2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 2.985 - Whole Child Model Program › Section 14094.13.

14094.13. (a) Each Medi-Cal managed care plan shall establish and maintain a process by which a CCS-eligible child or youth may maintain access to CCS providers that the child or youth has an existing relationship with for treatment of the child’s or youth’s CCS condition for up to 12 months, under the following conditions:
(1) The CCS-eligible child or youth has seen the out-of-network CCS provider for a nonemergency visit at least once during the 12 months immediately preceding the date the Medi-Cal managed care plan assumed responsibility for the child’s or youth’s CCS care under the Whole Child Model program.
(2) The CCS provider accepts the health plan’s rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher, unless the CCS provider enters into an agreement on an alternative payment methodology mutually agreed to by the CCS provider and the Medi-Cal managed care plan.
(3) The managed care plan confirms that the provider meets applicable CCS standards and has no disqualifying quality of care issues.
(4) The CCS provider provides treatment information to the Medi-Cal managed care plan, to the extent authorized by the state and federal patient privacy provisions.
(b) Each Medi-Cal managed care plan shall establish and maintain a process by which a CCS-eligible child or youth may maintain access to specialized or customized durable medical equipment providers for up to 12 months under the conditions in paragraph (2):
(1) For the purposes of this subdivision, “specialized or customized durable medical equipment” means durable medical equipment that meets all of the following criteria:
(A) Is uniquely constructed from raw materials or substantially modified from the base material solely for the full-time use of the specific beneficiary according to a physician’s description and orders.
(B) Is made to order or adapted to meet the specific needs of the beneficiary.
(C) Is uniquely constructed, adapted, or modified to permanently preclude the use of the equipment by another individual, and is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes.
(2) (A) The CCS-eligible child or youth has an ongoing relationship with a durable medical equipment provider who has previously provided specialized or customized equipment, such as power wheelchairs, repairs, and replacement parts; prosthetic limbs; customized orthotic devices; and individualized assistive technology. This does not include generally available or noncustomized durable medical equipment.
(B) The durable medical equipment provider shall accept the health plan’s rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher, unless the durable medical equipment provider enters into an agreement on an alternative payment methodology mutually agreed upon by the durable medical equipment provider and the Medi-Cal managed care plan.
(C) The durable medical equipment provider provides information to the Medi-Cal managed care plan as requested by the plan, to the extent authorized by state and federal patient privacy provisions.
(3) The department may extend the continuity of care duration period described in this subdivision for specialized or customized durable medical equipment that is under warranty as specified by the department.
(c) A managed care plan, at its discretion, may extend the continuity of care period beyond the length of time specified in subdivisions (a) and (b).
(d) (1) Each Medi-Cal managed care plan participating in the Whole Child Model program shall comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code and Section 14185 of this code.
(2) Each Medi-Cal managed care plan shall permit a CCS-eligible child or youth transitioned into the Whole Child Model program to continue use of any currently prescribed prescription drug that is part of a prescribed therapy for the enrollee’s CCS-eligible condition or conditions immediately prior to the date of enrollment, whether or not the prescription drug is covered by the plan, until the Medi-Cal managed care plan and the child’s or youth’s prescribing CCS provider has completed an assessment of the child or youth, created a treatment plan, and agrees with the Medi-Cal managed care plan that the particular prescription drug is no longer medically necessary, or the prescription drug is no longer prescribed by the enrollee’s CCS provider.
(e) Each Medi-Cal managed care plan participating in the Whole Child Model program shall ensure that children and youth are provided expert case management, care coordination, service authorization, and provider referral services. Each plan shall meet this requirement by, at the request of the child, youth, or his or her parent or guardian, allowing the child or youth to continue to receive case management and care coordination from his or her public health nurse. This election shall be made within 90 days of the transition of CCS services into the Medi-Cal managed care plan. A plan shall meet this requirement by either or both of the following:
(1) By entering into a memorandum of understanding with the county for case management and care coordination services to the child.
(2) By entering into a memorandum of understanding with the county for case management, care coordination, provider referral, and service authorization to all or some Whole Child Model program participants.
(f) At least 60 days before the transition of CCS services to the Medi-Cal managed care plan, a written notice shall be provided to all CCS children and youth whose CCS care will become the responsibility of the plan explaining their right to continue receiving case management and care coordination services pursuant to subdivision (e), including a written explanation of the process for that election. A reminder notification shall be sent 30 days prior to the start of the transition.
(g) In the event the county public health nurse leaves the CCS program or is no longer available to provide the services requested under this section, the Medi-Cal managed care plan shall transition the care coordination and case management of a child or youth to an employee or contractor of the plan who has received adequate training on the CCS program and who has clinical experience with the CCS population or pediatric patients with complex medical conditions.
(h) The department may waive the requirement of subdivision (e) if the Medi-Cal managed care plan demonstrates that it cannot meet the requirement because it would result in substantially increased program costs compared to the existing CCS program allocation as provided by the department through the annual Budget Act. The department shall confirm the information provided by the Medi-Cal managed care plan and meet with the county, affected labor organizations, and the plan in an attempt to reach a mutually agreeable contracting arrangement that fulfills the requirements of this section while also ensuring that the arrangement is not in excess of the current county program allocation.
(i) (1) A family or caregiver of a child or youth may appeal the continuity of care limitation in subdivision (a) to the director or his or her designee. When determining whether or not to grant the appeal, the director or his or her designee shall consider all of the following:
(A) Whether the noncontracting CCS provider has any relevant clinical experience or unique expertise that available contracting CCS providers do not have.
(B) If the noncontracting CCS provider is a special care center, whether or not any of the available contracting CCS providers is a special care center of the same type.
(C) The length of the ongoing relationship between the CCS provider and the child or youth.
(D) The proximity of the noncontracting CCS provider to the child’s or youth’s home as compared to the proximity of the contracting CCS provider being put forth by the plan.
(2) The opinion of the director or his or her designee shall be final and binding upon the plan.
(j) This section shall not preclude the right of the CCS child or youth to appeal or be eligible for a fair hearing regarding the extension of a continuity of care period.
(k) Each Medi-Cal managed care plan participating in the Whole Child Model program shall notify the CCS child or youth, in writing, 60 days prior to the end of his or her authorized continuity of care period. The notice shall explain the right to petition the plan for an extension of the continuity of care period, the criteria the plan will use to evaluate the petition, and the appeals process if the plan denies the petition.
(Added by Stats. 2016, Ch. 625, Sec. 7. (SB 586) Effective January 1, 2017.)