reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.792.

14124.792. If any provision of this article, or the application of any provision of this article to any person, firm, corporation, or other entity or to any circumstance or situation, shall be held invalid, the remaining provisions of this article shall not be affected thereby, and shall be given effect.
(Added by Stats. 2007, Ch. 188, Sec. 74. Effective August 24, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.795.

14124.795. It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has other available health coverage or insurance, the Medi-Cal program shall be the payer of last resort. Notwithstanding any other provision of law, any carrier described in Section 14124.70, including automobile, casualty, property, and malpractice insurers, shall enter into an agreement with the department to permit and assist the matching of the department’s Medi-Cal eligibility file against the carrier’s claim files, utilizing, if necessary, social security numbers as common identifiers for the purpose of determining whether Medi-Cal benefits were provided to a beneficiary because of an injury for which another person is liable, or for which a carrier is liable in accordance with the provisions of any policy of insurance. The carrier shall maintain a centralized file of claimants’ names, mailing addresses, and social security numbers or dates of birth. This information shall be made available to the department upon the department’s reasonable request. The agreement described in this section shall include financial arrangements for reimbursing carriers for necessary costs incurred in furnishing requested information.
(Added by Stats. 2003, Ch. 230, Sec. 70. Effective August 11, 2003.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.81.

14124.81. (a) The department shall administer the provisions of Sections 14124.82 to 14124.86, inclusive, pertaining to the State Department of Health Care Services’ administration of the personal injury and workers’ compensation recovery programs.
(b) An attorney or the beneficiary, guardian, personal representative, estate, or survivors of any of those, who are mandated under Section 14124.79 to report Medi-Cal involvement are excluded from any further remuneration benefits under Sections 14124.82 to 14124.86, inclusive.
(Repealed and added by Stats. 2017, Ch. 52, Sec. 38. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.82.

14124.82. (a) The department, in its reasonable discretion, may execute one or more at-risk performance contracts to identify, quantify, or recover, or any combination thereof, Medi-Cal payments from responsible third parties and carriers that may be subject to a claim for reimbursement.
(b) Priority, by the terms of the contract or contracts, shall be given to the identification and recovery of claims nearing the statute of limitation, prior adjudicated claims, and prior existing injury claims. However, all claims that are older, in whole or part, than 12 months, at the time of discovery and notification by the contractor to the department, shall be subject to contractual lien recovery unless departmental personnel have previously identified these claims and have filed appropriate liens, notices, or other payment demands. A claim arises and the 12-month period begins when the department or its fiscal agent has first made payment for medical services related to the personal or workers’ compensation action on behalf of a given recipient. The department may waive any time requirement, if it concludes that it will not otherwise discover the claim and be able to effect recovery.
(c) To implement this section, the department may contract with public or private entities. Contracts or amendments entered into under this section may be on an exclusive or nonexclusive basis, and on a noncompetitive bid basis. The contracts and amendments shall be exempt from all of the following:
(1) Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code and any policies, procedures, or regulations authorized by that part.
(2) Article 4 (commencing with Section 19130) of Chapter 5 of Part 2 of Division 5 of Title 2 of the Government Code.
(3) Review or approval of contracts by the Department of General Services.
(Amended by Stats. 2017, Ch. 52, Sec. 39. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.83.

14124.83. The agreement shall include, but is not limited to, the following provisions:
(a) The agreement shall stipulate when the contractor may identify, quantify, or recover amounts owing by third parties that may be subject to a claim for reimbursement.
(b) Payment to the contractor shall be based upon a no cost percentage of recovery formula, which shall not exceed 25 percent of the gross recovery upon the claim. It is the intent of the Legislature that “no cost” include all considerations for court costs, legal fees, and the universe of the case processing activity, not including, however, departmental processing.
(c) Payment for amounts determined to be owed to the state by third parties and carriers shall be made directly to the state.
(d) A bond in the amount required by the state for collection agencies shall be sufficient.
(e) Contractor’s files shall be subject to audit, pursuant to the contract, but shall remain the property of the contractor. At the request of the department, the contractor shall provide copies of any claims related to a particular recovery.
(f) The contractor shall report periodically to the department concerning its progress in the discovery of cases and the recovery of amounts subject to claim, and shall provide other information as the department may require, and at a reasonable frequency, to adequately monitor the progress of the contractor.
(Amended by Stats. 2017, Ch. 52, Sec. 40. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.84.

14124.84. The department shall provide the contractor with such information as is reasonably necessary for the contractor to perform its obligations under the contract, including accounting data and other information the contractor may request.
(Added by Stats. 1981, Ch. 102, Sec. 122. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.86.

14124.86. The contractor shall retain its rights to compensation upon recovery for completed duties under the contract with respect to any claims or liens processed in whole or in part prior to the termination date of the agreement.
(Repealed and added by Stats. 2017, Ch. 52, Sec. 43. (SB 97) Effective July 10, 2017.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.89.

14124.89. (a) (1) This section applies to all of the following entities:
(A) Health insurer, or any health care entity licensed through the Department of Insurance.
(B) Self-insured plan.
(C) Group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974.
(D) Service benefit plan.
(E) Managed care organization, including a health care service plan as defined in subdivision (f) of Section 1345 of the Health and Safety Code, 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).
(F) Pharmacy benefit manager.
(G) Third-party administrator.
(H) Union trust.
(I) Other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
(2) The entities listed in paragraph (1) shall, upon request of the department for any records, or any information contained in records pertaining to an individual or group health insurance policy or plan issued by such insurer or plan against, or pertaining to the medical or dental benefits paid by or claims made against such insurer or plan under a policy or plan, make the requested records or information available upon a certification by the department that the individual is an applicant for or recipient of services under this chapter or is a person who is legally responsible for such an applicant or recipient.
(b) The entities listed in paragraph (1) of subdivision (a) shall enter into a cooperative agreement with the department setting forth mutually agreeable procedures for the provision of appropriate information, not inconsistent with any law pertaining to the confidentiality and privacy of medical records, at no cost to the department, within 90 days of the department’s request.
(c) The information required to be made available pursuant to this section shall be limited to information necessary to determine whether health benefits have been or should have been claimed and paid pursuant to a health insurance policy or plan with respect to items of medical care and services received by a particular individual for which Medi-Cal coverage would otherwise be available.
(d) Not later than the date upon which the procedures agreed to pursuant to subdivision (b) become effective, the director shall establish guidelines to assure that information relating to an individual certified to be an applicant for or recipient of medical assistance, furnished to any insurer or plan pursuant to this section, is used only for the purpose of identifying the records or information requested in such manner so as not to violate the confidentiality of an applicant or recipient.
(Amended by Stats. 2021, Ch. 143, Sec. 381. (AB 133) Effective July 27, 2021.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.91.

14124.91. The State Department of Health Services shall, whenever it is cost-effective, pay the premium for third-party health coverage for beneficiaries under this chapter. The State Department of Health Services shall, when a beneficiary’s third-party health coverage would lapse due to loss of employment or change in health status, lack of sufficient income or financial resources, or any other reason, continue the health coverage by paying the costs of continuation of group coverage pursuant to federal law or converting from a group to an individual plan, whenever it is cost-effective. Notwithstanding any other provision of a contract or of law, the time period for the department to exercise either of these options shall be 60 days from the date of lapse of the policy.
(Amended by Stats. 1992, Ch. 722, Sec. 109. Effective September 15, 1992. Note: The amendment by Stats. 2003, Ch. 673, did not take effect because Ch. 673 was rejected as referendum Proposition 72 at the November 2, 2004, election.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.92.

14124.92. (a) The department may pay administrative expenses and make incentive payments to any county, state, or federal agency, or a contracting agent of the department for identifying and reporting third-party health care coverage held or offered to beneficiaries under this chapter.
(b) Unless the third-party health care coverage identified is excluded under subdivision (d) from the incentive payment plan, an agency or contractor may be entitled to an incentive payment if the agency or contractor does all of the following:
(1) Identifies a case of which the department was not previously aware.
(2) Provides to the department adequate and necessary information relevant to the third-party health care coverage in order to make a claim for benefits or reimbursement for services rendered that would otherwise be paid by Medi-Cal.
(3) Reports to the department the identified third-party health care coverage within 30 days of the date of discovery on a form approved by the department.
(c) In no event shall any one incentive for each case identified exceed one month of savings received by the department for benefits paid by the third-party health care coverage.
(d) Third-party health care coverage that does not qualify for the incentive payment plan under this section shall be identified by the department based on policy limitations and cost-effectiveness. The types of coverage that do not qualify under this section include those that to which any of the following apply:
(1) Not specifically intended to provide third-party health care coverage, such as coverage that provides life or car insurance benefits, periodic benefits for disability or hospitalization, or income protection.
(2) Coverage is limited to a specific diagnosis, unless the beneficiary has been diagnosed with a condition or disease specified in the coverage.
(3) Coverage is limited to a specific circumstance, such as accidental injury or dismemberment.
(4) Coverage is limited to one specific category of service.
(e) For the purposes of this section, “third-party health care coverage” means health care service plans, benefits, insurance policies, and funds, including those described in Section 14124.90.
(Added by Stats. 1992, Ch. 722, Sec. 110. Effective September 15, 1992.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.5 - Third Party Liability › Section 14124.94.

14124.94. (a) When the rights of a Medi-Cal beneficiary to health care benefits from an insurer have been assigned to the department, an insurer shall not impose any requirement on the department that is different from any requirement applicable to an agent or any assignee of the covered beneficiary.
(b) The department, in the administration of the Medi-Cal program, may garnish the wages, salary, or other employment income of, and withhold amounts from state tax refunds from, any person to whom both of the following apply:
(1) The person is required by a court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under the Medi-Cal program.
(2) The person has received payment from a third party for the costs of the health services for the child, but he or she has not used the payments to reimburse, as appropriate, either the other parent or the person having custody of the child, or the provider of the health services, to the extent necessary to reimburse the department for expenditures for those costs under the Medi-Cal program. All claims for current or past due child support shall take priority over claims made by the department for the costs of Medi-Cal services.
(c) For purposes of this section, “insurer” includes every health insurer, self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, including health care service plans as defined in subdivision (f) of Section 1345 of the Health and Safety Code, 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), pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
(Amended by Stats. 2007, Ch. 188, Sec. 77. Effective August 24, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.

14125. (a) The purpose of this article is to establish provider reimbursement rates for incontinence medical supplies covered by the Medi-Cal program. Reimbursement for incontinence medical supplies shall consist of the negotiated contract prices within each product category, plus a markup fee equal to 38 percent of the contract price.
(b) (1) In establishing the list of incontinence medical supplies, the department may enter into exclusive or nonexclusive contracts on a bid or negotiated basis with manufacturers, distributors, dispensers, or suppliers of incontinence medical supplies.
(2) To ensure that the health needs of Medi-Cal beneficiaries are met, the department shall, when evaluating a decision to execute a contract, and when evaluating incontinence medical supplies for retention on, addition to, or deletion from, the list of incontinence medical supplies, consider all of the following criteria:
(A) The safety of the product.
(B) The effectiveness of the product.
(C) The essential need for the product.
(D) The potential for misuse of the product.
(E) The immediate or long-term cost-effectiveness of the product.
(3) The deficiency of a product when measured by one of the criteria specified in paragraph (2) may be sufficient to support a decision that the product should be deleted from, should not be added to, or should not be retained on, the list of medical supplies. However, the superiority of a product under one criterion may be sufficient to warrant the addition or retention of the product, notwithstanding a deficiency in another criterion.
(4) In the evaluation of the effectiveness of a product, the department may require the manufacturer, distributor, dispenser, or supplier to submit their products to testing by an independent laboratory. For the purposes of this section, “independent laboratory” means an analytical laboratory that is not a subsidiary of, affiliated with, or on retainer for, the manufacturer, distributor, dispenser, or supplier.
(c) The department may use Healthcare Common Procedure Code System codes or Universal Product Number codes for the processing and payment of incontinence medical supplies.
(Amended by Stats. 2007, Ch. 188, Sec. 78. Effective August 24, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.1.

14125.1. Unless the context requires otherwise, the definitions set forth in this section shall govern the construction and meaning of the terms and phrases used in this article.
(a) “Incontinence medical supplies” means disposable medical supplies that are covered benefits under the Medi-Cal program pursuant to subdivision (s) of Section 14132 when prescribed by a physician for the treatment of individuals who are incontinent. Incontinence medical supplies include, but are not limited to, disposable diapers, briefs, underpads, undergarments, liners or pads, pant and pad systems, and skin care products.
(b) “Department” means the State Department of Health Services.
(c) “Manufacturer” means any person, partnership, or corporation who assembles or combines the components of incontinence supplies into a final product sold to dealers.
(d) “Principal labeler” means any person, partnership, or corporation who purchases from a manufacturer an assembled product which is sold to dealers under the principal labeler’s label.
(e) “Dealer” means any person, partnership, corporation, or other entity that is recognized by the manufacturer or principal labeler as a provider or retail outlet for its line of incontinence medical supplies, and which provide these supplies directly to consumers. The term “dealer” includes a retailer.
(Amended by Stats. 1992, Ch. 722, Sec. 112. Effective September 15, 1992.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.2.

14125.2. (a) (1) To qualify for Medi-Cal coverage a product shall be in general retail distribution, sold to the general public, and comply with any standards for products established by law or regulation. No product that is manufactured, distributed, or otherwise promoted for the exclusive use of beneficiaries of the Medi-Cal program shall be a Medi-Cal benefit.
(2) For purposes of this section, “product” means any product which is in general retail distribution.
(3) For purposes of this subdivision, “general retail distribution” means either of the following:
(A) The product is included in a listing of approved products for purchase either by the federal or state government.
(B) The product is on display and available for purchase by customers for private payment at licensed pharmacies or licensed medical supply dealers within California which are physical locations open to the general public.
(b) In order to qualify as a Medi-Cal provider of incontinence medical supplies, a dealer shall have an established place of business that is readily identifiable as a medical supply business, be open to the general public at regularly established business hours, have incontinence supplies in stock on the premises or in a warehouse under the provider’s direct control, and meet all local laws and ordinances regarding business licensing and operations. The department shall establish additional rules and regulations for participation in the Medi-Cal program as it deems necessary to ensure adequate safeguards to the integrity of the Medi-Cal program.
(Amended by Stats. 2007, Ch. 188, Sec. 79. Effective August 24, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.3.

14125.3. The department shall reduce the weighted average of the negotiated contract prices within each product category in effect on June 30, 1992, as follows:
(a) For all premium underpads, as defined by the department, by 24 percent.
(b) For all other incontinence medical supply products, as defined by the department, by 14 percent.
(Repealed and added by Stats. 1992, Ch. 1106, Sec. 4. Effective January 1, 1993.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.4.

14125.4. (a) No later than January 1, 1994, the department shall establish utilization controls that limit expenditures for incontinence medical supplies per beneficiary to no more than one hundred sixty-five dollars ($165) per month. Incontinence creams and washes shall be excluded from this limitation. The expenditure limit established by this section may be adjusted in the annual Budget Act to reflect changes in wholesale prices. These utilization controls shall be published in provider bulletins.
(b) The department shall, by prior authorization, allow a beneficiary to exceed the utilization limits established by this section when justified to the department’s satisfaction not later than January 1, 1994.
(c) Notwithstanding any other provision of law, no regulations shall be necessary to define the incontinence medical supplies subject to the reductions required in Section 14125.3, or to establish and implement the utilization controls required in this section.
(Amended by Stats. 1994, Ch. 813, Sec. 3. Effective January 1, 1995.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.8.

14125.8. (a) In order to more fully identify the owner or owners of companies or corporations that apply to be or currently are providers of incontinence medical supplies, within 30 days of the receipt of a request from the department, or a request to the department from the Department of Justice, the applicant or provider shall provide, as part of the application process or as a condition of continued participation in the Medi-Cal program, the following:
(1) The name of the corporation, the official titles of the applicants, and a list of all the corporate officers.
(2) The California driver’s license or California identification card number of the applicants, coowners, corporate officers, and financially interested parties.
(3) The applicant’s business permit control number, issued by the State Board of Equalization, for the business location where services are rendered to the public.
(4) A statement of all current sources of capital, identity of all investors, disclosure of all manufacturers, suppliers, and providers currently doing business with the applicant, and disclosure of all entities to whom the applicant has extended a line of credit.
(5) A statement certifying that all information supplied pursuant to this section is accurate.
(b) A Medi-Cal provider of incontinence supplies shall not submit a claim for goods or services to the department prior to the date the goods or services are delivered to the Medi-Cal beneficiary. The date of delivery to a beneficiary shall be the earlier of the date the beneficiary actually received the goods or services, or the date the goods were posted or otherwise dispatched from the provider’s premises and control. A claim submitted to the department prior to the date of delivery shall not be paid. Violation of this subdivision shall be grounds for expulsion from the Medi-Cal program.
(c) The department may implement a 180-day moratorium on the enrollment of new providers or new business addresses for incontinence medical supply dealers when the department determines this action is necessary to safeguard public funds or to maintain the fiscal integrity of the program.
(Amended by Stats. 2007, Ch. 188, Sec. 80. Effective August 24, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.7 - Incontinence Medical Supplies › Section 14125.9.

14125.9. Nothing in this article shall be interpreted as limiting or interfering in any way with the department’s authority to contract for the provision of incontinence medical supplies pursuant to subdivision (b) of Section 14105.3.
(Amended by Stats. 2006, Ch. 538, Sec. 705. Effective January 1, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.

14126. This article shall be known as the Medi-Cal Long-Term Care Reimbursement Act.
(Repealed and added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.02.

14126.02. (a) It is the intent of the Legislature to devise a Medi-Cal long-term care reimbursement methodology that more effectively ensures individual access to appropriate long-term care services, promotes quality resident care, advances decent wages and benefits for nursing home workers, supports provider compliance with all applicable state and federal requirements, and encourages administrative efficiency.
(b) The department shall implement a facility-specific ratesetting system, subject to federal approval and the availability of federal funds, that reflects the costs and staffing levels associated with quality of care for residents in nursing facilities, as defined in subdivision (c) of Section 1250 of the Health and Safety Code, except that the ratesetting system shall not apply to a unit that provides pediatric subacute services in a skilled nursing facility, or to a skilled nursing facility that is designated as an institution for mental diseases, as defined in Section 1396d(i) of Title 42 of the United States Code. The facility-specific ratesetting system shall be effective commencing on August 1, 2005, and shall be implemented commencing on the first day of the month following federal approval. The department may retroactively increase and make payment of rates to facilities.
(c) In implementing this section, the department may contract as necessary, on a bid or nonbid basis, for professional consulting services from nationally recognized higher education and research institutions, or other qualified individuals and entities not associated with a skilled nursing facility, with demonstrated expertise in long-term care reimbursement systems. The ratesetting system specified in subdivision (b) shall be developed with all possible expedience. This subdivision establishes an accelerated process for issuing contracts pursuant to this section and contracts entered into pursuant to this subdivision shall be exempt from the requirements of Chapter 1 (commencing with Section 10100) and Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.
(d) The department shall implement a facility-specific ratesetting system by August 1, 2004, subject to federal approval and availability of federal or other funds, that reflects the costs and staffing levels associated with quality of care for residents in hospital-based nursing facilities.
(Amended by Stats. 2005, Ch. 508, Sec. 8. Effective October 4, 2005. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.021.

14126.021. The department shall develop and implement a cost-based reimbursement rate methodology using the cost categories as described in Section 14126.023, for freestanding nursing facilities pursuant to this article, excluding nursing facilities that are a distinct part of a facility that is licensed as a general acute care hospital as identified pursuant to subdivision (d) of Section 14126.02. The cost-based reimbursement rate methodology shall be effective on August 1, 2005, and shall be implemented on the first day of the month following federal approval.
(Added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.025.

14126.025. (a) The department shall seek approval of an amendment to the Medicaid state plan specifically outlining the reimbursement methodology developed pursuant to this article not later than February 1, 2005.
(b) The amendment to the Medicaid state plan pursuant to subdivision (a), and any regulations, provider bulletins, or other similar instructions, shall be prepared in consultation with representatives of the long-term care industry, organized labor, seniors, and consumers.
(Added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.027.

14126.027. Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the director may implement this article, in whole or in part, by means of provider bulletins or other similar instructions, without taking regulatory action. The department shall make use of appropriate processes to ensure that affected stakeholders are informed of, and have access to, applicable guidance issued pursuant to this authority in a timely manner, and that this guidance remains publicly available while this article remains operative.
(Amended by Stats. 2020, Ch. 13, Sec. 12. (AB 81) Effective June 29, 2020. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.028.

14126.028. (a) The Legislature finds and declares both of the following:
(1) Section Q of the Minimum Data Set, Version 3.0, developed as part of the federal government’s nursing home quality initiative, uses a person-centered approach to ensure that all individuals have the opportunity to learn about home- and community-based services and have the opportunity to receive long-term care services in the least restrictive setting possible.
(2) More community care services and support options and choices are now available to meet the care preferences and needs in the least restrictive setting possible.
(b) Nursing facilities shall either meet the residents’ discharge planning and referral needs, or make referrals to a designated local contact agency (LCA) as determined by the State Department of Health Care Services. The LCA is responsible for contacting referred residents, and for providing information and counseling on available home- and community-based services. The LCA shall also either assist directly with transition services or make referrals to organizations that assist with transition services, as appropriate.
(c) It is the intent of the Legislature to ensure that nursing home residents who, during the Minimum Data Set, Version 3.0, Section Q assessment, express interest in the possibility of receiving care and services in the community are appropriately referred by nursing facilities to the LCA, as appropriate.
(d) The State Department of Health Care Services, in collaboration with the State Department of Public Health, shall, by April 1, 2013, provide the Legislature an analysis of the appropriate sections of the Minimum Data Set, Version 3.0, Section Q and nursing facilities referrals made to the LCA. This analysis shall also document the LCA’s response to referrals from nursing facilities and the outcomes of those referrals.
(e) The State Department of Public Health and the State Department of Health Care Services shall regularly, and at least quarterly, meet with representatives from the long-term care industry, organized labor, consumers, and consumer advocates to provide updates and receive input on the planning for, implementation of, and progress of the skilled nursing facility quality improvement program. To facilitate decisionmaking, the State Department of Public Health and the State Department of Health Care Services shall promptly convene this workgroup and provide ongoing guidance to reach tangible outcomes for implementation by no later than January 2013.
(Added by Stats. 2012, Ch. 631, Sec. 7. (AB 1489) Effective September 27, 2012. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.031.

14126.031. (a) In implementing this article, the department may use the process outlined in subdivision (c) of Section 14126.02 to obtain professional consulting services for the purpose of finalizing design of the system, procurement of required technical hardware and software, establishing operational parameters, implementation, and transitional management pending assumption of operational management by state staff.
(b) The ratesetting system described in subdivision (b) of Section 14126.02 shall be developed expeditiously in order to meet the implementation date required under Section 14126.02.
(c) To ensure compliance with the timeframes set forth in this article, it is the intent of the Legislature that the department be authorized to hire up to three full-time equivalents to support implementation and continuous operation of the system.
(Added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Conditionally inoperative as provided in subd. (a) of Section 14126.035. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.035.

14126.035. (a) This article shall remain operative only as long as Article 7.6 (commencing with Section 1324.20) of Chapter 2 of Division 2 of the Health and Safety Code, which imposes a skilled nursing facility quality assurance fee continues as approved by the federal Centers for Medicare and Medicaid Services pursuant to Section 1324.27 of the Health and Safety Code.
(b) In the event of 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 Centers for Medicare and Medicaid Services, that federal financial participation is not available with respect to any payment made under the methodology implemented pursuant to this article because the methodology is invalid, unlawful, or is contrary to any provision of federal law or regulations, or of state law, this section shall become inoperative.
(Added by Stats. 2004, Ch. 875, Sec. 5. Effective September 29, 2004. Inoperative after December 31, 2026, pursuant to Section 14126.036. Repealed as of January 1, 2028, pursuant to Section 14126.036. Note: Termination clause in subd. (a) affects Article 3.8, commencing with Section 14126.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.8 - Medi-Cal Long-Term Care Reimbursement Act › Section 14126.036.

14126.036. This article shall become inoperative after December 31, 2026, except that the department shall be authorized to conduct all necessary closeout activities after this date and to continue implementing this article for any rate period before December 31, 2026, and as of January 1, 2028, this article is repealed, unless a later enacted statute that is enacted before, January 1, 2028, deletes or extends that date.
(Amended by Stats. 2022, Ch. 46, Sec. 13. (AB 186) Effective June 30, 2022. Repealed as of January 1, 2028, by its own provisions. Note: Termination clause affects Article 3.8, commencing with Section 14126 (except Section 14126.022).)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.91 - Medi-Cal Emergency Medical Transportation Reimbursement Act › Section 14129.1.

14129.1. (a) (1) The department shall establish the manner and format for emergency medical transport providers to report the data required pursuant to this section.
(2) The department may establish an Internet Web site for the submission of reports required by this section.
(3) The department may require a certification by each emergency medical transport provider under penalty of perjury of the truth of the reports required under this section. Upon written notice to an emergency medical transport provider, the department may impose a penalty of one hundred dollars ($100) per day against an emergency medical transport provider for every day that an emergency medical transport provider fails to make a report required by this section within five days of the date upon which the report was due. Any funds resulting from a penalty imposed pursuant to this paragraph shall be deposited in the Medi-Cal Emergency Medical Transport Fund created pursuant to subdivision (f) of Section 14129.2.
(b) Each emergency medical transport provider shall report to the department data on the number of actual emergency medical transports by payer type, including, without limitation, Medi-Cal fee-for-service emergency medical transports and Medi-Cal managed care emergency medical transports per quarter, as follows:
(1) For each quarter beginning on July 1, 2015, through the quarter beginning on July 1, 2017, inclusive, the data shall be submitted on or before October 15, 2017.
(2) For the quarter beginning on October 1, 2017, and continuing each quarter thereafter, the data shall be submitted on or before the 45th day after the last day of the applicable quarter.
(c) Each emergency medical transport provider shall report to the department data on the gross receipts received from the provision of emergency medical transports per state fiscal year, as follows:
(1) For the state fiscal years beginning on July 1, 2015, and July 1, 2016, the data shall be submitted on or before October 15, 2017.
(2) For each state fiscal year beginning on July 1, 2017, and continuing each state fiscal year thereafter, the data shall be submitted on or before the 45th day after the last day of the applicable state fiscal year.
(Added by Stats. 2017, Ch. 773, Sec. 2. (SB 523) Effective October 13, 2017. Conditionally inoperative as prescribed in Section 14129.7. Repealed conditionally as provided in Section 14129.7.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.91 - Medi-Cal Emergency Medical Transportation Reimbursement Act › Section 14129.4.

14129.4. If there is a delay in the implementation of this article for any reason, including a delay in any required approval of the quality assurance fee and reimbursement methodology specified by the federal Centers for Medicare and Medicaid Services, both of the following shall apply:
(a) An emergency medical transport provider subject to the fee may be assessed the amount the provider would be required to pay to the department if the add-on increase to the fee-for-service payment schedule described in Section 14129.3 were already approved, but shall not be required to pay the fee until the add-on increase to the fee-for-service payment schedule described in Section 14129.3 is approved. The director shall establish a schedule for payment of retroactive fees pursuant to this subdivision in consultation with emergency medical transport providers to minimize the disruption to the cashflow of emergency medical transport providers.
(b) The department may retroactively implement the add-on increase to the fee-for-service payment schedule pursuant to Section 14129.3 to the extent the department determines that federal financial participation is available and is not otherwise jeopardized.
(Added by Stats. 2017, Ch. 773, Sec. 2. (SB 523) Effective October 13, 2017. Conditionally inoperative as prescribed in Section 14129.7. Repealed conditionally as provided in Section 14129.7.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3.91 - Medi-Cal Emergency Medical Transportation Reimbursement Act › Section 14129.5.

14129.5. 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 provider bulletins, plan letters, or other similar instructions, without taking regulatory action. The department shall provide notification to the fiscal and appropriate policy committees of the Legislature within 10 business days after the above-described action is taken. The department shall make use of appropriate processes to ensure that affected stakeholders are timely informed of, and have access to, applicable guidance issued pursuant to this authority, and that this guidance remains publicly available so long as this article remains operative.
(Added by Stats. 2017, Ch. 773, Sec. 2. (SB 523) Effective October 13, 2017. Conditionally inoperative as prescribed in Section 14129.7. Repealed conditionally as provided in Section 14129.7.)