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 2.9 - Primary Care Provider Case Management › Section 14088.18.

14088.18. (a) In order to increase the number of nonprofit providers under this article, the department may enter into contracts each fiscal year under this section with eligible nonprofit organizations to provide a one-time interest-bearing loan, repayable at the Pooled Money Investment Account rate, to that eligible organization.
(b) Contracts entered into pursuant to this section shall be limited to contracts within those counties where the department does not have contracts authorized by this article on the effective date of this section.
(c) Any loan entered into pursuant to this section shall not exceed one hundred thousand dollars ($100,000).
(d) The department shall adopt standards and procedures for loan applications and repayment of the loans made pursuant to this section.
(e) The department shall make no loan pursuant to this section until the department has made savings payments to contractors who have entered into contracts under this article on or before the effective date of this section.
(f) For purposes of this section, “eligible nonprofit organization” means any organization which meets all of the following requirements:
(1) The organization is exempt from taxation under Section 501(c)(3) or 501(c)(25)(C)(iii) of the federal Internal Revenue Code.
(2) The organization is organized to provide health care to the medically underserved and to provide services in service areas.
(Amended by Stats. 1998, Ch. 834, Sec. 5. Effective January 1, 1999.)
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 2.9 - Primary Care Provider Case Management › Section 14088.19.

14088.19. (a) The department may enter into primary care case management contracts pursuant to this article with any health care service plan that is licensed by the Director of the Department of Managed Health Care pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
The terms of the contracts entered into pursuant to this section shall be exempt from those provisions of Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code that regulate health care service plan contracts. Nothing in this section shall preclude the Director of the Department of Managed Health Care from otherwise regulating a health care service plan subject to the Knox-Keene Health Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
(b) When a health care service plan enters into a contract pursuant to this article and also pursuant to Chapter 8 (commencing with Section 14200), there shall be no duplication of service areas between the two contracts without prior written approval by the department.
(Amended by Stats. 2000, Ch. 857, Sec. 87. Effective January 1, 2001.)
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 2.9 - Primary Care Provider Case Management › Section 14088.22.

14088.22. Sections 14408, 14409, 14410, and 14411 shall apply to primary care case management plans.
(Amended by Stats. 1995, Ch. 859, Sec. 4. Effective January 1, 1996.)
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 2.9 - Primary Care Provider Case Management › Section 14088.25.

14088.25. (a) The department may conduct onsite reviews of a provider or facility that has agreed with the primary care case management contractor or a potential contractor to provide services to beneficiaries enrolled with the contractor. These reviews may be for purposes such as evaluating the capabilities of potential contractors, monitoring quality of care, investigating complaints, and ensuring contractor compliance with the terms of the contract entered into pursuant to this article.
(b) Prior to adding a provider or facility to an existing network of providers and facilities, the primary care case management contractor shall submit a complete prequalification package to the department. The department shall provide to the contractor written acknowledgment that the package is complete within 10 working days.
(c) (1) If the provider or facility proposed for addition to the contractor’s existing network is currently enrolled in the Medi-Cal program, the provider or facility may begin treating beneficiaries enrolled with the contractor immediately upon the contractor’s receipt of the acknowledgment required by subdivision (b), subject to paragraph (2) and subdivision (d).
(2) Whenever warranted, the department may rescind the privilege provided for in paragraph (1) by advance notification to the contractor, pending the onsite review required by subdivision (d). Notification shall be in writing and describe the conditions that support the rescission of the privilege.
(d) (1) The department shall conduct an onsite review of the provider or facility within a reasonable period of time after receipt of the package, which shall be not more than 60 days after receipt of the package, unless there are extenuating circumstances.
(2) The department shall notify the contractor in writing of the department’s final decision on the request to add the provider or facility to the contractor’s existing network within 10 working days of the date of the review.
(e) In the conduct of the onsite review of the provider or facility, the department shall not condition approval of the site on adherence by the provider or facility to requirements that are not contained in any statute, regulation, or commonly accepted community standard of medical practice that directly applies to the category of provider or facility being inspected. This subdivision does not, however, relieve the contractor of any obligations under the contract entered into pursuant to this article.
(Amended by Stats. 2007, Ch. 188, Sec. 56. 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 2.91 - Geographic Managed Care Pilot Project › Section 14089.07.

14089.07. (a) The Sacramento County Department of Health and Human Services may establish a stakeholder advisory committee to provide input on the delivery of health care services provided in the county pursuant to this article, Section 14182, and Part 3.6 (commencing with Section 15909). The advisory committee shall include, but not be limited to, Medi-Cal beneficiaries, patient representatives, health care providers, and representatives of Medi-Cal managed care health plans.
(b) The advisory committee may submit written input to the State Department of Health Care Services regarding policies that improve coordination with traditional and safety net providers, enhance the capacity of the county’s health care delivery system, and improve health care services and health outcomes.
(c) The advisory committee may request, in writing, and receive final reports submitted to the department by any managed care health plan operating in Sacramento County as long as the report is not exempt from disclosure pursuant to Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code, or any other contractual, statutory, or legal exemption, or privilege. The advisory committee may review and provide written comments to the department on these reports, that may include issues such as evaluation of access, quality, and consumer protections.
(d) No state General Fund moneys shall be used to fund advisory committee costs, nor to fund any related administrative costs incurred by the county.
(Amended by Stats. 2021, Ch. 615, Sec. 446. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.08.

14089.08. (a) Sacramento County may establish a stakeholder advisory committee to provide input on the delivery of oral health and dental care services, including prevention and education services, dental managed care, and fee-for-service Denti-Cal. The advisory committee shall include, but not be limited to, local nonprofit organizations, representatives from the First Five Sacramento Commission, representatives and members of the local dental society, local health and human services representatives, representatives of Medi-Cal dental managed care plans, Medi-Cal enrollees, and other interested individuals. The advisory committee may meet on a monthly basis.
(b) The advisory committee may submit written input to the State Department of Health Care Services or the Sacramento County Board of Supervisors, as applicable, regarding policies that improve the delivery of oral health and dental services in Sacramento under the Medi-Cal program or county-administered health care system.
(c) The State Department of Health Care Services shall meet periodically, but at least on a quarterly basis, with the advisory committee to facilitate communication, dissemination of information, and improvements in the provision of oral health and dental care services under the Medi-Cal program in the County of Sacramento. The dissemination of information shall include data reported from performance measures and benchmarks used by the department.
(d) The advisory committee may meet periodically, but at least twice annually, with the Sacramento County Department of Health and Human Services advisory committee established pursuant to Section 14089.07.
(e) No state General Fund moneys shall be used to fund advisory committee costs or to fund any related administrative costs incurred by the county.
(Added by Stats. 2012, Ch. 23, Sec. 79. (AB 1467) Effective June 27, 2012.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.1.

14089.1. In accordance with procedures required by Section 14408, all marketing activities shall require prior approval of the department.
(Added by Stats. 1984, Ch. 1509, Sec. 2.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.2.

14089.2. In accordance with procedures required by Chapter 8 (commencing with Section 14200), each contract with a capitated health system shall provide for a grievance procedure under which Medi-Cal beneficiaries may submit their grievances. The department shall establish standards for these procedures to include appeals to an entity other than the capitated health system.
(Added by Stats. 1984, Ch. 1509, Sec. 3.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.3.

14089.3. The department shall not contract with insurance carriers, organized health systems, or provider organizations, that employ or subcontract with plans that employ providers under suspension from the Medicare or Medi-Cal program.
(Added by Stats. 1984, Ch. 1509, Sec. 4.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.4.

14089.4. The department may consult with the Department of Insurance or the Department of Managed Health Care, and shall consult with the Division of Medi-Cal Fraud and Elder Abuse within the Office of the Attorney General, the appropriate licensing boards, and the laboratory field services unit of the department, for the purposes of determining the qualifications, performance capability, and financial stability of prospective contractors.
(Amended by Stats. 2021, Ch. 554, Sec. 10. (SB 823) Effective January 1, 2022.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.5.

14089.5. (a)  The department or its authorized agents shall conduct periodic audits or review, including onsite audits or review, to monitor compliance with Article 4 (commencing with Section 14400) of Chapter 8 with regard to any contract made pursuant to this article. These reviews may be conducted with or without notice and may include assistance by the Attorney General if requested.
(b)  The department may terminate a contract, in whole or in part, when the director determines that this action is necessary to protect the health of the beneficiaries or the funds appropriated to carry out the Medi-Cal program.
(Added by Stats. 1984, Ch. 1509, Sec. 6.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.6.

14089.6. Current prepaid health plan and primary care case management contracts entered into by the department pursuant to Chapter 7 (commencing with Section 14088) and Chapter 8 (commencing with Section 14200) shall not be terminated solely due to the implementation of this article in areas served by prepaid health plans and primary care case management contractors. Upon expiration of these contracts, the department shall enter into good faith negotiations for one renewal of these contracts. These plans may continue to serve their Medi-Cal enrollees and to enroll new beneficiaries. Upon expiration or final termination of these renewal contracts and subject to compliance with all applicable requirements prepaid health plan and primary care case management contractors in the areas shall be allowed the opportunity to participate as new contractors under this article.
(Amended by Stats. 1991, Ch. 95, Sec. 9. Effective June 30, 1991.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.7.

14089.7. (a)  The department may adopt emergency regulations to implement this article in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The initial adoption of emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The initial emergency regulations and the first readoption of those regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations and each shall remain in effect for no more than 180 days.
(b)  All regulations adopted pursuant to this section prior to the repeal and addition of this section by the act adding this section shall remain in full force and effect unless they are repealed or amended by the department in accordance with the Administrative Procedure Act.
(Repealed and added by Stats. 2001, Ch. 171, Sec. 41. Effective August 10, 2001.)
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 2.91 - Geographic Managed Care Pilot Project › Section 14089.8.

14089.8. (a)  In order to achieve maximum cost savings, the Legislature finds and declares that an expedited contract process for contracts under this article is necessary.
(b)  Contracts under this article shall be on a nonbid basis, and shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.
(Amended by Stats. 1998, Ch. 834, Sec. 8. Effective January 1, 1999.)
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 2.95 - Primary Care Provider Enrollment › Section 14092.

14092. It is the purpose of this article to ensure that the Medi-Cal program is operated in the most cost-effective and efficient manner possible by assuring that beneficiaries have early and ongoing access to identified sources of quality primary care who have agreed to accept Medi-Cal patients. In so doing, it is intended to optimally realize the quality of care and health care financing benefits demonstrated by the experience of successful commercial managed care plans when patients affiliate with a single, specified primary care provider and management of patient care is placed within the control of the responsible primary care provider.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.05.

14092.05. For purposes of this article “primary care provider” is defined as set forth in paragraph (1) of subdivision (a) of Section 14088.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.1.

14092.1. The department shall seek all federal waivers necessary to allow federal financial participation in expenditures under this article.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.15.

14092.15. The director shall investigate and may to the extent feasible require that:
(a) Primary care providers specify their capacity to accept Medi-Cal Patients and obtain a primary care provider project code under which fee-for-service Medi-Cal beneficiaries may enroll with the provider as their exclusive primary care source.
(b) Each primary care provider accept and enroll fee-for-service beneficiaries up to the provider’s specified capacity.
(c) Any managed care contractor serving children with conditions eligible under the California Children’s Services program shall maintain and follow standards of care established by the program, including use of paneled providers and CCS approved special care centers and shall follow treatment plans approved by the program, including specified services and providers of services. If there are insufficient paneled providers willing to enter into contracts with the managed care contractor, the program shall seek to establish new paneled providers willing to contract. If a paneled provider cannot be found, the managed care contractor shall seek program approval to use a specific nonpaneled provider with appropriate qualifications.
(d) Any managed care contractor serving children with conditions eligible under the CCS program shall report expenditures and savings separately for CCS covered services and CCS eligible children. If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be a separate actuarially sound rate for CCS-eligible children.
(e) This article is not intended to and shall not be interpreted to permit any reduction in benefits or eligibility levels under the CCS program. Any medically necessary service not available under the managed care contracts authorized under this article shall remain the responsibility of the state and county.
(f) To assure CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the state and local CCS program agencies for both services covered and not covered by the managed care contract.
(g) Beneficiaries enroll with or are assigned to a primary care provider who will be the exclusive source of fee-for-service primary care for the beneficiary. However, enrollment under this article shall be subordinated to any legal requirement that a beneficiary enroll in a Medi-Cal managed care plan contracting under this chapter or (Chapter 8 (commencing with Section 14200)).
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.2.

14092.2. The director may establish policy and procedures that assure that outpatient physician’s services, and any other Medi-Cal services the director may designate, provided by a source other than the primary care provider with whom a beneficiary is enrolled under this article, shall not be covered under the Medi-Cal program unless they are provided on an emergency basis or authorized by the responsible primary care provider.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.25.

14092.25. In areas where a Medi-Cal beneficiary has the opportunity to enroll in a Medi-Cal managed care plan or to enroll with a primary care provider under this article, the director may require a beneficiary who is certified pursuant to subdivision (c) of Section 14016.5 that he or she has an established relationship with a provider, to enroll in a managed care plan, a pilot project, or a primary care provider under this article, if the beneficiary relies on care provided by hospital emergency departments for nonemergency care.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.3.

14092.3. In implementing this article, the director has discretion to extend administrative or reimbursement flexibilities to participating primary care providers.
(Added by Stats. 1992, Ch. 722, Sec. 85. 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 2.95 - Primary Care Provider Enrollment › Section 14092.35.

14092.35. To the extent that this article proves to be effective in reducing the cost of uncoordinated primary care delivered in the hospital emergency room or the costs of duplicative, unnecessary, or avoidable services, program savings may be shared with primary care providers who enroll beneficiaries under this article.
(Amended by Stats. 2006, Ch. 538, Sec. 704. 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 2.97 - Managed Care Plan Contracts › Section 14093.

14093. The purpose of this article is to ensure quality of care and to provide increased access to health care services in the most cost-effective and efficient manner possible, to persons who are eligible to receive medical benefits under publicly supported programs other than Medi-Cal.
(Added by Stats. 1992, Ch. 722, Sec. 86. 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 2.97 - Managed Care Plan Contracts › Section 14093.06.

14093.06. (a) When a managed care contractor that is authorized to provide California Children’s Services (CCS) covered services pursuant to subdivision (a) of Section 14094.3 or Article 2.985 (commencing with Section 14094.4) expands a managed care plan’s CCS coverage area to other counties, the contractor shall comply with CCS program standards including, but not limited to, referral of newborns to the appropriate neonatal intensive care level, referral of children requiring pediatric intensive care to CCS-approved pediatric intensive care units, and referral of children with CCS eligible conditions to CCS-approved inpatient facilities and special care centers in accordance with subdivision (c) of Section 14093.05.
(b) The managed care contractor shall comply with CCS program medical eligibility regulations. Questions regarding interpretation of state CCS medical eligibility regulations, or disagreements between the county CCS program and the managed care contractor regarding interpretation of those regulations, shall be resolved by the local CCS program, in consultation with the state CCS program. The resolution determined by the CCS program shall be communicated in writing to the managed care contractor.
(c) In following the treatment plan developed in accordance with CCS program requirements, the managed care contractor shall ensure the timely referral of children with special health care needs to CCS-paneled providers who are board-certified in both pediatrics and in the appropriate pediatric subspecialty.
(d) The managed care contractor shall report expenditures and savings separately for CCS covered services and CCS eligible children, in accordance with paragraph (1) of subdivision (d) of Section 14093.05.
(e) All children who are enrolled with a managed care contractor who are seeking CCS program benefits shall retain all rights to CCS program appeals and fair hearings of denials of medical eligibility or of service authorizations. Information regarding the number, nature, and disposition of appeals and fair hearings shall be part of an annual report to the Legislature on managed care contractor compliance with CCS standards, regulations, and procedures. This report shall be made available to the public.
(f) The department, in consultation with stakeholder groups, shall develop unique pediatric plan performance standards and measurements, including, but not limited to, the health outcomes of children with special health care needs.
(Amended by Stats. 2016, Ch. 625, Sec. 4. (SB 586) Effective January 1, 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 2.97 - Managed Care Plan Contracts › Section 14093.07.

14093.07. For purposes of this article the following definitions apply:
(a) “Foster child” means any child who has been taken into custody or placed by a juvenile court pursuant to Article 6 (commencing with Section 300) of Chapter 2 of Part 1 of Division 2 or Section 601 or 602.
(b) “Medi-Cal managed care plan” means any person or entity that has entered into a contract with the director pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.9 (commencing with Section 14088), or Article 2.91 (commencing with Section 14089) of this chapter or pursuant to Article 1 (commencing with Section 14200) of Chapter 8.
(c) “Out-of-county placement” means any foster care placement in which the child has been placed outside of the county with the responsibility for the care and placement of the child.
(Added by Stats. 1997, Ch. 294, Sec. 65. Effective August 18, 1997.)
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 2.97 - Managed Care Plan Contracts › Section 14093.09.

14093.09. (a) No child in foster care shall be required to enroll in a Medi-Cal managed care plan. A foster child may be voluntarily enrolled in a Medi-Cal managed care plan only when the county child welfare agency with responsibility for the care and placement of the child, in consultation with the child’s foster caregiver, determines that it is in the best interest of the child to do so and the department determines that enrollment is available to the child.
(b) Whenever a foster child is placed in an out-of-county placement, the county child welfare agency with responsibility for the care and placement of the child shall determine, in consultation with the child’s foster caregiver, if the child should remain in, or has enrolled in, a Medi-Cal managed care plan in the county where the child will be placed or in the county with responsibility for the care and placement of the child, as long as the department determines that enrollment is available for the child.
(c) The State Department of Health Services shall establish for Medi-Cal managed care plans urgent disenrollment procedures that provide for disenrollment of foster children in out-of-county placements within two working days of receipt by the department’s enrollment contractor, or the department, if the department has no enrollment contractor, of a request for disenrollment made by the child welfare services agency, the foster caregiver, or other person authorized to make medical decisions on behalf of the foster child.
(d) Medi-Cal managed care plans shall process and pay appropriately documented claims submitted by out-of-plan providers for services provided to foster children in out-of-county placements while they are Medi-Cal members of the plan. This section shall not be construed to prevent a plan from requiring prior authorization for nonemergency services consistent with the plan’s established policies and procedures.
(Added by Stats. 1997, Ch. 294, Sec. 66. Effective August 18, 1997.)
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 2.97 - Managed Care Plan Contracts › Section 14093.10.

14093.10. (a) Whenever a foster child enrolled in a county organized health system, established pursuant to Article 2.8 (commencing with Section 14087.5), is placed in an out-of-county placement, the county child welfare agency or probation department with responsibility for the care and placement of the child shall determine, in consultation with the child’s foster caregiver, whether the child should remain enrolled in that county organized health system. The determination shall be made no later than one working day after the out-of-county placement begins.
(b) If it is determined, pursuant to subdivision (a) or at any later date, that a foster child should be disenrolled from a county organized health system due to an out-of-county placement, the county child welfare agency or probation department with responsibility for the care and placement of the child shall request that the child be disenrolled from the county organized health system. The request shall be made to the entity designated by the State Department of Health Care Services to receive requests for disenrollment or to the department, if the department has no designee, no later than one working day after either of the following occurs:
(1) The out-of-county placement begins.
(2) It is determined that a child who initially remained enrolled in the county organized health system following the out-of-county placement, pursuant to subdivision (a), should subsequently be disenrolled.
(c) The State Department of Health Care Services shall, in consultation with other agencies and organizations interested in health care access for foster children, establish for county organized health systems urgent disenrollment procedures that provide for disenrollment of foster children in out-of-county placements within two working days of receipt by the department’s designee or by the department, if the department has no designee, of a request for disenrollment made by the county child welfare services agency, the county probation department, the foster caregiver, or any other person authorized to make medical decisions on behalf of the foster child.
(d) The department shall issue all-county letters or similar instructions to implement subdivision (c) no later than January 1, 2009, and thereafter shall adopt any necessary implementing regulations.
(Added by Stats. 2007, Ch. 467, Sec. 2. Effective January 1, 2008.)
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 2.98 - California Children s Services Program and Medi-Cal Managed Care Contracts › Section 14094.

14094. For purposes of this article “CCS” means California Children’s Services.
(Added by Stats. 1994, Ch. 917, Sec. 2. Effective September 28, 1994.)
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 2.98 - California Children s Services Program and Medi-Cal Managed Care Contracts › Section 14094.1.

14094.1. (a) The director shall investigate and to the extent feasible require any managed care contractor serving children with conditions eligible under the CCS program, to maintain and follow standards of care established by the program, including use of paneled providers and CCS approved special care centers and to follow treatment plans approved by the program, including specified services and providers of services. If there are insufficient paneled providers willing to enter into contracts with the managed care contractor, the program shall seek to establish new paneled providers willing to contract. If a paneled provider cannot be found, the managed care contractor shall seek program approval to use a specific nonpaneled provider with appropriate qualifications.
(b) The director shall investigate and to the extent feasible require any managed care contractor serving children with conditions eligible under the CCS program, to report expenditures and savings separately for CCS covered services and CCS eligible children.
(c) (1) If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be a separate actuarially sound rate for CCS eligible children.
(2) Notwithstanding paragraph (1), a managed care pilot project may, if approval is obtained from the state CCS program director, utilize an alternative rate structure for CCS eligible children.
(Added by Stats. 1994, Ch. 917, Sec. 2. Effective September 28, 1994.)
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 2.98 - California Children s Services Program and Medi-Cal Managed Care Contracts › Section 14094.2.

14094.2. (a) This article is not intended, and shall not be interpreted, to permit any reduction in benefits or eligibility levels under the CCS program. Any medically necessary service not available under the managed care contracts authorized under this article shall remain the responsibility of the state and county.
(b) (1) In Whole Child Model counties authorized pursuant to Article 2.985 (commencing with Section 14094.4), in order to ensure that CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the department for both services covered and not covered by the managed care contract.
(2) In counties not listed in Section 14094.5, in order to ensure that CCS benefits are provided to enrollees with a CCS-eligible condition according to CCS program standards, there shall be oversight by the department and local CCS program agencies for both services covered and not covered by the managed care contract.
(Amended by Stats. 2016, Ch. 625, Sec. 5. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.4.

14094.4. For the purposes of this article, the following definitions shall apply:
(a) “CCS provider” means any of the following:
(1) A medical provider that is paneled by the CCS program to treat a CCS-eligible condition pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
(2) A licensed acute care hospital approved by the CCS program to treat a CCS-eligible condition.
(3) A special care center approved by the CCS program to treat a CCS-eligible condition.
(b) “County organized health system” or “COHS” means:
(1) A county organized health system contracting with the department to provide Medi-Cal services to beneficiaries pursuant to Article 2.8 (commencing with Section 14087.5).
(2) A regional health authority.
(c) “Medi-Cal managed care plan” means a COHS, or, commencing no sooner than January 1, 2024, an alternate health care service plan contracted with the department pursuant to Section 14197.11 in any county described in Section 14094.5.
(Amended by Stats. 2022, Ch. 73, Sec. 1. (AB 2724) Effective January 1, 2023.)
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 2.985 - Whole Child Model Program › Section 14094.5.

14094.5. (a) No sooner than July 1, 2017, the department may establish a Whole Child Model program for Medi-Cal eligible CCS children and youth enrolled in a managed care plan served by a county organized health system or Regional Health Authority, or commencing no sooner than January 1, 2024, an alternate health care service plan contracted with the department pursuant to Section 14197.11, in the following counties: Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Trinity, and Yolo.
(b) No sooner than January 1, 2025, the department may establish a Whole Child Model program for Medi-Cal eligible CCS children and youth enrolled in a managed care plan served by a county organized health system or Regional Health Authority in the following counties: Butte, Colusa, Glenn, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Yuba, Mariposa, and San Benito.
(Amended by Stats. 2023, Ch. 42, Sec. 128. (AB 118) Effective July 10, 2023.)
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 2.985 - Whole Child Model Program › Section 14094.6.

14094.6. The goals for the Whole Child Model program for children and youth under 21 years of age who meet the eligibility requirements of Section 123805 of the Health and Safety Code and are enrolled in a managed care plan under a county organized health system or Regional Health Authority, or an alternate health care service plan contracted with the department pursuant to Section 14197.11, shall include all of the following:
(a) Improving the coordination of primary and preventive services with specialty care services, medical therapy units, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term services and supports (LTSS), regional center services, and home- and community-based services using a child and youth and family-centered approach.
(b) Maintaining or exceeding CCS program standards and specialty care access, including access to appropriate subspecialties.
(c) Providing for the continuity of child and youth access to expert, CCS dedicated case management and care coordination, provider referrals, and service authorizations.
(d) Improving the transition of youth from CCS to adult Medi-Cal managed systems of care through better coordination of medical and nonmedical services and supports and improved access to appropriate adult providers for youth who age out of CCS.
(e) Identifying, tracking, and evaluating the transition of children and youth from CCS to the Whole Child Model program to inform future CCS program improvements.
(Amended by Stats. 2022, Ch. 73, Sec. 3. (AB 2724) Effective January 1, 2023.)
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 2.985 - Whole Child Model Program › Section 14094.65.

14094.65. This article shall not be construed to exclude or restrict the specialty of neonatology from reimbursement under the California Children’s Services (CCS) program, subject to the program’s existing or applicable prior authorization requirements or utilization review. Neonatology shall be included in the CCS program.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.9.

14094.9. (a) The department shall develop a memorandum of understanding template, which shall be utilized by participating counties and health plans, and which shall include, but not be limited to, the standards relating to the local administration of, and minimum services to be provided by, counties and Medi-Cal managed care plans in the administration of the Whole Child Model program. The department shall consult with counties and Medi-Cal managed care plans in the development of the Whole Child Model program memorandum of understanding template.
(b) The department shall provide written notice to the county agency, as designated in Section 123850 of the Health and Safety Code, of the calculation for determining the administrative allocation to the county CCS program by means of county information notice. The department shall consult with the Whole Child Model program counties in determining the calculation for determining the administrative allocation.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.10.

14094.10. (a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall establish an assessment process that, at a minimum, does all of the following:
(1) Assesses each CCS child’s or youth’s risk level and needs by performing a risk assessment process using means such as telephonic or in-person communication, review of utilization and claims processing data, or by other means as determined by the department.
(2) Assesses, in accordance with the transition agreement with the county CCS program, the health care needs of CCS-eligible children and youth and coordinates their CCS specialty services, Medi-Cal primary care services and mild to moderate mental health services, specialty mental health as appropriate through the county specialty mental health plan, and Drug Medi-Cal services as appropriate through county substance use disorder program, and regional center services across all settings, including coordination of necessary services within and, when necessary, outside of the managed care plan’s provider network.
(3) Follows timeframes for reassessment of risk and, if necessary, circumstances or conditions that require redetermination of risk level, which shall be set by the department.
(b) The risk assessment process shall be performed in accordance with all applicable federal and state laws.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.14.

14094.14. (a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall provide a mechanism for a CCS-eligible child’s and youth’s parent or caregiver to request a specialist or clinic as a primary care provider.
(b) A CCS specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of CCS-eligible conditions of the CCS child or youth.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.15.

14094.15. A Medi-Cal managed care plan shall meet all of the following requirements:
(a) Use all current and applicable CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices in developing criteria for use by the plan’s chief medical officer or the equivalent and other care management staff.
(b) In cases in which applicable CCS clinical guidelines do not exist, use evidence-based guidelines or treatment protocols that are medically appropriate given the child’s CCS-eligible condition.
(c) Utilize only CCS providers to treat CCS conditions in any circumstance in which the child’s CCS-eligible condition requires treatment from the provider types in paragraph (1), (2), or (3) of subdivision (a) of Section 14094.4, except a plan may use an out-of-state provider if an in-state CCS provider does not possess the clinical expertise to appropriately treat the CCS condition of the child or youth.
(d) Utilize a provider dispute resolution process that meets the standards established under Section 1371.38 of the Health and Safety Code.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 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 2.985 - Whole Child Model Program › Section 14094.16.

14094.16. (a) The department shall pay any managed care plan participating in the Whole Child Model program a separate, actuarially sound rate specifically for CCS children and youth, to the extent that an actuarially sound rate can be developed for the managed care plan’s CCS population. When contracting with managed care plans, the department may allow the use of risk corridors or other methods to appropriately mitigate a plan’s risk for this population. If services are already established in the rate of a Medi-Cal managed care plan prior to January 1, 2016, the department shall not be required to create a separate rate for the Whole Child Model program.
(b) Medi-Cal managed care plans shall pay physician and surgeon provider services at rates that are equal to or exceed the applicable CCS fee-for-service rates, unless the physician and surgeon enters into an agreement on an alternative payment methodology mutually agreed to by the physician and surgeon and the Medi-Cal managed care plan
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 2017.)