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 4 - The Medi-Cal Benefits Program › Section 14133.07.

14133.07. (a) A doctor of podiatric medicine shall not be required to submit prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician and surgeon providing the same services would not be required to submit prior authorization to the department.
(b) A doctor of podiatric medicine acting within their scope of practice and providing services pursuant to subdivision (a) is subject to the same Medi-Cal billing and services policies as required for a physician and surgeon, including, but not limited to, a maximum numerical service limitation in any one calendar month.
(Repealed and added by Stats. 2019, Ch. 433, Sec. 2. (AB 678) Effective January 1, 2020.)
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 4 - The Medi-Cal Benefits Program › Section 14133.1.

14133.1. (a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any specific service or group of services which are subject to utilization controls. Each utilization control shall be reasonably related to the purpose for which it is imposed.
(b) Except as provided in Sections 14103.6 and 14133.15, neither prior authorization nor the limitation specified in subdivision (d) of Section 14133 shall be required for the first two services per month which are included among the services listed in subdivision (a) of Section 14132, or for the first two drug prescriptions purchased during any one month, provided that the prescription drugs are included in the Medi-Cal Drug Formulary and the prescription otherwise conforms to applicable formulary requirements.
(c) The director shall, after a determination of cost benefit, modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment which costs less than one hundred dollars ($100), except for prescribed drugs, provided that the requirement of prior authorization for treatment, supplies, or equipment may be reinstituted upon a finding by the department that the elimination of the requirement has resulted in unnecessary utilization, and upon notice to the Joint Legislative Budget Committee 30 days prior to the reinstitution of the requirement of prior authorization. Modification of the utilization controls may include establishing prior authorization review thresholds at levels other than one hundred dollars ($100) if indicated by the cost-benefit analysis.
(Amended by Stats. 1986, Ch. 775, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14133.10.

14133.10. (a) Where it is expected to be cost-effective, the director may, in conducting Medi-Cal acute care inpatient hospital utilization control, establish a program of aggressive case management of elective, nonemergency acute care hospital admissions for the purpose of reducing both the numbers and duration of acute care hospital stays by Medi-Cal beneficiaries.
(b) In conducting the case management program, the department may, conduct daily reviews to determine the need for additional days of inpatient care.
(c) In undertaking this case management program, the director may enter into contracts, on a bid or nonbid basis, for the purposes of obtaining the necessary expertise to train and educate utilization control staff in case management concepts, principles and techniques, identify and recommend cost-effective therapies, services and technology as alternatives to elective acute care hospitalization or to directly provide the case management and diversion services.
(d) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts under this article may be on a nonbid basis, and shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. Contracts shall have no force and effect unless approved by the Department of Finance.
(e) The department shall seek all federal waivers necessary to allow for federal financial participation under this section.
(Added by Stats. 1992, Ch. 722, Sec. 122. 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 4 - The Medi-Cal Benefits Program › Section 14133.12.

14133.12. (a) The director shall apply utilization controls to continuous skilled nursing care services provided pursuant to the pilot program established under Section 14495.10, including, but not limited to, prior authorization and monitoring by the department. Prior authorization shall ensure that continuous skilled nursing care services are medically necessary, and that the provision of continuous skilled nursing care will avoid a transfer to, or placement at, a higher level of service. Monitoring shall be conducted by the department including, but not limited to, evaluation of quality of life, health, safety, and well-being of the beneficiary, and quality, efficiency, and cost effectiveness of the continuous skilled nursing care services. The department shall consult with the State Department of Developmental Services and regional centers to design monitoring efforts.
(b) Payment of the reimbursement rates established pursuant to Section 14110.55 shall be subject to all billing criteria of the Medi-Cal program and the utilization controls set forth in this section.
(c) This section shall become operative only if the federal waiver identified under Section 14495.10 is approved by the federal Health Care Financing Administration. The director shall maintain a record of the satisfaction of this condition.
(Added by Stats. 1999, Ch. 845, Sec. 2. Effective January 1, 2000. Conditionally operative by its own provisions.)
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 4 - The Medi-Cal Benefits Program › Section 14133.14.

14133.14. The criteria that the department shall use to identify providers to be placed on prior authorization for noninvasive testing procedures shall include, but not be limited to, Medi-Cal trend analysis, provider profiling data, provider and beneficiary history data, or appropriateness of the services as related to diagnosis, volume of services, utilization patterns, and specialty of provider. The existing prior authorization appeals process shall be available to these providers for denial of services.
(Added by Stats. 1997, Ch. 294, Sec. 72. 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 4 - The Medi-Cal Benefits Program › Section 14133.16.

14133.16. (a) Notwithstanding subdivision (l) of Section 14132, hearing aids are covered when supplied by a hearing aid dispenser on prescription of an otolaryngologist, or the attending physician where there is no otolaryngologist available in the community, plus an audiological evaluation, which shall be performed by or under the supervision of the attending physician or by a licensed audiologist.
(b) Prior to prescribing a hearing aid, a physician or otolaryngologist shall perform a complete ear, nose, and throat examination.
(c) Prior to coverage, a hearing aid assessment shall be performed by the dispensing practitioner, either a physician, a licensed audiologist, or a licensed hearing aid dispenser acting within the scope of practice as described in Section 3306 of the Business and Professions Code.
(d) Coverage shall be based on the results of the examination, evaluation, and assessment required by this section.
(e) One hearing aid assessment within a 12-month period is a covered benefit. In the event the beneficiary receives more than one hearing aid assessment within a 12-month period, Medi-Cal shall reimburse the first valid claim received by the program for only one hearing aid assessment unless additional assessments are deemed to be medically necessary.
(Added by Stats. 2002, Ch. 704, Sec. 1. Effective January 1, 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 4 - The Medi-Cal Benefits Program › Section 14133.2.

14133.2. (a) The director shall include in the Medi-Cal list of contract drugs any drug approved for the treatment of cancer by the federal Food and Drug Administration, so long as the manufacturer has executed a contract with the Health Care Financing Administration which provides for rebates in accordance with Section 1396r-8 of Title 42 of the United States Code. These drugs shall be exempt from the contract requirements of Section 14105.33.
(b) In addition to any drug added to the list of contract drugs pursuant to subdivision (a), any drug that meets either of the following criteria and for which the manufacturer has executed a contract with the Health Care Financing Administration that provides for rebates in accordance with Section 1396r-8 of Title 42 of the United States Code, shall be a Medi-Cal benefit, subject to utilization controls, unless the contract requirements of Section 14105.33 have been complied with:
(1) Any drug approved by the federal Food and Drug Administration for treatment of opportunistic infections associated with cancer.
(2) Any drug or biologic used in an anticancer chemotherapeutic regimen for a medically accepted indication, which has either been approved by the federal Food and Drug Administration, or recognized for that use in a compendia listed in Section 1927 of the federal Social Security Act (42 U.S.C. Sec. 1396r-8).
(Amended by Stats. 2009, Ch. 479, Sec. 6. (AB 830) Effective January 1, 2010.)
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 4 - The Medi-Cal Benefits Program › Section 14133.225.

14133.225. Notwithstanding any other law, the department shall not provide or pay for any prescription drug or other therapy to treat erectile dysfunction for any person who is required to register pursuant to Section 290 of the Penal Code, except to the extent required under federal law. The department may require from the Department of Justice the information necessary to implement this section.
(Added by Stats. 2005, Ch. 469, Sec. 3. Effective October 4, 2005.)
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 4 - The Medi-Cal Benefits Program › Section 14133.25.

14133.25. (a) The director shall identify those surgical and medical procedures capable of outpatient performance and establish conditions for assuring performance in an outpatient rather than inpatient setting when medically appropriate.
(b) The director shall identify and apply appropriate utilization controls to review outpatient and office medical and surgical procedures for medical necessity and program coverage. The director may under this section identify and require prior authorization for any specified outpatient or office medical or surgical procedure performed during a month without regard to the provisions of Section 14133.1, provided that, with respect to outpatient or office medical procedures, those medical procedures which remain not subject to prior authorization are sufficient in number and scope as to achieve the general purpose of Section 14133. 1.
(c) The director may establish a schedule of differential reimbursement rates to the operating surgeon for surgery procedures. Those surgery procedures which can safely be performed on an outpatient basis may be reimbursed at a higher level when performed in an outpatient setting than the same procedures performed on an inpatient basis.
(d) Provisions of this section shall not be applied to mental health services as defined under Division 5 (commencing with Section 5000) or Section 14021, or any other mental health services funded by the Medi-Cal program.
(Amended by Stats. 1982, Ch. 1594, Sec. 60. Effective September 30, 1982.)
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 4 - The Medi-Cal Benefits Program › Section 14133.3.

14133.3. (a) The director shall require fully documented medical justification from providers that the requested services are medically necessary or a medical necessity, as defined in Section 14059.5, on all requests for prior authorization.
(b) For services not subject to prior authorization controls, offered by noncontract hospitals in closed health facility planning areas to beneficiaries who were experiencing life-threatening or emergency situations, but could not be stabilized sufficiently in order to facilitate being transported to contracting hospitals, the director shall additionally determine utilization controls that shall be applied to ensure that the health care services provided and the conditions treated, are medically necessary to prevent significant illness, alleviate severe pain, to protect life, or prevent significant disability. These utilization controls shall take into account those diseases, illnesses, or injuries that require preventive health services or treatment to prevent serious deterioration of health.
(c) Nothing in this section shall preclude payment for family planning services or early and periodic screening, diagnosis, and treatment services mandated by federal law.
(d) For the purposes of this section, a “noncontract hospital” means a hospital that has not contracted with the department for the provision of inpatient services pursuant to Article 2.6 (commencing with Section 14081).
(e) This section shall not be applied to mental health services as defined under Division 5 (commencing with Section 5000) or Section 14021, or any other mental health services funded by the Medi-Cal program.
(Amended by Stats. 2018, Ch. 855, Sec. 2. (SB 1287) Effective January 1, 2019.)
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 4 - The Medi-Cal Benefits Program › Section 14133.37.

14133.37. For drugs covered under this chapter requiring prior authorization, the department shall ensure the timely and efficient processing of authorization requests by doing all of the following:
(a) Providing a response by telephone or other means of telecommunication within 24 hours of the receipt of an authorization request.
(b) To the extent permitted by federal law, providing for the dispensing of at least a 72-hour supply of a covered drug in an emergency situation, as defined by federal regulation.
(Added by Stats. 1991, Ch. 563, 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 4 - The Medi-Cal Benefits Program › Section 14133.4.

14133.4. Notwithstanding any other provision of law, utilization controls adopted by the State Department of Health Services shall not include prior authorization for portable X-ray services provided in nursing facilities and all categories of intermediate care facilities for the developmentally disabled, as defined in Section 1250 of the Health and Safety Code.
(Amended by Stats. 1990, Ch. 1329, Sec. 30. Effective September 26, 1990.)
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 4 - The Medi-Cal Benefits Program › Section 14133.45.

14133.45. (a) Utilization controls adopted by the department shall not include prior authorization for renal dialysis treatment provided to eligible recipients for the treatment of end stage renal disease.
(b) For purposes of this section, “end stage renal disease” is the same as defined in subdivision (d) of Section 1794.02 of the Health and Safety Code.
(c) Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of the Government Code, the department may implement this section by provider manual or similar notice without further regulatory action.
(Added by Stats. 2003, Ch. 321, Sec. 1. Effective January 1, 2004.)
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 4 - The Medi-Cal Benefits Program › Section 14133.6.

14133.6. In acting upon prior authorization requests for nonemergency medical transportation services, the department shall consider all relevant information in its possession regarding the beneficiary for whom services are requested. The department shall act upon such requests in a timely and expeditious manner. The department shall not form separate units within its field offices to receive and act upon prior authorization requests for nonemergency medical transportation. The provisions of this section shall be applicable only in counties having a population in excess of 6,000,000.
(Added by Stats. 1981, Ch. 1081, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14133.65.

14133.65. Prior authorization for the use of nonemergency medical transportation services by patients to and from dialysis treatment shall be approved for a period of up to one year when the patient has received the transportation services for the immediately preceding 12 months, the request for renewed prior authorization is supported by a physician’s certification that the patient’s condition is unlikely to improve during the period covered by the request, and the department has determined that there is medical necessity for the service. Whenever there is a change or improvement in the patient’s condition, the physician shall submit a new certification to the department.
(Added by Stats. 1985, Ch. 863, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14133.7.

14133.7. The department shall not require emergency certification statements for hospital inpatient claims which have been reviewed and approved by the department for appropriateness of emergency admission or length of stay.
(Added by Stats. 1981, Ch. 1164, Sec. 5.)
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 4 - The Medi-Cal Benefits Program › Section 14133.8.

14133.8. (a) A bone marrow transplant for the treatment of cancer for beneficiaries who are eligible for full-scope benefits under this chapter, shall be reimbursable under this chapter, when all of the following conditions are met:
(1) The bone marrow transplant is recommended by the recipient’s physician.
(2) The bone marrow transplant is performed in a hospital that is approved for participation in the Medi-Cal program.
(3) The bone marrow transplant is a reasonable course of treatment and is approved by the hospital medical policy committee when there is an existing committee or a committee can be established.
(4) The bone marrow transplant has been deemed appropriate for the recipient by the program’s medical consultant. The medical consultant shall not disapprove the bone marrow transplant solely on the basis that it is classified as experimental or investigational.
(b) The program shall provide reimbursement for both donor and recipient surgery.
(c) The department may establish inpatient rates of reimbursement not in accordance with the state plan for those hospitals not under contract with the state pursuant to Article 2.6 (commencing with Section 14081), provided that the state plan is subsequently amended to reflect the method of reimbursement.
(d) This section shall not be construed as prohibiting reimbursement for any bone marrow transplants otherwise provided for under this chapter.
(e) Any bone marrow transplant authorized by the department pursuant to this section shall be subject to utilization controls.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or other instructions, without taking any further regulatory action.
(Amended by Stats. 2007, Ch. 300, Sec. 6. 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 4 - The Medi-Cal Benefits Program › Section 14133.85.

14133.85. (a) (1) Except as otherwise provided in this subdivision, prior authorization shall not be required for hospice services.
(2) Paragraph (1) shall not apply to any admission which violates federal law.
(b) Prior authorization shall be required for inpatient hospice services.
(Added by Stats. 1992, Ch. 34, Sec. 2. Effective April 20, 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 4 - The Medi-Cal Benefits Program › Section 14134.2.

14134.2. The reimbursement rate for any three or more laboratory services for the same patient on the same day, which are commonly performed in an automated manner, as defined by the department, shall be reimbursed at the rate established for automated services. The director shall exempt from this provision laboratory services performed for urgent medical reasons or in rural areas, as defined by the department, if performed as individual tests.
(Amended by Stats. 1981, Ch. 1163, Sec. 17. Effective October 2, 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 4 - The Medi-Cal Benefits Program › Section 14134.25.

14134.25. (a) Tobacco cessation services are covered benefits under the Medi-Cal program, subject to utilization controls. Tobacco cessation services shall include all intervention recommendations, as periodically updated, assigned a grade A or B by the United States Preventive Services Task Force. Tobacco cessation services shall include quit attempts based on medical necessity, as defined in Section 14059.5, and consistent with United States Preventive Services Task Force grade A and B recommendations, with no required break between attempts, for all beneficiaries 18 years of age and older who use tobacco. For beneficiaries under 18 years of age, tobacco cessation services shall be provided in accordance with both the American Academy of Pediatrics Bright Futures periodicity schedule and anticipatory guidance as periodically updated, as well as services assigned a grade A or B by the United States Preventive Services Task Force.
(b) For purposes of this section, in addition to the services described in subdivision (a) and only to the extent consistent with the intervention recommendations, as periodically updated, assigned a grade A or B by the United States Preventive Services Task Force, tobacco cessation services for beneficiaries 18 years of age and older shall include all of the following:
(1) At least four tobacco cessation counseling sessions per quit attempt that may be conducted in person or by telephone and individually or as part of a group, at the beneficiary’s option.
(2) (A) A tobacco cessation treatment regimen of any medication approved by the federal Food and Drug Administration, and that is a covered Medi-Cal benefit, for tobacco cessation, including prescription and over-the-counter medications, in accordance with United States Preventive Services Task Force grade A and B recommendations.
(B) A prescription from a provider with authority to prescribe and proof of Medi-Cal coverage shall be sufficient documentation to fill a prescription for over-the-counter tobacco cessation medications.
(c) Beneficiaries who are covered under this section shall not be required to receive a particular form of tobacco cessation service as a condition of receiving any other form of tobacco cessation service.
(d) Effective January 1, 2017, the department shall seek any federal approvals that the department determines are necessary to implement this section.
(e) This section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(Amended by Stats. 2017, Ch. 561, Sec. 283. (AB 1516) Effective January 1, 2018.)
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 4 - The Medi-Cal Benefits Program › Section 14134.55.

14134.55. The department shall streamline and simplify existing Medi-Cal program procedures in order to improve access to lactation supports and breast pumps among Medi-Cal recipients.
(Added by Stats. 2007, Ch. 460, Sec. 5. 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 4 - The Medi-Cal Benefits Program › Section 14134.6.

14134.6. Long-term health care facilities may charge a resident only the actual price paid by the facility for goods and services actually supplied to the resident and may not charge for hospital gowns. Facilities in the original contract shall inform residents of charges for personal laundry and drycleaning, haircuts, beautician services, manicures, pedicures, phone calls, television rental, and any other services payable by the resident. The facility shall also inform residents of any changes in those charges, and shall indicate on a resident’s bill every good, product, service, and medication for which the resident is being charged, including, if the patient is a senior citizen, whether or not a senior discount was obtained on the medication.
(Added by Stats. 1984, Ch. 1628, 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 4 - The Medi-Cal Benefits Program › Section 14135.

14135. To assure maximum federal financial participation under this chapter, the director shall establish an enrollment fee, premium or similar charge to the extent required by federal law.
(Added by Stats. 1974, Ch. 1240.)
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 4 - The Medi-Cal Benefits Program › Section 14136.

14136. (a) No city or county shall establish equipment and personnel standards for the furnishing of nonemergency medical transportation services for eligible Medi-Cal beneficiaries which are in conflict with equipment and personnel standards for reimbursement established by the department pursuant to this chapter. No standard adopted by cities or counties shall require the use of ambulances to supply nonemergency medical transportation, where that standard would conflict with Section 14136.1.
(b) No city or county shall establish any permit, license, or inspection fees in excess of the actual cost of providing services directly associated with the provision of a permit, license, or inspection of nonemergency medical transportation vehicles.
(c) Prior to collection of any permit, license, or inspection fees, the city or county shall provide the nonemergency medical transportation provider from whom the fees will be collected with an itemized cost analysis specifying how the fees will be used.
(d) Nothing in this section shall be construed to otherwise limit the authority of a city or county to license, inspect, or regulate nonemergency medical transportation services so long as the regulation is not in conflict with standards established by the department.
(e) Nothing in this section shall be construed to prevent a city or county from allowing both emergency and nonemergency medical transportation services to operate within its jurisdiction under a sole franchise when such a franchise has been determined necessary to assure the economic viability of those services.
(f) Nothing in this section shall be construed to restrict the authority of local government to issue or deny licenses or permits to operate medical transportation services within its jurisdiction on the basis of need and necessity findings.
(Amended by Stats. 1988, Ch. 695, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14136.1.

14136.1. It is the intent of the Legislature that, in order for payment to be made to a medical transportation service provider, a patient who requires continuous intravenous medication, medical monitoring, or observation during transport and patients being transferred from an acute care facility to another acute care facility shall be transported by ambulance.
In other situations where nonemergency medical transportation is given, ambulances need not be used.
(Added by Stats. 1980, Ch. 1075, 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 4 - The Medi-Cal Benefits Program › Section 14136.3.

14136.3. No prior authorization shall be necessary for the provision of nonemergency medical transportation services to Medi-Cal beneficiaries when the beneficiary is being transported from an acute care hospital following a stay as an inpatient to a nursing facility or any category of intermediate care facility for the developmentally disabled licensed pursuant to Section 1250 of the Health and Safety Code.
(Amended by Stats. 1990, Ch. 1329, Sec. 31. Effective September 26, 1990.)
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 4 - The Medi-Cal Benefits Program › Section 14136.4.

14136.4. A written treatment authorization request for nonemergency medical transportation services for which a department employed medical consultant had provided conditional prior authorization to the provider of services via telephone, shall not be denied by the Medi-Cal field office when the written treatment authorization request subsequently submitted by the provider substantiates the medical information given with the earlier verbal request, so long as the beneficiary was eligible to receive such services.
(Added by Stats. 1982, Ch. 1372, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14136.5.

14136.5. No entity which has received funds under paragraph (2) of subsection (b) of Section 1601 of the federal Urban Mass Transportation Act shall receive reimbursement for medical transportation services rendered to beneficiaries of the Medi-Cal program in any amount greater or higher than the fee charged by the provider to persons for whom services are not reimbursed by Medi-Cal.
(Added by Stats. 1982, Ch. 645, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14136.8.

14136.8. No reimbursement shall be made for medical transportation services provided pursuant to subdivision (i) of Section 14132 when the services are prescribed or ordered by a person who has a significant beneficial interest in the medical transportation services rendered unless the nature and extent of that interest have been disclosed in accordance with, and subject to, Section 51466 of Title 22 of the California Administrative Code.
(Added by Stats. 1984, Ch. 746, Sec. 1.)
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 4 - The Medi-Cal Benefits Program › Section 14137.

14137. The State Department of Health Services, following review and approval from the State Health and Welfare Agency, shall seek all necessary waivers from the United States Department of Health and Human Services in order to provide in-home and community-based care, as provided for under Section 2176 of the federal Omnibus Budget Reconciliation Act of 1981. The waiver proposal shall specifically include plans for the provision of services to any person who would be eligible for community-based and in-home services, as defined by the Department of Health Services, and who would be eligible for the Medi-Cal program, provided for pursuant to this chapter, except for the person’s income and who can, therefore, become eligible by meeting spend-down requirements.
(Added by renumbering Section 14149 by Stats. 1986, Ch. 248, Sec. 271.)
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 4 - The Medi-Cal Benefits Program › Section 14137.6.

14137.6. (a) Notwithstanding any other provision of law, and subject to federal financial participation, covered services under this chapter shall include, subject to utilization controls, medically necessary inpatient and outpatient services associated with the administration of any drug that has been classified by the department or the Food and Drug Administration as having treatment Investigational New Drug (IND) status, when the drug is being administered for the treatment of acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), or human immunodeficiency virus (HIV), to otherwise eligible persons.
(b) The department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code to implement this section. The adoption of the regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health, or safety. Notwithstanding the provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, emergency regulations adopted by the department in order to implement this section shall not be subject to the review and approval of the Office of Administrative Law. These regulations shall become effective immediately upon filing with the Secretary of State.
(c) No part of this section shall be construed to require the department to pay for the cost of treatment IND drugs provided for research purposes by pharmaceutical companies or any other sponsors at no cost.
(d) Payment for care to any Medi-Cal eligible HIV infected person in need of treatment shall not be denied solely on the basis of the use of a drug having treatment IND status.
(e) When medically feasible, every effort shall be made to administer drugs having treatment IND status on an outpatient basis.
(Added by Stats. 1989, Ch. 1197, 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 4 - The Medi-Cal Benefits Program › Section 14137.8.

14137.8. Approval of a request for acute inpatient care shall be solely dependent upon the medical necessity for this care, as documented in the proposed treatment plan. Treatment with Investigational New Drugs, clinical trials, or other ancillary or investigational services, if medical necessity is otherwise documented, shall not in itself be construed to be part of a research study protocol, and shall not constitute grounds for denial on that basis.
(Added by Stats. 1992, Ch. 442, Sec. 2. 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 4 - The Medi-Cal Benefits Program › Section 14138.

14138. (a) To the extent permitted by federal law, the department shall purchase vaccines and biological products in bulk from the Centers for Disease Control or any other sources at the lowest cost possible, for use by providers of services under this chapter and the Child Health and Disability Prevention program under Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, in the immunization of eligible children.
(b) It is the intent of the Legislature that, to the maximum extent possible, any savings of General Fund moneys realized from the program established pursuant to this section shall be reinvested in programs that are most likely to increase access to, and the quality of, immunization services for children.
(c) In order to achieve maximum cost savings, the Legislature hereby determines that an expedited contract process for contracts under this section is necessary. Therefore, contracts under this section may be on a nonbid basis and shall be exempt from the provisions of the Public Contract Code.
(d) No part of this section shall be construed to require the department to undertake distribution of vaccines and biological products.
(Amended by Stats. 1996, Ch. 1023, Sec. 478. Effective September 29, 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 4.1 - Federally Qualified Health Center Alternative Payment Model Project › Section 14138.10.

14138.10. The Legislature finds and declares all of the following:
(a) Health care today is more than a face-to-face visit with a provider, but rather a whole-person approach, often including a physician, a care team of other health care providers, technology inside and outside of a health center, and wellness activities, including nutrition and exercise classes, all of which are designed to be more easily incorporated into a patient’s daily life.
(b) Accessible health care in a manner that fits a patient’s needs is important for improving patient satisfaction, building trust, and ultimately improving health outcomes.
(c) FQHCs are essential community providers, providing high-quality, cost-effective comprehensive primary care services to underserved communities.
(d) Today, FQHCs face certain restrictions because the current payment structure reimburses an FQHC only when there is a traditional encounter with a provider. Current law prohibits payment for both a primary care visit and mental health visit on the same day.
(e) A more practical approach financially incentivizes FQHCs to provide the right care at the right time. Restructuring the current visit-based, fee-for-service model with a capitated equivalent affords FQHCs the assurance of payment and the flexibility to deliver care in the most appropriate patient-centered manner.
(f) A reformed payment methodology will enable FQHCs to take advantage of alternative encounters. Alternative encounters, such as group visits and email consultations, are effective care delivery methods and contribute to a patient’s overall health and well-being.
(g) An alternative payment methodology for FQHCs, designed and implemented as permitted by federal law, should do all of the following:
(1) Provide patient-centered care delivery options to California’s expansive Medi-Cal population.
(2) Promote cost efficiencies, and improve population health and patient satisfaction.
(3) Improve the capacity of FQHCs to deliver high-quality care to a population growing in numbers and in complexity of needs.
(4) Transition away from a payment system that rewards volume with a flexible alternative that recognizes the value added when Medi-Cal beneficiaries are able to more easily access the care they need and when providers are able to deliver care in the most appropriate manner to patients.
(5) Promote timely, accurate, complete, and systemic reporting of alternative encounters at FQHCs.
(6) Implement the APM where the FQHC receives at least the same amount of funding it would receive under the current payment system, and in a manner that does not disrupt patient care or threaten FQHC viability.
(Repealed and added by Stats. 2022, Ch. 47, Sec. 107. (SB 184) Effective June 30, 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 4.1 - Federally Qualified Health Center Alternative Payment Model Project › Section 14138.12.

14138.12. (a) (1) The department shall authorize a payment reform project for FQHCs using an APM in accordance with this article.
(2) Implementation of the APM project shall begin no sooner than January 1, 2024, subject to any necessary federal approvals.
(3)  Before implementation of an APM project for a participating FQHC site, the department shall notify the FQHC site in writing of the applicable draft clinic-specific PMPM rate(s) for the participating FQHC site. A participating FQHC, with respect to one or more sites of its choosing, may opt to withdraw its participation in the project subject to a notice requirement as determined by the department, but not less than 120 days before implementation of an APM project.
(4) At least 90 days prior to implementation of an APM project for a participating FQHC site, the department shall notify a principal health plan in writing of the principal health plan’s specific APM supplemental capitation rates for the participating FQHC. The notification from the department to the principal health plan shall be based on the rates submitted by the department for federal approval. If the APM supplemental capitation rates are modified after the notification to a principal health plan, the department shall notify a principal health plan of the revised rates.
(5) At least 90 days prior to implementation of an APM project for a participating FQHC site, the department shall notify a principal health plan and the FQHC site in writing of the clinic-specific PMPM rate for the participating FQHC site.
(b) The APM project shall comply with federal APM requirements and the department shall file a state plan amendment and seek any federal approvals as necessary for the implementation of this article. Nothing in this article shall be construed to authorize the department to seek federal approval to affirmatively waive Section 1396a(bb)(6) of Title 42 of the United States Code.
(c) Nothing in this article shall be construed to limit or eliminate services provided by FQHCs as covered benefits in the Medi-Cal program.
(Amended by Stats. 2022, Ch. 47, Sec. 109. (SB 184) Effective June 30, 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 4.1 - Federally Qualified Health Center Alternative Payment Model Project › Section 14138.15.

14138.15. (a) A principal health plan shall be compensated by the department for the APM scope of services provided to its APM enrollees pursuant to this section.
(b) For each principal health plan that contains at least one participating FQHC in its provider network, the department shall determine an APM supplemental capitation amount for each APM aid category to be paid by the department to the principal health plan, which shall be expressed as a PMPM amount. This supplemental capitation amount will be in addition to the funding for the APM scope of services already contained in the principal health plan’s capitated rates paid by the department and shall be actuarially sound in accordance with Section 438.4 of Title 42 of the Code of Federal Regulations. The department shall determine the APM supplemental capitation amount for each APM aid category, taking into account all of the following factors:
(1) The clinic-specific PMPM amounts for each participating FQHC in the plan’s network.
(2) The funding for the APM scope of services already contained in the principal health plan’s capitated rates.
(3) The historical wrap-around payments paid by the department for participating FQHCs for assigned members in each APM aid category.
(4) As applicable, the likely distribution of members among multiple participating FQHCs.
(c) The principal health plan shall report to the department, in a form to be determined by the department in consultation with the principal health plan, the number of APM enrollees for each APM aid category in the plan each month.
(d) The department shall pay each principal health plan its applicable APM supplemental capitation amount for the number of APM enrollees for each APM aid category reported by the principal health plan pursuant to subdivision (c), and shall appropriately fund each principal health plan to pay the per-visit rate for unassigned Medi-Cal beneficiaries described in subdivision (e) of Section 14138.13.
(e) The department, in consultation with the principal health plans, shall develop methods to verify the information reported pursuant to subdivision (c), and may adjust the payments made pursuant to subdivision (d) as appropriate to reflect the verified number of APM enrollees for each APM aid category.
(f) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100, and changes in the projected mix of assigned members across applicable APM aid categories.
(Amended by Stats. 2022, Ch. 47, Sec. 112. (SB 184) Effective June 30, 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 4.1 - Federally Qualified Health Center Alternative Payment Model Project › Section 14138.16.

14138.16. (a) For the duration of the APM project, the department shall establish a risk corridor structure for the principal health plans relating only to the APM supplemental capitation payments pursuant to Section 14138.15, to the extent consistent with principles of actuarial soundness and in accordance with Section 438.6(b)(1) of Title 42 of the Code of Federal Regulations.
(b) The risk sharing of the costs under this section shall be constructed by the department with input from affected stakeholders so that it is symmetrical with respect to risk and profit. The department shall develop and specify the terms of the risk corridor in a form and manner specified by the department through all-plan letters or other technical guidance that shall be deemed incorporated into the contracts between each affected principal health plan and the department.
(Amended by Stats. 2022, Ch. 47, Sec. 113. (SB 184) Effective June 30, 2022.)