, Sec. 10.7. Effective August 16, 2004.)
14045.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. )
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Providers must not submit Medi-Cal reimbursement requests containing a beneficiary’s Social Security number when the beneficiary already has a Medi-Cal identification card with a beneficiary number that includes the issuance 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 1.3. Provider Enrollment, Application, and Participation [14043 - 14045] ( Heading of Article 1.3 amended by Stats. 2003, Ch. 601, Sec. 1. ) ## 14045. (a) A provider shall not submit a reimbursement request to the Medi-Cal program containing a beneficiary’s social security number if the department has issued that beneficiary a Medi-Cal beneficiary identification card containing a beneficiary number with the issuance date included in that number. (b) This section shall not apply to the submission of a request by a provider for beneficiary eligibility. (c) In order to reduce medical fraud and the black market for stolen social security cards, the State Department of Health Care Services may establish an automated HIPAA-compliant system using HIPAA transactions whereby all providers can access a beneficiary’s identification card number for submitting reimbursement requests. (d) When the provider makes a good faith effort to obtain a recipient’s beneficiary identification card number, this section shall not apply to the following types of services, or the following provider types, until the time that the department is able to establish a system described in subdivision (c): (1) A hospital licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code. (2) A long-term health care facility, as defined in Section 1418 of the Health and Safety Code. (3) A primary care clinic that is licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code. (4) Emergency medical transportation services. (5) A hospital-based physician. (Amended by Stats. 2008, Ch. 179, Sec. 246. Effective January 1, 2009.)
14045.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
Verify source ↗

The Legislature states that peer providers in California support clients with mental health and substance use needs, but there is no statewide scope of practice, standardized curriculum, training standards, supervision standards, or certification protocol yet.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.10. The Legislature finds and declares all of the following: (a) Peer providers in California provide individualized support, coaching, facilitation, and education to clients with mental health care needs and substance use disorders in a variety of settings. Yet, no statewide scope of practice, standardized curriculum, training standards, supervision standards, or certification protocol is available. (b) The United States Department of Veterans Affairs and at least 48 states utilize standardized curricula and certification protocols for peer support services. (c) The federal Centers for Medicare and Medicaid Services (CMS) recognizes that the experiences of peer support specialists, as part of an evidence-based model of care, can be an important component in a state’s delivery of effective mental health and substance use disorder treatment. The CMS encourages states to offer comprehensive programs. (d) A substantial number of research studies demonstrate that peer supports improve client functioning, increase client satisfaction, reduce family burden, alleviate depression and other symptoms, reduce homelessness, reduce hospitalizations and hospital days, increase client activation, and enhance client self-advocacy. (e) Certification can increase the diversity and effectiveness of the behavioral health workforce through the use of peers with lived experience. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.11.
## 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 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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The Legislature states that the peer support specialist certification program should further specified support and skill-building goals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.11. It is the intent of the Legislature that the peer support specialist certification program, established under this article, achieve all of the following: (a) Support the ongoing provision of services for individuals experiencing mental health care needs, substance use disorder needs, or both, by certified peer support specialists. (b) Support coaching, linkage, and skill building of individuals with mental health needs, substance use disorder needs, or both, and to families or significant support persons. (c) Increase family support by building on the strengths of families and helping them achieve a better understanding of mental illness in order to help individuals achieve desired outcomes. (d) Support collaboration with others providing care or support to the individual or family. (e) Assist parents, families, and individuals in developing coping mechanisms and problem-solving skills in order to help individuals achieve desired outcomes. (f) Promote skill building for individuals in the areas of socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, and maintenance of skills learned in other support services. (g) Encourage employment under the peer support specialist certification to reflect the culture, ethnicity, sexual orientation, gender identity, mental health service experiences, and substance use disorder experiences of the individuals the peer support specialists serve. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.12.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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This section defines key terms used in the peer support specialist certification 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 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.12. For purposes of this article, the following definitions apply: (a) “Certification” means the activities related to the verification that an individual has met all of the requirements under this article and that the individual may provide peer support specialist services pursuant to this article. (b) “Certified” means all federal and state requirements have been satisfied by an individual who is seeking designation under this article, including completion of curriculum and training requirements, testing, and agreement to uphold and abide by the code of ethics. (c) “Code of ethics” means the standards to which a peer support specialist is required to adhere. (d) “Core competencies” means the foundational and essential knowledge, skills, and abilities required for peer specialists. (e) “Cultural competence” means a set of congruent behaviors, attitudes, and policies that come together in a system or agency that enables that system or agency to work effectively in cross-cultural situations. A culturally competent system of care acknowledges and incorporates, at all levels, the importance of language and culture, intersecting identities, assessment of cross-cultural relations, knowledge and acceptance of dynamics of cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs to provide services in a culturally competent manner. (f) “Department” means the State Department of Health Care Services. (g) “Peer support specialist” means an individual who is 18 years of age or older, who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder, or both, either as a consumer of these services or as the parent or family member of the consumer, and who has been granted certification under a county peer support specialist certification program. (h) “Peer support specialist services” means culturally competent services that promote engagement, socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths. Peer support specialist services include, but are not limited to, prevention services, support, coaching, facilitation, or education that is individualized and is conducted by a certified peer support specialist. (i) “Recovery” means a process of change through which an individual improves their health and wellness, lives a self-directed life, and strives to reach their full potential. This process of change recognizes cultural diversity and inclusion, and honors the different routes to resilience and recovery based on the individual and their cultural community. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.13.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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The department must set statewide peer support specialist certification standards and related training, ethics, renewal, complaint, and reciprocity processes by July 1, 2022, subject to Section 14045.19 and any 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 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.13. By July 1, 2022, subject to Section 14045.19, the department shall do all of the following: (a) Establish statewide requirements for counties, or an agency representing counties, to use in developing certification programs for the certification of peer support specialists. (b) Define the qualifications, range of responsibilities, practice guidelines, and supervision standards for peer support specialists. The department may utilize best practice materials published by the federal Substance Abuse and Mental Health Services Administration, the United States Department of Veterans Affairs, and related notable experts in the field as a basis for development of these definitions. (c) Determine curriculum and core competencies required for certification of an individual as a peer support specialist, including curriculum that may be offered in areas of specialization, including, but not limited to, transition-age youth, veterans, gender identity, sexual orientation, and any other areas of specialization identified by the department. Core-competencies-based curriculum shall include, at a minimum, training related to all of the following elements: (1) The concepts of hope, recovery, and wellness. (2) The role of advocacy. (3) The role of consumers and family members. (4) Psychiatric rehabilitation skills and service delivery, and addiction recovery principles, including defined practices. (5) Cultural competence training. (6) Trauma-informed care. (7) Group facilitation skills. (8) Self-awareness and self-care. (9) Cooccurring disorders of mental health and substance use. (10) Conflict resolution. (11) Professional boundaries and ethics. (12) Preparation for employment opportunities, including study and test-taking skills, application and résumé preparation, interviewing, and other potential requirements for employment. (13) Safety and crisis planning. (14) Navigation of, and referral to, other services. (15) Documentation skills and standards. (16) Confidentiality. (d) Specify peer support specialist employment training requirements, including core-competencies-based training and specialized training necessary to become certified under this article, and require training to include people with lived experience as consumers and family members. (e) Establish a code of ethics. (f) Determine continuing education requirements for biennial certification renewal. (g) Determine the process for initial certification issuance and biennial certification renewal. (h) Determine a process for investigation of complaints and corrective action, including suspension and revocation of certification and appeals. (i) Determine a process for an individual employed as a peer support specialist on January 1, 2022, to obtain certification under this article. (j) Determine requirements for peer support specialist certification reciprocity between counties, and for peer support specialists from out of state. (k) Seek any federal approvals, related to the statewide certification standards, that it deems necessary to implement this article. For any federal approvals that the department deems necessary related to the statewide certification standards, this article shall be implemented only if and to the extent that the department obtains those federal approvals. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.14.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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A county, or an agency representing a county, may create a peer support specialist certification program only with department approval, and must oversee, report on, and submit to review for the program. The state must fund startup costs if the Legislature appropriates money.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.14. (a) Subject to department approval, a county, or an agency representing the county, may develop a peer support specialist certification program in accordance with this article and any standards established by the department. That county, or an agency representing that county, shall oversee and enforce the certification requirements developed pursuant to this article. To request department approval of the county peer support specialist program, a county, or an agency representing the county, shall do all of the following: (1) Submit to the department a peer support specialist program plan describing how the peer support specialist program will meet all of the federal and state requirements for the certification and oversight of peer support specialists. (2) Submit to periodic reviews conducted by the department to ensure adherence to all federal and state requirements. (3) Submit annual peer support specialist program reports to the department. (b) If a county chooses not to develop peer support specialist certification programs in accordance with this article, the county may fund peer programs to the extent those programs meet all requirements of the applicable funding source. (c) The Legislature finds that peer support specialist certification is conducted at the state level in other states, but this section passes this responsibility to counties. Subject to an appropriation by the Legislature, the state shall fund the startup costs to implement this section. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.15.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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An applicant must meet listed requirements to get peer support specialist certification, and a certified peer support specialist must keep meeting maintenance 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 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.15. (a) To receive a certification under this article, an applicant shall meet all of the following requirements: (1) Be at least 18 years of age. (2) Possess a high school diploma or equivalent degree. (3) Be self-identified as having experience with the process of recovery from mental illness or substance use disorder either as a consumer of these services or as the parent or family member of the consumer. (4) Be willing to share their experience. (5) Have a strong dedication to recovery. (6) Agree, in writing, to adhere to a code of ethics. (7) Successfully complete the curriculum and training requirements for a peer support specialist. (8) Pass a certification examination approved by the department for a peer support specialist. (b) To maintain certification under this article, a certified peer support specialist shall meet both of the following requirements: (1) Adhere to the code of ethics and biennially sign an affirmation. (2) Complete any required continuing education, training, and recertification requirements. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.16.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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A certified individual under this article is not authorized to diagnose illness, prescribe medication, or provide clinical services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.16. This article does not authorize an individual who is certified pursuant to this article to diagnose an illness, prescribe medication, or provide clinical services. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.17.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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The department must solicit stakeholder input and hold regular stakeholder meetings when implementing this article; it may also conduct technical workgroups if stakeholders request 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 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.17. The department shall solicit stakeholder input that may include input from the Office of Statewide Health Planning and Development, peer support and family organizations, mental health services and substance use disorder treatment providers and organizations, the County Behavioral Health Directors Association of California, and the California Behavioral Health Planning Council in implementing this article. Consultation shall include regular stakeholder meetings. The department may additionally conduct technical workgroups upon the request of stakeholders. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.18.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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A participating county or its agency may set a certification fee schedule, but the department must review it and either approve or disapprove it before it can be implemented.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.18. A participating county, or an agency representing a participating county, is authorized to establish a certification fee schedule for the purpose of supporting the activities associated with the ongoing administration of the peer support specialist certification program. Before the fee schedule may be implemented, the department shall review and either approve or disapprove the fee schedule of the participating county or an agency representing the participating county. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.19.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
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The department must seek needed federal waivers to set up a peer support services demonstration or pilot project, and participating counties must fund and certify the nonfederal share 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.19. (a) The department shall seek any federal waivers it deems necessary to establish a demonstration or pilot project for the provision of peer support services in counties that agree to participate and provide the necessary nonfederal share funding for the demonstration or pilot project. The demonstration or pilot project shall do all of the following: (1) Include a peer support specialist certified pursuant to this article as a Medi-Cal provider type for purposes of the demonstration or pilot project. (2) Include peer support specialist services as a distinct service type in counties that opt in to the demonstration or pilot project. (3) Develop and implement one or more billing codes, reimbursement rates, and claiming requirements for peer support specialist services. (b) (1) This section does not require a county to participate in a demonstration or pilot project pursuant to this section. A county that opts to participate in a demonstration or pilot project and provide the necessary nonfederal share funding shall be considered to do so voluntarily for purposes of all state and federal laws. (2) A county that opts to participate in a demonstration or pilot project pursuant to this section agrees to fund the nonfederal share of any applicable expenditures through certified public expenditures or intergovernmental transfers in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations. Each participating county shall certify that the local funds it uses to fund the nonfederal share of expenditures pursuant to this section qualify for federal financial participation pursuant to applicable federal Medicaid laws and any terms of federal approval, in the form and manner as required by the department. (3) Demonstration or pilot projects developed and implemented pursuant to this section shall not constitute a mandate of a new program or higher level of service that has an overall effect of increasing the costs mandated by the 2011 realignment legislation for the counties that opt in to a demonstration or pilot project. (4) General Fund moneys shall not be used to fund the nonfederal share of any expenditures made pursuant to a demonstration or pilot project under this section. (c) This section shall be implemented only if and to the extent that the department obtains any necessary federal approvals, and federal financial participation is available and is not otherwise jeopardized. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.20.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
Verify source ↗

The department may make certain contracts to implement this article, and those contracts are exempt from specified procurement rules and from review or approval by certain divisions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.20. For the purpose of implementing this article, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. 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 or the Department of Technology. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14045.21.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. )
Verify source ↗

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

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.4. Peer Support Specialist Certification Program [14045.10 - 14045.21] ( Article 1.4 added by Stats. 2020, Ch. 150, Sec. 2. ) ## 14045.21. 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 or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action. (Added by Stats. 2020, Ch. 150, Sec. 2. (SB 803) Effective January 1, 2021.)
14047.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. )
Verify source ↗

This section names the Medi-Cal Conflict of Interest Law and defines key terms used in 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 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. ) ## 14047. (a) This article shall be known as the “Medi-Cal Conflict of Interest Law.” It is the intent of the Legislature that provisions be made for disclosure of the interests of providers of service in the services, facilities, and organizations to which they refer Medi-Cal recipients so that it is possible to determine the extent to which conflicts of interests may exist because of such referrals. It is the further intent of the Legislature that provision be made for the regulation of employment of present and former employees of state and local agencies responsible for the expenditure of funds under Medi-Cal so as to avoid the risk of conflicts of interests. (b) As used in this article, the term “referral” means (1) the referral of a recipient by a provider of service to any other provider of service; (2) the placement of a recipient by a provider of service in any facility; or (3) the obtaining, requesting, ordering, or prescribing of services or supplies by a provider of service on behalf of a recipient from any other provider of service. As used in this article, the term “immediate family” includes the spouse and children of the provider of service, the parents of the provider of service and their spouses, and the spouses of the children of the provider of service. As used in this article, the term “state or local officer or employee who is responsible for the expenditure of substantial amounts of funds under Medi-Cal” means (1) the Director of the State Department of Health Care Services, and (2) those other state officers or employees, and those local officers or employees, who are determined by the director by regulation to be responsible for the expenditure of substantial amounts of funds under the California Medical Assistance Act and California’s State Plan under Title XIX of the federal Social Security Act. As used in this article, the term “substantial amounts of funds” shall have the meaning defined by the director by regulation. As used in this article, “judicial, quasi-judicial or other proceeding” shall have the meaning defined in Article 4 (commencing with Section 87400) of Chapter 7 of Title 9 of the Government Code. (Added by renumbering Section 14030 by Stats. 2019, Ch. 497, Sec. 316. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)
14047.5.
## 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 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. )
Verify source ↗

Payments under this chapter cannot be made in certain conflict-of-interest situations unless the required interest statement is on file with the director and the Advisory Health Council.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. ) ## 14047.5. A payment under this chapter shall not be made to a provider of services or to any facility or organization in which a provider of service or the immediate family of the provider of service has a significant beneficial interest, for services rendered in connection with any referral of a recipient, unless there is on file with the director and the Advisory Health Council a statement of the nature and extent of such interest. (Added by renumbering Section 14031 by Stats. 2019, Ch. 497, Sec. 317. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)
14047.6.
## 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 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. )
Verify source ↗

Certain state and local Medi-Cal officials, former officials, and their partners must not do acts tied to Medi-Cal that would be barred for similar federal officials under 18 U.S.C. 207 or 208.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. ) ## 14047.6. (a) A state or local officer or employee who is responsible for the expenditure of substantial amounts of funds under Medi-Cal, an individual who formerly was such an officer or employee, or a partner of such an officer or employee shall not commit any act, in connection with any activity concerning Medi-Cal, if the commission of such act by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee, in connection with any activity concerning the United States Government, would be prohibited by Section 207 or 208 of Title 18 of the United States Code. (b) Upon the petition of any interested person or party, a court or state administrative agency or any officer thereof in any judicial, quasi-judicial or other proceeding may, after notice and an opportunity for hearing, exclude any person found to be in violation of this section from further participation in any judicial, quasi-judicial or other proceeding then pending before such court, agency or officer. (c) The prohibitions of this section do not apply to any person who left government service prior to the effective date of this section except that any such person who returned to government service on or after the effective date of this section shall be covered thereby. (Added by renumbering Section 14032 by Stats. 2019, Ch. 497, Sec. 318. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed in Section 14047.7. After repeal, see related provisions in Section 14022.)
14047.7.
## 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 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. )
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This article stays in force only until a specified federal Social Security Act provision is repealed, invalidated by a court of appeal, or otherwise made inoperative; then this article is repealed too.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 1.6. Medi-Cal Conflict of Interest Law [14047 - 14047.7] ( Heading of Article 1.6 renumbered from Article 1.1 by Stats. 2019, Ch. 497, Sec. 315. ) ## 14047.7. This article shall remain in effect only until Section 1902(a)(4)(C) of the federal Social Security Act, as added by Public Law 95-559 is repealed, held invalid by a court of appeal, or otherwise made inoperative, and as of such date is repealed. (Added by renumbering Section 14033 by Stats. 2019, Ch. 497, Sec. 319. (AB 991) Effective January 1, 2020. Repealed conditionally as prescribed by its own provisions. After repeal, see related provisions in Section 14022. Note: Repeal affects Article 1.6, commencing with Section 14047.)
14050.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

The definitions in this article govern how this chapter is interpreted, 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14050. Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter. (Repealed and added by Stats. 1965, 2nd Ex. Sess., Ch. 4.)
14050.1.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “categorically needy person” for this chapter.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14050.1. For purposes of this chapter, “categorically needy person” means a person whose coverage is mandatory under Title XIX of the Social Security Act including, but not limited to, the individuals covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the United States Code. (Amended by Stats. 1991, Ch. 735, Sec. 3.)
14050.2.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “aid” as financial assistance provided to or for needy persons under specified chapters of the 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14050.2. For the purposes of this chapter “aid” means financial assistance provided to or in behalf of needy persons under the provisions of Chapters 2 (commencing with Section 11200), 3 (commencing with Section 12000), and 5 (commencing with Section 13000) of this part. (Added by Stats. 1976, Ch. 126.)
14050.3.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “a person in long-term care” as an inpatient in a medical facility who stays beyond the month of admission and is expected to remain for the full next month.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14050.3. “A person in long-term care” means a person who is an inpatient in a medical facility for more than the month of admission who is expected to remain for the full month after the month of admission. (Added by Stats. 1976, Ch. 126.)
14051.7.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “post-eligibility treatment of income” for long-term care patient liability calculations.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14051.7. “Post-eligibility treatment of income” means the determination of long-term care patient liability for each month in which the patient is described in Section 14050.3 or as an institutionalized spouse described in Section 14002.5 determined in accordance with Section 435.725 of Title 42 of the Code of Federal Regulations, without regard to paragraph (1) of subsection (b) of that section, and Sections 435.832, and 435.845 of Title 42 of the Code of Federal Regulations, as appropriate. (Added by Stats. 2023, Ch. 42, Sec. 124. (AB 118) Effective July 10, 2023.)
14051.8.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “long-term care patient liability” as the result of a post-eligibility income calculation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14051.8. “Long-term care patient liability” is the term given to the result of the post-eligibility treatment of income calculation under Section 14051.7. The person in long-term care or an institutionalized spouse shall incur or expect to incur an amount of medical expenses that equal this amount pursuant to subdivision (d) of Section 14005.12. (Added by Stats. 2023, Ch. 42, Sec. 125. (AB 118) Effective July 10, 2023.)
14052.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “State-only Medi-Cal person” as a person in certain nursing or intermediate care facilities who does not qualify as specified needy persons, is over 21, and meets Section 14005.4 eligibility 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14052. “State-only Medi-Cal person” means a person who resides in a nursing facility or any category of intermediate care facility for the developmentally disabled, and who meets all of the following requirements: (a) Could not meet the definition of a categorically needy person under Section 14050.1, a medically needy person under subdivision (a) of Section 14051 or a medically needy family person under subdivision (b) of Section 14051. (b) Is over 21 years of age. (c) Meets the eligibility requirements of Section 14005.4. (Amended by Stats. 1990, Ch. 1329, Sec. 15. Effective September 26, 1990.)
14052.1.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “Cuban-Haitian entrant or refugee” as a person eligible under the Cuban-Haitian Entrant Program or Refugee Resettlement Program, as defined in federal 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14052.1. “Cuban-Haitian entrant or refugee” means a person eligible under the Cuban-Haitian Entrant Program or Refugee Resettlement Program, as defined in federal regulations. (Added by Stats. 1985, Ch. 1354, Sec. 19.)
14053.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “health care services” and lists what it includes and excludes.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053. (a) The term “health care services” means the benefits set forth in Article 4 (commencing with Section 14131) of this chapter and in Section 14021. The term includes inpatient hospital services for any individual under 21 years of age in an institution for mental diseases. Any individual under 21 years of age receiving inpatient psychiatric hospital services immediately preceding the date on which he or she attains age 21 may continue to receive these services until he or she attains age 22. The term also includes early and periodic screening, diagnosis, and treatment for any individual under 21 years of age. (b) The term “health care services” does not include, except to the extent permitted by federal law, any of the following: (1) Care or services for any individual who is an inmate of an institution (except as a patient in a medical institution). (2) Care or services for any individual who has not attained 65 years of age and who is a patient in an institution for tuberculosis. (3) Care or services for any individual who is 21 years of age or over, except as provided in the first paragraph of this section, and has not attained 65 years of age and who is a patient in an institution for mental disease. (4) Inpatient services provided to individuals 21 to 64 years of age, inclusive, in an institution for mental diseases operating under a consolidated license with a general acute care hospital pursuant to Section 1250.8 of the Health and Safety Code, unless federal financial participation is available for such inpatient services. (Amended by Stats. 2000, Ch. 93, Sec. 64. Effective July 7, 2000.)
14053.1.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Ancillary outpatient services for certain eligible individuals in institutions for mental diseases must be covered, even if federal financial participation is not 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.1. Notwithstanding Section 14053, ancillary outpatient services, pursuant to Section 14132, for any eligible individual who is 21 years of age or over, and has not attained 65 years of age and who is a patient in an institution for mental diseases shall be covered regardless of the availability of federal financial participation. (Amended by Stats. 2001, Ch. 171, Sec. 38. Effective August 10, 2001. Note: Because the previously existing Section 14053.1 was repealed on July 1, 2001, Ch. 171, this section may have been added.)
14053.3.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Mental health plans must report certain IMD admission and discharge dates to the department quarterly. If Medi-Cal reimbursement was paid for ancillary services for IMD residents, the department must recover the federal and state funds from counties.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.3. (a) Except as provided under federal law, federal financial participation reimbursement is not allowed for ancillary services provided to persons residing in facilities that have been found to be institutions for mental disease (IMD), and since, consistent with Part 2 (commencing with Section 5600) of Division 5 and Chapter 6 (commencing with Section 17600) of Part 5, counties are financially responsible for specialty mental health services and related ancillary services provided to persons through county mental health programs when Medi-Cal reimbursement is not available, when it is determined that Medi-Cal reimbursement has been paid for ancillary services for residents of IMDs, both the federal financial participation reimbursement and any state funds paid for the ancillary services provided to residents of IMDs shall be recovered from counties by the department in accordance with applicable state and federal statutes and regulations. (b) Mental health plans shall report to the department admission and discharge dates for Medi-Cal beneficiaries in institutions for mental diseases on a quarterly basis in a format provided by the department. (Amended by Stats. 2012, Ch. 34, Sec. 225. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
14053.5.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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For Medi-Cal, certain drugs are not counted as “prescribed drug” or “prescription drug” if they are sold on discriminatory terms or are overpriced compared with a drug with equivalent therapeutic effect, unless the director finds the drug is vital and has no acceptable substitute.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.5. For the purposes of the Medi-Cal Act, the terms “prescribed drug” and “prescription drug” shall not include any drug which, because of differing prices charged by the manufacturer on a discriminatory basis or discriminatory refusal to sell by the manufacturer, or both, is not available on the same terms and conditions to all providers of prescription services, or any drug which is found to be overpriced in comparison to another drug which has an equivalent therapeutic effect, unless the director determines that the drug is vital to the program and no acceptable substitute is available. Before the director determines that any drug has an equivalent therapeutic effect in comparison to another drug, or is vital to the program and no acceptable substitute is available, he must have received a report to that effect from the Medi-Cal Contract Drug Advisory Committee. Nothing in this section shall be construed to apply to quantity or other nondiscriminatory discounts available on the same terms and conditions to all providers of prescription services, to sales by competitive bidding to federal, state or local governmental agencies, or to sales to wholesalers so long as the manufacturer does not require or induce the wholesalers to make the drug available other than on the same terms and conditions to all providers of prescription services. This section shall not be construed to deny reimbursement to hospitals for prescribed drugs furnished to inpatients or, unless the regulations provide to the contrary, to registered outpatients. (Amended by Stats. 1990, Ch. 456, Sec. 11. Effective July 31, 1990.)
14053.6.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Before adding or removing a drug from the program, the director must notify affected California and national pharmaceutical and health professional associations and consider their advice.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.6. Prior to including or excluding any drug from the program, the director shall give adequate notice to those California associations of health professionals and those recognized national associations of pharmaceutical manufacturers that are affected by such action and shall seek and consider the advice of those associations. (Amended by Stats. 1969, Ch. 21.)
14053.7.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section lets the department handle Medi-Cal eligibility, reimbursement, and enrollment decisions for certain inmates, subject to federal funding and approvals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.7. (a) Notwithstanding any other provision of law, and only to the extent that federal financial participation is available, the department may provide Medi-Cal eligibility and reimbursement for acute inpatient hospital services available under this chapter in accordance with Section 5072 of the Penal Code. (b) The department may disenroll inmates made eligible for services under this section or in accordance with Section 5072 of the Penal Code from Medi-Cal managed care health plans, and may exempt inmates from enrollment into new or existing plans. (c) Except as provided for in paragraph (2) of subdivision (e), the Department of Corrections and Rehabilitation shall be responsible for the nonfederal share of any reimbursement made for the provision of acute inpatient hospital services rendered to inmates who are eligible for and enrolled in a LIHP and receive services pursuant to this section and Section 5072 of the Penal Code. (d) (1) Notwithstanding any other provision of law, including Section 11050, the department, as the single state agency, may make eligibility determinations and redeterminations for inmates in accord with this section and Section 5072 of the Penal Code. (2) The department may enroll and disenroll inmates eligible for acute inpatient hospital services under this section or in accord with Section 5072 of the Penal Code in Medi-Cal or in the LIHP in which the inmate’s county of last legal residence participates. (e) (1) In accordance with the requirements and conditions set forth under this section and Section 5072 of the Penal Code, the county may seek from the Medi-Cal program or from the responsible LIHP in which the county participates, reimbursement for the provision of inpatient hospital services to adults involuntarily detained or incarcerated in county facilities. (2) (A) To the extent that a county seeks reimbursement for the provision of acute inpatient hospital services to adults who are involuntarily detained or incarcerated in county facilities and who are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, the county shall be responsible for the nonfederal share of the reimbursement. (B) To the extent that a county seeks reimbursement for the provision of acute inpatient hospital services to adults who are involuntarily detained or incarcerated in county facilities and who are otherwise eligible for and enrolled in the LIHP in which the county participates, the LIHP shall be responsible for the nonfederal share of the reimbursement. (f) Reimbursement pursuant to this section shall be limited to only those services for which federal financial participation pursuant to Title XIX of the federal Social Security Act is allowed. (g) This section shall be implemented only if and to the extent that existing levels of federal financial participation are not otherwise jeopardized. To the extent that the department determines that existing levels of federal financial participation are jeopardized, this section shall no longer be implemented. (h) The department shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only if and to the extent that any necessary federal approvals are obtained. (i) This section shall have no force or effect if there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services, that disallows, defers, or alters the implementation of this section or in accord with Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the hospitals used to provide acute inpatient hospital services to inmates. (j) It is the intent of the Legislature that the implementation of this section will result in state General Fund savings for the funding of acute inpatient hospital services provided to inmates and any related administrative costs. (k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions. (l) For purposes of this section, the following terms have the following meanings: (1) The term “county of last legal residence” means the county in which the inmate resided at the time of arrest that resulted in conviction and incarceration in a state prison facility. (2) The term “inmate” means an adult who is involuntarily residing in a state prison facility operated, administered or regulated, directly or indirectly, by the Department of Corrections and Rehabilitation. (Amended by Stats. 2011, Ch. 36, Sec. 82. (SB 92) Effective June 30, 2011.)
14053.8.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must create and coordinate a process for counties to receive federal financial participation for certain hospital and psychiatric services for eligible juvenile inmates, while protecting Medi-Cal eligibility and allowing some implementation flexibility.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.8. (a) Notwithstanding any other law, the department shall develop a process to allow counties to receive any available federal financial participation for acute inpatient hospital services and inpatient psychiatric services provided to juvenile inmates who are admitted as inpatients in a medical institution off the grounds of the correctional facility, and who, but for their institutional status as inmates, are otherwise eligible for Medi-Cal benefits pursuant to this chapter. This process shall be coordinated, to the extent possible, with the processes and procedures established pursuant to Section 14053.7 of this code and Section 5072 of the Penal Code. This section shall not be construed to alter or abrogate any obligation of the state pursuant to an administrative action or a court order that is final and no longer subject to appeal to reimburse counties for any acute inpatient hospital services or inpatient psychiatric services provided to a juvenile inmate. (b) A juvenile inmate who is an inpatient in a medical institution off the grounds of the correctional facility shall not be denied eligibility for Medi-Cal benefits under this section because of his or her institutional status as an inmate of a public institution. (c) The department shall consult with counties in the development of the process pursuant to this section. (d) This section shall not be construed to limit the department’s authority to suspend or terminate Medi-Cal eligibility pursuant to Section 14011.10, except during such times that the juvenile inmate is receiving acute inpatient hospital services or inpatient psychiatric services pursuant to subdivision (b). (e) This section shall be implemented only if and to the extent that existing levels of federal financial participation are not otherwise jeopardized. To the extent that the department determines that existing levels of federal financial participation are jeopardized, this section shall no longer be implemented. (f) The department shall seek any federal approvals necessary to implement the process developed pursuant to this section. This section shall be implemented only if and to the extent that any necessary federal approvals have been obtained, and only to the extent that federal financial participation is available. (g) Notwithstanding any other law, as part of the process developed pursuant to this section, the department may exempt juvenile inmates from enrollment into new or existing managed care health plans. (h) The process developed pursuant to this section shall be implemented in only those counties that elect to provide the county’s pro rata portion of the nonfederal share of the state’s administrative costs associated with implementation of this section and the nonfederal share of expenditures for acute inpatient hospital services and inpatient psychiatric services provided to eligible juvenile inmates described in subdivision (a). (i) (1) The federal financial participation received pursuant to the process implemented under this section shall be paid to the participating counties for services rendered to the juvenile inmates. If a federal audit disallowance and interest results from claims made under the process created pursuant to this section, the department shall recoup from the county that received the disallowed funds the amount of the disallowance and any applicable interest. (2) It is the intent of the Legislature that implementation of this section will result in no increased cost to the state General Fund. (j) (1) If there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services (CMS), that disallows, defers, or alters the implementation of this section or, to the extent applicable, Section 14053.7 of this code or Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the facilities used to provide acute inpatient hospital services and inpatient psychiatric services to juvenile inmates, then any provision of this section that is inconsistent with the final judicial or CMS determination shall have no force or effect. (2) In addition, the department may, at its discretion, cease to implement any other part of this section that is implicated by the final judicial or CMS determination. (k) For the purposes of Medi-Cal eligibility pursuant to this section, “juvenile inmate” means an individual under 21 years of age who is involuntarily residing in a public institution, including state and local institutions. (l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions. (Amended by Stats. 2014, Ch. 836, Sec. 1. (SB 1089) Effective January 1, 2015.)
14053.9.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must create and coordinate a process for certain juvenile inmates to receive federal financial participation for specified inpatient services, and those inmates cannot be denied Medi-Cal eligibility because of inmate status.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14053.9. (a) Notwithstanding any other provision of law, the department shall develop a process to allow the Department of Corrections and Rehabilitation, Division of Juvenile Facilities, or any successor, to receive any available federal financial participation for acute inpatient hospital services and inpatient psychiatric services provided to any juvenile inmates in the Division of Juvenile Facilities who are admitted as inpatients in a medical institution off the grounds of the correctional facility, and who, but for their institutional status as juvenile inmates, are otherwise eligible for Medi-Cal benefits pursuant to this chapter. This process shall be coordinated, to the extent possible, with the processes and procedures established pursuant to Section 14053.7 of this code and Section 5072 of the Penal Code. (b) Any juvenile inmate in the Division of Juvenile Facilities who is an inpatient in a medical institution off the grounds of the correctional facility shall not be denied eligibility for Medi-Cal benefits under this section because of his or her institutional status as an inmate in the Division of Juvenile Facilities. (c) The department shall consult with the Division of Juvenile Facilities in the development of the process pursuant to this section. (d) The department shall seek any federal approvals necessary to implement the process developed pursuant to this section. This section shall be implemented only if and to the extent that any necessary federal approvals have been obtained, and only to the extent that federal financial participation is available. (e) Notwithstanding any other provision of law, as part of the process developed pursuant to this section, the department may exempt any juvenile inmate in a facility operated by the Division of Juvenile Facilities from enrollment into new or existing managed care health plans. (f) The process developed pursuant to this section shall be implemented only to the extent that the Division of Juvenile Facilities agrees voluntarily to provide the nonfederal share of any costs to the department associated with the administration of this section and the nonfederal share of expenditures for acute inpatient hospital services and inpatient psychiatric services provided off the grounds of the correctional facility to any juvenile inmate of the Division of Juvenile Facilities who is eligible for Medi-Cal benefits pursuant to this section. (g) The federal financial participation received pursuant to this section shall be paid to the Department of Corrections and Rehabilitation for services rendered to any juvenile inmate in the Division of Juvenile Facilities. (h) Reimbursement pursuant to this section shall be limited to only those services for which federal financial participation is available. (i) (1) If there is a final judicial determination made by any state or federal court that is not appealed, or by a court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services (CMS), that disallows, defers, or alters the implementation of this section or, to the extent applicable, Section 14053.7 of this code or Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the facilities used to provide acute inpatient hospital services and inpatient psychiatric services to juvenile inmates in the Division of Juvenile Facilities, then any provision of this section that is inconsistent with the final judicial or CMS determination shall have no force or effect. (2) In addition, the department may, at its discretion, cease to implement any other part of this section that is implicated by the final judicial or CMS determination. (j) For the purposes of Medi-Cal eligibility pursuant to this section, “juvenile inmate” means an individual under 21 years of age who is involuntarily residing in a public institution, including state and local institutions. (k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may, without taking any further regulatory action, implement this section by means of all-county letters or similar instructions. (Amended by Stats. 2012, Ch. 162, Sec. 212. (SB 1171) Effective January 1, 2013.)
14054.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “share of cost” or “spend down of excess income” for certain health care eligibility cases.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14054. (a) “Share of cost” or “spend down of excess income” means the amount of the costs of health care that a person or family eligible under Section 14005.4 or 14005.7 shall incur prior to being certified by the department as specified in Section 14018. (b) Upon the effective date of the act that added this subdivision, any reference to “share of cost” in this chapter or elsewhere in this code that relates to an individual Medi-Cal beneficiary’s or applicant’s eligibility under the medically needy persons or medically needy family persons categories shall be read as “spend down of excess income” and the definition in subdivision (a) shall apply. (Amended by Stats. 2023, Ch. 42, Sec. 126. (AB 118) Effective July 10, 2023.)
14054.5.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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“Elective services” means treatment services that can usually be postponed without seriously affecting the patient’s health.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14054.5. “Elective services” means any treatment service which generally can be postponed without seriously affecting the health of the person requiring the service. (Added by Stats. 1968, Ch. 1242.)
14055.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section defines “caretaker relative” for this chapter.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14055. (a) For the purposes of this chapter, “caretaker relative” means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following: (1) The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, great grandparent, uncle, aunt, nephew, niece, great-great grandparent, great uncle or aunt, first cousin, great-great-great grandparent, great-great uncle or aunt, or first cousin once removed. (2) The spouse or registered domestic partner of one of the relatives identified in paragraph (1), even after the marriage is terminated by death or divorce or the domestic partnership has been legally terminated. (b) This section shall become operative on January 1, 2014. (Added by Stats. 2013, 1st Ex. Sess., Ch. 3, Sec. 23. (AB 1 1x) Effective September 30, 2013. Section operative January 1, 2014, by its own provisions.)
14056.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

“Minimum coverage” means certain prescribed drugs and listed care or coverage, but not elective services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14056. “Minimum coverage” means prescribed drugs for public assistance recipients as established by the director, and care or coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of Section 14053, except that it shall not include elective services. (Amended by Stats. 1972, Ch. 1101.)
14057.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “insurance affordability program” for this chapter and lists the programs that count.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14057. (a) For the purposes of this chapter, “insurance affordability program” means a program that is one of the following: (1) The state’s Medi-Cal program under Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.). (2) The state’s children’s health insurance program (CHIP) under Title XXI of the federal Social Security Act (42 U.S.C. Sec. 1397aa et seq.). (3) A program that makes available to qualified applicants coverage in a qualified health plan through the California Health Benefit Exchange, established pursuant to Title 22 (commencing with Section 100500) of the Government Code, with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code. (4) A program that makes available coverage in a qualified health plan through the California Health Benefit Exchange, established pursuant to Title 22 (commencing with Section 100500) of the Government Code, with cost-sharing reductions established under Section 1402 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), and any subsequent amendments to that act. (b) This section shall become operative on October 1, 2013. (Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 24. (SB 1 1x) Effective September 30, 2013. Section operative October 1, 2013, by its own provisions.)
14057.5.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “contract hospital.”

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14057.5. “Contract hospital” means a nonprofit medical facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, with which the board of supervisors of a county which does not maintain a county hospital has executed a contract, currently in effect, to care for medically indigent individuals. (Amended by Stats. 1973, Ch. 142.)
14059.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section says health care under this chapter may include diagnostic, preventive, corrective, and curative services and supplies, and may also include other remedial care.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14059. Health care provided under this chapter may include diagnostic, preventive, corrective, and curative services and supplies essential thereto, provided by qualified medical and related personnel for conditions that cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity including employment, or for conditions which may develop into some significant handicap. Medical care shall include, but is not limited to, other remedial care, not necessarily medical. Other remedial care shall include, without being limited to, treatment by prayer or healing by spiritual means in the practice of the religion of any church or religious denomination. (Amended by Stats. 1969, Ch. 21.)
14059.5.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines when a service is “medically necessary” for people 21 and older and for people under 21, and it directs the department to update materials and regulations for the under-21 standard.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14059.5. (a) For individuals 21 years of age or older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. (b) (1) For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if the service meets the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code. (2) The department and its contractors shall update any model evidence of coverage documents, beneficiary handbooks, and related material to ensure the medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials. (3) 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, and make specific this subdivision by means of all-county letters, plan letters, plan provider bulletins, manuals, plan contract amendments, or similar instructions until regulations are revised or adopted. (4) By July 1, 2022, the department shall revise or adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. This paragraph shall not apply to a Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101. (c) This section shall not be construed to limit the application of subdivisions (a) and (b) of Section 51184 of Title 22 of the California Code of Regulations. (d) Medical necessity for covered benefits provided in a Medi-Cal behavioral health delivery system, as defined in subdivision (i) of Section 14184.101, shall also be governed in accordance with Section 14184.402. (Amended by Stats. 2021, Ch. 143, Sec. 371. (AB 133) Effective July 27, 2021.)
14060.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

A recipient entitled to visual care under this chapter may choose either a licensed optometrist or a licensed physician to provide the service.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14060. Every recipient who is entitled to visual care under this chapter, which may be rendered either by an optometrist or a physician, may select a duly licensed member of either profession to render the service. (Added by Stats. 1965, 2nd Ex. Sess., Ch. 4.)
14061.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

In this chapter, “director” means 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14061. As used in this chapter, “director” means the State Director of Health Services. (Amended by Stats. 1977, Ch. 1252.)
14062.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “department” as the State Department of Health Services for this chapter.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14062. As used in this chapter, “department” means the State Department of Health Services. (Amended by Stats. 1977, Ch. 1252.)
14063.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “Medi-Cal” as the California Medical Assistance Program for use in this chapter.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14063. As used in this chapter, “Medi-Cal” means the California Medical Assistance Program. (Added by Stats. 1971, Ch. 577.)
14064.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

Inpatient intensive rehabilitation hospital services must consist of specified rehabilitation programs and use a multidiscipline approach under physician supervision.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14064. (a) Inpatient intensive rehabilitation hospital services shall consist of programs for: (1) Strengthening and training of selected muscle groups. (2) Preservation and restoration of joint mobility (prevention and correction of contractures). (3) Training in application and use of equipment. (4) Training in activities of daily living, self-care, locomotion and homemaking skills. (5) Cognitive reorganization and communication skills. (6) Resolution of psychological and social problems which are impeding rehabilitation. (b) These programs shall use a multidiscipline approach carried out under the general or direct supervision of a physician with special training or experience in the field of rehabilitation. When medically indicated, a program of this scope includes but is not limited to: (1) Skilled rehabilitation nursing care. (2) Physical therapy. (3) Occupational therapy. (4) Speech therapy. (5) Prosthetic or orthotic services. (6) Psychologist services. (7) Medical social worker services. (Amended by Stats. 2023, Ch. 42, Sec. 127. (AB 118) Effective July 10, 2023.)
14065.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section defines “Director of Health” and “Director of Benefit Payments” as the State Director of Health Services for specified chapters.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14065. As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Director of Health” and “Director of Benefit Payments” shall be construed to refer to and mean the State Director of Health Services. (Amended by Stats. 1978, Ch. 429.)
14066.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

This section says certain health and benefit department names are to be read as referring to 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14066. As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Department of Health,” “State Department of Health,” “Department of Benefit Payments,” and “State Department of Benefit Payments” shall be construed to refer to and mean the State Department of Health Services. (Added by renumbering Section 14064 (as added by Stats. 1977, Ch. 1252) by Stats. 1978, Ch. 429.)
14067.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

The department may run a community outreach and education campaign for Medi-Cal and Healthy Families, and may work with other child-serving entities to do it. If funding is provided, the department must implement the campaign and the related subdivision.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14067. (a) The department, in conjunction with the Managed Risk Medical Insurance Board, may develop and conduct a community outreach and education campaign to help families learn about, and apply for, Medi-Cal and the Healthy Families Program of the Managed Risk Medical Insurance Board, subject to the requirements of federal law. In conducting this campaign, the department may seek input from, and contract with, various entities and programs that serve children, including, but not limited to, the State Department of Education, counties, Women, Infants, and Children program agencies, Head Start and Healthy Start programs, and community-based organizations that deal with potentially eligible families and children to assist in the outreach, education, and application completion process. The department shall implement the campaign if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute. (b) In implementing this section, the department may amend any existing or future media outreach campaign contract that it has entered into pursuant to Section 14148.5. Notwithstanding any other provision of law, any such contract entered into, or amended, as required to implement this section, shall be exempt from the approval of the Director of General Services and from the provisions of the Public Contract Code. (c) (1) The department, in conjunction with the Managed Risk Medical Insurance Board, may award contracts to community-based organizations to help families learn about, and enroll in, the Medi-Cal program and Healthy Families Program, and other health care programs for low-income children. The department shall implement this subdivision if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute. (2) Contracts for these outreach and enrollment projects shall be awarded based on, but not limited to, all of the following criteria: (A) Capacity to reach populations or geographic areas with disproportionately low enrollment rates. If it is not possible to estimate the number of uninsured children in a geographic area who are eligible for the Medi-Cal program or the Healthy Families Program, proxy measures for rates of eligible children may be used. These measures may include, but are not limited to, the number of children in families with gross annual household incomes at or below the federal poverty levels pertinent to the programs. (B) Organizational capacity and experience, including, but not limited to, any of the following: (i) Organizational experience in serving low-income families. (ii) Ability to work effectively with populations that have disproportionately low enrollment rates. (iii) Organizational experiences in helping families learn about, and enroll in, the Medi-Cal program and Healthy Families Program. Organizations that do not have experience helping families learn about, and enroll in, the Medi-Cal program and Healthy Families Program shall be eligible only to the extent that they support and collaborate with the outreach and enrollment activities of entities with that experience. (C) Effectiveness of the outreach and education plan, including, but not limited to, all of the following: (i) Culturally and linguistically appropriate outreach and education strategies. (ii) Strategies to identify and address barriers to enrollment, such as transportation limitations and community perceptions regarding the Medi-Cal program and Healthy Families Program. (iii) Coordination with other outreach efforts in the community, including the statewide Healthy Families Program and Medi-Cal program outreach campaign, the state and federally funded county Medi-Cal outreach program, and any other Medi-Cal program and Healthy Families Program outreach projects in the target community. (iv) Collaboration with other local organizations that serve families of eligible children. (v) Strategies to ensure that children and families retain coverage and are informed of options for health coverage and services when they lose eligibility for a particular program. (vi) Plans to inform families about all available health care programs and services. (Amended by Stats. 2012, Ch. 728, Sec. 199. (SB 71) Effective January 1, 2013.)
14067.3.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

The department may run and fund county outreach and enrollment plans to enroll and keep eligible children in Medi-Cal and Healthy Families, subject to allocation limits and federal approval.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14067.3. (a) (1) The department may maintain an allocation program for the management and funding of county outreach and enrollment plans to enroll and retain eligible children in the Medi-Cal program and the Healthy Families Program. (2) Notwithstanding any other provision of law, and in a manner that the director shall provide, the department may allocate an amount to fund county outreach and enrollment plans identified in this section. (b) (1) The sum of three million dollars ($3,000,000) in the 2006–07 fiscal year, and thereafter adjusted proportionately on a pro rata basis contingent upon the annual appropriation, but not less than two million dollars ($2,000,000), shall be set aside, from the annual allocation for purposes of this section, for counties identified in subdivision (d). (2) Notwithstanding paragraph (1), the total of all county allocations made pursuant to this section shall not exceed the annual appropriation for the implementation of this section. (c) The director shall make allocations to not more than 20 counties that have the highest number of children who appear to be eligible for the Medi-Cal program or the Healthy Families Program, as determined by the director, but who are not currently enrolled in either program, and the highest number of Medi-Cal program and Healthy Families Program cases for children. This number shall be weighted to emphasize those who appear eligible, but are not currently enrolled in the programs. (d) With funds set aside under paragraph (1) of subdivision (b), the director shall make allocations to those counties that have an existing infrastructure for outreach, enrollment, retention, and utilization, and that can demonstrate they have well established and documented county coalitions for children’s coverage with organizations such as community-based organizations, schools, clinics, labor organizations, and other safety net providers in place for at least 12 months. (e) (1) To obtain an allocation authorized under this section, a county shall submit an allocation plan, which shall include an outreach and enrollment plan, as outlined in paragraph (2). The director shall establish the procedures and format for submission to the department of all county allocation plans. (2) The following shall constitute the minimum components required of a county outreach and enrollment plan: (A) An active collaboration with a wide range of organizations, such as community-based organizations, schools, clinics, labor organizations, and other safety net providers. (B) A streamlined application assistance process. (C) Establishment of an oversight, performance management, and review program to ensure that the outreach and enrollment plan submitted by the county is properly implemented and administered. (D) A description of each of the following: (i) The amount of the current funding and funding source for application, enrollment, retention, and utilization activities. (ii) The current application, enrollment, retention, and utilization activities. (iii) How the allocation funds awarded under this section will be used to supplement and not supplant existing application, enrollment, retention, and utilization activities. (E) A detailed proposed budget of all expenditures for the relevant fiscal year or years for the county’s outreach and enrollment plan activities, expenses, services, materials, and support. (f) Counties receiving an allocation under this section shall provide reports to the department, as determined by the department, on the progress made in achieving the objectives of the allocation plan. (g) (1) The funds allocated under this section shall be used only for outreach, enrollment, retention, and utilization. The funds allocated under this section may supplement, but shall not supplant, existing local, state, and foundation funding of county outreach, enrollment, retention, and utilization activities. Notwithstanding Section 10744, the department may recoup or withhold all or part of a county’s allocation for failure to comply with the standards set forth in the county’s outreach and enrollment plan upon which the allocation was based. (2) Notwithstanding any other provision in this section, any acquisitions made with funds allocated under this section shall be made in compliance with federal law. (h) Reimbursements for costs incurred under the allocation plan authorized under this section shall be made in arrears and in a manner as provided by the director. The allocations may be used only to fund activities provided in each of the designated fiscal years and in accordance with the county’s approved outreach and enrollment plan and budget for the fiscal year. (i) As authorized by the director, on a case by case basis, funds allocated pursuant to this section may be used to support automated enrollment of children in the Medi-Cal program or the Healthy Families Program. Funds under this subdivision shall further the goal of increasing the enrollment of uninsured children, as well as increasing the retention of children, in the Medi-Cal program and Healthy Families Program in the same fiscal year for which the funds are allocated. (j) The department and the Managed Risk Medical Insurance Board shall seek approval of any amendments to the state plan necessary to implement this section for purposes of funding under Titles XIX and XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq. and 1397aa et seq., respectively). This section shall be implemented only when federal approvals have been obtained and only to the extent federal financial participation is available. (k) The department shall reimburse a county pursuant to this section in lieu of commencing a cooperative agreement or contract with a county for the operation of an outreach program. (l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all county letters, provider bulletins, or similar instructions. (m) For the purposes of this section, “county outreach and enrollment plan” means a county outreach program designed to identify and enroll children who are eligible either for the Healthy Families Program or the Medi-Cal program, but are not currently enrolled in either program, and to facilitate the retention of eligible children currently enrolled in these programs. (Added by Stats. 2006, Ch. 74, Sec. 63. Effective July 12, 2006.)
14067.5.
## 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 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

The department must encourage counties to place extra Medi-Cal eligibility workers at nontraditional sites, allow counties to redirect some existing administration funds for that purpose, and require an annual county report if funds are redirected.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14067.5. The department shall encourage counties to outstation additional Medi-Cal eligibility workers in nontraditional sites, such as schools, private hospitals, clinics, mental health centers, sites providing services under California Supplemental Food Program for Women, Infants, and Children sites, and community-based organizations. The department shall permit counties to redirect a portion of existing funding for Medi-Cal eligibility administration for this purpose. The department shall require counties that redirect funds to provide an annual report on the cost of the additional outstationed workers and their effectiveness in increasing or facilitating Medi-Cal enrollment. Expenditures under this section shall be subject to the availability of federal financial participation, and shall not cause an increase in the allocation of funds for the administration of the Medi-Cal program. (Added by Stats. 2000, Ch. 93, Sec. 66. Effective July 7, 2000.)
14068.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

When conducting outreach for Medi-Cal managed care enrollment of special needs populations, the department and its contractors must work with organizations that can reach low-income seniors and people with disabilities.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2. Definitions [14050 - 14068] ( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14068. In conducting outreach activities for the enrollment of special needs populations into a Medi-Cal managed care program, the department and its contractors, as deemed applicable by the department, shall work with state, local, and regional organizations with the ability to target low-income seniors and individuals with disabilities in the communities where they live. This shall include, but not be limited to, all applicable state departments that serve these individuals, regional centers, seniors’ organizations, local health consumer centers, and other consumer-focused organizations that are engaging in providing assistance to this population. (Added by Stats. 2006, Ch. 74, Sec. 64. Effective July 12, 2006.)
14075.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

The Legislature states that Medi-Cal recipients should have reasonable access to medical care, especially primary and maternity care, and that physicians should be reimbursed equally statewide for comparable services when feasible and allowed by federal law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14075. The Legislature intends that Medi-Cal recipients have reasonable access to medical care services and especially to primary and maternity care services. In order to obtain such access, the Legislature intends that, to the extent feasible and permitted by federal law, physicians be reimbursed equally statewide for comparable services, at a rate sufficient to provide Medi-Cal recipients with such reasonable access, and also intends that higher rates be paid, relatively, for providing primary and maternity care services. (Added by Stats. 1976, Ch. 1207.)
14076.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

This section defines “medically underserved area,” “primary care services,” and “maternity care services” 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 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14076. As used in this article: (a) “Medically underserved area” means a county, standard metropolitan statistical area, or other area within the state in which the director determines that Medi-Cal recipients do not have access to an adequate number of physicians. (b) “Primary care services” means those general medical services, as determined by the director, which are not performed on an emergency, referral, or consulting basis. (c) “Maternity care services” are prenatal, postnatal, perinatal, and neonatal services. (Added by Stats. 1976, Ch. 1207.)
14077.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

The director must create a statewide uniform physician reimbursement schedule for Medi-Cal patients within 15 days, and may set higher rates in certain underserved or equity-related 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. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14077. Notwithstanding any other provisions of this chapter the director shall establish, within 15 days of the effective date of this act a statewide, uniform schedule for reimbursing physician services to Medi-Cal patients provided on or after July 1, 1976; except that, the director may establish physician reimbursement rates higher than the statewide rates for; (a) areas which the director determines to be medically underserved: and (b) other problems of equity in payment levels which adversely affect the accessibility of physician services to Medi-Cal recipients. Nothing in this section shall be construed to prevent the director from adopting physician reimbursement rates for primary care services and maternity care services which are relatively higher than the rates paid for other types of physician services. (Added by Stats. 1976, Ch. 1207.)
14078.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

The director must set physician reimbursement rates at specified minimum increases when setting the statewide rate for physician services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14078. The director shall establish, at the time he or she establishes the statewide rate for physician services required by Section 14077, a level of reimbursement for physician services which represents at least an average increase over the statewide average amounts paid under the Medi-Cal program for the three-month period ending February 29, 1976, of 9.5 percent for all physician services except primary care services and maternity care services; of 20 percent for primary care services; and of 30 percent for maternity care services. (Added by Stats. 1976, Ch. 1207.)
14079.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

The director must periodically review Medi-Cal physician and dental reimbursement levels and periodically revise reimbursement rates when needed to meet 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 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14079. (a) The director shall periodically review the reimbursement levels for physician and dental services in the Medi-Cal fee-for-service delivery system, and shall periodically revise the rates of reimbursement to physicians and dentists to the extent the director deems necessary to comply with applicable federal Medicaid program requirements, including provisions on reasonable access to physician and dental services for Medi-Cal beneficiaries. (b) To the extent consistent with the department’s federally approved access monitoring plan, or any successor methodology for monitoring reasonable access to Medi-Cal covered services, as described in Section 1396a(a)(30)(A) of Title 42 of the United States Code, this periodic review, as it relates to rates for physician services, shall take into account at least the following factors: (1) Annual cost increases for physicians as reflected by the Consumer Price Index. (2) Physician reimbursement levels under the Medicare Program. (3) Prevailing customary physician charges within the state and in various geographical areas. (4) Characteristics of the current population of Medi-Cal beneficiaries and the medical services needed. (Amended by Stats. 2020, Ch. 12, Sec. 56. (AB 80) Effective June 29, 2020.)
14079.5.
## 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 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

Reimbursement rates under this chapter must not distinguish between physician and dentist services, and the director must not lower physician-service reimbursement rates to comply with this 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 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14079.5. Rates of reimbursement established pursuant to this chapter shall make no distinction based on whether a particular service is provided by a physician or a dentist. The director shall not reduce any rate of reimbursement for physician services in order to comply with this section. (Added by Stats. 1981, Ch. 995, Sec. 1.)
14080.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

For dental services provided to people 21 or older, reimbursement is capped at $1,800 per beneficiary per calendar year, with listed exceptions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14080. (a) Notwithstanding any other provision of this chapter, reimbursement to providers for dental services provided to individuals 21 years of age or older at the time of services shall be limited to not more than one thousand eight hundred dollars ($1,800) per beneficiary in any calendar year, commencing January 1, 2006. This limitation shall not apply to any of the following: (1) Emergency dental services within the scope of covered dental benefits defined as a dental condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. (2) Services that are federally mandated under Part 440 (commencing with Section 440.1) of Title 42 of the Code of Federal Regulations, including pregnancy-related services and services for other conditions that might complicate the pregnancy. (3) Dentures. (4) Maxillofacial and complex oral surgery. (5) Maxillofacial services, including dental implants and implant-retained prostheses. (6) Services provided in long-term care 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 section by means of all-county letters, provider bulletins, or similar instructions. No later than January 1, 2008, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (c) The department shall pursue any state plan amendment or other federal approval necessary in order to effectuate this section. This section shall be implemented only to the extent that federal financial participation is available. (Amended by Stats. 2008, Ch. 758, Sec. 35. Effective September 30, 2008.)
14080.5.
## 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 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. )
Verify source ↗

Reimbursement levels for physician and dental services under Medi-Cal may not be increased during the stated period, unless the Budget Act of 1982 provides funds for that increase.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.5. Physicians Costs [14075 - 14080.5] ( Article 2.5 added by Stats. 1976, Ch. 1207. ) ## 14080.5. Notwithstanding any other provision of this article, no increase in the reimbursement levels for physician and dental services under Medi-Cal shall be made for the period from July 1, 1982, to September 30, 1982, inclusive, except to the extent funds may be provided therefor by the Budget Act of 1982. (Added by Stats. 1982, Ch. 115, Sec. 51. Effective March 13, 1982.)
14081.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This section says the article is the exclusive way to provide inpatient hospital services for eligible recipients, gives the special negotiator broad discretion, allows previously eligible hospitals to keep participating for a limited time, and says the negotiator’s determination does not require a hearing.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14081. It is the purpose of this article to ensure that the Medi-Cal program shall be operated in the most cost-effective and efficient manner possible with the optimum number of inpatient hospital service providers. In order to carry out this purpose it is the specific intent of the Legislature that the special negotiator have maximum discretion and flexibility in order to select among various methods of arranging for the provision of health services while achieving significant cost savings. This article shall be the exclusive means of providing inpatient hospital services to recipients qualifying for such care under this chapter. All previously eligible hospitals may continue to participate in the Medi-Cal program and receive reimbursement for the provision of inpatient hospital services under this article until the special negotiator has negotiated contracts with a sufficient number of hospitals to assure bed capacity to meet the needs of Medi-Cal beneficiaries in an area and notifies the hospital that it is no longer eligible to serve Medi-Cal inpatients except as provided for in Section 14087. A determination by the negotiator under this section shall not require a hearing under Section 14123 or any other section. (Amended by Stats. 1982, Ch. 1594, Sec. 35. Effective September 30, 1982.)
14081.1.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The Legislature states that hospital reporting requirements should be reviewed and revised for efficiency, with an eye toward a single consolidated report where possible.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14081.1. (a) The Legislature finds and declares the need to improve the reporting relationship between the state and hospitals eligible to contract with the state for the provision of inpatient services to Medi-Cal eligible persons as provided for in the Medi-Cal reform legislation enacted during the 1981–82 Legislative Session. (b) Existing statutes require hospitals to file a multiplicity of reports with various state agencies for a variety of purposes, including, but not limited to, the development of Medi-Cal reimbursement rates for inpatient services. The Medi-Cal reform legislation enacted during the 1981–82 Legislative Session significantly altered the manner in which hospitals are reimbursed under the program for these services, thereby establishing the opportunity to redefine and restructure the existing hospital reporting requirements. (c) It is the Legislature’s intent, therefore, that the existing reporting requirements be reviewed and revised for efficiency, wherever possible, with consideration given to the development of a consolidated, single, multipurpose report for use by all state agencies. (d) It is the Legislature’s further intent that, in determining these efficiencies, the purposes for which the reports are required be preserved. (Added by Stats. 1983, Ch. 1120, Sec. 1.)
14081.5.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Some hospitals that were not chosen for contracting and that negotiated in good faith do not have to meet certain preexisting inpatient-service obligations to Medi-Cal beneficiaries while this article is in effect.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14081.5. Hospitals that are not selected for contracting under this article and that have negotiated in good faith to obtain a contract need not fulfill preexisting obligations relating to the provision of inpatient services to Medi-Cal beneficiaries arising under Section 15459 of the Government Code, and subdivision (j) of Section 129050 of, paragraph (4) of subdivision (b) of Section 127175 of, the Health and Safety Code, so long as this article remains in effect. (Amended by Stats. 1996, Ch. 1023, Sec. 470. Effective September 29, 1996.)
14082.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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This section requires the Governor to appoint a special negotiator for hospital inpatient service contracts and sets out the negotiator’s powers, duties, and emergency rulemaking process.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14082. Notwithstanding any other provision of law, the Governor shall designate a person in his office to act as a special negotiator to negotiate rates, terms, and conditions for contracts with hospitals for inpatient services to be rendered to Medi-Cal program beneficiaries. The negotiator may also, if he or she deems it expedient, call for bids, in lieu of negotiations. The special negotiator shall consider, when contracting, the total funds appropriated for inpatient hospital services. The department and every other state agency concerned with health care or public social services shall provide such assistance as the negotiator may require. The department shall enter into contracts with hospitals and shall be bound by the rates, terms, and conditions negotiated by the negotiator. The negotiator shall have the powers of a head of a department pursuant to Chapter 2 (commencing with Section 11150) of Part 1 of Division 3 of Title 2 of the Government Code, except, that he or she shall adopt only such rules and regulations pursuant to Section 11152 of the Government Code as are necessary to carry out those duties specifically conferred upon the negotiator by Articles 2.6 (commencing with Section 14081), 2.8 (commencing with Section 14087.5), 2.91 (commencing with Section 14089), and 2.92 (commencing with Section 14090) of this chapter. The negotiator shall adopt such regulations as emergency regulations in accordance with the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. For the purposes of the Administrative Procedure Act, the adoption of the regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted in accordance with this section shall not be subject to the review and approval of the Office of Administrative Law. These regulations shall become effective immediately upon filing with the Secretary of State. In addition to the powers specified in this section, the negotiator has the authority to negotiate contracts under Article 2.8 (commencing with Section 14087.5), Article 2.91 (commencing with Section 14089), and Article 2.92 (commencing with Section 14090) of this chapter. Also, the California Medical Assistance Commission shall have the authority to enter into contracts for the provision of acute inpatient hospital services for the care of County Medical Services Program beneficiaries pursuant to Section 16809 of the Welfare and Institutions Code. Nothing in this article or the Budget Act of 1984 prohibits the negotiator from adjusting rates paid to hospitals to reflect inflation, provided that such adjustments are determined during the negotiating process. The amendment of this section made at the 1983–84 Regular Session of the Legislature does not constitute a change in, but is declaratory of, the existing law. (Amended by Stats. 1992, Ch. 722, Sec. 68.5. Effective September 15, 1992.)
14082.5.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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The negotiator serves through the 1982–83 fiscal year, then the California Medical Assistance Commission takes over the negotiator’s functions; from July 1, 1983, references to the negotiator are treated as references to the commission, and the negotiator serves as the commission’s executive 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14082.5. The negotiator provided for in Section 14082 shall serve in such capacity for the 1982–83 fiscal year, after which his or her functions shall be assumed by the California Medical Assistance Commission. Commencing on July 1, 1983, any reference in this article or in Article 2.8 (commencing with Section 14087.5), and Article 2.91 (commencing with Section 14089) of this chapter to the negotiator shall be deemed to be references to the California Medical Assistance Commission. As of July 1, 1983, the negotiator shall serve as the executive director of the commission. (Added by Stats. 1982, Ch. 328, Sec. 17. Effective June 30, 1982.)
14083.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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When negotiating contracts or setting competitive bidding specifications under this article, the negotiator must consider a listed set of factors.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14083. The factors to be considered by the negotiator in negotiating contracts under this article, or in drawing specifications for competitive bidding, include, but are not limited to, all of the following: (a) Beneficiary access. (b) Utilization controls. (c) Ability to render quality services efficiently and economically. (d) Demonstrated ability to provide or arrange needed specialized services. (e) Protection against fraud and abuse. (f) Any other factor which would reduce costs, promote access, or enhance the quality of care. (g) The capacity to provide a given tertiary service, such as specialized children’s services, on a regional basis. (h) Recognition of the variations in severity of illness and complexity of care. (i) Existing labor-management collective bargaining agreements. (j) The situation of county hospitals and university medical centers contracting with counties for provision of health care to indigent persons entitled to care under Section 17000, which are burdened to a greater extent than private hospitals with bad debts, indirect costs, medical education programs, and capital needs. (k) The special circumstances of hospitals serving a disproportionate number of Medi-Cal beneficiaries and patients who are not covered by other third-party payers, including the costs associated with assuring an adequate supply of registered nurses. (l) The costs of providing complex emergency services, including the costs of meeting and maintaining state and local requirements for trauma center designation. (m) The hospital does any of the following: (1) Provides additional obstetrical beds. (2) Contracts with one or more comprehensive perinatal providers. (3) Permits certified nurse midwives, subject to hospital rules, and consistent with existing laws and regulations, to admit patients to the health facility. (4) Expands overall obstetrical services in the hospital. (n) The special circumstances of hospitals whose Medi-Cal inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate by at least one-half of one standard deviation. (o) The ability and capacity of the contracting hospital in a closed health facility planning area to provide health care services to beneficiaries who are in life-threatening or emergency situations, but have been sufficiently stabilized at another noncontracting facility in order to facilitate transportation to the contracting hospital. (p) The ability of the contracting hospital to provide a secure environment for the provision of health care services. In this regard, the negotiator shall consider additional security measures that the contracting hospital may have taken to provide a secure environment, including, but not limited to, the use of detection equipment or procedures to detect lethal weapons, the appropriate use of surveillance cameras, limiting access of unauthorized personnel to the emergency department, installation of bullet proof glass as appropriate in designated areas, the use of emergency “panic” buttons to alert local law enforcement agencies, and assigning full-time security personnel to the emergency department. (Amended by Stats. 2010, Ch. 328, Sec. 244. (SB 1330) Effective January 1, 2011.)
14083.5.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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The negotiator must give special consideration to reimbursement issues affecting hospitals that care for Medi-Cal beneficiaries receiving AIDS treatment.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14083.5. In addition to considering factors specified in Section 14083, the negotiator, in negotiating contracts under this article, or in drawing specifications for competitive bidding, shall give special consideration to the reimbursement issues faced by hospitals caring for Medi-Cal beneficiaries who are receiving treatment for acquired immune deficiency syndrome (AIDS). (Added by Stats. 1987, Ch. 1470, Sec. 1. Effective September 30, 1987.)
14084.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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Contract payments may use capitation, prepayment, a mix of both, or other feasible methods; hospitals may take on some or all utilization or cost risk, and the department must ensure the reimbursement system can make 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14084. (a) Payments to the contractor may be either on a capitation or prepayment basis, or on a combination of both methods of payment, or such other methods as the negotiator determines to be feasible. Hospitals may assume all or part of the risk of utilization of services, or costs of services, or both. (b) The department shall insure that the system for reimbursing contracting hospitals is capable of making contract payments in the manner determined pursuant to subdivision (a). At a minimum, the department shall insure that the reimbursement system is capable of making contract payments on a per diem and a per case basis. (Amended by Stats. 1983, Ch. 1315, Sec. 2.)
14085.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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The director must keep applying existing utilization controls to inpatient hospital services, but may waive controls that are no longer necessary for hospitals under negotiated, capitated, at-risk 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085. All utilization controls applied to inpatient hospital services by the director in accordance with Section 14133.1 shall continue to be applied to inpatient hospital services rendered under this article, except that the director may waive utilization controls which are no longer necessary in the case of hospitals entering into negotiated, capitated, at-risk contracts under this article. (Added by Stats. 1982, Ch. 328, Sec. 17. Effective June 30, 1982.)
14085.5.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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Qualifying hospitals may receive supplemental reimbursement for eligible capital projects, but they must document debt service and use the reimbursement only for debt service on the related bonds.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.5. (a) Each disproportionate share hospital contracting to provide services under this article or contracting with a county organized health system, and which has or would have met the state criteria developed pursuant to the federal medicaid requirements regarding disproportionate hospitals for the three most recent years prior to submitting final plans for an eligible project in accordance with subparagraph (C) of paragraph (1) of subdivision (b), may, in addition to the rate of payment provided for in the contract entered into under this article, receive supplemental reimbursement to the extent provided for in this section. (b) (1) (A) A hospital qualifying pursuant to subdivision (a) shall submit documentation regarding debt service on revenue bonds used for financing the construction, renovation, or replacement of hospital facilities, including buildings and fixed equipment. (B) Qualified hospitals may submit debt service instruments to the department and to the commission regarding debt issued for new capital projects. (C) Eligible projects shall include those new capital projects funded by new debt for which final plans have been submitted to the Office of the State Architect and the Office of Statewide Health Planning and Development after September 1, 1988, and prior to June 30, 1994, except that projects submitted between September 1, 1988, and June 30, 1989, shall be eligible only if the submitting hospital had all of the following additional characteristics during the 1989 calendar year: (i) No less than 400 general acute care licensed beds. (ii) An average Medi-Cal patient census of not less than 30 percent of the total patient days. (iii) No less than 50,000 emergency department visits. (iv) An existing basic emergency department, obstetrical services, and a neonatal intensive care unit. (D) The department shall confirm in writing hospital and project eligibility for partial financing under this section. (E) Department advisory letters, conditioned on hospital and project conformity to plans, may be requested by hospitals prior to final plan submission. (F) Capital projects receiving partial financing under this section shall finance the upgrading or construction of buildings and equipment to a level required by currently accepted medical practice standards, including projects designed to correct Joint Commission on Accreditation of Hospitals and Health Systems fire and life safety, seismic, or other related regulatory standards. (2) Projects may also expand service capacity as needed to maintain current or reasonably foreseeable necessary bed capacity to meet the needs of Medi-Cal beneficiaries after giving consideration to bed capacity needed for other patients, including unsponsored patients. (3) (A) Debt service shall only be paid for projects, or for that portion of projects, that are available and accessible to patients treated under this article or by successor programs. (B) Each project shall cost at least five million dollars ($5,000,000) or, if less than five million dollars ($5,000,000), the project shall be necessary for retention of federal and state licensing and certification and for meeting fire and life safety, seismic, or other related regulatory standards. (4) Supplemental reimbursement payments shall commence no later than 30 days after receipt of the certificate of occupancy by the hospital. (5) (A) The state shall pledge to, and agree with, the holders of any revenue bonds issued to finance projects qualifying under this section that until debt service on the revenue bonds is fully paid, or until the supplemental rate is no longer required as provided by this section, the state will not limit or alter the rights vested in the hospital to receive supplemental reimbursement pursuant to this section. (B) The state shall pledge, and the hospital shall, as a condition of encumbering supplemental reimbursement payments received pursuant to this section, pledge that supplemental reimbursement payments shall be used for the payment of debt service on the revenue bonds. The hospital shall include its pledge and the agreement with the state in any agreement with the holders of the revenue bonds. (c) The hospital’s supplemental reimbursement for a project qualifying pursuant to subdivisions (a) and (b) shall be calculated as follows: (1) For any fiscal year for which the hospital is eligible to receive reimbursement, the hospital shall report to the department the amount of debt service on the revenue bonds issued to finance the project. (2) (A) The department shall use the medicaid inpatient utilization rate as determined pursuant to Section 4112 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) to determine the ratio of the hospital’s total paid Medi-Cal patient days to total patient days. (B) (i) Notwithstanding any other provision of law, in determining the hospital’s medicaid inpatient utilization rate for the purposes of this section, the department shall include in both the numerator and denominator all Medi-Cal inpatient days of care provided by the hospital after December 31, 1994, to Medi-Cal beneficiaries who are enrolled in prepaid health plans contracting with the department. Where reliable data regarding those days are available from Medi-Cal prepaid health plans contracting with participating hospitals for services rendered prior to January 1, 1995, that data may be used by the department in the calculations. (ii) For purposes of this section, Medi-Cal prepaid health plan programs, and the days relating thereto, shall include, but not be limited to, the programs listed in paragraph (1) of subdivision (b) of Section 14105.985, Section 14089, and any prepaid programs implemented under Section 14087.3, including the two-plan model described in the report issued on March 31, 1993, by the department, entitled “The State Department of Health Services’ Plan for Expanding Medi-Cal Managed Care: Protecting Vulnerable Populations.” (3) (A) (i) The supplemental Medi-Cal reimbursement to the hospital for each fiscal year shall equal the amount determined annually in paragraph (1) multiplied by the percentage figure determined in paragraph (2). In no instance shall the percentage figure determined pursuant to the ratio derived under paragraph (2) be decreased by more than 10 percent of the initial ratio determined pursuant to paragraph (2) prior to the retirement of the debt. (ii) Hospitals whose Medi-Cal ratio falls below 90 percent of the initial level established at the point of final plan submission shall at least maintain the volume of Medi-Cal utilization which was recorded at the time of final plan submission unless forces beyond the hospital’s control have decreased the absolute volume of care. (B) (i) In no instance shall the total amount of reimbursement received under this section combined with that received from all other sources dedicated exclusively to debt service exceed 100 percent of the debt service over the life of the loan. (ii) A hospital qualifying for and receiving supplemental Medi-Cal reimbursement shall continue to receive the reimbursement until the qualifying loan is paid off, or the hospital is terminated as a Medi-Cal selective contractor and the hospital does not contract with a county organized health system. (iii) It is the intent of the Legislature that the state and the qualifying hospital shall negotiate in good faith for rates sufficient to ensure continued hospital participation in the program and to ensure adequate access to services for Medi-Cal beneficiaries. (iv) The state shall not terminate a contract with a qualified provider for the purpose of terminating the capital supplement. (v) If negotiations fail to permit continuation of a contract of a hospital qualifying for the supplemental Medi-Cal reimbursement, the supplemental Medi-Cal reimbursement shall cease as of the date of discontinuance of the selective provider contract. (4) In order to ensure provision of qualified supplemental payments to disproportionate share hospitals contracting with county organized health systems, the department shall make the qualified supplemental payments directly to these hospitals. (5) Funding for these supplemental payments shall be separately appropriated as a line item in the Budget Act for each fiscal year for any project for which a request for payment is received after April 1 of each fiscal year. The department shall request a deficiency appropriation if funds for the payment are not appropriated in the Budget Act. (6) (A) Paragraphs (1) to (4), inclusive, shall be incorporated into an amendment to any contract entered into by a hospital pursuant to this article. (B) (i) Any contract amendment required by paragraph (A) shall include a payment methodology based on inpatient hospital services rendered to Medi-Cal patients, either on a per diem basis, a per-discharge basis, or any other federally permissible basis, and which is consistent with the hospital’s Medi-Cal contract. (ii) The payment methodology specified in clause (i) shall ensure that the hospital, on an annual basis, receives the amount of supplemental reimbursement calculated pursuant to paragraph (3), excluding only the federal portion of costs which have been determined by the federal government not to be allowable under Title XIX of the federal Social Security Act (Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code). (iii) The payment methodology specified in clause (i) shall contain a retrospective adjustment mechanism to ensure that, regardless of the payment methodology, the department shall pay the hospital the full amount owed to the hospital for the year, as determined pursuant to this section. (7) In negotiating contracts with hospitals receiving payments under this section, the commission shall take appropriate steps to ensure the duplicate payments are not made to the hospital for the debt service costs relating to the eligible project. (d) All reimbursement received by a hospital pursuant to this section shall be placed in a special account, the funds in which shall be used exclusively for the payment of debt service on the revenue bonds issued to finance the project. (e) If contracting under this section is superseded by other arrangements for payment of inpatient hospital services, the successor program shall include separate reimbursement, as determined pursuant to paragraph (3) of subdivision (c). (f) (1) For purposes of this section, “revenue bonds” are defined as that term is defined in subdivision (c) of Section 15459 of the Government Code, and shall also include general obligation bonds issued by or on behalf of eligible hospitals for projects of more than five million dollars ($5,000,000). (2) (A) The aggregate principal amount of general obligation bonds to be issued as revenue bonds under this subdivision for the anticipated allowable portion of projects shall not, in any fiscal year, exceed a statewide amount established in the Medi-Cal estimates submitted to the fiscal committees of the Legislature pursuant to Section 14100.5, or as otherwise statutorily determined by the Legislature. (B) In preparing Medi-Cal estimates, the department shall consider, but need not include, all actual and anticipated projects. (g) (1) The department shall promptly seek any necessary federal approvals for the implementation of this section, and, if necessary to obtain federal approval, the department may, for federal purposes, limit the program to those costs which are allowable expenditures under Title XIX of the federal Social Security Act (Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code), subject to paragraph (2). (2) The department shall continue to be responsible for the reimbursement of eligible providers from state funds for the amount of supplemental reimbursement pursuant to paragraph (3) of subdivision (c), excluding only the federal portion of costs which have been determined by the federal government not to be allowable under Title XIX of the federal Social Security Act. (h) (1) 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. (2) The department shall submit claims for federal financial participation for all elements of the supplemental reimbursements which are allowable expenditures under federal law. (3) The department shall, on an annual basis, submit any necessary materials to the federal government to provide assurances that claims for federal financial participation will include only those expenditures which are allowable under federal law. (4) (A) The department may require that hospitals receiving supplemental reimbursement submit data necessary for the department to determine the appropriate amounts to claim as expenditures qualifying for federal financial participation. (B) Unless otherwise permitted by federal law, the total statewide payment under the selective provider contracting program, in the aggregate on an annual basis, shall not exceed an amount that would otherwise have been paid under the Medi-Cal program on a statewide basis for the same services, in the aggregate on an annual basis, if the contracting program were not implemented. (i) (1) Subject to paragraph (2), any hospital that met the criteria specified in subdivision (a) at the time it submitted its final plans for an eligible project in accordance with subparagraph (C) of paragraph (1) of subdivision (b) shall continue to receive reimbursement as set forth in this section irrespective of whether or not the hospital qualifies as a disproportionate share hospital after submission of its final plans. (2) A hospital that fails to meet the criteria for disproportionate share status on or before June 30, 2002, shall be required to submit data to the department that demonstrates that the hospital failed to meet the criteria for a disproportionate share hospital because its low-income utilization rate, as determined pursuant to Section 4112 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203), does not exceed 25 percent due to one or more of the following factors: (A) An increase in outpatient utilization. (B) A decrease in the average length of stay for Medi-Cal beneficiaries or charity care patients due to technological advances in the provision of care. (C) Increased implementation within the state of Medi-Cal prepaid health plan programs. (D) The level of reimbursement that the hospital receives for outpatient visits. (E) Other circumstances beyond the hospital’s control that affect the hospital’s ability to meet the criteria for disproportionate status, even though the hospital continues to have a mission to provide care to Medi-Cal and charity care patients. (Amended by Stats. 2001, Ch. 745, Sec. 248. Effective October 12, 2001.)
14085.51.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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Certain qualifying disproportionate share hospitals may file substitute final plans and can receive supplemental reimbursement if the listed 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.51. (a) A disproportionate share hospital that qualifies under Section 14085.5 that has submitted final plans for an eligible capital project in accordance with subparagraph (C) of paragraph (1) of subdivision (b) of Section 14085.5 may submit substitute final plans and shall qualify for supplemental reimbursement under Section 14085.5 for the revised capital project as described in the substitute final plans if all of the following conditions are met: (1) The substituted capital project continues to meet the requirements for eligible projects as specified in Section 14085.5. (2) The hospital provides written notification to the department of the status of the project on or before January 1 of each year commencing January 1, 1999. This notification shall, at a minimum, include a narrative description of the project, identification of medical services to be provided, documentation substantiating service needs, projected construction timeframes, and total estimated revised capital project costs. (3) The substitute final plans are submitted to the Office of Statewide Health Planning and Development prior to June 30, 1995, or, where debt was issued prior to July 1, 1996, for the capital project for which the plans were originally submitted, the substitute final plans are submitted to the Office of Statewide Health Planning and Development prior to December 31, 2000. (b) The revised capital project may provide for any one or more of the following: (1) A reduction in size and scope of the original project plan. (2) Tenant interior improvements for the entire building not specified in the original project plan. (3) Modifications to the foundation, structural frame, and building exterior shell, commonly known as the shell and core. (4) Modifications necessary to comply with current seismic safety standards. (c) The supplemental reimbursement under Section 14085.5 for the revised capital project shall be no greater than the supplemental reimbursement for the original capital project as evidenced by the architects’ and engineers’ certified cost estimate of the original plan submission and the substitute plan submission. (d) (1) A project, if eligible under the criteria set forth in this section and Section 14085.5, shall commence construction on or before January 1, 2002. (2) In addition, the project shall be licensed for operation and available for occupancy on or before January 1, 2009. (Amended by Stats. 1997, Ch. 723, Sec. 1. Effective January 1, 1998.)
14085.52.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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A qualifying disproportionate share hospital may file revised plans for an eligible capital project and can receive supplemental reimbursement if the stated conditions are met.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.52. (a) A disproportionate share hospital that qualifies under Section 14085.5 that has submitted final plans for an eligible capital project in accordance with subparagraph (C) of paragraph (1) of subdivision (b) of Section 14085.5 may submit revised plans and shall qualify for supplemental reimbursement under Section 14085.5 for the revised capital project as described in the revised plans if all of the following conditions are met: (1) The revised capital project continues to meet all other requirements for eligibility as specified in Section 14085.5. (2) The revised plans are submitted to the Office of Statewide Health Planning and Development prior to December 31, 1996. (3) The modifications in the revised plans are necessary to comply with current seismic safety standards. (b) The supplemental reimbursement under Section 14085.5 for the revised capital project shall be no greater than the supplemental reimbursement for the original capital project as evidenced by the architects’ and engineers’ certified cost estimate of the original plan submission and substitute plans submitted between July 1, 1994, and June 30, 1995, whichever is less. (Added by Stats. 1996, Ch. 55, Sec. 1. Effective June 6, 1996.)
14085.53.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
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Alameda Health System may revise certain capital project plans and submit them for supplemental reimbursement if stated conditions are met.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.53. (a) The Alameda Health System may revise plans submitted in accordance with subparagraph (C) of paragraph (1) of subdivision (b) of Section 14085.5 for the Alameda Health System capital project and submit those revised plans pursuant to this section. The revised capital project plans shall qualify for supplemental reimbursement under Section 14085.5 for the revised capital project as described in the revised plans, notwithstanding the assignment of a different permit number, if all of the following conditions are met: (1) The revised capital project continues to meet all other requirements for eligibility as specified in Section 14085.5. (2) The revised plans are submitted to the Office of Statewide Health Planning and Development prior to June 30, 1997. (3) The modifications do not involve a deviation from the original capital project plan’s stated architectural building footprint. (b) The revised capital project plan for the Alameda Health System may provide for any or all or any combination of the following: (1) A reduction in size and scope of the original project plan. (2) Tenant interior improvements for the entire building not specified in the original project plan. (3) Modifications to the foundation, structural frame, and building exterior shell, commonly known as the shell and core. (4) Modifications necessary to comply with current seismic safety standards. (c) The revised capital project plans for the Alameda Health System, as described in this section, shall qualify for supplemental reimbursement as calculated pursuant to subdivision (c) of Section 14085.5, as limited by this section. The initial Medi-Cal inpatient utilization rate for the Alameda Health System, for purposes of calculating the supplemental reimbursement, shall be that which was established at the point of the original project plan submission. The supplemental reimbursement shall be based on actual costs of the revised capital project eligible for reimbursement under Section 14085.5. However, in no event shall the supplemental reimbursement for the revised capital project exceed 85 percent of the supplemental reimbursement for that portion of the original Alameda Health System capital project that qualified for the supplemental reimbursement, the original qualifying amount that was sixty-two million six hundred ninety-six thousand three hundred forty dollars ($62,696,340), as indicated by the budgetary estimate as prepared and submitted by Alameda County to the department July 11, 1994. (Amended by Stats. 2014, Ch. 46, Sec. 4. (SB 1352) Effective January 1, 2015.)
14085.54.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This section lets LAC-USC Medical Center submit revised final plans, but only if specified conditions are met, and it ties funding to those conditions and 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.54. (a) The Los Angeles County University of Southern California (LAC-USC) Medical Center may submit revised final plans to the Office of Statewide Health Planning and Development to replace the original capital expenditure project plans that met the initial eligibility requirements provided for under Section 14085.5 if all of the following conditions are met: (1) The revised capital expenditure project meets all other requirements for eligibility as specified in Section 14085.5. (2) The revised plans are submitted to the Office of Statewide Health Planning and Development on or before December 31, 2002, except that, with respect to a facility in the San Gabriel Valley of not less than 80 beds, the revised plans may be submitted not later than December 31, 2003. (3) The scope of the capital project shall consist of two facilities with not less than a total of 680 beds. (b) Funding under Section 14085.5 shall not be provided unless all of the conditions specified in subdivision (a) are met. (c) The revised plans for the LAC-USC Medical Center capital expenditure project may provide for one or more of the following variations from the original capital expenditure project plan submission: (1) Total revisions or reconfigurations, or reductions in size and scope. (2) Reduction in, or modification of, some or all inpatient project components. (3) Tenant interior improvements not specified in the original capital expenditure project plan submission. (4) Modifications to the foundation, structural frame, and building exterior shell, commonly known as the shell and core. (5) Modifications necessary to comply with current seismic safety standards. (6) Expansion of outpatient service facilities that operate under the LAC-USC Medical Center license. (d) The revised capital expenditure project may provide for an additional inpatient service site to the current LAC-USC Medical Center only if the additional inpatient service site meets both of the following criteria: (1) The San Gabriel Valley site is owned and operated by the County of Los Angeles. (2) The San Gabriel Valley site is consolidated under the LAC-USC Medical Center license. (e) (1) Supplemental reimbursement for the revised capital expenditure project for LAC-USC Medical Center, as described in this section, shall be calculated pursuant to subdivision (c) of Section 14085.5, as authorized and limited by this section. The initial Medi-Cal inpatient utilization rate for the LAC-USC Medical Center, for purposes of calculating the supplemental reimbursement, shall be that which was established at the point of the original capital expenditure project plan submission. The revised capital expenditure project costs, including project costs related to the additional inpatient service site, eligible for supplemental reimbursement under this section shall not exceed 85 percent of the project costs, including all eligible construction, architectural and engineering, design, management and consultant costs that would have qualified for supplemental reimbursement under the original capital project. The Legislature finds that the original qualifying amount was one billion two hundred sixty-nine million seven hundred thirty-five thousand dollars ($1,269,735,000). (2) Notwithstanding any other provision of this section, any portion of the revised capital expenditure project for which the County of Los Angeles is reimbursed by the Federal Emergency Management Agency and the Office of Emergency Services shall not be considered eligible project costs for purposes of determining supplemental reimbursement under Section 14085.5. (3) The department shall seek a Medicaid state plan amendment in order to maximize federal financial participation. However, if the department is unable to obtain federal financial participation at the Medi-Cal inpatient adjustment rate as described in paragraph (1), the state shall fully fund any amount that would otherwise be funded under this section, but for which federal financial participation cannot be obtained. (f) The LAC-USC Medical Center shall provide written notification to the department of the status of the project on or before January 1 of each year, commencing January 1, 2002. This notification shall, at a minimum, include a narrative description of the project, identification of services to be provided, documentation substantiating service needs, projected construction timeframes, and total estimated revised capital project costs. (g) The project, if eligible under the criteria set forth in this section and Section 14085.5, shall commence construction at both facilities referred to in subdivision (a) on or before January 1, 2004. (h) In addition to the requirements of subdivision (f), the project shall be licensed for operation and available for occupancy on or before January 1, 2009. (i) On or before August 15, 2001, the County of Los Angeles may withdraw any revised final plans that are submitted pursuant to this section prior to that date if the Board of Supervisors of Los Angeles County finds that insufficient funds are available to carry out the capital expenditure project described in this section. (Amended by Stats. 2013, Ch. 352, Sec. 538. (AB 1317) Effective September 26, 2013. Operative July 1, 2013, by Sec. 543 of Ch. 352.)
14085.55.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This section expands the definition of eligible projects to include certain new capital projects funded by new debt if specified plan-submission dates 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.55. Notwithstanding subparagraph (C) of paragraph (1) of subdivision (b) of Section 14085.5, eligible projects shall include those new capital projects funded by new debt for which final plans for the foundation, frame, and building shell, commonly known as the shell and core, have been submitted to the Office of the State Architect and the Office of Statewide Health Planning and Development after September 1, 1988, and prior to June 30, 1994, and for which final plans for tenant improvements have been submitted to the Office of the State Architect and the Office of Statewide Health Planning and Development after September 1, 1988, and prior to January 1, 1995. (Added by Stats. 1994, Ch. 1283, Sec. 1. Effective January 1, 1995.)
14085.56.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This section lets Contra Costa County Regional Medical Center build or renovate the former Los Medanos site and sets rules for when the project can get supplemental reimbursement.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.56. (a) For the purposes of this section, “Los Medanos site,” means the site of the former Los Medanos Medical Center. (b) Contra Costa County Regional Medical Center may construct or renovate, or both, at the former Los Medanos site, and the construction or renovation, or both, may be considered eligible for supplemental reimbursement under Section 14085.5, if the Los Medanos site meets both of the following conditions: (1) The site is owned or leased, and operated, by Contra Costa County. (2) The site is consolidated under the Contra Costa County Regional Medical Center general acute care license. (c) Contra Costa County Regional Medical Center shall qualify to receive supplemental reimbursement for revised final plans for construction or renovation, or both, submitted to the Office of Statewide Health Planning and Development on or before November 30, 1998, for the Los Medanos site, and shall qualify for supplemental reimbursement under Section 14085.5 for the revised capital project if the revised capital project continues to meet the requirements for eligibility specified in Section 14085.5, as modified by this section. (d) The revised final plans may provide for a capital project with one or more of the following variations from the original capital project plan submission: (1) Total revision or reconfiguration, or a reduction in size and scope. (2) Modifications necessary to comply with current seismic safety standards. (3) Expansion of outpatient service facilities. (4) Modifications to the foundation, structural frame, and building exterior shell, commonly known as the shell and core. (e) For purposes of calculating supplemental reimbursement pursuant to Section 14085.5 for a revised capital project complying with this section, the initial Medi-Cal inpatient utilization rate shall be that which is determined at the time of submission of the revised capital project plan. (f) For purposes of determining supplemental reimbursement under Section 14085.5 for a revised capital project complying with this section, supplemental reimbursement shall be based on actual costs of the revised capital project eligible for reimbursement under Section 14085.5. However, in no event shall the revised capital project costs be considered eligible for supplemental reimbursement for the construction or renovation, or both, of the Los Medanos site if these costs exceed eight million five hundred ten thousand dollars ($8,510,000). (g) Supplemental reimbursement paid under this section for construction shall not duplicate any reimbursement received by the Contra Costa County Regional Medical Center for services provided at the Los Medanos site. (h) Subject to subdivisions (g) and (h) of Section 14085.5, Contra Costa County Regional Medical Center shall receive supplemental reimbursement under this section for debt service associated with the revised capital project over the lesser of the following periods: (1) The life of the revenue bonds. (2) The period during which the Los Medanos site is either leased or owned by Contra Costa County. (Added by Stats. 2000, Ch. 846, Sec. 1. Effective January 1, 2001.)
14085.57.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Certain qualifying designated public hospitals may receive supplemental reimbursement, but they must submit documentation, stay open for the life of the reimbursement, and the department must seek federal approvals and claim federal expenditures.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14085.57. (a) A designated public hospital, as defined in subdivision (d) of Section 14166.1, that is contracting to provide services under this article, and that has or would have fulfilled the criteria set forth in Section 14105.98 or subparagraph (B) of paragraph (1) of subdivision (c) of Section 14166.3 for the three most recent years prior to submitting final plans for an eligible project in accordance with paragraph (3) of subdivision (b), may receive supplemental reimbursement to the extent provided for in Section 14085.5, subject to subdivision (c), in addition to the rate of payment provided for in the contract entered into under this article. (b) (1) A hospital qualifying pursuant to subdivision (a) that elects to receive reimbursement under this section shall submit documentation to the department regarding debt service on general obligation bonds or revenue bonds used for financing the construction, renovation, or replacement of hospital facilities, including buildings and fixed equipment. (2) A hospital qualifying pursuant to subdivision (a) shall remain open for the life of the supplemental reimbursements provided for pursuant to this section. (3) (A) Eligible projects shall include those new capital projects funded by new debt for which final plans have been submitted to the Office of Statewide Health Planning and Development after January 1, 2007, and prior to December 31, 2011. (B) Eligible projects that may receive supplemental reimbursement pursuant to subdivision (a) are limited to projects related to meeting seismic safety deadlines. (c) No expenditure of state funds, either from the General Fund or any special fund, shall be made for the nonfederal share of the supplemental reimbursement provided for in this section. The department shall, for designated public hospitals that meet the criteria in subdivision (a), claim federal expenditures through the use of certified public expenditures or intergovernmental transfers, as necessary and appropriate. (d) The department shall promptly seek any necessary, and all available, federal approvals for the implementation of this section. This section shall be implemented only to the extent that federal approval and federal financial participation are available. (Amended by Stats. 2010, Ch. 328, Sec. 245. (SB 1330) Effective January 1, 2011.)
14086.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This article applies only to hospitals and does not apply to certain hospital inpatient services, state hospitals, or out-of-state 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14086. (a) The provisions of this article relating to contracts with hospitals, to be negotiated or let out to bid by the negotiator, shall apply only to hospitals and shall not apply to hospital inpatient services rendered by health maintenance organizations and other organized health systems, contracting with the department under this chapter or Chapter 8 (commencing with Section 14200). (b) The provisions of this article shall also not apply to state hospitals or out-of-state hospitals. These hospitals shall continue to be eligible for reimbursement in accordance with the state plan adopted by the department under Section 14105.1. (Amended by Stats. 1993, Ch. 69, Sec. 51. Effective June 30, 1993.)
14087.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

This section says it should not be read to block certain hospital reimbursement and requires managed care plans not to disclose reimbursement information, except to the department.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087. The provisions of this article shall not, however, be construed to preclude an otherwise qualified hospital from obtaining reimbursement as determined by the department based on the state plan adopted by the department under Section 14105.1, for any of the following: (a) Providing stabilizing services as required to program beneficiaries located in a closed health facility planning area who are in a life threatening or emergency situation before the beneficiary may be transported to a contracting hospital. (b) If a beneficiary is located in a closed health facility planning area and experiencing a life threatening or emergency situation but cannot be stabilized sufficiently to facilitate a transfer to a contracting facility, those health services medically necessary for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which, if not immediately diagnosed and treated, could lead to significant disability or death. (c) Providing services to beneficiaries who are also eligible for benefits under the federal program of hospital insurance for the aged and disabled. (d) Providing services to beneficiaries who live or reside farther than the community travel time standard from a contract hospital, as defined by the department, if the hospital providing services is closer than a contract hospital. (e) Managed care plans making payments to a contract hospital shall not release any information regarding the reimbursement paid to the hospital when the rate is a Medi-Cal contract rate negotiated pursuant to article 2.6 (commencing with Section 14081), except to the department. (f) Nothing in this section shall be construed as limiting reimbursement for medically necessary care following stabilization, in the event that a contract hospital does not accept transfer of the patient or pending the transfer to a contract hospital. (Amended by Stats. 1992, Ch. 722, Sec. 72. Effective September 15, 1992.)
14087.1.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The department or its authorized agents must conduct periodic audits or reviews, including onsite reviews, of contract performance under 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.1. The department or its authorized agents shall conduct periodic audits or reviews, including onsite audits or reviews, of performance under any contract made pursuant to this article. These audits or reviews may evaluate the following: (a) Level and quality of care, and the necessity and appropriateness of the services provided. (b) Internal procedures for assuring efficiency, economy and quality of care. (c) Grievances relating to medical care and their disposition. (d) Financial records only when determined necessary by the department to protect public funds. (Amended by Stats. 1982, Ch. 1594, Sec. 41. Effective September 30, 1982.)
14087.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

A contract hospital that meets the stated service and capacity conditions must accept transfer of a Medi-Cal beneficiary from a noncontract hospital.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.10. Any contract hospital that provides the services required by a Medi-Cal beneficiary and has a physician with staff privileges who is willing to accept the Medi-Cal beneficiary and has the appropriate bed, personnel, and equipment necessary to treat the Medi-Cal beneficiary shall accept the transfer of the Medi-Cal beneficiary from a noncontract hospital. (Added by Stats. 1992, Ch. 722, Sec. 76. Effective September 15, 1992.)
14087.101.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The director may recover excessive administrative costs from certain health plans, and those health plans must follow the referenced California regulation on administrative 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. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.101. For administrative costs incurred after January 1, 2004, the director may recover any administrative costs incurred by a health plan authorized by this article deemed excessive pursuant to Section 1300.78 of Title 28 of the California Code of Regulations. Health plans that compensate their subcontractors on a capitated basis shall comply with Section 1300.78 of Title 28 of the California Code of Regulations, regarding administrative costs, considering the combined administrative cost for the Medi-Cal business of the health plan and its capitated subcontractors, that are Knox-Keene licensed health care service plans. The recovery of excess administrative cost shall be made in accordance with Sections 14087.103 and 14087.105. (Added by Stats. 2003, Ch. 230, Sec. 60. Effective August 11, 2003.)
14087.103.
## 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. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The department must give the health plan 30 days’ notice before starting recovery of excess administrative costs. The health plan may dispute or appeal, and recovery may be delayed until appeal procedures are exhausted if it does.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.103. The department shall notify the health plan of the director’s decision to seek recovery of excess administrative costs pursuant to Section 14087.101 at least 30 days prior to initiating the recovery process. The department may recover excess administrative costs immediately after the 30-day notification period, if the health plan does not file an appeal. A health plan may dispute or appeal the director’s decision in accordance with the disputes section of the health plan’s contract with the department for services under this article. If a health plan elects to dispute or appeal the director’s decision, the director may recover any administrative costs deemed excessive, but only after the health plan has had the opportunity to exhaust all appeal procedures provided for in the disputes section of the health plan’s contract with the department. (Added by Stats. 2003, Ch. 230, Sec. 61. Effective August 11, 2003.)
14087.105.
## 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. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The director may recover excessive administrative costs from a health plan by offsetting amounts due, using a repayment agreement, or other legal means.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.105. When it has been determined that the director may recover any administrative costs deemed excessive pursuant to Section 14087.103, the director may recover any excess administrative costs through an offset against any amount currently due to the health plan under this chapter. The director may also recover any administrative costs deemed excessive by means of a repayment agreement executed between that health plan and the director, and by any other means available at law. (Added by Stats. 2003, Ch. 230, Sec. 62. Effective August 11, 2003.)
14087.11.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Certain County Organized Health System contracts must cover routine patient care costs for qualifying cancer clinical trials.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.11. (a) The provisions of this section shall be applicable to any county that seeks to provide or arrange for the provision of health care services provided under Article 2.8 and to Santa Barbara County if it seeks to provide or arrange the provision of health care services pursuant to Section 14499.5. (b) For an enrollee diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer, every County Organized Health System contract that is issued, amended, delivered, or renewed in this state, shall provide coverage for all routine patient care costs related to the clinical trial if the enrollee’s treating physician, who is providing covered health care services to the enrollee under the enrollee’s County Organized Health System contract, recommends participation in the clinical trial after determining that participation in the clinical trial has a meaningful potential to benefit the enrollee. For purposes of this section, physicians that are providing care under a subcontract with an entity under contract with a County Organized Health System shall be considered to be physicians providing covered health care services to the enrollee under the County Organized Health System contract. For purposes of this section, a clinical trial’s endpoints shall not be defined exclusively to test toxicity, but shall have a therapeutic intent. (c) (1) “Routine patient care costs” means the costs associated with the provision of health care services, including drugs, items, devices, and services that would otherwise be covered by the County Organized Health System if those drugs, items, devices, and services were not provided in connection with an approved clinical trial program, including: (A) Health care services typically provided absent a clinical trial. (B) Health care services required solely for the provision of the investigational drug, item, device, or service. (C) Health care services required for the clinically appropriate monitoring of the investigational item or service. (D) Health care services provided for the prevention of complications arising from the provision of the investigational drug, item, device, or service. (E) Health care services needed for the reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or treatment of the complications. (2) For purposes of this section, “routine patient care costs” does not include the costs associated with the provision of any of the following: (A) Drugs or devices that have not been approved by the federal Food and Drug Administration and that are associated with the clinical trial. (B) Services other than health care services, such as travel, housing, companion expenses, and other nonclinical expenses, that an enrollee may require as a result of the treatment being provided for purposes of the clinical trial. (C) Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient. (D) Health care services that, except for the fact that they are being provided in a clinical trial, are otherwise specifically excluded from coverage under the enrollee’s County Organized Health System. (E) Health care services customarily provided by the research sponsors free of charge for any enrollee in the trial. (d) The treatment shall be provided in a clinical trial that either: (1) Involves a drug that is exempt under federal regulations from a new drug application. (2) Is approved by one of the following: (A) One of the National Institutes of Health. (B) The federal Food and Drug Administration, in the form of an investigational new drug application. (C) The United States Department of Defense. (D) The United States Veterans’ Administration. (e) In the case of health care services provided by a participating provider, the payment rate shall be at the agreed-upon rate. In the case of a nonparticipating provider, the payment shall be at the negotiated rate the plan would otherwise pay to a participating provider for the same services, less any applicable copayments and deductibles. (f) Nothing in this section shall be construed to prohibit a County Organized Health System from restricting coverage for clinical trials to participating hospitals and physicians in California unless the protocol for the clinical trial is not provided for at a California hospital or by a California physician. (g) The provision of services when required by this section shall not, in itself, give rise to liability on the part of the County Organized Health System. (h) Nothing in this section shall be construed to otherwise limit or modify any existing requirements under the provisions of this chapter. (Added by Stats. 2001, Ch. 172, Sec. 3. Effective January 1, 2002.)
14087.2.
## 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Children’s hospitals are not required to contract under this article until October 31, 1984, and earlier services must be reimbursed under the January 1, 1984 state plan.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.2. It is the intent of the Legislature that children’s hospitals need not contract under the provisions of this article until October 31, 1984. Services provided by these hospitals prior to November 1, 1984, shall be reimbursed according to the state plan in effect on January 1, 1984. Children’s hospitals are defined as those hospitals where 30 percent of the infants and children served by the single institution qualify for Medi-Cal payment systems and the institution serves primarily children. If a children’s hospital elects to contract pursuant to this article in the 1982–83 or 1983–84 fiscal year, the negotiator shall give consideration to the special services provided in this hospital, including those services provided to children. The California Medical Assistance Commission shall continue to extend this consideration to these hospitals following the 1983–84 fiscal year. (Amended by Stats. 2004, Ch. 193, Sec. 240. Effective January 1, 2005.)
14087.21.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Children’s hospital reimbursement must reflect the relative severity of pediatric diagnostic case types.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.21. Commencing November 1, 1984, reimbursement to children’s hospitals shall be on a basis that reflects the relative severity of pediatric diagnostic case types. For the purposes of this section, “children’s hospital” means those hospitals where 30 percent of the infants and children served by the single institution qualify for Medi-Cal payment systems, and the institution serves primarily children. (Amended by Stats. 1989, Ch. 325, Sec. 1. Effective September 8, 1989.)
14087.23.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Certain county-operated community clinics must be reimbursed for Medi-Cal services using the same method as a licensed surgical center, if the stated conditions are met. Providers independently billing physician services in those clinics are subject to a reimbursement reduction.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.23. (a) Notwithstanding any other provision of law, and except as provided in subdivision (b), a county-operated community clinic, exempt from licensure under Section 1206 of the Health and Safety Code, which is operated by a county which, on or before November 30, 1997, ceased to operate a county-operated hospital with an outpatient department, shall be reimbursed for Medi-Cal services using the same methodology used for reimbursement of a licensed surgical center, to the extent federal financial participation is available. (b) Providers that are independently billing for physician services provided in clinics described in subdivision (a) shall be subject to the reduction in reimbursement consistent with physician services provided in an outpatient hospital department. (Added by Stats. 2001, Ch. 526, Sec. 1. Effective January 1, 2002.)
14087.25.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Contracts under this article may be awarded on a nonbid basis and are exempt from certain Government Code provisions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.25. In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore, contracts under this article may be on a nonbid basis, and shall be exempt from the provisions of Chapter 6 (commencing with Section 14780), Part 5.5, Division 3 of the Government Code. (Added by Stats. 1982, Ch. 328, Sec. 17. Effective June 30, 1982.)
14087.26.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

A negotiator may designate a specific group of hospitals as the negotiating unit when negotiating contracts under 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.26. In negotiating contracts pursuant to this article, the negotiator may designate a specific group of hospitals as the negotiating unit. The Legislature finds and declares that, in any case where the negotiator designates a group of hospitals for purposes of negotiation there is a compelling state interest in negotiating on this basis, thereby exempting such negotiations from federal antitrust provisions. (Added by Stats. 1982, Ch. 328, Sec. 17. Effective June 30, 1982.)
14087.27.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

The section allows judicial review for certain contract disputes and requires administrative review procedures for contract hospitals, with the director making the final decision.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.27. (a) Notwithstanding any other provision of law, judicial review pursuant to Section 1085 of the Code of Civil Procedure, shall be available to resolve disputes relating to the terms, performance, or termination of contracts entered into pursuant to this article, or any act, failure to act, conduct, order, or decision of the special hospital negotiator or the commission which violate the provisions of this article. (b) Subdivision (a) shall not apply to recoupment efforts based on an audit or review of hospital performance of the terms and conditions of the negotiated contract. These recoupment efforts shall be reviewable pursuant to Section 14171. (c) As an alternative for a contract hospital, to the remedy provided in subdivision (a), contracts entered into pursuant to this article shall provide for administrative review of disputes relating to performance under the contracts. The proceedings for review of the disputes shall be conducted by an independent hearing examiner who shall render a proposed decision. The final decision shall be rendered by the director. (d) Venue for judicial review pursuant to this section shall lie only in counties in which the Attorney General maintains an office. (Amended by Stats. 1982, Ch. 1594, Sec. 43. Effective September 30, 1982.)
14087.28.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

A hospital contracting with Medi-Cal may not deny medical staff membership or clinical privileges for improper reasons; decisions must be based on the physician’s individual qualifications. The special negotiator may allow reasonable limits for exclusive pathology, radiology, and anesthesiology contracts, except for consulting services requested by the admitting physician.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.28. (a) A hospital contracting with the Medi-Cal program pursuant to this chapter shall not deny medical staff membership or clinical privileges for reasons other than a physician’s individual qualifications as determined by professional and ethical criteria, uniformly applied to all medical staff applicants and members. Determination of medical staff membership or clinical privileges shall not be made upon the basis of any of the following: (1) The existence of a contract with the hospital or with others. (2) Membership in, or affiliation with, any society, medical group, or teaching facility, or upon the basis of any criteria lacking professional justification, such as any basis listed in subdivision (a) of Section 12940 of the Government Code, as those bases are defined in Sections 12926 and 12926.1 of the Government Code, except as otherwise provided in Section 12940 of the Government Code. (b) The special negotiator may authorize a contracting hospital to impose reasonable limitations on the granting of medical staff membership or clinical privileges to permit an exclusive contract for the provision of pathology, radiology, and anesthesiology services, except for consulting services requested by the admitting physician. (Amended by Stats. 2004, Ch. 788, Sec. 35. Effective January 1, 2005.)
14087.29.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. )
Verify source ↗

Hospitals or groups of hospitals that have a contract under this article are exempt from a specified Health and Safety Code chapter when carrying out 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 2.6. Selective Provider Contracts [14081 - 14087.29] ( Article 2.6 added by Stats. 1982, Ch. 328, Sec. 17. ) ## 14087.29. Hospitals or groups of hospitals with which a contract has been entered into pursuant to this article shall be exempt from the provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out the contracts. (Added by Stats. 1982, Ch. 1594, Sec. 44. Effective September 30, 1982.)
14087.3.
## 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
Verify source ↗

The director may contract for Medi-Cal case management services, and the department must handle waiver, rate, and agreement steps tied to managed care expansion.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.3. (a) The director may contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for or case manage the care of Medi-Cal beneficiaries. At the director’s discretion, the contract may be exclusive or nonexclusive, statewide or on a more limited geographic basis, and include provisions to do the following: (1) Perform targeted case management of selected services or beneficiary populations where it is expected that case management will reduce program expenditures. (2) Provide for delivery of services in a manner consistent with managed care principles, techniques, and practices directed at ensuring the most cost-effective and appropriate scope, duration, and level of care. (3) Provide for alternate methods of payment, including, but not limited to, a prospectively negotiated reimbursement rate, fee-for-service, retainer, capitation, shared savings, volume discounts, lowest bid price, negotiated price, rebates, or other basis. (4) Secure services directed at any or all of the following: (A) Recruiting and organizing providers to care for Medi-Cal beneficiaries. (B) Designing and implementing fiscal or other incentives for providers to participate in the Medi-Cal program in cost-effective ways. (C) Linking beneficiaries with cost-effective providers. (5) Provide for: (A) Medi-Cal managed care plans contracting under this chapter or Chapter 8 (commencing with Section 14200) to share in the efficiencies and economies realized by those contracts. (B) Effective coordination between contractors operating under this article and Medi-Cal managed care plans in the management of health care provided to Medi-Cal beneficiaries. (6) Permit individual physicians, groups of physicians, or other providers to participate in a manner that supports the organized system mode of operation. (7) Encourage group practices with relationships with hospitals having low unit costs. (b) The director may require individual physicians, groups of physicians, or other providers as a condition of participation under the Medi-Cal program, to enter into capitated contracts pursuant to this section in order to correct or prevent irregular or abusive billing practices. No physician, groups of physicians, or other providers shall be reimbursed for services rendered to Medi-Cal beneficiaries if the physician, group of physicians, or other providers has declined to enter into a contract required by the director pursuant to this section. (c) The department shall seek federal waivers necessary to allow for federal financial participation under this section. (d) (1) Notwithstanding the provisions of this chapter, the department shall determine preliminary per capita rates of payment for services provided to Medi-Cal beneficiaries enrolled in a managed care program contracting in areas specified by the director for expansion of the Medi-Cal managed care program under this section, or Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, or 14087.96. The department shall provide to each managed care plan the preliminary contract rates and source documents at least 60 days prior to the effective date of each new rate period. (2) On or before June 1, 1999, the department shall enter into a memorandum of understanding with the managed care plans subject to paragraph (1) regarding the development of capitation rates. This memorandum of understanding, which is intended to ensure that capitation rates become effective in a timely manner and remain stable throughout the rate year, shall establish all of the following: (A) A process and timetable for the managed care plans to review and comment on any modifications in the rate development methodology. (B) A process and timetable for managed care plans to provide comments on the draft rates. (C) A process and timetable for the department to respond to managed care plan comments on the draft rates. (D) A process and timetable to managed care finalize capitation rates. (Amended by Stats. 1998, Ch. 834, Sec. 1. Effective January 1, 1999.)
14087.301.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
Verify source ↗

The department may require certain health care service plans to pay oversight costs tied to their contract 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.301. When entering into contracts with health care service plans that provide comprehensive dental benefits to Medi-Cal beneficiaries on an at-risk basis, the department may require that the health care service plans pay for the costs of the administrative and regulatory oversight required to monitor the contract compliance terms of the agreement with the department. (Added by Stats. 1999, Ch. 146, Sec. 43. Effective July 22, 1999.)
14087.305.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section requires counties and the department to inform Medi-Cal and CalWORKs applicants and beneficiaries about managed care options, and it sets deadlines for choosing a plan and primary care 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.305. (a) In areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3 and where the department is contracting with a prepaid health plan that is contracting with, governed, owned or operated by a county board of supervisors, a county special commission or county health authority authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96, a Medi-Cal or California Work Opportunity and Responsibility for Kids (CalWORKs) applicant or beneficiary shall be informed of the health care options available regarding methods of receiving Medi-Cal benefits. The county shall ensure that each beneficiary is informed of these options and informed that a health care options presentation is available. (b) The managed care options information described in subdivision (a) shall include the following elements: (1) Each beneficiary or eligible applicant shall be provided, at a minimum, with the name, address, telephone number, and specialty, if any, of each primary care provider, by specialty, or clinic, participating in each managed care health plan option through a personalized provider directory for that beneficiary or applicant. This information shall be presented under the geographic area designations, by the name of the primary care provider and clinic and shall be updated based on information electronically provided monthly by the health care plans to the department, setting forth any changes in the health care plan’s provider network. The geographic areas shall be based on the applicant’s residence address, the minor applicant’s school address, the applicant’s work address, or any other factor deemed appropriate by the department, in consultation with health plan representatives, legislative staff, and consumer stakeholders. In addition, directories of the entire service area of the local initiative and commercial plan provider networks, including, but not limited to, the name, address, and telephone number of each primary care provider and hospital, shall be made available to beneficiaries or applicants who request them from the health care options contractor. Each personalized provider directory shall include information regarding the availability of a directory of the entire service area, provide telephone numbers for the beneficiary to request a directory of the entire service area, and include a postage-paid mail card to send for a directory of the entire service area. The personalized provider directory shall be implemented as a pilot project in Los Angeles County pursuant to this article, and in Sacramento County (Geographic Managed Care Model) pursuant to Article 2.91 (commencing with Section 14089). The content, form, and the geographic areas used in the personalized provider directories shall be determined by the department, in consultation with a workgroup to include health plan representatives, legislative staff, and consumer stakeholders, with an emphasis on the inclusion of stakeholders from Los Angeles and Sacramento Counties. The personalized provider directories may include a section for each health plan. Prior to implementation of the pilot project, the department, in consultation with consumer stakeholders, legislative staff, and health plans, shall determine the parameters, methodology, and evaluation process of the pilot project. The pilot project shall thereafter be in effect for a minimum of two years. Following two years of operation as a pilot project in two counties, the department, in consultation with consumer stakeholders, legislative staff, and health plans, shall determine whether to implement personalized provider directories as a permanent program statewide. If necessary, the pilot project shall continue beyond the initial two-year period until this determination is made. This pilot project shall only be implemented to the extent that it is budget neutral to the department. (2) Each beneficiary or eligible applicant shall be informed that he or she may choose to continue an established patient-provider relationship in a managed care option, if his or her treating provider is a primary care provider or clinic contracting with any of the prepaid health plan options available and has available capacity and agrees to continue to treat that beneficiary or applicant. (3) Each beneficiary or eligible applicant shall be informed that if he or she fails to make a choice, he or she shall be assigned to, and enrolled in, a prepaid health plan. (c) No later than 30 days following the date a Medi-Cal or CalWORKs beneficiary or applicant is determined eligible for Medi-Cal, the beneficiary shall indicate his or her choice, in writing, from among the available prepaid health plans in the region and his or her choice of primary care provider or clinic contracting with the selected prepaid health plan. Notwithstanding the 30-day deadline set forth in this subdivision, if a beneficiary requests a directory for the entire service area within 30 days of receiving an enrollment form, the deadline for choosing a plan shall be extended an additional 30 days from the date of the request. (d) At the time the beneficiary or eligible applicant selects a prepaid health plan, the department shall, when applicable, encourage the beneficiary or eligible applicant to also indicate, in writing, his or her choice of primary care provider or clinic contracting with the selected prepaid health plan. (e) In areas specified by the director for expansion of the Medi-Cal managed care program under Section 14087.3, and where the department is contracting with a prepaid health plan that is contracting with, governed, owned or operated by a county board of supervisors, a county special commission or county health authority authorized by Sections 14018.7, 14087.31, 14087.35, 14087.36, 14087.38, and 14087.96, a Medi-Cal or CalWORKs beneficiary who does not make a choice of managed care plans, shall be assigned to and enrolled in an appropriate Medi-Cal prepaid health plan providing service within the area in which the beneficiary resides. (f) If a beneficiary or eligible applicant does not choose a primary care provider or clinic, or does not select any primary care provider who is available, the prepaid health plan that was selected by or assigned to the beneficiary shall ensure that the beneficiary selects a primary care provider or clinic within 30 days after enrollment or is assigned to a primary care provider within 40 days after enrollment. (g) Any Medi-Cal or CalWORKs beneficiary dissatisfied with the primary care provider or prepaid health plan shall be allowed to select or be assigned to another primary care provider within the same prepaid health plan. In addition, the beneficiary shall be allowed to select or be assigned to another prepaid health plan contracted for pursuant to this article that is in effect for the geographic area in which he or she resides, in accordance with Section 1903(m)(2)(F)(ii) of the Social Security Act. (h) The department or its contractor shall notify a prepaid health plan when it has been selected by or assigned to a beneficiary. The prepaid health plan that has been selected by or assigned to a beneficiary shall notify the primary care provider that has been selected or assigned. The prepaid health plan shall also notify the beneficiary of the prepaid health plan and primary care provider or clinic selected or assigned. (i) (1) The managed health care plan shall have a valid Medi-Cal contract, adequate capacity, and appropriate staffing to provide health care services to the beneficiary. (2) The department shall establish standards for all of the following: (A) The maximum distances a beneficiary is required to travel to obtain primary care services from the managed care plan, in which the beneficiary is enrolled. (B) The conditions under which a primary care service site shall be accessible by public transportation. (C) The conditions under which a managed care plan shall provide nonmedical transportation to a primary care service site. (3) In developing the standards required by paragraph (2) the department shall take into account, on a geographic basis, the means of transportation used and distances typically traveled by Medi-Cal beneficiaries to obtain fee-for-service primary care services and the experience of managed care plans in delivering services to Medi-Cal enrollees. The department shall also consider the provider’s ability to render culturally and linguistically appropriate services. (j) To the extent possible, the arrangements for carrying out subdivision (e) shall provide for the equitable distribution of Medi-Cal beneficiaries among participating prepaid health plans, or managed care plans. (k) This section shall be implemented in a manner consistent with any federal waiver required to be obtained by the department in order to implement this section. (Amended by Stats. 2012, Ch. 728, Sec. 200. (SB 71) Effective January 1, 2013.)
14087.31.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section lets the Tulare and San Joaquin county boards create a commission to handle certain Medi-Cal health care contracting and service arrangements, and sets rules for the commission’s powers, duties, confidentiality, and termination.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.31. (a) It is necessary that a special commission be established in the Counties of Tulare and San Joaquin in order to meet the problems of delivery of publicly assisted medical care in the county and to demonstrate ways of promoting quality care and cost efficiency. Because there is no general law under which such a commission could be formed, the adoption of a special act and the formation of a special commission is required. (b) (1) The Board of Supervisors of the County of Tulare and the County of San Joaquin may, for each respective county, by ordinance, establish a commission to negotiate and enter into contracts authorized by Section 14087.3, and to arrange for the provision of health care services provided pursuant to this chapter. If the board of supervisors elects to enact this ordinance, all rights, powers, duties, privileges, and immunities vested in a county contracting with the department under this article shall be vested in the county commission. (2) Health plans operated by the commission may also include, but are not limited to, individuals covered under Title XVIII of the Social Security Act (Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code), individuals and groups entitled to coverage under other publicly supported programs, individuals and groups employed by public agencies or private businesses, and uninsured or indigent persons. (c) The enabling ordinance shall specify the membership of the county commission, the qualifications for individual members, the manner of appointment, selection, or removal of commissioners, and how long they shall serve, and any other matters as the board of supervisors deems necessary or convenient for the conduct of the county commission’s activities. Members of the commission shall be appointed by the county board of supervisors to represent the interests of the public, county, beneficiaries, physicians, hospitals, other health care providers, or other health care organizations. The commission so established shall be considered an entity separate from the county and shall file a statement required by Section 53051 of the Government Code. The commission shall have the power to acquire, possess, and dispose of real or personal property, as may be necessary for the performance of its functions, to employ personnel and contract for services required to meet its obligations, to sue or be sued, and to enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. Any obligations of a commission, statutory, contractual or otherwise, shall be obligations solely of the commission and shall not be the obligations of the county or of the state. (d) Upon creation, the commission may borrow from the county, and the county may lend the commission, funds or issue revenue anticipation notes to obtain those funds necessary to commence operations. Prior to commencement of operations, the commission shall be 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). (e) In the event a commission may no longer function for the purposes for which it is established, at the time as the commission’s then existing obligations have been satisfied or the commission’s assets have been exhausted, the board of supervisors may, by ordinance, terminate the commission. (f) Prior to the termination of the commission, the board of supervisors shall notify the department of its intent to terminate the commission. The department shall conduct an audit of the commission’s records within 30 days of the notification to determine the liabilities and assets of the commission. The department shall report its findings to the board within 10 days of completion of the audit. The board shall prepare a plan to liquidate or otherwise dispose of the assets of the commission and to pay the liabilities of the commission to the extent of the commission’s assets, and present the plan to the department within 30 days upon receipt of these findings. (g) Any assets of the commission shall be disposed of pursuant to provisions contained in the contract entered into between the state and the commission pursuant to Section 14087. (h) (1) It is the intent of the Legislature that if a commission is formed pursuant to this section, the county shall, with respect to its medical facilities and programs, occupy no greater or lesser status than any other health care provider with similar cost structure and patient population including, but not limited to, considerations of indigent care burden, capital requirements, graduate medical education, and disproportionate share status, in negotiating with the commission for contracts to provide health care services. (2) Contracts between the department and the commission shall be on a nonbid basis and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (3) Nothing in this subdivision shall be construed to interfere with or limit the commission from giving preference in negotiating to disproportionate share hospitals or other providers of health care to medically indigent or uninsured persons. (i) Upon termination of the commission by the board, the county shall manage any remaining assets of the commission until superseded by a department approved plan. Any liabilities of the commission shall not become obligations of the county upon either the termination of the commission or the liquidation or disposition of the commission’s remaining assets. (j) (1) The commission shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code. (2) The commission, its members, and employees, are protected by the immunities applicable to public entities and public employees governed by Division 3.6 (commencing with Section 810) of Title 1 of the Government Code, except as provided by other statutes or regulations that apply expressly to the commission. (k) Notwithstanding any other provision of law, a member of the commission shall not be deemed to be interested in a contract entered into by the commission within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all of the following apply: (1) The member was appointed to represent the interest of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations. (2) The contract authorizes the member or the organization the member represents to provide services to Medi-Cal beneficiaries under the commission’s programs. (3) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the member was appointed to represent. (4) The member does not influence or attempt to influence the commission or another member of the commission to enter into the contract in which the member is interested. (5) The member discloses the interest to the commission and abstains from voting on the contract. (6) The commission notes the member’s disclosure and abstention in its official records and authorized the contract in good faith by a vote of its membership sufficient for the purpose without counting the vote of the interested member. (l) All claims for money or damages against the commission shall be governed by Part 3 (commencing with Section 900) and Part 4 (commencing with Section 940) of Division 3.6 of Title 1 of the Government Code, except as provided by other statutes or regulations that expressly apply to the commission. (m) Notwithstanding any other provision of law, except as otherwise provided in this section, a county shall not be liable for any act or omission of the commission. (n) For the purposes of this section, “commission” means an entity separate from the county that meets the requirements of state and federal law and the quality, cost, and access criteria established by the department. (o) The transfer of responsibility for health care services shall not relieve the county of its responsibility for indigent care pursuant to Section 17000. (p) Notwithstanding any other provision of law, the commission may meet in closed session to consider and take action on matters pertaining to contracts and contract negotiations by commission staff with providers of health care services concerning all matters related to rates of payment. (q) Notwithstanding Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of the Government Code and Article 2 (commencing with Section 54340) of Chapter 6 of Division 2 of Title 5 of the Government Code, or any other provision of law, any “peer review body,” as defined in paragraph (1) of subdivision (a) of Section 805 of the Business and Professions Code, formed pursuant to the powers granted to the commission authorized by this section, may, at its discretion and without notice to the public, meet in closed session, so long as the purpose of the meeting is the peer review body’s discharge of its responsibility to evaluate and improve the quality of care rendered by health facilities of health practitioners, pursuant to the powers granted the commission. The peer review body and its members shall receive to the fullest extent all immunities, privileges, and protections available to these peer review bodies, their individual members, and persons or entities assisting in the peer review process, including, but not limited to, those afforded by Section 1370 of the Health and Safety Code. (r) Notwithstanding any other provision of law, both the county and the commission shall be eligible to receive funding under subdivision (p) of Section 14163, and the commission shall be considered for all purposes to satisfy the requirements of subdivision (p) of Section 14163. (s) The commission shall be deemed to be a public agency that is a unit of local government for purposes of all grant programs and other funding and loan guarantee programs. (t) Notwithstanding any other provision of law, those records of the commission and of the county that reveal the rates of payment for health care services or the commission’s deliberative processes, discussions, communications, or any other portion of the negotiations with providers of health care services for rates of payment, shall not be disclosed pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or any similar local law requiring disclosure of public records. However, three years after a contract or amendment to a contract is fully executed, the portion of the contract or amendment containing the rates of payment shall be open to inspection. (u) Notwithstanding the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), Article 3 (commencing with Section 11200) of Chapter 1 of Part 1 of Division 3 of Title 2 of the Government Code, Chapter 9 (commencing with Section 54960) of Part 1 of Division 2 of Title 5 of the Government Code, or any other provision of state or local law requiring disclosure of public records, those records of the commission and the county that reveal the proceedings of a peer review body, as defined in paragraph (1) of subdivision (a) of Section 805 of the Business and Professions Code, formed pursuant to the powers granted to the commission authorized by this section, shall not be required to be disclosed. The records and proceedings of the peer review body and its members shall receive to the fullest extent, all immunities, privileges, and protections available to these records and proceedings, including, but not limited to, those afforded by Section 1157 of the Evidence Code. (v) (1) Provisions of the Evidence Code, the Government Code, including the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), the Civil Code, the Business and Professions Code, and other applicable law pertaining to the confidentiality of peer review activities of peer review bodies shall apply to the peer review activities of the commission. Peer review proceedings shall constitute an official proceeding authorized by law within the meaning of Section 47 of the Civil Code, and those privileges set forth in that section with respect to official proceedings shall apply to peer review proceedings of the commission. If the commission is required by law or contractual obligation to submit to the state or federal government peer review information or information relevant to the credentialing of a participating provider, that submission shall not constitute a waiver of confidentiality. All laws pertaining to the confidentiality of peer review activities shall be construed together as extending, to the extent permitted by law, the maximum degree of protection of confidentiality. (2) Notwithstanding any other provision of law, Section 1461 of the Health and Safety Code shall apply to hearings on the reports of hospital medical audit or quality assurance committees as they relate to network providers or applicants. (w) Except as expressly provided by other provisions of this section, all exemptions and exclusions from disclosure as public records pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), including, but not limited to, those pertaining to trade secrets and information withheld in the public interest, shall be fully applicable for all state agencies and local agencies with respect to all writings that the commission is required to prepare, produce, or submit pursuant to this section. (x) (1) The commission may use a computerized management information system in connection with the administration of its health delivery system, including the administration of the state-mandated two-plan Medi-Cal managed care model. (2) Information maintained in the management information system that pertains to persons who are Medi-Cal applicants or recipients shall be confidential pursuant to Section 14100.2, and shall not be open to examination other than for purposes directly connected with the administration of the Medi-Cal program, including, but not limited to, those set forth in subdivision (c) of Section 14100.2. This safeguarded information includes, but is not limited to, the names and addresses of recipients, the medical services provided, the social and economic conditions or circumstances of the recipients, an evaluation by the commission of personal information, and medical data, including the diagnosis and past history of disease or disability. (3) Information maintained in the management information system that pertains to peer review-related activities shall be confidential and subject to the full protections of the law with respect to the confidentiality of activities related to peer review generally. (y) (1) The records of the commission, whether paper records, records maintained in the management information system, or records in any other form, that relate to rates of payment, including records relating to rates of payment determination, allocation or distribution methodologies, formulas or calculations, and records of the health authority that relate to contract negotiations with providers of health care for alternative rates, shall not be subject to disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code). (2) The transmission of the records of the commission, or the information contained therein in an alternative form, to the board of supervisors shall not constitute a waiver of exemption from disclosure, and the records and information, once transmitted to the county board of supervisors, shall be subject to this same exemption. The information, if compelled pursuant to an order of a court of competent jurisdiction or administrative body in a manner permitted by law, shall be limited to in camera review, and shall not be shared with the parties to the proceeding. (3) The submission, to the Department of Managed Health Care, of information described in this section for the purpose of obtaining licensure under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, or to the State Department of Health Services, shall not constitute a waiver of exemption from disclosure. (z) (1) (A) Notwithstanding the Ralph M. Brown Act (Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of the Government Code), the commission may meet in closed session for the purpose of discussion of, or taking action on matters involving, commission trade secrets. (B) The requirement that the commission make a public report of actions taken in closed session and the vote or abstention of every member present may be limited to a brief general description of the action taken and the vote so as to prevent the disclosure of a trade secret. (C) For purposes of this subdivision, “commission trade secret” means a trade secret, as defined in subdivision (d) of Section 3426.1 of the Civil Code, that also meets both of the following criteria: (i) The secrecy of the information is necessary for the commission to initiate a new service, program, marketing strategy, business plan, or technology, or to add a benefit or product. (ii) Premature disclosure of the trade secret would create a substantial probability of depriving the commission of a substantial economic benefit or opportunity. (2) Those records of the commission that reveal the commission’s trade secrets are exempt from disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. This exemption shall apply for a period of two years after the service, program, marketing strategy, business plan, technology, benefit, or product that is the subject of the trade secret is formally adopted by the governing body of the commission, provided that the service, program, marketing strategy, business plan, technology, benefit, or product continues to be a trade secret. The commission may delete the portion or portions containing trade secrets from any documents that were finally approved in the closed session held pursuant to paragraph (1) that are provided to persons who have made the timely or standing request. (3) Nothing in this section shall be construed as preventing the commission from meeting in closed session as otherwise provided by law. (Amended by Stats. 2004, Ch. 228, Sec. 12.1. Effective August 16, 2004.)
14087.316.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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Tulare County may negotiate the Medi-Cal services contract and arrange health care services instead of creating a special commission; the county board of supervisors must establish and maintain an advisory commission.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.316. (a) In lieu of establishing the special commission authorized by Section 14087.31, the county may, itself, negotiate with the department the contract specified in Section 14087.3 and arrange for the provision of health care services provided pursuant to this chapter. If the county elects to exercise this option, subdivisions (p), (q), (t), (u), (v), (w), (x), and (z), of Section 14087.31 shall apply with equal force and effect to the County of Tulare, its board of supervisors and its members, and any advisory commission and its members appointed by the board of supervisors to assist with the provision of health care services provided pursuant to this section. (b) The Tulare County Board of Supervisors shall establish and maintain an advisory commission. The advisory commission shall have a membership that includes beneficiaries, representatives of the community clinics, representatives of hospitals, and physicians. Physician membership shall be nominated by the Tulare County Medical Society. (Added by Stats. 1996, Ch. 1017, Sec. 2. Effective January 1, 1997.)
14087.32.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section requires monthly financial reporting and immediate notice of financial risk, lets the commission design its system, and requires the department to test it before capitated payments begin.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.32. Commencing on the date the authority first receives Medi-Cal capitated payments for the provision of health care services to Medi-Cal beneficiaries and until a commission established pursuant to Section 14087.31 is in compliance with all the requirements regarding tangible net equity applicable to a health care service plan licensed under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, all of the following shall apply: (a) The commission may select and design its automated management information system. The department, in cooperation with the commission, prior to making capitated payments, shall test the system to ensure that the system is capable of producing detailed, accurate, and timely financial information on the financial condition of the commission, and any other information that is generally required by the department in its contracts with other health care service plans. (b) In addition to the reports required by the Department of Managed Health Care under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, and the rules of the Director of the Department of Managed Health Care promulgated thereunder, a commission established pursuant to Section 14087.31 shall provide, on a monthly basis, to the department, the Department of Managed Health Care, and the members of the commission, a copy of the automated report described in subdivision (a) and a projection of assets and liabilities, including those that have been incurred but not reported, with an explanation of material increases or decreases in current or projected assets or liabilities. The explanation of increases and decreases in assets or liabilities shall be provided, upon request, to a hospital, independent physicians’ practice association or community clinic, which has contracted with the authority to provide health care services. (c) In addition to the reporting and notification obligations the commission has under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, the chief executive officer or director of the commission shall immediately notify the department, the Department of Managed Health Care, and the members of the commission, in writing, of any fact or facts that, in the chief executive officer’s or director’s reasonable and prudent judgment, is likely to result in the commission being unable to meet its financial obligations to health care providers or to other parties. The written notice shall describe the fact or facts, the anticipated fiscal consequences, and the actions which will be taken to address the anticipated consequences. (d) The Department of Managed Health Care shall not, in any way, waive or vary, nor shall the department request the Department of Managed Health Care to waive or vary, the tangible net equity requirements for a commission under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, after three years from the date of commencement of capitated payments to the commission. Until the commission is in compliance with all of the tangible net equity requirements under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, and the rules of the Director of the Department of Managed Health Care adopted thereunder, the commission shall develop a stop-loss program appropriate to the risks of the commission, which program shall be satisfactory to both the department and the Department of Managed Health Care. (e) (1) If the commission votes to file a petition of bankruptcy, or the county board of supervisors notifies the department of its intent to terminate the commission, the department shall immediately transfer the authority’s Medi-Cal beneficiaries as follows: (A) To other managed care contractors, when available, provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees. (B) To the extent that other managed care contractors are unavailable or the department determines that it is otherwise in the best interest of any particular beneficiary, to a fee-for-service reimbursement system pending the availability of managed care contractors provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees, or the department determines that providing care to any particular beneficiary pursuant to a fee-for-service reimbursement system is no longer necessary to protect the continuity of care or other interests of the beneficiary. (2) Beneficiary eligibility for Medi-Cal shall not be affected by actions taken pursuant to paragraph (1). (3) Beneficiaries who have been or who are scheduled to be transferred to a fee-for-service reimbursement system or managed care contractor may make a choice to be enrolled in another managed care system, if one is available, in full compliance with the federal freedom-of-choice requirements. (f) (1) A commission established pursuant to Section 14087.31 shall submit to a review of financial records when the department determines, based on data reported by the commission or otherwise, that the commission will not be able to meet its financial obligations to health care providers contracting with the commission. Where the review of financial records determines that the commission will not be able to meet its financial obligations to contracting health care providers for the provision of health care services, the Director of Health Services shall immediately terminate the contract between the commission and the state, and immediately transfer the commission’s Medi-Cal beneficiaries in accordance with subdivision (e) in order to ensure uninterrupted provision of health care services to the beneficiaries and to minimize financial disruption to providers. (2) The action of the Director of Health Services pursuant to paragraph (1) shall be the final administrative determination. Beneficiary eligibility for Medi-Cal shall not be affected by this action. (3) Beneficiaries who have been or who are scheduled to be transferred under subdivision (e) may make a choice to be enrolled in another managed care plan, if one is available, in full compliance with federal freedom-of-choice requirements. (g) It is the intent of the Legislature that the department shall implement Medi-Cal capitated enrollments in a manner that ensures that appropriate levels of health care services will be provided to Medi-Cal beneficiaries and that appropriate levels of administrative services will be furnished to health care providers. The contract between the department and the commission shall authorize and permit the department to administer the number of covered Medi-Cal enrollments in such a manner that the commission’s provider network and administrative structure are able to provide appropriate and timely services to beneficiaries and to participating providers. (h) In the event a commission is terminated, files for bankruptcy, or otherwise no longer functions for the purpose for which it was established, the county shall, with respect to compensation for provision of health care services to beneficiaries, occupy no greater or lesser status than any other health care provider in the disbursement of assets of the commission. (i) Nothing in this section shall be construed to impair or diminish the authority of the Director of the Department of Managed Health Care under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, nor shall anything in the section be construed to reduce or otherwise limit the obligation of a commission licensed as a health care service plan to comply with the requirements of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code and the rules of the Director of the Department of Managed Health Care adopted thereunder. (j) Except as expressly provided by other provisions of this section, all exemptions and exclusions from disclosure as public records pursuant to the Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), including, but not limited to, those pertaining to trade secrets and information withheld in the public interest, shall be fully applicable for all state agencies and local agencies with respect to all writings that the commission is required to prepare, produce, or submit pursuant to this section. (Amended by Stats. 2001, Ch. 159, Sec. 197. Effective January 1, 2002.)
14087.325.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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The department must require certain contracts to include subcontract offers to federally qualified health centers, set payment and reimbursement rules, approve covered contracts, and may establish pilot 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.325. (a) The department shall require, as a condition of obtaining a contract with the department, that a local initiative, as defined in subdivision (w) of Section 53810 of Title 22 of the California Code of Regulations, offer a subcontract to an entity defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code providing services as defined in Section 1396d(a)(2)(C) of Title 42 of the United States Code and operating in the service area covered by the local initiative’s contract with the department. These entities are also known as federally qualified health centers. (b) Except as otherwise provided in this section, managed care subcontracts offered to a federally qualified health center or a rural health clinic, as defined in Section 1396d(l)(1) of Title 42 of the United States Code, by a local initiative, county organized health system, as defined in Section 12693.05 of the Insurance Code, commercial plan, as defined in subdivision (i) of Section 53810 of Title 22 of the California Code of Regulations, or a health plan contracting with a geographic managed care program, as defined in subdivision (g) of Section 53902 of Title 22 of the California Code of Regulations, shall be on the same terms and conditions offered to other subcontractors providing a similar scope of service. A beneficiary, subscriber, or enrollee of a program or plan who affirmatively selects, or is assigned by default to, a federally qualified health center or rural health clinic under the terms of a contract between a plan, government program, or a subcontractor of a plan or program, and a federally qualified health center or rural health clinic, shall be assigned directly to the federally qualified health center or rural health clinic, and not to an individual provider performing services on behalf of the federally qualified health center or rural health clinic. (c) The department shall provide incentives in the competitive application process described in paragraph (1) of subdivision (b) of Section 53800 of Title 22 of the California Code of Regulations, to encourage potential commercial plans as defined in subdivision (i) of Section 53810 of Title 22 of the California Code of Regulations to offer subcontracts to these federally qualified health centers. (d) Reimbursement to federally qualified health centers and rural health centers for services provided pursuant to a subcontract with a local initiative, a commercial plan, geographic managed care program health plan, or a county organized health system, shall be paid in a manner that is not less than the level and amount of payment that the plan would make for the same scope of services if the services were furnished by a provider that is not a federally qualified health center or rural health clinic. (e) (1) The department shall administer a program to ensure that total payments to federally qualified health centers and rural health clinics operating as managed care subcontractors pursuant to subdivision (d) comply with applicable federal law pursuant to Sections 1902(aa) and 1903(m)(2)(A)(ix) of the Social Security Act (42 U.S.C. Secs. 1396a(aa) and 1396b(m)(2)(A)(ix)). Under the department’s program, federally qualified health centers and rural health clinics subcontracting with local initiatives, commercial plans, county organized health systems, and geographic managed care program health plans shall seek supplemental reimbursement from the department through a per visit fee-for-service billing system utilizing the state’s Medi-Cal fee-for-service claims processing system contractor. To carry out this per visit payment process, each federally qualified health system and rural health clinic shall submit to the department for approval a rate differential calculated to reflect the amount necessary to reimburse the federally qualified health center or rural health clinic for the difference between the payment the center or clinic received from the managed care health plan and either the interim rate established by the department based on the center’s or clinic’s reasonable cost or the center’s or clinic’s prospective payment rate. The department shall adjust the computed rate differential as it deems necessary to minimize the difference between the center’s or clinic’s revenue from the plan and the center’s or clinic’s cost-based reimbursement or the center’s or clinic’s prospective payment rate. (2) In addition, to the extent feasible, within six months of the end of the center’s or clinic’s fiscal year, the department shall perform an annual reconciliation to reasonable cost, and make payments to, or obtain a recovery from, the center or clinic. (f) In calculating the capitation rates to be paid to local initiatives, commercial plans, geographic managed care program health plans, and county organized health systems, the department shall not include the additional dollar amount applicable to cost-based reimbursement that would otherwise be paid, absent cost-based reimbursement, to federally qualified health centers and rural health clinics in the Medi-Cal fee-for-service program. (g) On or before September 30, 2002, the director shall conduct a study of the actual and projected impact of the transition from a cost-based reimbursement system to a prospective payment system for federally qualified health centers and rural health clinics. In conducting the study, the director shall evaluate the extent to which the prospective payment system stimulates expansion of services, including new facilities to expand capacity of the centers, and the extent to which actual and estimated prospective payment rates of federally qualified health centers and rural health clinics for the first five years of the prospective payment system are reflective of the cost of providing services to Medi-Cal beneficiaries. Clinics may submit cost reporting information to the department to provide data for the study. (h) The department shall approve all contracts between federally qualified health centers or rural health clinics and a local initiative, commercial plan, geographic managed care program health plan, or county organized health system in order to ensure compliance with this section. (i) This section shall not preclude the department from establishing pilot programs pursuant to Section 14087.329. (Amended by Stats. 2017, Ch. 561, Sec. 281. (AB 1516) Effective January 1, 2018.)
14087.329.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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The department may set up up to two Medi-Cal pilot programs for reimbursement methods, review them yearly, and must end them if they add any cost to the General Fund.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.329. (a) The department may establish, for local initiative and for commercial plans, that are providing services to Medi-Cal beneficiaries under a two-plan model contract with the department, not more than two pilot programs for the establishment of reimbursement methodologies. The reimbursement methodologies shall not be limited to those provided in Section 14087.325. The pilot programs may be implemented by amendment to the contract between the department and the local initiative or commercial plan. The department may select the pilot program county or counties on a nonbid basis. The selected counties shall include one county with a sizable number of entities defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code. The department shall review each pilot program annually. Following the review, and notwithstanding any determination made pursuant to subdivision (d), the department shall terminate a pilot program established under this section and shall delete amendments made to the contract implementing the pilot program if the department determines that the pilot program creates any additional cost to the General Fund. The department may also terminate a pilot program based upon criteria specified in the department’s contract establishing the pilot program. The department shall provide the local initiative and commercial plan with notice of the department’s decision to terminate the pilot program for this reason at least 90 days prior to the termination date of the pilot program and deletion of the contract amendments. (b) Each local initiative and commercial plan participating in a pilot program under this section shall make available to the department any and all financial, membership, utilization, and other information reasonably required by the department to conduct the annual review described in subdivision (a). The information may include, but is not limited to, the financial or other records of participating providers. The amendment to the contract between the local initiative or commercial plan and the department establishing the pilot program shall specify a reasonable timeframe in which the commercial plan or local initiative shall furnish records to the department pursuant to the request of the department. (c) In assessing whether the pilot program creates any additional cost to the General Fund, as described in subdivision (a), the department shall specifically consider all of the following factors, and may consider additional factors: (1) Increases in the number of Medi-Cal beneficiaries assigned by the plan to cost-based primary care providers. To enable the department to evaluate these factors, the department may include in the contract amendments establishing the pilot program a requirement that contractors shall periodically report data regarding the number of plan members assigned to each cost-based primary care provider in the plan’s network. (2) Expansions in the services provided by providers entitled to cost-based reimbursement under the Medi-Cal program. (3) Medi-Cal caseload or plan membership growth. (4) Inflation or other reasonable costs of provider operations. (5) The necessity for a plan to assign plan members to specific primary care providers to meet all of the following requirements: (A) Medi-Cal contract requirements for access to care. (B) Unique Medi-Cal member cultural and linguistic needs. (C) Unique member needs for age-appropriate, gender-appropriate, or pregnancy care requirements. (d) The pilot program shall be deemed to be successful if the alternative reimbursement methodologies tested result in no additional cost to the General Fund as described in subdivision (c), and the local initiatives, commercial plans, and federally qualified health centers participating in the pilot program agree to accept full financial risk for the scope of services provided by the federally qualified health centers during the final year of the pilot program. (Added by Stats. 1997, Ch. 649, Sec. 1. Effective January 1, 1998.)
14087.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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Alameda County’s board may create a separate health authority, and the authority must be licensed before operations and carry liability insurance.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.35. (a) Because of the unique circumstances that exist in the County of Alameda, it is necessary that the Board of Supervisors of the County of Alameda be given authority to create a health authority separate and apart from the County of Alameda as a means of establishing the local initiative component of the state-mandated two-plan managed care model for the delivery of medical care and services to the Medi-Cal populations. It is further necessary to enable the board of supervisors to expand publicly assisted medical and health care delivery by the newly created health authority to other populations should the board of supervisors elect to do so. Thus, the adoption of a special act is required. (b) The Board of Supervisors of the County of Alameda may, by ordinance, establish a health authority separate and apart from the County of Alameda, whose governing board shall reflect the diversity of local stakeholders such as provider groups, beneficiary groups, and officials of government, and that is appointed by the board of supervisors. Notwithstanding any other provision of this chapter, the governing board may include, but need not be limited to, the following: a member of the board of supervisors, individuals that represent and further the interests of the perspectives of Medi-Cal beneficiaries, and individuals that represent and further the interests of the perspectives of Medi-Cal provider physicians and other health practitioners, hospitals, and nonprofit community health centers. Other perspectives may be represented at the discretion of the board of supervisors. The enabling ordinance shall more specifically set forth the membership of the health authority governing board, the qualifications for individual members, the manner of appointment, selection, or removal of governing board members, their terms of office, and all other matters that the board of supervisors deems necessary or convenient for the conduct of the health authority’s activities. (c) The governing board of the health authority and the appropriate state departments, to the extent permitted by federal law, may negotiate and enter into contracts to provide or arrange for health care services for any or all persons who are eligible to receive benefits under the Medi-Cal program and for other targeted populations. The contracts may be on an exclusive or nonexclusive basis, and shall include payment provisions on any basis negotiated between the state and health authority. Prior to the commencement of operations, the health authority shall be licensed as a health care service plan pursuant to the Knox-Keene Health Care Services Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code). (d) The board of supervisors may transfer responsibility for administration of county-provided health care services to the health authority for the purpose of service of populations including uninsured and indigent persons subject to the provisions of any ordinances or resolutions passed by the board of supervisors. The transfer of administrative responsibility for those health care services shall not relieve the county of its responsibility for indigent care pursuant to Section 17000. In addition, the services and programs of the health authority may include, but are not limited to, individuals covered under Title XVIII of the Social Security Act, contained in Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, and individuals and groups employed by public agencies and private businesses. (e) As a legal entity separate and apart from the County of Alameda, the health authority shall file the statement required by Section 53051 of the Government Code. The health authority shall have the power to acquire, possess, and dispose of real or personal property as may be necessary for the performance of its functions, to sue or be sued, to employ personnel and contract for services required to meet its obligations, and to enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. (f) (1) The health authority shall be deemed to be a legal entity separate and apart from the County of Alameda, and shall not be considered to be an agency, division, department, or instrumentality of the County of Alameda. (2) The health authority shall not be governed by, nor be subject to, the Charter of the County of Alameda and shall not be subject to county policies or operational rules, including, but not limited to, those relating to personnel and procurement. (g) The health authority shall be considered a public entity, and employees of the health authority shall be considered public employees, for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code, relating to claims and actions against public entities and public employees. Members of the governing board of the health authority shall not be vicariously liable for injuries caused by the act or omission of the health authority or advisory body to the extent that protection applies to members of governing boards of local public entities generally under Section 820.9 of the Government Code. (h) Upon the enactment of the ordinance, all rights, powers, duties, privileges, and immunities vested in the County of Alameda with respect to the subject matter of this section shall be vested in the health authority. Any obligation of the health authority, statutory, contractual, or otherwise, shall be the obligation solely of the health authority and shall not be the obligation of the County of Alameda or the state. (i) The health authority shall not be a “person” subject to suit under the Cartwright Act, Chapter 2 (commencing with Section 16700) of Part 2 of Division 7 of the Business and Professions Code. (j) The health authority created pursuant to this section may borrow from the county and the county may lend the health authority funds, or issue revenue anticipation notes to obtain those funds necessary to commence operations. (k) The health authority or the county, or both, may engage in marketing, advertising, and promotion of the medical and health care services made available to the target populations by the health authority. (l) Provisions for the termination of the health authority’s activities with respect to the delivery of services to Medi-Cal populations shall be contained in the appropriate contracts executed by and between the health authority and the appropriate state departments. (m) If the board of supervisors expands publicly assisted medical and health care delivery by the health authority to other populations, and the board of supervisors subsequently determines that the health authority may no longer function for the purpose of the expanded delivery, at the time as the health authority’s existing obligations with respect thereto have been satisfied, the board of supervisors may, by ordinance, terminate the expanded delivery activities of the health authority. (n) All assets of the health authority that are related to Medi-Cal services shall be disposed of pursuant to the Medi-Cal related contract entered into between the state and the health authority. (o) All liabilities or obligations of the health authority with respect to its activities pursuant to the state-mandated two-plan managed care model for the delivery of medical care and services to the Medi-Cal population shall be the liabilities or obligations of the health authority, and shall not become the liabilities or obligations of the county upon the termination of the health authority or at any other time. Any liabilities or obligations of the health authority with respect to the liquidation or disposition of the health authority’s assets upon termination of the health authority shall not become the liabilities or obligations of the county, except that the county shall manage any remaining Medi-Cal related assets of the health authority until superseded by a plan approved by the department. (p) The Legislature finds and declares that Section 14105 provides that the Director of Health Services prescribe the policies for the administration of Medi-Cal managed care contracts. The state-mandated two-plan managed care model distributed by the director sets forth that policy, expressly providing that local stakeholders, including government officials, providers, and community-based organizations, are afforded maximum flexibility and control in designing a delivery system that reflects the needs and priorities of the community that it serves. The mandated model requires that the governing board of the local initiative reflect an effort to include representation of the perspectives of provider and beneficiary groups. To effectuate this policy, all of the following shall apply: (1) Notwithstanding any provision of law to the contrary, a member of the governing board of the health authority shall be deemed not to be interested in a contract entered into by the health authority within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all the following apply: (A) The member was appointed to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations. (B) The contract authorizes the member or the organization the member represents to provide services to beneficiaries or administrative services under the health authority’s programs. (C) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the member was appointed to represent. (D) The member does not influence or attempt to influence the health authority or another member of the health authority to enter into the contract in which the member is interested. (E) The member discloses the interest to the health authority and abstains from voting on the contract. (F) The health authority notes the member’s disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for the purpose without counting the vote of the interested member. (2) Notwithstanding Article 4.7 (commencing with Section 1125) of Chapter 1 of Division 4 of Title 1 of the Government Code related to incompatible activities, no member of the governing board, no officer, and no member of the alliance staff shall be considered to be engaged in activities inconsistent and incompatible with his or her duties as a governing board member, officer, or staff person solely as a result of employment or affiliation with the county, private hospital, clinic, pharmacy, other provider group, employee organization, or citizen’s group. (q) (1) The health authority may use a computerized management information system in connection with the administration of its health delivery system, including the administration of the state-mandated two-plan Medi-Cal managed care model. (2) Information maintained in the management information system that pertains to persons who are Medi-Cal applicants or recipients shall be confidential pursuant to Section 14100.2, and shall not be open to examination other than for purposes directly connected with the administration of the Medi-Cal program, including, but not limited to, those set forth in subdivision (c) of Section 14100.2. This safeguarded information includes, but is not limited to, names and addresses, medical services provided, social and economic conditions or circumstances, health authority evaluation of personal information, and medical data, including diagnosis and past history of disease or disability. (3) Information maintained in the management information system that pertains to peer review-related activities shall be confidential and subject to the full protections of the law with respect to the confidentiality of activities related to peer review generally. (r) The records of the health authority, whether paper records, records maintained in the management information system, or records in any other form, that relate to rates of payment, including records relating to rates of payment determination, allocation or distribution methodologies, formulas or calculations, and records of the health authority that relate to contract negotiations with providers of health care for alternative rates, shall not be subject to disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code). The transmission of the records, or the information contained therein in an alternative form, to the board of supervisors shall not constitute a waiver of exemption from disclosure, and the records and information once transmitted to the board of supervisors shall be subject to this same exemption. (s) (1) (A) Notwithstanding the Ralph M. Brown Act (Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of the Government Code), the governing board of the health authority may meet in closed session for the purpose of discussion of, or taking action on matters involving, health authority trade secrets. (B) The requirement that the authority make a public report of actions taken in closed session and the vote or abstention of every member present may be limited to a brief general description of the action taken and the vote so as to prevent the disclosure of a trade secret. (C) For purposes of this subdivision, “health authority trade secret” means a trade secret, as defined in subdivision (d) of Section 3426.1 of the Civil Code, that also meets both of the following criteria: (i) The secrecy of the information is necessary for the health authority to initiate a new service, program, marketing strategy, business plan, or technology, or to add a benefit or product. (ii) Premature disclosure of the trade secret would create a substantial probability of depriving the health authority of a substantial economic benefit or opportunity. (2) Those records of the health authority that reveal the health authority’s trade secrets are exempt from disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. This exemption shall apply for a period of two years after the service, program, marketing strategy, business plan, technology, benefit, or product that is the subject of the trade secret is formally adopted by the governing body of the health authority, provided that the service, program, marketing strategy, business plan, technology, benefit, or product continues to be a trade secret. The governing board may delete the portion or portions containing trade secrets from any documents that were finally approved in the closed session held pursuant to paragraph (1) that are provided to persons who have made the timely or standing request. (3) Nothing in this section shall be construed as preventing the governing board from meeting in closed session as otherwise provided by law. (t) Open sessions of the health authority shall constitute official proceedings authorized by law within the meaning of Section 47 of the Civil Code, and those privileges set forth in that section with respect to official proceedings shall apply to open sessions of the health authority. (u) The health authority shall be considered a public agency for purposes of eligibility with respect to grants and other funding and loan guarantee programs. Contributions to the health authority shall be tax deductible to the extent permitted by state and federal law. (v) Contracts by and between the health authority and the state, and contracts by and between the health authority and providers of health care, goods, or services may be let on a nonbid basis, and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (w) (1) Provisions of the Evidence Code, the Government Code, including the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), the Civil Code, the Business and Professions Code, and other applicable law pertaining to the confidentiality of peer review activities of peer review bodies shall apply to the peer review activities of the health authority. Peer review proceedings shall constitute an official proceeding authorized by law within the meaning of Section 47 of the Civil Code, and those privileges set forth in that section with respect to official proceedings shall apply to peer review proceedings of the health authority. If the health authority is required by law or contractual obligation to submit to the state or federal government peer review information or information relevant to the credentialing of a participating provider, that submission shall not constitute a waiver of confidentiality. The laws pertaining to the confidentiality of peer review activities shall be together construed as extending, to the extent permitted by law, the maximum degree of protection of confidentiality. (2) Notwithstanding any other provision of law, Section 1461 of the Health and Safety Code shall apply to hearings on the reports of hospital medical audit or quality assurance committees as they relate to network providers or applicants. (x) The health authority shall carry general liability insurance to the extent sufficient to cover its activities. (y) The establishment of a health authority under Article 2.8 (commencing with Section 14087.5) shall be valid as if established pursuant to this section and this section shall apply to that health authority. (Amended by Stats. 2004, Ch. 228, Sec. 12.2. Effective August 16, 2004.)
14087.36.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section sets up a San Francisco health authority framework, including how it is created, governed, and terminated, and what it may do under Medi-Cal-related 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 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.36. (a) The following definitions shall apply for purposes of this section: (1) “County” means the City and County of San Francisco. (2) “Board” means the Board of Supervisors of the City and County of San Francisco. (3) “Department” means the State Department of Health Care Services. (4) “Governing body” means the governing body of the health authority. (5) “Health authority” means the separate public agency established by the board of supervisors to operate a health care system in the county and to engage in the other activities authorized by this section. (b) The Legislature finds and declares that it is necessary that a health authority be established in the county to arrange for the provision of health care services in order to meet the problems of the delivery of publicly assisted medical care in the county, to enter into a contract with the department under Article 2.97 (commencing with Section 14093), or to contract with a health care service plan on terms and conditions acceptable to the department, and to demonstrate ways of promoting quality care and cost efficiency. (c) The county may, by resolution or ordinance, establish a health authority to act as and be the local initiative component of the Medi-Cal state plan pursuant to regulations adopted by the department. If the board elects to establish a health authority, all rights, powers, duties, privileges, and immunities vested in a county under Article 2.8 (commencing with Section 14087.5) and Article 2.97 (commencing with Section 14093) shall be vested in the health authority. The health authority shall have all power necessary and appropriate to operate programs involving health care services, including, but not limited to, the power to acquire, possess, and dispose of real or personal property, to employ personnel and contract for services required to meet its obligations, to sue or be sued, to take all actions and engage in all public and private business activities, subject to any applicable licensure, as permitted a health care service plan pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, and to enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. (d) (1) (A) The health authority shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code, separate and distinct from the county, and shall file the statement required by Section 53051 of the Government Code. The health authority shall have primary responsibility to provide the defense and indemnification required under Division 3.6 (commencing with Section 810) of Title 1 of the Government Code for employees of the health authority who are employees of the county. The health authority shall provide insurance under terms and conditions required by the county in order to satisfy its obligations under this section. (B) For purposes of this paragraph, “employee” shall have the same meaning as set forth in Section 810.2 of the Government Code. (2) The health authority shall not be considered to be an agency, division, department, or instrumentality of the county and shall not be subject to the personnel, procurement, or other operational rules of the county. (3) Notwithstanding any other provision of law, any obligations of the health authority, statutory, contractual, or otherwise, shall be the obligations solely of the health authority and shall not be the obligations of the county, unless expressly provided for in a contract between the authority and the county, nor of the state. (4) Except as agreed to by contract with the county, no liability of the health authority shall become an obligation of the county upon either termination of the health authority or the liquidation or disposition of the health authority’s remaining assets. (e) (1) To the full extent permitted by federal law, the department and the health authority may enter into contracts to provide or arrange for health care services for any or all persons who are eligible to receive benefits under the Medi-Cal program. The contracts may be on an exclusive or nonexclusive basis, and shall include payment provisions on any basis negotiated between the department and the health authority. The health authority may also enter into contracts for the provision of health care services to individuals including, but not limited to, those covered under Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, individuals employed by public agencies and private businesses, and uninsured or indigent individuals. (2) Notwithstanding paragraph (1), or subdivision (f), the health authority may not operate health plans or programs for individuals covered under Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, or for private businesses, until the health authority is in full compliance with all of the requirements of the Knox-Keene Health Care Service Plan Act of 1975 under Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code, including tangible net equity requirements applicable to a licensed health care service plan. This limitation shall not preclude the health authority from enrolling persons pursuant to the county’s obligations under Section 17000, or from enrolling county employees. (f) The board of supervisors may transfer responsibility for administration of county-provided health care services to the health authority for the purpose of service of populations including uninsured and indigent persons, subject to the provisions of any ordinances or resolutions passed by the county board of supervisors. The transfer of administrative responsibility for those health care services shall not relieve the county of its responsibility for indigent care pursuant to Section 17000. The health authority may also enter into contracts for the provision of health care services to individuals including, but not limited to, those covered under Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, and individuals employed by public agencies and private businesses. (g) Upon creation, the health authority may borrow from the county and the county may lend the authority funds, or issue revenue anticipation notes to obtain those funds necessary to commence operations or perform the activities of the health authority. Notwithstanding any other provision of law, both the county and the health authority shall be eligible to receive funding under subdivision (p) of Section 14163. (h) The county may terminate the health authority, but only by an ordinance approved by a two-thirds affirmative vote of the full board. (i) Prior to the termination of the health authority, the county shall notify the department of its intent to terminate the health authority. The department shall conduct an audit of the health authority’s records within 30 days of notification to determine the liabilities and assets of the health authority. The department shall report its findings to the county and to the Department of Managed Health Care within 10 days of completion of the audit. The county shall prepare a plan to liquidate or otherwise dispose of the assets of the health authority and to pay the liabilities of the health authority to the extent of the health authority’s assets, and present the plan to the department and the Department of Managed Health Care within 30 days upon receipt of these findings. (j) Any assets of the health authority derived from the contract entered into between the state and the authority pursuant to Article 2.97 (commencing with Section 14093), after payment of the liabilities of the health authority, shall be disposed of pursuant to the contract. (k) (1) The governing body shall consist of 18 voting members, 14 of whom shall be appointed by resolution or ordinance of the board as follows: (A) One member shall be a member of the board or any other person designated by the board. (B) One member shall be a person who is employed in the senior management of a hospital not operated by the county or the University of California and who is nominated by the San Francisco Section of the West Bay Hospital Conference or any successor organization, or, if there is no successor organization, a person who shall be nominated by the Hospital Council of Northern and Central California. (C) Two members, one of whom shall be a person employed in the senior management of San Francisco General Hospital and one of whom shall be a person employed in the senior management of St. Luke’s Hospital (San Francisco). If San Francisco General Hospital or St. Luke’s Hospital, at the end of the term of the person appointed from its senior management, is not designated as a disproportionate share hospital, and if the governing body, after providing an opportunity for comment by the West Bay Hospital Conference, or any successor organization, determines that the hospital no longer serves an equivalent patient population, the governing body may, by a two-thirds vote of the full governing body, select an alternative hospital to nominate a person employed in its senior management to serve on the governing body. Alternatively, the governing body may approve a reduction in the number of positions on the governing body as set forth in subdivision (p). (D) Two members shall be employees in the senior management of either private nonprofit community clinics or a community clinic consortium, nominated by the San Francisco Community Clinic Consortium, or any successor organization. (E) Two members shall be physicians, nominated by the San Francisco Medical Society, or any successor organization. (F) One member shall be nominated by the San Francisco Labor Council, or any successor organization. (G) Two members shall be persons nominated by the member advisory committee of the health authority. Nominees of the member advisory committee shall be enrolled in any of the health insurance or health care coverage programs operated by the health authority or be the parent or legal guardian of an enrollee in any of the health insurance or health care coverage programs operated by the health authority. (H) Two members shall be persons knowledgeable in matters relating to either traditional safety net providers, health care organizations, the Medi-Cal program, or the activities of the health authority, nominated by the program committee of the health authority. (I) One member shall be a person nominated by the San Francisco Pharmacy Leadership Group, or any successor organization. (2) One member, selected to fulfill the appointments specified in subparagraph (A), (G), or (H) shall, in addition to representing the member’s specified organization or employer, represent the discipline of nursing, and shall possess or be qualified to possess a registered nursing license. (3) The initial members appointed by the board under the subdivision shall be, to the extent those individuals meet the qualifications set forth in this subdivision and are willing to serve, those persons who are members of the steering committee created by the county to develop the local initiative component of the Medi-Cal state plan in San Francisco. Following the initial staggering of terms, each of those members shall be appointed to a term of three years, except the member appointed pursuant to subparagraph (A) of paragraph (1), who shall serve at the pleasure of the board. At the first meeting of the governing body, the members appointed pursuant to this subdivision shall draw lots to determine seven members whose initial terms shall be for two years. Each member shall remain in office at the conclusion of that member’s term until a successor member has been nominated and appointed. (l) In addition to the requirements of subdivision (k), one member of the governing body shall be appointed by the Mayor of the City of San Francisco to serve at the pleasure of the mayor, one member shall be the county’s director of public health or designee, who shall serve at the pleasure of that director, one member shall be the Chancellor of the University of California at San Francisco or the chancellor’s designee, who shall serve at the pleasure of the chancellor, and one member shall be the county director of mental health or the director’s designee, who shall serve at the pleasure of that director. (m) There shall be one nonvoting member of the governing body who shall be appointed by, and serve at the pleasure of, the health commission of the county. (n) Each person appointed to the governing body shall, throughout the member’s term, either be a resident of the county or be employed within the geographic boundaries of the county. (o) (1) The composition of the governing body and nomination process for appointment of its members shall be subject to alteration upon a two-thirds vote of the full membership of the governing body. This action shall be concurred in by a resolution or ordinance of the county. (2) Notwithstanding paragraph (1), no alteration described in that paragraph shall cause the removal of a member prior to the expiration of that member’s term. (p) A majority of the members of the governing body shall constitute a quorum for the transaction of business, and all official acts of the governing body shall require the affirmative vote of a majority of the members present and voting. However, no official shall be approved with less than the affirmative vote of six members of the governing body, unless the number of members prohibited from voting because of conflicts of interest precludes adequate participation in the vote. The governing body may, by a two-thirds vote, adopt, amend, or repeal rules and procedures for the governing body. Those rules and procedures may require that certain decisions be made by a vote that is greater than a majority vote. (q) For purposes of Section 87103 of the Government Code, members appointed pursuant to subparagraphs (B) to (E), inclusive, of paragraph (1) of subdivision (k) represent, and are appointed to represent, respectively, the hospitals, private nonprofit community clinics, and physicians that contract with the health authority, or the health care service plan with which the health authority contracts, to provide health care services to the enrollees of the health authority or the health care service plan. Members appointed pursuant to subparagraphs (F) and (G) of paragraph (1) of subdivision (k) represent, and are appointed to represent, respectively, the health care workers and enrollees served by the health authority or its contracted health care service plan, and traditional safety net and ancillary providers and other organizations concerned with the activities of the health authority. (r) A member of the governing body may be removed from office by the board by resolution or ordinance, only upon the recommendation of the health authority, and for any of the following reasons: (1) Failure to retain the qualifications for appointment specified in subdivisions (k) and (n). (2) Death or a disability that substantially interferes with the member’s ability to carry out the duties of office. (3) Conviction of any felony or a crime involving corruption. (4) Failure of the member to discharge legal obligations as a member of a public agency. (5) Substantial failure to perform the duties of office, including, but not limited to, unreasonable absence from meetings. The failure to attend three meetings in a row of the governing body, or a majority of the meetings in the most recent calendar year, may be deemed to be unreasonable absence. (s) Any vacancy on the governing body, however created, shall be filled for the unexpired term by the board by resolution or ordinance. Each vacancy shall be filled by an individual having the qualifications of the individual’s predecessor, nominated as set forth in subdivision (k). (t) The chair of the authority shall be selected by, and serve at the pleasure of, the governing body. (u) The health authority shall establish all of the following: (1) A member advisory committee to advise the health authority on issues of concern to the recipients of services. (2) A program committee to advise the health authority on matters relating to traditional safety net providers, ancillary providers, and other organizations concerned with the activities of the health authority. (3) Any other committees determined to be advisable by the health authority. (v) (1) Notwithstanding any provision of state or local law, including, but not limited to, the county charter, a member of the health authority shall not be deemed to be interested in a contract entered into by the authority within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code, or within the meaning of conflict-of-interest restrictions in the county charter, if all of the following apply: (A) The member does not influence or attempt to influence the health authority or another member of the health authority to enter into the contract in which the member is interested. (B) The member discloses the interest to the health authority and abstains from voting on the contract. (C) The health authority notes the member’s disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for the purpose without counting the vote of the interested member. (D) The member has an interest in or was appointed to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations. (E) The contract authorizes the member or the organization the member has an interest in or represents to provide services to beneficiaries under the authority’s program or administrative services to the authority. (2) In addition, no person serving as a member of the governing body shall, by virtue of that membership, be deemed to be engaged in activities that are inconsistent, incompatible, or in conflict with their duties as an officer or employee of the county or the University of California, or as an officer or an employee of any private hospital, clinic, or other health care organization. The membership shall not be deemed to be in violation of Section 1126 of the Government Code. (w) Notwithstanding any other provision of law, those records of the health authority and of the county that reveal the authority’s rates of payment for health care services or the health authority’s deliberative processes, discussions, communications, or any other portion of the negotiations with providers of health care services for rates of payment, or the health authority’s peer review proceedings shall not be required to be disclosed pursuant to the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. However, three years after a contract or amendment to a contract is fully executed, the portion of the contract or amendment containing the rates of payment shall be open to inspection. (x) Notwithstanding any other provision of law, the health authority may meet in closed session to consider and take action on peer review proceedings and on matters pertaining to contracts and contract negotiations by the health authority’s staff with providers of health care services concerning all matters relating to rates of payment. However, a decision as to whether to enter into, amend the services provisions of, or terminate, other than for reasons based upon peer review, a contract with a provider of health care services, shall be made in open session. (y) (1) (A) Notwithstanding the Ralph M. Brown Act (Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of the Government Code), the governing board of the health authority may meet in closed session for the purpose of discussion of, or taking action on matters involving, health authority trade secrets. (B) The requirement that the authority make a public report of actions taken in closed session and the vote or abstention of every member present may be limited to a brief general description of the action taken and the vote so as to prevent the disclosure of a trade secret. (C) For purposes of this subdivision, “health authority trade secret” means a trade secret, as defined in subdivision (d) of Section 3426.1 of the Civil Code, that also meets both of the following criteria: (i) The secrecy of the information is necessary for the health authority to initiate a new service, program, marketing strategy, business plan, or technology, or to add a benefit or product. (ii) Premature disclosure of the trade secret would create a substantial probability of depriving the health authority of a substantial economic benefit or opportunity. (2) Those records of the health authority that reveal the health authority’s trade secrets are exempt from disclosure pursuant to the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. This exemption shall apply for a period of two years after the service, program, marketing strategy, business plan, technology, benefit, or product that is the subject of the trade secret is formally adopted by the governing body of the health authority, provided that the service, program, marketing strategy, business plan, technology, benefit, or product continues to be a trade secret. The governing board may delete the portion or portions containing trade secrets from any documents that were finally approved in the closed session held pursuant to this subdivision that are provided to persons who have made the timely or standing request. (z) The health authority shall be deemed to be a public agency for purposes of all grant programs and other funding and loan guarantee programs. (aa) Contracts under this article between the State Department of Health Services and the health authority shall be on a nonbid basis and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (ab) (1) The county controller or the controller’s designee, at intervals the county controller deems appropriate, shall conduct a review of the fiscal condition of the health authority, shall report the findings to the health authority and the board, and shall provide a copy of the findings to any public agency upon request. (2) Upon the written request of the county controller, the health authority shall provide full access to the county controller all health authority records and documents as necessary to allow the county controller or the controller’s designee to perform the activities authorized by this subdivision. (ac) A Medi-Cal recipient receiving services through the health authority shall be deemed to be a subscriber or enrollee for purposes of Section 1379 of the Health and Safety Code. (Amended by Stats. 2021, Ch. 615, Sec. 442. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)
14087.37.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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A health authority must provide monthly financial reports, notify officials immediately if it may miss financial obligations, develop a stop-loss program while not yet compliant with tangible net equity requirements, and may have its beneficiaries converted if bankruptcy or termination occurs.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.37. Commencing on the date that a health authority established pursuant to Section 14087.35 or 14087.36 first receives Medi-Cal capitated payments for the provision of health care services to Medi-Cal beneficiaries and until the time that the health authority is in compliance with all the requirements regarding tangible net equity applicable to a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975, the following provisions shall apply: (a) The health authority may select and design its automated management information system, but the department, in cooperation with the health authority, prior to making capitated payments shall test the system to ensure that the system is capable of producing detailed, accurate, and timely financial information on the financial condition of the health authority and any other information generally required by the department in its contracts with health care service plans. (b) In addition to the reports required by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder, the health authority shall provide on a monthly basis to the department, the Department of Managed Health Care, and the members of the health authority, a copy of the automated report described in subdivision (a) and a projection of assets and liabilities, including those that have been incurred but not reported, with an explanation of material increases or decreases in current or projected assets or liabilities. The explanation of increases and decreases in assets or liabilities shall be provided, upon request, to a hospital, independent physicians’ practice association, or community clinic, that has contracted with the health authority to provide health care services. (c) In addition to the reporting and notification obligations the health authority has under the Knox-Keene Health Care Service Plan Act of 1975, the chief executive officer or director of the health authority shall immediately notify the department, the Department of Managed Health Care, and the members of the health authority in writing of any fact or facts that, in the chief executive officers’ or director’s reasonable and prudent judgment, is likely to result in the health authority being unable to meet its financial obligations to health care providers or to other parties. Written notice shall describe the fact or facts, the anticipated fiscal consequences, and the actions that will be taken to address the anticipated consequences. (d) The Department of Managed Health Care shall not waive or vary, nor shall the department request the Department of Managed Health Care to waive or vary, the tangible net equity requirements for a health authority under the Knox-Keene Health Care Service Plan Act of 1975 after three years from the date of commencement of capitated payments to the health authority. Until the time the health authority is in compliance with all of the tangible net equity requirements under the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder, the health authority shall develop a stop-loss program appropriate to the risks of the health authority. The program shall be satisfactory to both the department and the Department of Managed Health Care. (e) In the event that the health authority votes to file a petition of bankruptcy, or the board of supervisors notifies the department of its intent to terminate the health authority, the department shall immediately convert the health authority’s Medi-Cal beneficiaries to either of the following: (1) To other managed care contractors when available, provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees. (2) To the extent that other managed care contractors are unavailable or the department determines that the action is otherwise in the best interest of any particular beneficiary, to a fee-for-service reimbursement system pending the availability of managed care contractors, provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees, or if the department determines that providing care to any particular beneficiary pursuant to a fee-for-service reimbursement system is no longer necessary to protect the continuity of care or other interests of the beneficiary. Beneficiary eligibility for Medi-Cal shall not be affected by this action. Beneficiaries who have been or who are scheduled to be converted to a fee-for-service reimbursement system or managed care contractor may make a choice to be enrolled in another managed care system, if one is available, in full compliance with the federal freedom-of-choice requirements. (f) The health authority shall submit to a review of financial records when the department determines, based on data reported by the health authority or otherwise, that the health authority will not be able to meet its financial obligations to health care providers contracting with the health authority. Where the review of financial records determines that the health authority will not be able to meet its financial obligations to contracting health care providers for the provision of health care services, the director shall immediately terminate the contract between the health authority and the state, and immediately convert the health authority Medi-Cal beneficiaries in accordance with subdivision (e) in order to ensure uninterrupted provision of health care services to the beneficiaries and to minimize financial disruption to providers. The action of the director shall be the final administrative determination. Beneficiary eligibility for Medi-Cal shall not be affected by this action. Beneficiaries who have been or who are scheduled to be converted under subdivision (e) may make a choice to be enrolled in another managed care plan, if one is available, in full compliance with federal freedom-of-choice requirements. (g) It is the intent of the Legislature that the department shall implement Medi-Cal capitated enrollments in a manner that ensures that appropriate levels of health care services will be provided to Medi-Cal beneficiaries and that appropriate levels of administrative services will be furnished to health care providers. The contract between the department and the health authority shall authorize and permit the department to administer the number of covered Medi-Cal enrollments in such a manner that the health authority’s provider network and administrative structure are able to provide appropriate and timely services to beneficiaries and to participating providers. (h) In the event a health authority is terminated, files for bankruptcy, or otherwise no longer functions for the purpose for which it was established, the county shall, with respect to compensation for provision of health care services to beneficiaries, occupy no greater or lesser status than any other health care provider in the disbursement of assets of the health authority. (i) Nothing in this subdivision shall be construed to impair or diminish the authority of the Director of the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, nor shall anything in the section be construed to reduce or otherwise limit the obligation of a health authority licensed as a health care service plan to comply with the requirements of the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder. (Amended by Stats. 2000, Ch. 857, Sec. 83. Effective January 1, 2001.)
14087.38.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section lets certain counties create a health authority, and it sets reporting, licensing, confidentiality, and termination rules for that authority.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.38. (a) (1) In counties selected by the director with the concurrence of the county, a special county health authority may be established in order to meet the problems of delivery of publicly assisted medical care in each county, and to demonstrate ways of promoting quality care and cost efficiency. Nothing in this section shall be construed to preclude the department from expanding Medi-Cal managed care in ways other than those provided for in this section, including, but not limited to, the establishment of a public benefit corporation as set forth in Section 5110 of the Corporations Code. (2) For purposes of this section, “health authority” means an entity separate from the county that meets the requirements of state and federal law and the quality, cost, and access criteria established by the department. (b) The board of supervisors of a county described in subdivision (a) may, by ordinance, establish a health authority to negotiate and enter into contracts authorized by Section 14087.3, and to arrange for the provision of health care services provided pursuant to this chapter. If the board of supervisors elects to enact this ordinance, all rights, powers, duties, privileges, and immunities vested in a county contracting with the department under this article shall be vested in the health authority. The health authority may also enter into contracts for the provision of health care services to individuals including, but not limited to, those covered under Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, those entitled to coverage under other publicly supported programs, those employed by public agencies or private businesses, and uninsured or indigent individuals. (c) The enabling ordinance shall specify the membership of the governing board of the health authority, the qualifications for individual members, the manner of appointment, selection, or removal of board members, and how long they shall serve, and any other matters the board of supervisors deems necessary or convenient for the conduct of the health authority’s activities. Members of the governing board shall be appointed by the board of supervisors to represent the interests of the county, the general public, beneficiaries, physicians, hospitals, clinics, and other nonphysician health care providers. The health authority so established shall be considered an entity separate from the county and shall file a statement required by Section 53051 of the Government Code. The health authority shall have the power to acquire, possess, and dispose of real or personal property, as necessary for the performance of its functions, to employ personnel and contract for services required to meet its obligations, to sue or be sued, and to enter into agreements under Chapter 5 (commencing with Section 6500) of Division 7 of Title 1 of the Government Code. Any obligations of a health authority, statutory, contractual, or otherwise, shall be obligations solely of the health authority and shall not be the obligations of the county or of the state. (d) Upon creation, the health authority may borrow from the county, and the county may lend the health authority funds or issue revenue anticipation notes to obtain those funds necessary to commence operations. (e) Notwithstanding any other provision of law, both the county and the health authority shall be eligible to receive funding under subdivision (p) of Section 14163, and the health authority shall be considered to have satisfied the requirements of that subdivision. (f) The health authority shall be deemed to be a public agency that is a unit of local government for purposes of all grant programs and other funding and loan guarantee programs. (g) It is the intent of the Legislature that if a health authority is formed pursuant to this section, the county shall, with respect to its medical facilities and programs, occupy no greater or lesser status than any other health care provider in negotiating with the health authority for contracts to provide health care services. Nothing in this subdivision shall be construed to interfere with or limit the health authority in giving preference in negotiating to disproportionate share hospitals or other providers of health care to medically indigent or uninsured individuals. (h) Notwithstanding any other provision of law, a member of the governing board of the health authority shall not be deemed to be interested in a contract entered into by the health authority within the meaning of Article 4 (commencing with Section 1090) of Chapter 1 of Division 4 of Title 1 of the Government Code if all the following apply: (1) The member was appointed to represent the interests of physicians, health care practitioners, hospitals, pharmacies, or other health care organizations, or beneficiaries. (2) The contract authorizes the member or the organization the member represents to provide services to beneficiaries under the health authority’s programs. (3) The contract contains substantially the same terms and conditions as contracts entered into with other individuals or organizations that the member was appointed to represent. (4) The member does not influence or attempt to influence the health authority or another member of the health authority to enter into the contract in which the member is interested. (5) The member discloses the interest to the health authority and abstains from voting on the contract. (6) The governing board notes the member’s disclosure and abstention in its official records and authorizes the contract in good faith by a vote of its membership sufficient for the purpose without counting the vote of the interested member. (i) All claims for money or damages against the health authority shall be governed by Part 3 (commencing with Section 900) and Part 4 (commencing with Section 940) of Division 3.6 of Title 1 of the Government Code, except as provided by other statutes or regulations that expressly apply to the health authority. (j) (1) The health authority shall be considered a public entity for purposes of Division 3.6 (commencing with Section 810) of Title 1 of the Government Code. (2) The health authority, members of its governing board, and its employees, are protected by the immunities applicable to public entities and public employees governed by Part 1 (commencing with Section 810) and Part 2 (commencing with Section 814) of Division 3.6 of Title 1 of the Government Code, except as provided by other statutes or regulations that apply expressly to the health authority. (k) Notwithstanding any other provision of law, except as otherwise provided in this section, a county shall not be liable for any act or omission of the health authority. (l) The transfer of responsibility for health care services to the health authority shall not relieve the county of its responsibility for indigent care pursuant to Section 17000. (m) Notwithstanding any other provision of law, the governing board of the health authority may meet in closed session to consider and take action on matters pertaining to contracts, and to contract negotiations by health authority staff with providers of health care services concerning all matters related to rates of payment. (n) (1) (A) Notwithstanding the Ralph M. Brown Act (Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of the Government Code), the governing board of the health authority may meet in closed session for the purpose of discussion of, or taking action on matters involving, health authority trade secrets. (B) The requirement that the authority make a public report of actions taken in closed session and the vote or abstention of every member present may be limited to a brief general description of the action taken and the vote so as to prevent the disclosure of a trade secret. (C) For purposes of this section, “health authority trade secret” means a trade secret, as defined in subdivision (d) of Section 3426.1 of the Civil Code, that also meets both of the following criteria: (i) The secrecy of the information is necessary for the health authority to initiate a new service, program, marketing strategy, business plan, or technology, or to add a benefit or product. (ii) Premature disclosure of the trade secret would create a substantial probability of depriving the health authority of a substantial economic benefit or opportunity. (2) Those records of the health authority that reveal the health authority’s trade secrets are exempt from disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. This exemption shall apply for a period of two years after the service, program, marketing strategy, business plan, technology, benefit, or product that is the subject of the trade secret is formally adopted by the governing body of the health authority, provided that the service, program, marketing strategy, business plan, technology, benefit, or product continues to be a trade secret. The governing board may delete the portion or portions containing trade secrets from any documents that were finally approved in closed session held pursuant to this subdivision that are provided to persons who have made the timely or standing request. (o) Notwithstanding Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of, and Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of, the Government Code, or any other provision of law, any peer review body, as defined in paragraph (1) of subdivision (a) of Section 805 of the Business and Professions Code, formed pursuant to the powers granted to the health authority authorized by this section, may, at its discretion and without notice to the public, meet in closed session, so long as the purpose of the meeting is the peer review body’s discharge of its responsibility to evaluate and improve the quality of care rendered by health facilities and health practitioners, pursuant to the powers granted to the health authority. The peer review body and its members shall receive, to the fullest extent, all immunities, privileges, and protections available to those peer review bodies, their individual members, and persons or entities assisting in the peer review process, including those afforded by Section 1157 of the Evidence Code and Section 1370 of the Health and Safety Code. (p) Notwithstanding any other provision of law, those records of the health authority and of the county that reveal the health authority’s rates of payment for health care services or the health authority’s deliberative processes, discussions, communications, or any other portion of the negotiations with providers of health care services for rates of payment, shall not be required to be disclosed pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or any similar local law requiring the disclosure of public records. However, three years after a contract or amendment to a contract is fully executed, the portion of the contract or amendment containing the rates of payment shall be open to inspection. (q) Notwithstanding the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code), or Article 9 (commencing with Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of, and Chapter 9 (commencing with Section 54950) of Part 1 of Division 2 of Title 5 of, the Government Code, or any other provision of state or local law requiring disclosure of public records, those records of a peer review body, as defined in paragraph (1) of subdivision (a) of Section 805 of the Business and Professions Code, formed pursuant to the powers granted to the health authority authorized by this section, shall not be required to be disclosed. The records and proceedings of the peer review body and its individual members shall receive, to the fullest extent, all immunities, privileges, and protections available to those records and proceedings, including those afforded by Section 1157 of the Evidence Code and Section 1370 of the Health and Safety Code. (r) Except as expressly provided by other provisions of this section, all exemptions and exclusions from disclosure as public records pursuant to the California Public Records Act, including, but not limited to, those pertaining to trade secrets and information withheld in the public interest, shall be fully applicable for all state agencies and local agencies with respect to all writings that the health authority is required to prepare, produce, or submit pursuant to this section. (s) (1) Any health authority formed pursuant to this section shall obtain licensure as a health care service plan under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code). (2) Notwithstanding subdivisions (b) and (t), a health authority may not operate health plans or programs for individuals covered under Subchapter XVIII (commencing with Section 1395) of Chapter 7 of Title 42 of the United States Code, or for private businesses, until the health authority is in full compliance with all of the requirements of the Knox-Keene Health Care Service Plan Act of 1975, including tangible net equity requirements applicable to a licensed health care service plan. (t) Commencing on the date that the health authority first receives Medi-Cal capitated payments for the provision of health care services to Medi-Cal beneficiaries and until the time that the health authority is in compliance with all the requirements regarding tangible net equity applicable to a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975, the following provisions shall apply: (1) The health authority may select and design its automated management information system, but the department, in cooperation with the health authority, prior to making capitated payments, shall test the system to ensure that the system is capable of producing detailed, accurate, and timely financial information on the financial condition of the health authority and any other information generally required by the department in its contracts with health care service plans. (2) In addition to the reports required by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder, the health authority shall provide on a monthly basis to the department, the Department of Managed Health Care, and the members of the health authority, a copy of the automated report described in paragraph (1) and a projection of assets and liabilities, including those that have been incurred but not reported, with an explanation of material increases or decreases in current or projected assets or liabilities. The explanation of increases and decreases in assets or liabilities shall be provided, upon request, to a hospital, independent physicians’ practice association, or community clinic, that has contracted with the health authority to provide health care services. (3) In addition to the reporting and notification obligations the health authority has under the Knox-Keene Health Care Service Plan Act of 1975, the chief executive officer or director of the health authority shall immediately notify the department, the Department of Managed Health Care, and the members of the governing board of the health authority in writing of any fact or facts that, in the chief executive officer’s or director’s reasonable and prudent judgment, is likely to result in the health authority being unable to meet its financial obligations to health care providers or to other parties. Written notice shall describe the fact or facts, the anticipated fiscal consequences, and the actions that will be taken to address the anticipated consequences. (4) The Department of Managed Health Care shall not waive or vary, nor shall the department request the Department of Managed Health Care to waive or vary, the tangible net equity requirements for a health authority under the Knox-Keene Health Care Service Plan Act of 1975 after three years from the date of commencement of capitated payments to the health authority. Until the time the health authority is in compliance with all of the tangible net equity requirements under the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder, the health authority shall develop a stop-loss program appropriate to the risks of the health authority. The program shall be satisfactory to both the department and the Department of Managed Health Care. (5) In the event that the health authority votes to file a petition of bankruptcy, or the board of supervisors notifies the department of its intent to terminate the health authority, the department shall immediately convert the authority’s Medi-Cal beneficiaries to either of the following: (A) To other managed care contractors when available, provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees. (B) To the extent that other managed care contractors are unavailable or the department determines that the action is otherwise in the best interest of any particular beneficiary, to a fee-for-service reimbursement system pending the availability of managed care contractors, provided those contractors are able to demonstrate that they can absorb the increased enrollment without detriment to the provision of health care services to their existing enrollees, or if the department determines that providing care to any particular beneficiary pursuant to a fee-for-service reimbursement system is no longer necessary to protect the continuity of care or other interests of the beneficiary. Beneficiary eligibility for Medi-Cal shall not be affected by this action. Beneficiaries who have been or who are scheduled to be converted to a fee-for-service reimbursement system or managed care contractor may make a choice to be enrolled in another managed care system, if one is available, in full compliance with the federal freedom-of-choice requirements. (6) The health authority shall submit to a review of financial records when the department determines, based on data reported by the health authority or otherwise, that the health authority will not be able to meet its financial obligations to health care providers contracting with the health authority. Where the review of financial records determines that the health authority will not be able to meet its financial obligations to contracting health care providers for the provision of health care services, the director shall immediately terminate the contract between the health authority and the state, and immediately convert the health authority Medi-Cal beneficiaries in accordance with paragraph (5) in order to ensure uninterrupted provision of health care services to the beneficiaries and to minimize financial disruption to providers. The action of the director shall be the final administrative determination. Beneficiary eligibility for Medi-Cal shall not be affected by this action. Beneficiaries who have been or who are scheduled to be converted under paragraph (5) may make a choice to be enrolled in another managed care plan, if one is available, in full compliance with federal freedom-of-choice requirements. (7) It is the intent of the Legislature that the department shall implement Medi-Cal capitated enrollments in a manner that ensures that appropriate levels of health care services will be provided to Medi-Cal beneficiaries and that appropriate levels of administrative services will be furnished to health care providers. The contract between the department and the health authority shall authorize and permit the department to administer the number of covered Medi-Cal enrollments in such a manner that the health authority’s provider network and administrative structure are able to provide appropriate and timely services to beneficiaries and to participating providers. (8) In the event a health authority is terminated, files for bankruptcy, or otherwise no longer functions for the purpose for which it was established, the county shall, with respect to compensation for provision of health care services to beneficiaries, occupy no greater or lesser status than any other health care provider in the disbursement of assets of the health authority. (9) Nothing in this subdivision shall be construed to impair or diminish the authority of the Director of the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, nor shall anything in this section be construed to reduce or otherwise limit the obligation of a health authority licensed as a health care service plan to comply with the requirements of the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder. (u) In the event a health authority may no longer function for the purposes for which it is established, at the time the health authority’s then-existing obligations have been satisfied or the health authority’s assets have been exhausted, the board of supervisors may, by ordinance, terminate the health authority. (v) (1) Prior to the termination of the health authority, the board of supervisors shall notify the department of its intent to terminate the health authority. The department shall conduct an audit of the health authority’s records within 30 days of the notification to determine the liabilities and assets of the health authority. (2) The department shall report its findings to the board within 10 days of completion of the audit. The board shall prepare a plan to liquidate or otherwise dispose of the assets of the health authority and to pay the liabilities of the health authority to the extent of the health authority’s assets, and present the plan to the department within 30 days upon receipt of these findings. (w) Any assets of the health authority shall be disposed of pursuant to provisions contained in the contract entered into between the state and the health authority pursuant to this section. (x) Upon termination of a health authority by the board, the county shall manage any remaining assets of the health authority until superseded by a department-approved plan. Any liabilities of the health authority shall not become obligations of the county upon either the termination of the health authority or the liquidation or disposition of the health authority’s remaining assets. (y) This section shall apply to any county health authority or any county special commission operating under this article or Article 2.81 (commencing with Section 14087.96), except to the extent that this section conflicts with Sections 14087.31, 14087.35, and 14087.36 or Article 2.81 (commencing with Section 14087.96). (Amended by Stats. 2004, Ch. 228, Sec. 12.4. Effective August 16, 2004.)
14087.385.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section defines several terms and gives the Sacramento County health authority and the department powers and duties about Medi-Cal managed care plan designation and procurement.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.385. (a) The following definitions apply for purposes of this section: (1) “Board” means the Board of Supervisors of the County of Sacramento. (2) “County” means the County of Sacramento. (3) “Department” means the State Department of Health Care Services. (4) “Health authority” means a separate public entity established by the board that meets the requirements of state and federal law and criteria established by the department and engages in activities authorized by this section. (b) The Legislature finds and declares that it is necessary that a health authority be established in the county to meet the problems of delivery of publicly assisted medical care in the county and to demonstrate ways of promoting timely access, quality care, and cost efficiency. (c) A health authority established by the board, consistent with Section 14087.38, may do all of the following: (1) Designate a number of Knox-Keene licensed health plans for purposes of the department’s Medi-Cal managed care plan procurement under Section 14089 for the County of Sacramento as specified under subdivision (d), until the health authority implements a county-sponsored local initiative health plan as authorized by Section 14087.38 as described in paragraph (3). (2) Meet with health plans that operate as Medi-Cal managed care plans in the county pursuant to Section 14089 to review and discuss strategies for improving quality, cost, and access of Medi-Cal services in the county, until the health authority implements any activity described in paragraph (3). (3) (A) Consistent with Section 14087.38, and upon approval of the health authority and the board, pursue either of the following activities: (i) Seek and obtain Knox-Keene health plan licensure in order to serve as the county-sponsored local initiative to contract with the department to arrange for the provision of health care services to qualifying individuals, as authorized by Section 14087.3. (ii) Negotiate and enter into a contract with a Knox-Keene licensed health plan to be the designated county-sponsored local initiative health plan for the purpose of contracting with the department for the provision of health care services to qualifying individuals as authorized by Section 14087.3. (B) Upon the implementation of any activity described in subparagraph (A), the county may continue to administer its stakeholder advisory committee, as described under Section 14089.07. (d) (1) For purposes of the designation of health plans pursuant to paragraph (1) of subdivision (c), prior to procurement under Section 14089, the health authority shall meet with any health plans intending to contract with the department as Medi-Cal managed care plans in the county. Any health plan intending to contract with the department as a Medi-Cal managed care plan in the county, and intending to submit a proposal to the department in a procurement process, shall first be required to meet with the health authority. (2) Subsequent to meeting with all interested health plans, the health authority shall designate to the department at least two Knox-Keene licensed health plans for the department’s approval based on the criteria described in paragraph (3). (3) Any criteria used by the health authority to determine the designation of health plans pursuant to paragraph (1) of subdivision (c) shall not conflict with requirements for Medi-Cal managed care plans established by the department, the Department of Managed Health Care, the federal Medicaid program, or state law, and shall conform with any guidance issued by the department pursuant to paragraph (7). Designation requirements imposed by the health authority shall further the department’s goals and requirements for procurement under Section 14089 including, but not limited to, increased quality, access, network adequacy, reduction of health disparities, and integration of behavioral and oral health within the delivery of health care services in the Medi-Cal program. (4) Notwithstanding any designation by the health authority, only health plans approved by the department as meeting plan procurement requirements determined by the department shall be eligible to contract with the department as Medi-Cal managed care plans in the county. Designation by the health authority provides the health plan only with the opportunity to compete in the procurement process under Section 14089 and does not guarantee the award of a Medi-Cal managed care plan contract with the department. (5) If the health authority does not designate at least two health plans that receive approval from the department, the department shall determine other health plans to contract with as Medi-Cal managed care plans to ensure there are at least two Medi-Cal managed care plans in Sacramento County. (6) Designation of health plans by the health authority shall continue for the term of the Medi-Cal contract, unless the department determines that the criteria for designation specified in paragraph (3) is no longer met. (7) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this subdivision by means of letters or other similar instructions, without taking any further regulatory action. This may include, but need not be limited to, guidance to the health authority with respect to the requisite criteria and timing for the designation of health plans pursuant to this subdivision. (Added by Stats. 2021, Ch. 446, Sec. 1. (SB 226) Effective January 1, 2022.)
14087.39.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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When county functions are transferred to a qualifying health authority, the authority must keep recognizing the employees’ organization and honor any existing memorandum of understanding; the county is also authorized to provide medical care at its public health and hospital facilities.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.39. (a) In any transfer of functions from county employees to a health authority established pursuant to Section 14087.35, 14087.36, or 14087.38, the health authority shall continue to recognize the employee organization that represented the employees performing those functions at the time of the transfer of duties. (b) Any health authority to which this section applies shall be bound by the terms of any memorandum of understanding that is in effect as of the date of the transfer of functions for the duration of the transfer of functions, or until replaced by a subsequent memorandum of understanding between the health authority and the employee organization. (c) Subdivision (b) shall not apply to administrative functions performed by the authority that are directly related to the operation of a health care service plan licensed under Chapter 2.2 (commencing with Section 1340) of Division 3 of the Health and Safety Code, unless the functions were transferred from county employees to the authority. (d) In order to further the statewide interest in the development of an effective managed care delivery system to Medi-Cal beneficiaries in the county, it is necessary to ensure that the public health and hospital facilities of the county are financially viable so that the county may participate in that delivery system through the use of those facilities. Accordingly, notwithstanding any provision of the county charter to the contrary, the county shall be fully authorized to offer and provide medical care to members of the health service system of the county at the public health and hospital facilities of the county. (Added by Stats. 1994, Ch. 642, Sec. 7. Effective September 20, 1994.)
14087.4.
## 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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Contracts under this article may be renewed if the provider still meets the chapter, regulation, and contract requirements. The department may also set correction plans as a renewal condition, and it may end or refuse renewal to protect beneficiaries or Medi-Cal funds. Some contracts are exempt from the Public Contract Code, and the Managed Health Care director must grant a requested exemption from specified Health and Safety Code provisions for contracts entered under 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.4. (a) Any contract made pursuant to this article may be renewed if the provider continues to meet the requirements of this chapter, regulations promulgated pursuant thereto, and the contract. Failure to meet these requirements shall be cause for nonrenewal of the contract. The department may condition renewal on timely completion of a mutually agreed upon plan of correction of any deficiencies. (b) The department may terminate or decline to renew a contract, in whole or in part, when the director determines that such action is necessary to protect the health of the beneficiaries or the funds appropriated to carry out the Medi-Cal program. Nonrenewal or termination under this article shall not qualify the applicant for an administrative hearing including a hearing pursuant to Section 14123. (c) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore contracts under this article shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (d) For any contract entered into pursuant to this article, the Director of the Department of Managed Health Care shall, at the director’s request and with all due haste, grant an exemption from the provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out the contract. (Amended by Stats. 2000, Ch. 857, Sec. 85. Effective January 1, 2001.)
14087.41.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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The department must create a simple notice form for Medi-Cal managed care plans and require those plans to use 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.41. The department shall develop a simple form, consistent with the notice requirements of Sections 51014.1 and 51014.2 of Title 22 of the California Code of Regulations, for Medi-Cal managed care plans to use to notify a Medi-Cal enrollee of a denial, termination, delay, or modification in benefits. The department shall require all Medi-Cal managed care plans to use the form as a condition of participation in Medi-Cal managed care pursuant to any contract negotiated after the effective date of this section. (Added by Stats. 1999, Ch. 539, Sec. 6. Effective January 1, 2000.)
14087.45.
## 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This article does not take effect until July 1, 1983.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.45. The provisions of this article shall not become operative until July 1, 1983, the date upon which the California Medical Assistance Commission, created pursuant to Assembly Bill 3480, assumes its full responsibilities. (Added by Stats. 1982, Ch. 328, Sec. 18. Effective June 30, 1982. Section operative July 1, 1983, by its own provisions.)
14087.46.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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The department must run a Medi-Cal dental managed care program, contract competitively for dental plans, and give beneficiaries choices and access protections.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.46. (a) The department shall implement a dental managed care program for Medi-Cal beneficiaries to achieve major cost savings, while ensuring access and quality of care, pursuant to this section. (b) The department shall issue a request for proposals and award contracts on a competitive basis to one or more dental health care service contractors 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) in each county or region that the department determines to be feasible. The department may contract with county organized health systems. (c) To ensure access and continuity of care, the department shall award contracts to plans that agree to negotiate in good faith and subcontract with any provider who agrees to provide dental services to Medi-Cal beneficiaries at a reimbursement rate comparable to that paid by the plan to other participating providers. A plan shall contract whenever feasible with traditional and safety net providers of dental services to Medi-Cal beneficiaries. In evaluating the plans, the department shall assign favorable weighting to contractors that include traditional and safety net providers. (d) The department shall implement a process to inform each Medi-Cal beneficiary of their choice of participating dentists and to allow a beneficiary to choose or change their participating dentist. (e) The department shall make every effort to achieve operational contracts to place Medi-Cal beneficiaries in dental managed care by October 1, 1995. The department may determine which counties or categories of Medi-Cal beneficiaries are to be included in the dental managed care program. If the department has achieved one or more operational managed care contracts in a county or region, fee-for-service dental services shall not be an option for selection by a beneficiary, except that the department may provide for fee-for-service dental care if needed to ensure adequate access in rural or underserved areas, or for unique populations. (f) The department shall require a participating plan to provide, at a minimum, the full scope of dental benefits pursuant to state and federal law. (g) In order to achieve maximum cost savings, the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts under this section shall be exempt from the Public Contract Code. (h) A Medi-Cal beneficiary shall be able to receive their dental care from federally qualified health centers and rural health clinics certified pursuant to Public Law 95-210 that provide dental care in their service area. At the time of informing the Medi-Cal beneficiary of their choice of participating dentists, the beneficiary shall be informed of this option. Federally qualified health centers and rural health clinics shall continue to be reimbursed for dental services through the medical payment system in accordance with federal regulations. (i) The department shall monitor the implementation of dental managed care, and for each of the first three years of implementation, shall annually evaluate the program on a county-by-county basis in terms of access, quality of care, and cost savings. The evaluation shall be provided to the Legislature within 120 days of the close of each of the three fiscal years. (j) The department shall seek federal waivers necessary to allow for federal financial participation in the program implemented pursuant to this section. This article shall not be implemented unless and until the director has executed a declaration, to be retained by the director, that approval of all necessary federal waivers have been obtained by the department. (k) Notwithstanding any other law, to the extent any necessary federal approvals are obtained, the department shall extend the dental managed care contracts, which are in effect on the effective date of the act that added this subdivision, for the provision of covered dental services authorized under this section pursuant to all of the following: (1) These existing contracts shall be extended through December 31, 2023, or through the calendar day immediately preceding the effective date for the new dental managed care contracts described in paragraph (3), to the extent that effective date is later than January 1, 2024. (2) Contract extensions shall be secured on a sole source basis. (3) The department shall conduct a competitive bid and procurement process to award new dental managed care contracts, commencing on an effective date of January 1, 2024, subject to the department obtaining all necessary federal approvals for the contracts. (4) If new dental managed care contracts have not taken effect on or before July 1, 2024, the department shall provide an update to the Legislature detailing the specific circumstances that contributed to the delay and an expected commencement date for the new contracts. (5) Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and the State Administrative Manual, and shall be exempt from the review or approval of any division of the Department of General Services. (l) 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 information notices, plan letters, or other similar instructions, without taking any further regulatory action. (Amended by Stats. 2022, Ch. 47, Sec. 88. (SB 184) Effective June 30, 2022.)
14087.47.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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This section lets the department contract with selected counties to run a fee-for-service managed care program and sets rules for assignments, provider participation, beneficiary choice, county oversight, 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 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.47. (a) The department may contract under this article with the Counties of Sonoma, Placer, and San Luis Obispo, which have been selected by the department through a request for proposal process, for the operation of a fee-for-service managed care program administered by the county through which primary care, specialty care, and case management are provided to residents of the county who are Medi-Cal eligible persons designated by the director. (b) (1) Upon receipt of the necessary federal medicaid freedom of choice waivers, the department may, consistent with the federal waivers, assign to a fee-for-service managed care program residents of the county who are Medi-Cal eligible persons with Medi-Cal aid codes designated by the director. The department may require that assigned beneficiaries receive their Medi-Cal services and case management through the program. (2) Medi-Cal eligible county residents who are dually eligible for Medi-Cal and Medicare benefits shall not, however, be assigned to a fee-for-service managed care program. (3) Medi-Cal beneficiaries eligible for benefits through age, blindness, or disability, as defined in Title XVI of the Social Security Act (42 U.S.C. Sec. 1381 et. seq.) shall be assigned to a fee-for-service managed care program. However, each county participating in the program authorized by this section shall allow these beneficiaries to select a provider or providers of their choice and shall ensure that existing provider-patient relationships are permitted to continue. (4) Services covered by the California Children’s Services program shall not be incorporated into a fee-for-service managed care program in a manner that is inconsistent with Article 2.98 (commencing with Section 14094). (5) A foster child may be enrolled voluntarily in a fee-for-service managed care program if the county director of social services, or his or her delegated representative, makes an individual determination that enrollment in a fee-for-service managed care program is in the best interest of the child. In determining what is in the best interest of the foster child, the county director of social services, or his or her delegated representative, shall consult with the child’s caretaker, and shall include the decision of whether or not to enroll the child in a fee-for-service managed care program in the child’s case plan provided for pursuant to subdivision (b) of Section 11400. (c) Each contract entered into by the department under this section may have an initial term of up to three years. Contracts may be renewed for periods of up to three years upon a determination by the department that a contract is successful. (d) The department shall periodically evaluate each fee-for-service managed care program through an independent assessment as required under the department’s approved federal waiver request to determine if the program is successfully providing quality health care while not placing the Medi-Cal program or counties at additional financial risk. The assessment shall evaluate quality of care, access, the provision of preventive health care, and costs. The department shall terminate a contract when the department finds that the fee-for-service managed care program is unsuccessful. (e) In order to ensure maximum cost effectiveness, the Legislature hereby determines that an expedited contract process for contracts entered into under this section between the department and the counties is necessary. Therefore, contracts under this article shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (f) Fee-for-service managed care program contractors shall ensure broad participation of primary care and other providers, including specialists, safety net and traditional Medi-Cal providers, in the program and shall contract with any primary care provider that agrees to provide services in accord with the same terms and conditions that the fee-for-service managed care program contractor requires of other primary care providers. To the extent possible, the fee-for-service managed care program contractor shall contract with primary care providers in a manner that minimizes the disruption of existing relationships between Medi-Cal eligible residents and their primary care providers. (g) Medi-Cal eligible county residents in the aid codes designated by the director shall be informed about the fee-for-service managed care program through the health care options process established by the department in each county in which the program is operated consistent with the health care options process authorized in other Medi-Cal managed care counties designated by the director. (h) Designated Medi-Cal residents shall have the right to select a primary care provider from among the primary care providers contracting with the fee-for-service managed care program contractor and to change primary care providers. Covered Medi-Cal residents shall be informed of this right and the selection and change processes through the health care options process established in the county by the department consistent with the health care options process authorized in other Medi-Cal managed care counties designated by the director. The fee-for-service managed care program contractor shall also include this information in its membership materials. (i) The board of supervisors of each county participating in the project authorized by this section shall establish or cause to be established an advisory committee comprised of county, physician, hospital, clinic, and beneficiary representatives to advise the county on the implementation and operation of the project provided for under this section. (j) The department may adopt regulations to implement this section in accordance with the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The initial adoption of any emergency regulations implementing this section shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Initial emergency regulations adopted pursuant to this subdivision shall remain in effect for no more than 120 days. (Amended by Stats. 1998, Ch. 834, Sec. 3. Effective January 1, 1999.)
14087.48.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. )
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Before a Medi-Cal managed care plan starts operations after a director-approved geographic expansion, the department must evaluate whether the affected plan is ready.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 2.7. Contracts for Medi-Cal Services and Case Management [14087.3 - 14087.48] ( Heading of Article 2.7 amended by Stats. 1992, Ch. 722, Sec. 73. ) ## 14087.48. (a) For purposes of this section, “Medi-Cal managed care plan” means any individual, 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 2.9 (commencing with Section 14088), or Article 2.91 (commencing with Section 14089), or pursuant to Article 1 (commencing with Section 14200), or Article 7 (commencing with Section 14490) of Chapter 8. (b) Before a Medi-Cal managed care plan commences operations based upon an action of the director that expands the geographic area of Medi-Cal managed care, the department shall perform an evaluation to determine the readiness of any affected Medi-Cal managed care plan to commence operations. The evaluation shall include, at a minimum, all of the following: (1) The extent to which the Medi-Cal managed care plan demonstrates the ability to provide reliable service utilization and cost data, including, but not limited to, quarterly financial reports, audited annual reports, utilization reports of medical services, and encounter data. (2) The extent to which the Medi-Cal managed care plan has an adequate provider network, including, but not limited to, the location, office hours, and language capabilities of primary care physicians and, if applicable, nonphysician medical practitioners, specialists, pharmacies, and hospitals, that the types of specialists in the provider network are based on the population makeup and particular geographic needs, and that whether requirements will be met for availability of services and travel distance standards, as set forth in Sections 53852 and 53885, respectively, of Title 22 of the California Code of Regulations. (3) The extent to which the Medi-Cal managed care plan has developed procedures for the monitoring and improvement of quality of care, including, but not limited to, procedures for retrospective reviews which include patterns of practice reviews and drug prescribing practice reviews, utilization management mechanisms to detect both under- and over-utilization of health care services, and procedures that specify timeframes for medical authorization. (4) The extent to which the Medi-Cal managed care plan has demonstrated the ability to meet accessibility standards in accordance with Section 1300.67.2 of Title 28 of the California Code of Regulations, including, but not limited to, procedures for appointments, waiting times, telephone procedures, after hours calls, urgent care, and arrangement for the provision of unusual specialty services. (5) The extent to which the Medi-Cal managed care plan has met all standards and guidelines established by the department that demonstrate readiness to provide services to enrollees. (6) The extent to which the Medi-Cal managed care plan has submitted all required contract deliverables to the department, including, but not limited to, quality improvement systems, utilization management, access and availability, member services, member grievance systems, and enrollments and disenrollments. (7) The extent to which the Medi-Cal managed care plan’s Evidence of Coverage, Member Services Guide, or both, conforms to federal and state statutes and regulations, is accurate, and is easily understood. (8) The extent to which the Medi-Cal managed care plan’s primary care and facility sites have been reviewed and evaluated by the department. (Amended by Stats. 2013, Ch. 684, Sec. 3. (SB 494) Effective January 1, 2014.)

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