reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 3 - Services and Standards › Section 14554.

14554. The adult day health care provider shall maintain a complete standard medical record for each participant, including records of treatment rendered by a subcontractor, according to specifications established by the department and as may be further specified by the California Department of Aging.
(Amended by Stats. 2001, Ch. 681, Sec. 19. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 3 - Services and Standards › Section 14555.

14555. Each adult day health care provider shall establish a grievance procedure under which participants may submit their grievances. Such procedure shall be approved by the department prior to the approval of the certification. The department shall establish standards for such procedures to insure adequate consideration and rectification of participant grievances. A provider shall make written findings of fact in the case of each grievance processed, a copy of which shall be transmitted to the participant. If the Medi-Cal participant has an unresolved grievance, the fair hearing provided in Chapter 7 (commencing with Section 10950) of Part 2 of this division shall be available to resolve all grievances regarding care and administration by the adult day health care provider. The findings and recommendations of the department, based on the decision of the hearing officer, shall be binding upon the adult day health care provider.
(Amended by Stats. 1998, Ch. 151, Sec. 16. Effective January 1, 1999.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14570.

14570. (a) The department shall adopt all necessary rules and regulations providing for quality of care and payment for services rendered under this chapter pursuant to Chapter 7 (commencing with Section 14000). All regulations heretofore adopted by the department pursuant to this chapter, and that are in effect immediately preceding the operative date of the amendment of this section enacted by the Legislature during the 1977–78 Regular Session, shall remain in effect and shall be fully enforceable unless and until readopted, amended, or repealed by the director.
(b) The director shall establish a distinct organizational entity within the department that shall have primary responsibility for the Adult Day Health Care Medi-Cal program. This entity shall coordinate and direct all departmental activities required by this chapter.
(Amended by Stats. 2001, Ch. 681, Sec. 20. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14571.

14571. The department, in consultation with the California Association for Adult Day Services, shall develop a rate methodology. The methodology shall take into consideration all allowable costs associated with providing adult day health care services. Once a methodology has been approved by the department, it shall be the basis of future annual rate reviews.
Payment shall be for services provided in accordance with an approved individual plan of care. Billing shall be submitted directly to the department. Additionally, the department shall establish a separately billable and reasonable rate of reimbursement for the initial assessment that takes into account the intensity of services and the skill level of the health professionals required to conduct the mandated three-day assessment of new participant needs and living environment. Subsequent assessments, as needed or required, shall be billed at a lesser amount. The department shall establish utilization controls for assessment days to ensure the appropriate use of assessment and reassessment activity.
Nothing in this section shall preclude the department from entering into specific prospective budgeting and reimbursement agreements with providers.
(Amended by Stats. 2006, Ch. 691, Sec. 8. Effective January 1, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14571.1.

14571.1. The Legislature finds and declares all of the following:
(a) Adult day health care is a necessary component in achieving an integrated home- and community-based long-term care system consistent with the principles of the decision of the United States Supreme Court in Olmstead v. L.C. by Zimring (1999) 527 U.S. 581.
(b) The federal Centers for Medicare and Medicaid Services has directed the State of California to segregate certain skilled services from the all-inclusive per diem rate currently in use for adult day health care centers and to bill for those services using separate billing codes and reimbursement rates.
(c) The reimbursement methodology for adult day health care services that is established by the department should provide for fair and equitable reimbursement to adult day health care centers for services that are provided to each participant.
(Added by Stats. 2006, Ch. 691, Sec. 9. Effective January 1, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14571.5.

14571.5. Federally qualified health centers shall be reimbursed on a prospective payment system rate basis pursuant to Section 14132.100 for the provision of adult day health care services.
(Added by Stats. 2006, Ch. 691, Sec. 11. Effective January 1, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14572.

14572. (a) No Medi-Cal reimbursement shall be made for a service rendered by an adult day health care provider that does not have a license as an adult day health care center or that does not have currently effective Medi-Cal certification pursuant to this chapter.
(b) Notwithstanding subdivision (a), Medi-Cal certification shall be granted as of the date of licensure with respect to, and reimbursement shall be made for, a service rendered on or after that date if the provider meets all of the following requirements:
(1) Is exempt from the moratorium imposed on the certification and enrollment of new adult day health care centers pursuant to paragraph (5) of subdivision (b) of Section 14043.46.
(2) Meets all certification requirements for adult day health care centers, and is enrolled as a Medi-Cal provider.
(3) Provides services in compliance with the requirements of this chapter as of the date the center began providing services to beneficiaries.
(Amended by Stats. 2006, Ch. 74, Sec. 70. Effective July 12, 2006.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14573.

14573. (a) Initial Medi-Cal certification for adult day health care providers shall expire 12 months from the date of issuance. The director shall specify any date he or she determines is reasonably necessary because of the record of the applicant and to carry out the purposes of this chapter, but not more than 24 months from the date of issuance, when renewal of the certification shall expire. The certification may be extended for periods of not more than 60 days if the department determines it to be necessary.
(b) Before certification renewal the provider shall submit with the application for renewal a report according to department specifications that includes an analysis of income and expenditures, continued demonstrated community need, services, participant statistics and outcome, and adherence to policies and procedures.
(c) Prior to approving renewal of Medi-Cal certification, the California Department of Aging shall conduct a financial review and onsite medical and management reviews. The reviews shall be conducted by a team of persons with appropriate technical skills. The management review shall be performed by the entity responsible for directing and coordinating the program, as specified in the interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code.
(d) Where the director determines that the public interests would be served thereby, a public hearing may be held on any renewal application subject to this section. The findings of the departmental program and licensing reviews and the provider’s annual evaluation report shall be presented at the hearing.
(Amended by Stats. 2004, Ch. 797, Sec. 4. Effective January 1, 2005.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14574.

14574. (a) The director shall terminate the Medi-Cal certification of any adult day health care provider at any time if he or she finds the provider is not in compliance with standards prescribed by this chapter or Chapter 7 (commencing with Section 14000) or regulations adopted pursuant to these chapters. The director shall give reasonable notice of his or her intention to terminate the certification to the provider and participants in the center. The notice shall state the effective date of, and the reason for, the termination.
(b) The California Department of Aging and the department shall coordinate proceedings to deny an application for certification, to terminate or suspend certification, or to revoke or suspend licensure to the extent appropriate to ensure consistency and uniformity.
(c) The provider shall have the right to appeal the department’s decision made pursuant to Section 14123.
(d) This section is not applicable to denials of initial certification made pursuant to a moratorium imposed in accordance with Section 14043.46 of the Welfare and Institutions Code.
(Amended by Stats. 2011, Ch. 119, Sec. 7. (SB 91) Effective July 25, 2011.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14574.1.

14574.1. (a) Every adult day health care center shall be periodically inspected and evaluated for quality of care by a representative or representatives designated by the director, unless otherwise specified in the interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code. Inspections shall be conducted prior to the expiration of certification, but at least every two years, and as often as necessary to ensure the quality of care being provided. As resources permit, an inspection may be conducted prior to, as well as within, the first 90 days of operation.
(b) If, as a result of the inspection, the department or the California Department of Aging, as specified in the interagency agreement, determines that the adult day health care center has serious deficiencies that pose a risk to the health and safety of the participants, the department or the California Department of Aging, as specified in the interagency agreement, may immediately take any of the following actions, including, but not limited to:
(1) Require a plan of correction, including as requested, a program plan pursuant to Section 14552.2.
(2) Limit participant enrollment.
(3) Prohibit new participant enrollment.
(c) The provider shall have the right to dispute an action taken under paragraphs (2) and (3) of subdivision (b). The department or the California Department of Aging, as specified in the interagency agreement, shall accept, consider, and resolve disputes filed pursuant to this subdivision in a timely manner. The dispute resolution process shall be determined by the California Department of Aging in consultation with the department.
(d) The director shall ensure that public records accurately reflect the current status of any potential actions including the resolution of disputes.
(Amended by Stats. 2004, Ch. 797, Sec. 5. Effective January 1, 2005.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14575.

14575. Each adult day health care provider shall maintain a uniform accounting and reporting system as developed by the department, in consultation with the provider. The department shall implement a uniform cost accounting system and train providers in this system by July 1, 1987. The California Department of Aging, in coordination with the department may approve an alternative cost accounting system where the provider demonstrates the ability to report comparable and reliable data. The provider shall submit annual cost reports to the department, unless otherwise specified in an interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code, no later than five months after the close of the licensee’s fiscal year. The report shall be submitted in the format prescribed by the state. Each facility shall maintain, for a period of four years following the submission of annual cost reports, financial and statistical records of the period covered by the cost reports which are accurate and in sufficient detail to substantiate the cost data reported. These records shall be made available to state or federal representatives upon request. The department, unless otherwise specified in an interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code, may request a financial review performed by an independent certified public accountant as part of the provider’s annual cost report. All certified financial statements shall be filed with the department within a period no later than three months after the department’s request. The department, unless otherwise specified in an interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code, may require a limited or complete certified public accountant audit when the monitoring activities carried out pursuant to Section 14573 reveal significant financial management deficiencies.
(Amended by Stats. 2001, Ch. 681, Sec. 25. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14576.

14576. Each adult day health care provider shall furnish to the department, unless otherwise specified by the interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code, all additional information and reports that the department may find necessary in performing its functions under this chapter. The information and reports shall include, but not be limited to, any statistical information regarding utilization of services, individual treatment plans and individual service reports, costs of health care, and administration the department may require.
(Amended by Stats. 2001, Ch. 681, Sec. 26. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 4 - Administration › Section 14577.

14577. All subcontracts for services reimbursable under this chapter shall be entered into pursuant to regulations of the department. All subcontracts shall be in writing, and a copy shall be transmitted to the department for approval prior to taking effect. Each subcontract submitted to the department for approval shall contain the amount of compensation or other consideration which the subcontractor will receive under the terms of the subcontract with the adult day health care provider. However, this section shall not apply to employment contracts of salaried employees of an adult day health care licensee.
All subcontracts to provide health care benefits, including emergency services, shall include a specification that services will be provided to participants to meet the needs of the participants based upon the plans of care. All subcontracts to provide any of the basic services specified in Section 14550 through subcontractors, shall meet all of the qualifications required by, or pursuant to, this chapter as appropriate for the services which the subcontractors are required to perform.
Each subcontract shall require that the subcontractor make all of its books and records pertaining to the goods or services furnished under the terms of the subcontract available for inspection, examination, or copying by the department during normal working hours at the subcontractor’s principal place of business, or at such other place in the state as the department shall designate. Subcontracts between an adult day health care provider and a subcontractor shall be public records and shall be kept on file and be available at the center. The names of the officers and stockholders of the subcontractor shall also be kept on file and be available as public records at the center.
(Amended by Stats. 1998, Ch. 151, Sec. 19. Effective January 1, 1999.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 5 - Conflict of Interest › Section 14585.

14585. For purposes of this article, “state officer or employee” means a Member of Congress representing the State of California; a Member of the Legislature; a secretary of a state agency and those members of the secretary’s staff who hold policymaking positions; those members of the Governor’s staff who hold policymaking positions; an administrative aide or committee consultant of the Legislature; the appointive or civil service employee of the highest class or grade in each department, system, program, section, or other administrative subdivision of the department and the California Department of Aging, as defined in regulations adopted by those departments; any other employee in the department and the California Department of Aging who has any responsibility for the negotiation and development, or management of Medi-Cal contracts of an adult day health care center certified under the provisions of this chapter. The director shall adopt regulations further delineating the class of employees covered by this section.
(Amended by Stats. 1998, Ch. 151, Sec. 20. Effective January 1, 1999.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 5 - Conflict of Interest › Section 14586.

14586. No Medi-Cal certification for an adult day health center shall be approved or renewed pursuant to this chapter if a state officer or employee, or the spouse or a minor child of a state officer or employee, is a member of the board of directors, board of trustees, executive committee or other governing board or committee, the principal officer, a shareholder in the case of a corporation, or a partner in the case of a partnership, in any entity contracting with an adult day health center to provide services reimbursable pursuant to this chapter.
(Added by Stats. 1977, Ch. 1066.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 5 - Conflict of Interest › Section 14587.

14587. No Medi-Cal certification for an adult day health center shall be approved or renewed if any state officer or employee has a direct financial interest in such a subcontractor.
For the purposes of this section, “direct financial interest” means the ownership of common stock, preferred stock, warrants, options, partnership interests, and debt instruments if convertible to equity investments in a subcontractor specified in this section. A convertible debt includes bonds, notes, debentures, and mortages. As used in this section, “direct financial interest” also includes such financial interest of a spouse or a minor child of a state officer or employee in any business entity or in real property held for income or gain.
(Added by Stats. 1977, Ch. 1066.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 5 - Conflict of Interest › Section 14588.

14588. No Medi-Cal certification for an adult day health center shall be approved or renewed if a state officer or employee, or the spouse or a minor child of a state officer or employee, provides legal solicitation or management services to the adult day health center or shares in the income or any remuneration derived from the providing of legal or management services to an adult day health center.
(Added by Stats. 1977, Ch. 1066.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 6 - Cessation of Adult Day Health Care and Assistance with Transition from Adult Day Health Care Services to Other Services › Section 14589.

14589. (a) The Legislature finds and declares the following:
(1) During times of economic crisis, it is crucial to find areas within the program where efficiencies can be achieved while continuing to provide community-based services that support independence.
(2) Adult Day Health Care (ADHC) has been vulnerable to fraud and, despite attempts to curtail and prevent fraud, including, but not limited to, a moratorium on new facilities and onsite treatment authorization request review, fraud continues in this area.
(3) The state has added services and programs to enable vulnerable populations to remain in the community, including, but not limited to, the Money Follows the Person project, California’s Section 1115(a) Comprehensive Medi-Cal Demonstration Project Waiver: a Bridge to Reform, and services and supports, including day programs, provided under the Lanterman Developmental Disabilities Services Act (Division 4.5 (commencing with Section 4500)). It also continues to explore opportunities to add additional services and programs to help individuals remain in the community, including, but not limited to, pilot projects to better meet the health care needs of individuals dually eligible for both Medicare and Medicaid, and exploring the Community First Choice Option as a Medi-Cal benefit.
(4) There are alternative services to meet the needs of Medi-Cal beneficiaries utilizing ADHC, including in-home supportive services, physical, occupational, and speech therapies, nonemergency medical transportation, and home health services.
(b) Therefore, it is the intent of the Legislature for the department to obtain federal approval to eliminate ADHC as an optional Medi-Cal benefit.
(Amended by Stats. 2012, Ch. 162, Sec. 225. (SB 1171) Effective January 1, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.7 - Adult Day Health Care Programs › ARTICLE 6 - Cessation of Adult Day Health Care and Assistance with Transition from Adult Day Health Care Services to Other Services › Section 14589.5.

14589.5. (a) Notwithstanding any other provision of law related to the Medi-Cal program or to adult day health care, adult day health care is excluded from coverage under the Medi-Cal program.
(b) This section shall only be implemented to the extent permitted by federal law.
(c) 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 the provisions of this section by means of all-county letters, provider bulletins, or similar instructions, without taking further regulatory action.
(d) This section shall be implemented on the first day of the first calendar month following 90 days after the effective date of the act that adds this section or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(Added by Stats. 2011, Ch. 3, Sec. 104. (AB 97) Effective March 24, 2011. Implementation is on date prescribed in subd. (d).)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.75 - Program of All-Inclusive Care for the Elderly › Section 14591.

14591. The Legislature finds and declares all of the following:
(a) Community-based services to the frail elderly are often uncoordinated, fragmented, inappropriate, or insufficient to meet the needs of frail elderly who are at risk of institutionalization, often resulting in unnecessary placement in nursing homes.
(b) Steadily increasing health care costs for the frail elderly provide incentive to develop programs providing quality services at reasonable costs.
(c) Capitated “risk-based” financing provides an alternative to the traditional fee-for-service payment system by providing a fixed, per capita monthly payment for a package of health care services and requiring the provider to assume financial responsibility for cost overruns.
(d) On Lok Senior Health Services began as a federal and state demonstration program in 1973 to test whether comprehensive community-based services could be provided to the frail elderly at no greater cost than nursing home care.
(e) Since 1983, On Lok Senior Health Services of San Francisco has successfully provided a comprehensive package of services and operated within a cost-effective, capitated risk-based financing system.
(f) Recognizing On Lok’s success, Congress passed legislation in 1986 and 1987 encouraging the expansion of capitated long-term care programs by permitting federal Medicare and Medicaid waivers to be granted indefinitely to On Lok and authorizing the federal Centers for Medicare and Medicaid Services (CMS) to grant waivers in up to 10 new sites throughout the nation in order to replicate the On Lok model.
(g) In response, the Legislature authorized the State Department of Health Care Services to seek a waiver to contract with up to 10 demonstration projects to develop risk-based, long-term care pilot programs modeled upon On Lok Senior Health Services.
(h) The demonstration projects authorized by the Legislature proved to be successful at providing comprehensive, community-based services to frail elderly individuals at no greater cost than providing nursing home care.
(i) In 1997, Congress passed the Balanced Budget Act of 1997 (Public Law 105-33) authorizing states to offer PACE program services as optional services under the state’s Medicaid state plan.
(j) Based upon the success of the demonstration projects in California, the state is now providing community-based, risk-based, and capitated long-term care services under the PACE program as optional services under California’s Medi-Cal State Plan.
(Added by Stats. 2011, Ch. 367, Sec. 19. (AB 574) Effective January 1, 2012.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.75 - Program of All-Inclusive Care for the Elderly › Section 14594.

14594. (a) For the purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.
(b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the health care provider.
(c) No PACE organization shall require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the PACE organization, and between the PACE organization and its participating providers or provider groups.
(d) No PACE organization shall limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the PACE organization, and between the PACE organization and its participating providers or provider groups.
(e) Notwithstanding any other provision, this section shall not be interpreted to authorize a PACE organization to require the use of telehealth when the health care provider has determined that it is not appropriate.
(Added by Stats. 2012, Ch. 782, Sec. 14. (AB 1733) Effective January 1, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 1 - General Provisions › Section 14600.

14600. The Legislature finds and declares that expenditure demands on health service costs at the federal, state, and local level, now, and will in the foreseeable future, exceed available public resources. In order to live within fiscal constraints, the state must develop alternative methods of managing Medi-Cal care that utilizes resources to the maximum advantage of people requiring public medical assistance.
The purposes of the program alternatives described in this chapter are to provide limited implementation and experimentation prior to statewide enactment of these alternative approaches to funding and management of health care services.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 1 - General Provisions › Section 14601.

14601. As used in this chapter:
(a) “Department” means State Department of Health Services.
(b) “Director” means State Director of Health Services.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14610.

14610. As used in this article:
(a) “Rate” means the rate of reimbursement per unit of service which is agreed to by the department and a hospital.
(b) “Unit of service” means an inpatient day, a case, a discharge or admission, an episode, or any other measure of service which is a basis for reimbursement agreed to by a hospital and the department.
(c) “Commission” means the California Health Facilities Commission.
(d) “Private entity” means any private organization with appropriate experience and expertise to negotiate Medi-Cal hospital reimbursement rates on behalf of the state.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14611.

14611. It is the intention of the Legislature to enact a method for reimbursing hospitals for inpatient and outpatient services provided to Medi-Cal beneficiaries on a prospectively negotiated contractual basis. The provisions of this article are intended to develop and test alternatives for contractually arranging for the payment and delivery of such services which will become the basis for a permanent contracting system.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14612.

14612. The Legislature further intends that the alternatives developed and tested pursuant to the provisions of this article shall be consistent with the following objectives:
(a) Providing reasonable access to all levels and types of hospital care by beneficiaries.
(b) Providing reasonable geographical access to hospital care by beneficiaries.
(c) Promoting efficiency and economy in the delivery of hospital care.
(d) Fairness to the contracting hospitals.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14613.

14613. (a) The department shall develop at least three alternative methods of reimbursing hospitals for providing inpatient and outpatient hospital services to Medi-Cal beneficiaries on a prospectively negotiated rate basis. Each method shall provide for prospectively negotiating rates for such care. Each method shall require the hospital to agree to provide a minimal number of units of service at the negotiated rate.
(b) The department shall consult with associations and other appropriate representatives of the hospital industry. The department shall make every reasonable effort to develop at least one alternative for prospectively negotiating hospital rates which is supported by such representatives of the hospital industry.
(c) The department shall consult with the commission regarding the development of at least one alternative for prospectively negotiating hospital rates. The department may enter into an interagency agreement with the commission for the development of such an alternative.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14614.

14614. Each alternative method for prospectively negotiated rate reimbursement developed pursuant to this article shall do the following:
(a) Reduce administrative cost to the department and to hospitals.
(b) Provide incentives to hospitals to participate in the Medi-Cal program, including prospective interim payments, unless the parties agree otherwise.
(c) Provide incentives to hospitals to provide services on an outpatient basis wherever possible.
(d) Provide incentives to hospitals to reduce their costs.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14616.

14616. Not sooner than 30 days after providing notification to the Joint Legislative Budget Committee, the department may implement on a test basis any of the alternatives for prospective hospital rate negotiations which have been reported to the Legislature pursuant to Section 14614. The department may enter into an interagency agreement with the commission, or contract with a private entity, for implementing any such alternative.
In testing alternatives, the department shall attempt to obtain participation by hospitals representing various sizes, types, ownership, and geographic locations. The department may not discriminate against hospitals wishing to participate on the basis of any of the characteristics described in the immediately preceding sentence.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14617.

14617. Nothing in this article shall be construed to require that hospitals participate in a prospectively negotiated rate test, as provided by this article, as a condition of participation in the Medi-Cal program.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14619.

14619. For the 1981–82 fiscal year, the Controller may transfer such funds among Items 426-001-001, 426-001-890, 426-101-001, and 426-101-890 of the Budget Act of 1981 as are necessary to implement the provisions of this article.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 2 - Negotiated Hospital Rates › Section 14620.

14620. Authority to implement negotiated hospital rates after the completion of the pilot study and after June 30, 1983, shall be contingent on both of the following:
(a) A special Budget Act item, following the submission by the State Department of Health Services of a final report which evaluates the results of the projects conducted under the provisions of this article.
(b) Enactment of legislation specifying the negotiated hospital rate program.
(Added by Stats. 1981, Ch. 102, Sec. 133. Effective June 28, 1981.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14680.

14680. (a) The Legislature finds and declares that there is a need to establish a standard set of guidelines that governs the provision of managed Medi-Cal specialty mental health services at the local level, consistent with federal law.
(b) Therefore, in order to ensure quality and continuity, and to efficiently utilize mental health services under the Medi-Cal program, there shall be developed mental health plans for the provision of those services that are consistent with guidelines established by the department. The guidelines shall be consistent with federal Medicaid requirements and the approved Medicaid state plan and waivers to ensure full and timely federal reimbursement to mental health plans for services that are rendered and reimbursed consistent with federal Medicaid requirements.
(c) It is the intent of the Legislature that mental health plans be developed and implemented regardless of whether other systems of Medi-Cal managed care are implemented.
(d) It is further the intent of the Legislature that Sections 14681 to 14685, inclusive, shall not be construed to mandate the participation of counties in Medi-Cal managed mental health care plans.
(e) This section shall become operative on July 1, 2012.
(Amended (as added by Stats. 2011, Ch. 651, Sec. 10) by Stats. 2012, Ch. 34, Sec. 236. (SB 1009) Effective June 27, 2012. Section operative July 1, 2012, by its own provisions.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14681.

14681. The department shall ensure that all contracts for Medi-Cal managed care include a process for screening, referral, and coordination with any mental health plan established, of medically necessary specialty mental health care services.
(Amended by Stats. 2012, Ch. 34, Sec. 237. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14682.1.

14682.1. (a) The State Department of Health Care Services shall be designated as the state agency responsible for development, consistent with the requirements of Section 4060, and implementation of, mental health plans for Medi-Cal beneficiaries.
(b) The department shall convene a steering committee for the purpose of providing advice and recommendations on the transition and continuing development of the Medi-Cal mental health managed care systems pursuant to subdivision (a). The committee shall include work groups to advise the department of major issues to be addressed in the managed mental health care plan, as well as system transition and transformation issues pertaining to the delivery of mental health care services to Medi-Cal beneficiaries, including services to children provided through the Early and Periodic Screening, Diagnosis, and Treatment Program.
(c) The committee shall consist of diverse representatives of concerned and involved communities, including, but not limited to, beneficiaries, their families, providers, mental health professionals, substance use disorder treatment professionals, statewide representatives of health care service plans, representatives of the California Behavioral Health Planning Council, public and private organizations, county behavioral health directors, and others as determined by the department. The department has the authority to structure this steering committee process in a manner that is conducive for addressing issues effectively, and for providing a transparent, collaborative, meaningful process to ensure a more diverse and representative approach to problem-solving and dissemination of information.
(Amended by Stats. 2017, Ch. 511, Sec. 32. (AB 1688) Effective January 1, 2018.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14683.

14683. The department shall ensure all of the following:
(a) That mental health plans include a process for screening, referral, and coordination with other necessary services, including, but not limited to, health, housing, and vocational rehabilitation services. For Medi-Cal eligible children, the mental health plans shall also provide coordination with education programs and any necessary medical or rehabilitative services, including, but not limited to, those provided under the California Children’s Services Program (Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code) and the Child Health and Disability Prevention Program (Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code), and those provided by a fee-for-service provider or a Medi-Cal managed care plan. This subdivision shall not be construed to establish any higher level of service from a county than is required under existing law. The mental health plan shall not be liable for the failure of other agencies responsible for the provision of nonmental health services to provide those services or to participate in coordination efforts.
(b) That mental health plans include a system of outreach to enable Medi-Cal beneficiaries and providers to participate in and access Medi-Cal specialty mental health services under the plans, consistent with existing law.
(c) That standards for quality and access developed by the department in consultation with the steering committee established pursuant to Section 14682.1 are included in mental health plans serving Medi-Cal beneficiaries.
(Amended by Stats. 2012, Ch. 34, Sec. 240. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14684.1.

14684.1. (a) The department shall establish a process for second level treatment authorization request appeals to review and resolve disputes between mental health plans and hospitals.
(b) When the department establishes an appeals process, the department shall comply with all of the following:
(1) The department shall review appeals initiated by hospitals and render decisions on appeals based on findings that are the result of a review of supporting documents submitted by mental health plans and hospitals.
(2) If the department upholds a mental health plan denial of payment of a hospital claim, a review fee shall be assessed on the provider.
(3) If the department reverses a mental health plan denial of payment of a hospital claim, a review fee shall be assessed on the mental health plan.
(4) If the department decision regarding a mental health plan denial of payment upholds the claim in part and reverses the claim in part, the department shall prorate the review fee between the parties accordingly.
(c) The amount of the review fees shall be calculated and adjusted annually. The methodology and calculation used to determine the fee amounts shall result in an aggregate fee amount that, in conjunction with any other outside source of funding for this function, may not exceed the aggregate annual costs of providing second level treatment authorization request reviews.
(d) Fees collected by the department shall be retained by the department and used to offset administrative and personnel services costs associated with the appeals process.
(e) The department may use the fees collected, in conjunction with other available appropriate funding for this function, to contract for the performance of the appeals process function.
(Amended by Stats. 2012, Ch. 34, Sec. 242. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.8 - Medi-Cal Management: Alternative Methods › ARTICLE 5 - Mental Health Managed Care › Section 14685.1.

14685.1. Section 14685 is hereby repealed on November 7, 2012, if Section 36 has been added to Article XIII of the California Constitution as of that date.
(Added by Stats. 2012, Ch. 34, Sec. 244. (SB 1009) Effective June 27, 2012.)