reglab/housing_qa huggingface dataset:
CA Welf & Inst Code § 14138.13 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.13.

14138.13.  (a) The department shall notify every FQHC in the state of the APM pilot project and shall invite any interested FQHC to apply for participation in the APM with respect to one or more of the FQHC’s sites. Consistent with federal law, the state plan amendment described in subdivision (b) of Section 14138.12 shall specify that the department and each participating FQHC voluntarily agrees to the APM.(b) (1) The department shall develop, in consultation with interested FQHCs and principal health plans and consistent with federal law, the eligibility criteria to be used in evaluating applications from interested FQHCs for participation in the pilot project, which shall include, but need not be limited to, the following:(A) The FQHC has the demonstrated ability to collect and submit encounter data in a form and manner that satisfies department requirements.(B) The FQHC is in good standing with the relevant state and federal regulators.(C) The FQHC has the financial and administrative capacity to undertake payment reform.(2) In addition to the criteria listed in paragraph (1), the department may take into consideration the number of APM enrollees assigned by a plan at each FQHC site as an eligibility requirement for FQHC participation.(3) In accordance with the process and criteria developed pursuant to paragraphs (1) and (2), the department shall approve or deny an interested FQHC site application for participation in the pilot project. The department may limit the number of participating FQHCs in the pilot project and the number of counties in which the pilot project will operate.(4) All principal health plans and applicable subcontracting payers are required to participate in the APM pilot project pursuant to this article to the extent that one or more contracted FQHC sites located in the plan’s county are selected to participate in the pilot project.(c) The APM shall be applied only with respect to a participating FQHC for services the FQHC provides to its APM enrollees that are within its APM scope of services.(d) Payment to the participating FQHC shall continue to be governed by the provisions of Sections 14087.325 and 14132.100 for services provided with respect to both of the following categories of patients:(1) A Medi-Cal beneficiary who receives services from any FQHC to which the beneficiary is not assigned for primary care services under the APM pilot project by a principal health plan or subcontracting payer.(2) A person who is a Medi-Cal beneficiary, but who is not a Medi-Cal beneficiary within a designated APM aid category.(e) A participating FQHC, with respect to one or more sites of its choosing, may opt to discontinue its participation in the pilot project subject to a notice requirement of no less than 120 days.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.14 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.14.

14138.14.  (a) A participating FQHC shall be compensated for the APM scope of services provided to its APM enrollees pursuant to this section.(b) A participating FQHC shall receive from the principal health plan or applicable subcontracting payer reimbursement for each APM enrollee in the form of a clinic-specific PMPM for the applicable APM aid category. The department shall determine the clinic-specific PMPM for each APM aid category taking into account all the following factors:(1) Historical utilization of FQHC services by assigned members in each APM aid category.(2) The participating FQHC’s prospective payment system rate and applicable adjustments relevant for the fiscal year, such as annual rate adjustments.(3) Other trend and utilization adjustments as appropriate in order to reflect the level of reimbursement that would have been received by the participating FQHCs in the absence of the APM pilot project.(c) A participating FQHC and applicable principal health plan or subcontracting payer may enter into arrangements in which the clinic-specific PMPM amount required in subdivision (b) is paid in more than one capitated increment, as long as the total capitation each month received by the participating FQHC is equivalent to the clinic-specific PMPM.(d) In cases where a subcontracting payer is involved, the principal health plan shall demonstrate and certify to the department that it has contracts or other arrangements in place that provide for meeting the requirements in subdivision (b) and to the extent that the subcontracting payer fails to comply with the applicable requirements in this article, the principal health plan shall then be responsible to ensure the participating FQHC receives all payments due under this article in a timely manner.(e) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, and any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100.(f) An FQHC site participating in the APM pilot project shall not receive traditional wrap-around payments pursuant to Sections 14132.100 and 14087.325 for visits within the APM scope of services it provides to its APM enrollees.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.15 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.15.

14138.15.  (a) A principal health plan shall be compensated by the department for the services provided to its APM enrollees pursuant to this section.(b) For each principal health plan that contains at least one participating FQHC in its provider network, the department shall determine an APM supplemental capitation amount for each APM aid category to be paid by the department to the principal health plan, which shall be expressed as a PMPM amount. This supplemental capitation amount will be in addition to the funding for the APM scope of services already contained in the principal health plan’s capitated rates paid by the department and shall be actuarially sound. The department shall determine the APM supplemental capitation amount for each APM aid category, taking into account all of the following factors:(1) The clinic-specific PMPM amounts for each APM aid category for each participating FQHC in the plan’s network.(2) The funding for the APM scope of services already contained in the principal health plan’s capitated rates.(3) The historical wrap-around payments paid by the department for participating FQHCs for assigned members in each APM aid category.(4) As applicable, the likely distribution of members among multiple participating FQHCs.(c) The principal health plan shall report to the department, in a form to be determined by the department in consultation with the principal health plan, the number of APM enrollees for each APM aid category in the plan each month.(d) The department shall pay each principal health plan its applicable APM supplemental capitation amount for the number of APM enrollees for each APM aid category reported by the principal health plan pursuant to subdivision (c).(e) The department, in consultation with the principal health plans, shall develop methods to verify the information reported pursuant to subdivision (c), and may adjust the payments made pursuant to subdivision (d) as appropriate to reflect the verified number of APM enrollees for each APM aid category.(f) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, and any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.16 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.16.

14138.16.  (a) For the duration of the APM pilot project, the department shall establish a risk corridor structure for the principal health plans relating only to the APM supplemental capitation payments pursuant to Section 14138.15, to the extent consistent with principles of actuarial soundness.(b) The risk sharing of the costs under this section shall be constructed by the department so that it is symmetrical with respect to risk and profit, and so that all of the following apply:(1) The principal health plan is fully responsible for all costs up to one-half of 1 percent in excess of the APM supplemental capitation amounts.(2) The principal health plan shall fully retain the revenues paid through the APM supplemental capitation amounts in excess of the costs incurred up to one-half of 1 percent below the APM supplemental capitation amounts.(3) The principal health plan and the department shall share equally in the responsibility for costs in excess of the APM supplemental capitation amounts that are greater than one-half of 1 percent but less than 1 percent above the APM supplemental capitation amounts.(4) The principal health plan and the department shall share equally the benefit of the revenues paid through the APM supplemental capitation amounts in excess of the costs incurred that are greater than one-half of 1 percent but less than 1 percent below the APM supplemental capitation amounts.(5) The department shall be fully responsible for all costs in excess of the APM supplemental capitation amounts that are more than 1 percent above the APM supplemental capitation amounts.(6) The department shall fully retain the revenues paid through the APM supplemental capitation amounts in excess of the costs incurred greater than 1 percent below the supplemental capitation amounts.(c) The department shall develop specific contract language to implement the requirements of this section that shall be incorporated into the contracts of each affected principal health plan.(d) This section shall be implemented only to the extent that any necessary federal approvals or waivers are obtained.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.18 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.18.

14138.18.  (a) The department, in consultation with interested FQHCs and principal health plans, may modify any methodology, process, or provision specified in this article to the extent necessary to comply with federal law or to obtain any necessary federal approvals.(b) This article shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.(c) In the event of a conflict between a provision in this article and the terms of a federally approved APM, the terms of the federally approved APM shall control.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.19 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.19.

14138.19.  In the event of an epidemic, or similar catastrophic occurrence that the department determines is likely to result in at least a 30 percent increase in actual utilization per member per month within the APM scope of services for one or more APM aid categories at a participating FQHC site, the department may adjust, or require the adjustment of, payments made pursuant to this article as it deems necessary to account for the utilization increase at the affected participating FQHC site. The department shall make the determination described in this section upon written request of a participating FQHC site.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.21 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.21.

14138.21.  (a) This article shall not be deemed to affect the amounts paid or the reimbursement methodology applicable to FQHCs for dental services that are provided outside the scope of a contract between the department and an applicable principal health plan that is in effect as of July 1, 2015.(b) The department shall contract with an independent entity to perform an evaluation of the APM pilot project authorized pursuant to this article. To the extent practicable, the evaluation shall be completed and provided to the appropriate fiscal and policy committees of the Legislature within six months of the conclusion of the pilot project in those counties that are included in the initial pilot project implementation authorized pursuant to paragraph (2) of subdivision (a) of Section 14138.12. The department shall carry out the duty imposed pursuant to this subdivision only if there are sufficient private foundation or nonprofit foundation funds available for this purpose. A report submitted pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code.(c) The evaluation by the independent entity shall assess and report on whether the APM pilot project produced improvements in access to primary care services, care quality, patient experience, and overall health outcomes for APM enrollees. The evaluation shall include existing FQHC required quality metrics and an assessment of how the changes in financing allowed for alternative types of primary care visits and alternative encounters between the participating FQHC and the patient and how those changes affected volume of same-day visits for mental and physical health conditions. The evaluation shall also assess whether the APM pilot project’s efforts to improve primary care resulted in changes to patient service utilization patterns, including the reduced utilization of avoidable high-cost services and services provided outside the FQHC. The evaluation shall also identify any administrative and financial implementation issues for FQHCs that may arise if subsequent legislation makes the pilot program operative statewide.(Amended by Stats. 2016, Ch. 86, Sec. 322. (SB 1171) Effective January 1, 2017.)
CA Welf & Inst Code § 14138.22 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.22.

14138.22.  (a) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.(b) Beginning January 1, 2017, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature regarding any instruction issued by the department pursuant to subdivision (a) on a semiannual basis until six months after implementation of the pilot project authorized pursuant to this article.(c) It is the intent of the Legislature, if the scope of the pilot project authorized by this article is extended, that the department adopt regulations to implement this article.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.23 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.1 - Payment Reform Pilot Program for Federally Qualified Health Centers|Section 14138.23.

14138.23.  For purposes of implementing this article, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance. Any contract entered into or amended pursuant to this section shall be exempt from Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code, and shall be exempt from the review or approval of any division of the Department of General Services.(Added by Stats. 2015, Ch. 760, Sec. 1. (SB 147) Effective January 1, 2016.)
CA Welf & Inst Code § 14138.5 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.2 - Reinvestment of Savings|Section 14138.5.

14138.5.  The State Department of Health Services shall report to the Legislature on a biennial basis on all of the following data with respect to the child health and disability prevention program provided for pursuant to Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code:(a) The number of children, by age and by county, enrolled in each plan contracting with the department or with the California Medical Assistance Commission.(b) The improved reporting capabilities of the new contract for the Management Information System/Decision Support System (MIS/DSS), with specific emphasis on how it can be used to gather data from the PM 160 forms that are useful for analytical purposes.(c) Information on what actions are being taken to ensure compliance with Child Health and Disability Prevention Program examination requirements.(d) The statewide percentage of all children enrolled in managed care plans, by age, who received a comprehensive Child Health and Disability Prevention Program examination, and the percentage of all children enrolled who received a comprehensive Child Health and Disability Prevention Program examination, by county and by plan.(e) The number of children in each plan, by age, who are current on periodicity health assessments, with appropriate documentation. If the capability to report this information does not exist, a timeline of when the information will be available and the barriers that exist to reporting the information.(f) The number of children in each plan, by county and by age, who were referred for followup diagnosis or treatment following a Child Health and Disability Prevention Program comprehensive examination.(g) The number of children in each plan, by county and by age, who received needed diagnosis and treatment as a result of a Child Health and Disability Prevention Program examination. If the capability to report this information does not exist, a timeline of when it will be available and the barriers that exist to reporting this information.(Amended by Stats. 2001, Ch. 745, Sec. 255. Effective October 12, 2001.)
CA Welf & Inst Code § 14139 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 4.2 - Reinvestment of Savings|Section 14139.

14139.  (a) The department shall expend, upon appropriation, any savings accrued from the establishment and implementation of a bulk purchase vaccine program to increase the participation of physicians and surgeons, public and community-based health clinics, and health care facilities as immunization providers under the Medi-Cal program and under the child health and disability prevention programs established pursuant to Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code and to increase access to, and the quality of, immunization services for publicly insured and uninsured children, and to provide funding to counties to assist in the administration of local immunization programs. These funds shall supplement, not supplant, existing state and local funds.(b) The department shall implement subdivision (a) at the earliest possible time after a bulk purchase program for child vaccines is implemented and savings from that program are realized.(c) The department is encouraged to enlist the help of state and local medical, nursing, and other appropriate associations and societies to enhance private provider outreach programs, that shall include, but not be limited to, components emphasizing the purposes of the public vaccine program and discouraging the practice of sending Medi-Cal and child health and disability prevention program eligible children into county and other public clinics for immunizations.(Amended by Stats. 1996, Ch. 1023, Sec. 479. Effective September 29, 1996.)