Source: http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=WIC&division=9.&title=&part=3.&chapter=7.&article=2
Timestamp: 2020-07-07 02:51:13
Document Index: 179142727

Matched Legal Cases: ['art 4', 'art 4', 'art 2', 'art 5', 'art 3', 'art 1', 'art 1']

ARTICLE 2. Definitions [14050 - 14068]
( Article 2 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
(Repealed and added by Stats. 1965, 2nd Ex.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.
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.
“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.
(a) “Medically needy person” means any of the following:
(1) An aged, blind, or disabled person who meets the definition of aged, blind, or disabled under the Supplemental Security Income program and whose income and resources are insufficient to provide for the costs of health care or coverage.
(2) A child in foster care for whom public agencies are assuming financial responsibility, in whole or in part, or a person receiving aid under Chapter 2.1 (commencing with Section 16115) of Part 4.
(3) A child who is eligible to receive Medi-Cal benefits pursuant to interstate agreements for adoption assistance and related services and benefits entered into under Chapter 2.6 (commencing with Section 16170) of Part 4, to the extent federal financial participation is available.
(b) “Medically needy family person” means a parent or caretaker relative of a child or a child under 21 years of age or a pregnant woman of any age with a confirmed pregnancy, exclusive of those persons specified in subdivision (a), whose income and resources are insufficient to provide for the costs of health care or coverage.
(Amended by Stats. 2014, Ch. 831, Sec. 10. (SB 508) Effective January 1, 2015.)
14051.5.
(a) “Medically needy person” also means any person who receives in-home supportive services pursuant to Section 12305.5 and whose income and resources are insufficient to provide for the costs of health care or coverage.
(Added by Stats. 1977, Ch. 1107.)
“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.
“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.)
(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:
(Amended by Stats. 2000, Ch. 93, Sec. 64. Effective July 7, 2000.)
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.
(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.
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.
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.
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.
(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.)
(Amended by Stats. 2014, Ch. 836, Sec. 1. (SB 1089) Effective January 1, 2015.)
(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.
(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.
(Amended by Stats. 2012, Ch. 162, Sec. 212. (SB 1171) Effective January 1, 2013.)
“Share of cost” means the amount of the costs of health care which a person or family eligible under Section 14005.4 or 14005.7 must incur prior to being certified by the department as specified in Section 14018.
(Amended by Stats. 1976, Ch. 126.)
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.)
(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.)
“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.)
(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.
“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.)
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. 2018, Ch. 855, Sec. 1. (SB 1287) Effective January 1, 2019.)
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.)
As used in this chapter, “director” means the State Director of Health Services.
As used in this chapter, “department” means the State Department of Health Services.
As used in this chapter, “Medi-Cal” means the California Medical Assistance Program.
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.
4. Speech therapy.
5. Prosthetic or orthotic services.
6. Psychologist services.
7. Medical social worker services.
C. A typical program shall provide for:
1. Initial evaluation (7–10 days) for assessment of medical condition, functional limitations, possible need for surgery, attitude toward rehabilitation, functional goals and plans for discharge.
2. Where the rehabilitation potential is undetermined, the patient shall be placed on a 14-day trial program. If no improvement is noted after this period, definitive plans for discharge should be made.
3. Where the initial evaluation results in a conclusion by the rehabilitation team that a significant practical improvement can be expected in a reasonable period of time, the program should continue until such time as further progress toward the established rehabilitation goals is unlikely or it can be achieved in a less intensive setting.
(Added by Stats. 1976, Ch. 914.)
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.
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.)
(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.
(Amended by Stats. 2012, Ch. 728, Sec. 199. (SB 71) Effective January 1, 2013.)
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.
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.)
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.)