reglab/statecodes huggingface dataset:
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.06.

14105.06. (a) Notwithstanding Section 14105 and any other provision of law, the Medi-Cal reimbursement rates in effect on August 1, 2003, shall remain in effect through July 31, 2005, for the following providers:
(1) Freestanding nursing facilities licensed as either of the following:
(A) An intermediate care facility pursuant to subdivision (d) of Section 1250 of the Health and Safety Code.
(B) An intermediate care facility for the developmentally disabled pursuant to subdivision (e), (g), or (h) of Section 1250 of the Health and Safety Code.
(2) A skilled nursing facility that is a distinct part of a general acute care hospital. For purposes of this paragraph, “distinct part” shall have the same meaning as defined in Section 72041 of Title 22 of the California Code of Regulations.
(3) A subacute care program, as described in Section 14132.25 or subacute care unit, as described in Sections 51215.5 and 51215.8 of Title 22 of the California Code of Regulations.
(4) An adult day health care center.
(b) (1) The director may adopt regulations as are necessary to implement subdivision (a). These regulations shall be adopted as emergency regulations in accordance with the rulemaking provisions of the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. For purposes of this section, the adoption of regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare.
(2) As an alternative to paragraph (1), and Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the director may implement this article by means of a provider bulletin, or similar instructions, without taking regulatory action.
(c) The director shall implement subdivision (a) in a manner that is consistent with federal medicaid law and regulations. The director shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only to the extent that federal approval is obtained.
(d) The provisions of subdivision (a) shall apply to a skilled nursing facility, as defined in subdivision (c) of Section 1250 of the Health and Safety Code, only until the first day of the month following federal approval to implement both the skilled nursing quality assurance fee imposed by Article 7.6 (commencing with Section 1324.20) of Chapter 2 of Division 2 of the Health and Safety Code and the rate methodology developed pursuant to Article 3.8 (commencing with Section 14126) of Chapter 7 of Part 3 of Division 9.
(Amended by Stats. 2005, Ch. 508, Sec. 7. 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 3 - Administration › Section 14105.076.

14105.076. (a) Notwithstanding any other law, for dates of service on or after January 1, 2024, the department shall adopt a rate year based on the calendar year for nursing facilities providing level A services in accordance with Sections 51120 and 51510 of Title 22 of the California Code of Regulations, and intermediate care facilities that are licensed pursuant to subdivision (d) of Section 1250 of the Health and Safety Code.
(b) In implementing this section, the department shall seek any federal approvals it deems necessary. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(c) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section, in whole or in part, by means of provider bulletins or other similar instructions, without taking regulatory action.
(Added by Stats. 2023, Ch. 42, Sec. 136. (AB 118) Effective July 10, 2023.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.08.

14105.08. (a) Notwithstanding any other provision of law, in order to implement changes in the level of funding for radiology services, as defined in Section 51139 of Title 22 of the California Code of Regulations, the director shall reduce reimbursement rates applicable to radiology services, as specified in this section.
(b) Except as otherwise provided in this section, reimbursement rates applicable to radiology services shall not exceed 80 percent of the lowest maximum allowance established under the federal Medicare Program for the same or similar services with dates of service on or after October 1, 2010.
(c) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in this section by means of a provider bulletin or notice, policy letter, or other similar instruction, without taking regulatory action.
(d) (1) The reimbursement rates provided for in this section shall be implemented only if the director determines that the rates, as established by this section, will comply with applicable federal Medicaid requirements and that federal financial participation will be available.
(2) In assessing whether federal financial participation is available, the director shall determine whether the rates comply with applicable federal Medicaid requirements, including those set forth in Section 1396a(a)(30)(A) of Title 42 of the United States Code.
(3) To the extent that the director determines that the rates do not comply with applicable federal Medicaid requirements, the director shall retain the discretion not to implement that rate and may revise the rate as necessary to comply with the federal Medicaid requirements.
(e) The director shall seek any necessary federal approval for the implementation of this section. To the extent that federal financial participation is not available with respect to any rate of reimbursement described by this section, the director shall retain the discretion not to implement that rate and may revise the rate as necessary to comply with the federal Medicaid requirements.
(Added by Stats. 2010, Ch. 717, Sec. 148. (SB 853) Effective October 19, 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 3 - Administration › Section 14105.09.

14105.09. Notwithstanding any other provision of law, if subdivision (b) of Section 3.94 of the Budget Act of 2011 is operative, effective on or after January 1, 2012, the payment reductions in Sections 14105.07, 14105.192, 14126.033, 14131.05, and 14131.07 shall apply to managed care health plans that contract with the department pursuant to Chapter 8.75 (commencing with Section 14591) and to contracts with the Senior Care Action Network and AIDS Healthcare Foundation, to the extent that the services are provided through any of these contracts, payments shall be reduced by the actuarial equivalent amount of the payment reductions pursuant to contract amendments or change orders effective on July 1, 2011, or thereafter.
(Amended by Stats. 2012, Ch. 162, Sec. 213. (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 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.1.

14105.1. (a) Notwithstanding any other provision of law, to the extent permitted by federal law, reimbursement to hospitals for inpatient services rendered to Medi-Cal program beneficiaries between July 1, 1981 and June 30, 1982, shall be adjusted to provide that the average payment per discharge upon final settlement shall not exceed a rate of increase of 6 percent over the average payment per discharge at final settlement for services rendered during the period of July 1, 1980 to June 30, 1981.
(b) Interim payment rates to hospitals shall be adjusted on October 1, 1981, or as shortly thereafter as reasonably possible and consistent with federal law, to accomplish a rate of payment increase to hospitals for inpatient services for the period of July 1, 1981 to June 30, 1982, which is consistent with the provisions of this section.
(c) It is the intent of the Legislature that the reimbursement principles employed by the department in final settlement pursuant to this section will be the methods in effect prior to October 1, 1981, for any services rendered prior to that time, and for services rendered between October 1, 1981, and June 30, 1982, that reimbursement principles be in accordance with the alternative methods adopted for use subsequent to October 1, 1981.
(d) Nothing in this section shall be construed to limit adjustments to hospital reimbursement based upon volume or case mix changes.
(Repealed and added by Stats. 1981, Ch. 1163, Sec. 9. 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 3 - Administration › Section 14105.11.

14105.11. (a) The department may negotiate settlements with acute care hospitals with psychiatric units that unintentionally violate Medi-Cal cost reimbursement policies or procedures governing the operation of acute psychiatric hospitals and that had, prior to the violations, been changed by the department.
(b) In any case to which this section applies, the department may waive all or part of the overpayments made under this chapter that would otherwise be reimbursable to the department by an acute care hospital.
(c) This section shall only apply to hospitals in counties of the 20th and 42nd classes.
(Added by Stats. 1997, Ch. 639, Sec. 2. Effective January 1, 1998.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.115.

14105.115. (a) The department may negotiate or renegotiate settlements with any acute care hospital in San Diego County that has a distinct part pediatric convalescent facility and that has violated any Medi-Cal reimbursement policy or procedure governing the operation of acute care hospitals.
(b) In any settlement negotiated or renegotiated pursuant to this section, the department may waive all or part of any overpayment made under this chapter to any acute care hospital described in subdivision (a) that would otherwise be reimbursable to the department by that acute care hospital.
(Added by Stats. 2002, Ch. 486, Sec. 1. Effective September 12, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.12.

14105.12. (a) The department shall specify circumstances under which requests shall be granted for authorization for services provided by a health facility licensed under subdivisions (c) and (d) of Section 1250 of the Health and Safety Code for periods of up to two years. This subdivision shall be implemented not later than July 1, 1994. The department shall consult with nursing facility providers and appropriate health care professionals in the development of the criteria and process for granting two-year authorizations pursuant to this subdivision.
(b) (1) As of July 1, 1997, the department shall specify circumstances under which requests shall be granted for authorization for services provided by a health facility licensed under subdivisions (e), (g), and (h) of Section 1250 of the Health and Safety Code for periods up to two years. The department shall consult with facility providers cited in this subdivision and appropriate health care professionals in the development of the criteria and process for granting two-year authorizations pursuant to this subdivision.
(2) The department shall not implement paragraph (1) unless and until federal approval of a change in existing utilization control methods as provided in this section is obtained.
(Amended by Stats. 1996, Ch. 446, Sec. 1. Effective January 1, 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 3 - Administration › Section 14105.13.

14105.13. (a) Private duty nursing agencies shall be a provider of skilled nursing services provided on a shift basis covered under the early and periodic screening, diagnosis, and treatment supplemental and home- and community-based waiver programs, subject to federal approval and availability of federal financial participation. In addition to satisfying any other requirements as a condition to participating in the Medi-Cal program under this chapter, a private duty nursing agency licensed under Chapter 8.3 (commencing with Section 1743) of Division 2 of the Health and Safety Code shall satisfy all of the following requirements:
(1) The agency shall be in compliance with the requirements of Chapter 8.3 (commencing with Section 1743) of Division 2 of the Health and Safety Code, and any regulations adopted under that chapter.
(2) The agency shall provide services as specified in Section 1743.2 of the Health and Safety Code.
(3) The agency shall provide skilled nursing services on a shift basis in a patient’s home or other community-based site appropriate for patient care.
(b) The department shall request federal approval of an amendment to the existing nursing facility waiver and model nursing facility waiver in order to include private duty nursing agencies as a provider of skilled nursing services on a shift basis.
(c) The department shall review all other federally approved existing waivers that include home health care as a covered service and request federal approval for adding private duty nursing agencies as a provider of skilled nursing services provided on a shift basis, including home- and community-based waivers under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)).
(Added by Stats. 2001, Ch. 242, Sec. 4. Effective January 1, 2002.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.15.

14105.15. (a) (1) In determining rates of reimbursement for inpatient hospital services the department shall use the reimbursement policy existing on June 29, 1982. The director shall have authority to modify this reimbursement policy. The director shall implement a new reimbursement policy of peer grouping of hospitals through the promulgation of emergency regulations after required federal approvals are obtained. The department may adjust interim payment percentages to hospitals in order to approximate final settlement and may control or freeze charges in order to carry out this section.
(2) This section shall cease to apply to a hospital when the department enters into a contract, pursuant to Article 2.6 (commencing with Section 14081), either with that hospital or with other hospitals to the exclusion of that hospital for services covered under the contracts.
(b) Notwithstanding any other provision of law, the department may make interim rate adjustments and also implement collection procedures to recover overpayments to hospitals, at tentative and final settlement. These recoveries shall be based on audits or examinations made by or on behalf of the department pursuant to Sections 10722 and 14170, including the application of Sections 51536, 51537, and 51539 of Title 22 of the California Administrative Code at tentative and final settlement. Recovery may be made whether or not appeals by the hospitals are pending. Collection of overpayments shall be made in accordance with Section 14172.5.
(c) The amendment of this section made at the 1985 portion of the 1985–86 Regular Session of the Legislature does not constitute a change in, but is declaratory of, the existing law. This declaration shall not apply to any lawsuits filed on or before July 9, 1985.
(d) No new payment system may be implemented without specific authorization from the Legislature.
(e) Notwithstanding any other provision of law, reimbursement for out-of-state acute inpatient hospital services provided to Medi-Cal beneficiaries shall not exceed the current statewide average of contract rates for acute inpatient hospital services negotiated by the California Medical Assistance Commission or the actual billed charges, whichever is less.
(Amended by Stats. 2004, Ch. 193, Sec. 245. Effective January 1, 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 3 - Administration › Section 14105.16.

14105.16. (a) The department may establish per diem or bundled reimbursement rates for pharmacies that provide home infusion supplies and services. The per diem or bundled reimbursement rate shall be budget neutral. Only pharmacies that comply with Sections 4127 and 4127.1 of the Business and Professions Code may be determined to be eligible for reimbursement rates established under this subdivision.
(b) In implementing this section the department shall consult with pharmacies providing home infusion supplies and services with respect to all of the following:
(1) Notifying the provider representatives of the proposed change.
(2) Scheduling at least one meeting to discuss the change.
(3) Obtaining actual costs from providers regarding supplies, services, and administrative costs.
(4) Allowing for written input regarding the change.
(5) Providing 30-day advance notice to providers on the implementation and effective date of the change.
(c) Changes made in the Medi-Cal program pursuant to this section are exempt from the requirements of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340), Chapter 4 (commencing with Section 11370), and Chapter 5 (commencing with Section 11500), of Part 1 of Division 3 of Title 2 of the Government Code), and shall not be subject to the review and approval of the Office of Administrative Law.
(Added by Stats. 2006, Ch. 525, Sec. 1. Effective January 1, 2007.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.17.

14105.17. (a) Each hospital designated by the department as a critical access hospital, and certified as such by the Secretary of the United States Department of Health and Human Services under the federal Medicare rural hospital flexibility program, shall be eligible for supplemental payments for Medi-Cal covered outpatient services rendered to Medi-Cal eligible persons.
(b) Payments made pursuant to subdivision (a) shall be contingent upon receipt of federal financial participation, and shall be limited by the appropriation in the annual Budget Act for the nonfederal share of these payments. Supplemental payments shall be apportioned among critical access hospitals based upon their number of Medi-Cal outpatient visits.
(c) Nothing in this section shall be interpreted as meaning that a critical access hospital is not a general acute care hospital.
(d) The department shall promptly seek any necessary federal approvals for the implementation of this section. If necessary to obtain federal approval, the department may, for federal purposes, limit implementation of this section to those payments that are allowable expenses under Title XIX of the federal Social Security Act (Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code). If federal approval is not obtained for implementation of this section, this section shall become inoperative.
(e) The department may adopt emergency regulations in accordance with the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 1 of Title 2 of the Government Code) to implement this section. One initial adoption of the emergency regulations and one readoption of the initial regulations shall be deemed to be an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. Initial emergency regulations and the first readoption of those regulations shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and publication in the California Code of Regulations, and shall remain in effect for no more than 180 days. If the department adopts emergency regulations pursuant to this section, the department shall seek prior input from representatives of the hospital industry, including the California Healthcare Association.
(Added by Stats. 2000, Ch. 93, Sec. 70. Effective July 7, 2000. Conditionally inoperative as provided in subd. (d).)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.18.

14105.18. (a) Notwithstanding any other law, provider rates of payment for services rendered in all of the following programs shall be identical to the rates of payment for the same service performed by the same provider type pursuant to the Medi-Cal program:
(1) The California Children’s Services Program established pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
(2) The Genetically Handicapped Persons Program established pursuant to Article 1 (commencing with Section 125125) of Chapter 2 of Part 5 of Division 106 of the Health and Safety Code.
(3) The Breast and Cervical Cancer Early Detection Program established pursuant to Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103 of the Health and Safety Code and the breast cancer programs specified in Section 30461.6 of the Revenue and Taxation Code.
(4) The State-Only Family Planning Program established pursuant to Division 24 (commencing with Section 24000).
(5) The Family Planning, Access, Care, and Treatment (Family PACT) Program established pursuant to subdivision (aa) of Section 14132.
(6) The Healthy Families Program established pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code if the health care services are provided by a Medi-Cal provider pursuant to subdivision (b) of Section 12693.26 of the Insurance Code.
(7) The Access for Infants and Mothers Program established pursuant to Part 6.3 (commencing with Section 12695) of Division 2 of the Insurance Code if the health care services are provided by a Medi-Cal provider.
(b) The director may identify in regulations other programs not listed in subdivision (a) in which providers shall be paid rates of payment that are identical to the rates of payments in the Medi-Cal program pursuant to subdivision (a).
(c) Notwithstanding subdivision (a), services provided under any of the programs described in subdivisions (a) and (b) may be reimbursed at rates greater than the Medi-Cal rate that would otherwise be applicable if those rates are adopted by the director in regulations.
(d) Payment increases made pursuant to Section 14105.196 shall not apply to provider rates of payment described in this section for services provided to individuals not eligible for Medi-Cal or Family PACT.
(e) This section shall become operative on January 1, 2011.
(Amended by Stats. 2015, Ch. 303, Sec. 610. (AB 731) Effective January 1, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.181.

14105.181. (a) For purposes of this section, the following definitions shall apply:
(1) “The Family Planning, Access, Care, and Treatment (Family PACT) waiver” or “Family PACT waiver” means the program described in subdivision (aa) of Section 14132, as approved by a federal demonstration waiver.
(2) “Comprehensive clinical family planning services” means those services described in paragraph (8) of subdivision (aa) of Section 14132.
(3) “Office visits” means those procedures billed under Common Procedure Terminology codes 99201, 99202, 99203, 99204, 99211, 99212, 99213, and 99214.
(b) Reimbursement rates for office visits billed as comprehensive clinical family planning services by Family PACT waiver providers and for office visits billed as family planning services by Medi-Cal providers shall receive a rate augmentation equal to the weighted average of at least 80 percent of the amount that the federal Medicare program reimburses for these same or similar office visits. The rate augmentation shall be based upon Medicare rates in effect on December 31, 2007.
(c) The augmentation of reimbursement rates described in subdivision (b) shall be made for office visits rendered on or after January 1, 2008.
(d) (1) The director may adopt regulations as necessary to implement this section. These regulations may be adopted as emergency regulations in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. For purposes of this section, the adoption of the regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health and safety, or the general welfare.
(2) As an alternative to paragraph (1), and notwithstanding the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), the director may administer this section, in whole or in part, by means of a provider bulletin, or other similar instructions, without taking regulatory action.
(Added by Stats. 2007, Ch. 636, Sec. 1. 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 3 - Administration › Section 14105.195.

14105.195. (a) Notwithstanding Sections 14105.191 and 14105.192, the department shall not seek to retroactively implement the reductions and limitations to the reimbursement for services provided by skilled nursing facilities that are distinct parts of general acute care hospitals set forth in Sections 14105.191 and 14105.192 for dates of service on or after June 1, 2011, and on or before September 30, 2013. For purposes of this section, “distinct part” has the same meaning as defined in Section 72041 of Title 22 of the California Code of Regulations.
(b) The department shall not seek to recoup any overpayments from skilled nursing facilities that are distinct parts of general acute care hospitals resulting from the reductions and limitations to the reimbursement for these facilities pursuant to Sections 14105.191 and 14105.192 for dates of service on or after June 1, 2011, and on or before September 30, 2013.
(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 this section by means of provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action.
(Added by Stats. 2016, 2nd Ex. Sess., Ch. 3, Sec. 14. (AB 1 2x) Effective June 9, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.197.

14105.197. (a) For dates of service on and after July 1, 2022, or the effective date of any necessary federal approvals as required by subdivision (b), whichever is later, the reimbursement rates or payments for all of the following services and providers may be maintained, using General Fund or other state funds appropriated to the department as the state share, at the payment levels in effect on December 31, 2021, including supplemental payments or rate increases, or both, as applicable, under the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56, an initiative measure approved at the November 8, 2016, statewide general election) that were implemented with funds from the Healthcare Treatment Fund, as established pursuant to subdivision (a) of Section 30130.55 of the Revenue and Taxation Code:
(1) Case management services provided under the Medi-Cal HIV/AIDS Waiver Program.
(2) Targeted payments for qualifying providers of Community-Based Adult Services (CBAS), as described in Section 14186.3 and subdivision (d) of Section 14184.201, based on criteria established and updated by the department, which may include, but need not be limited to, higher operating costs for CBAS providers in certain areas of the state.
(3) Developmental screenings for individuals zero to three years of age, inclusive, as described in Section 14132.195.
(4) Adverse Childhood Experiences (ACEs) trauma screenings.
(5) Nonemergency medical transportation.
(6) Home health providers of medically necessary in-home services for children and adults in the Medi-Cal fee-for-service system or through home and community-based services waivers.
(7) Pediatric day health care facilities in the Medi-Cal fee-for-service system.
(b) In implementing this section, the department shall seek any federal approvals it deems necessary. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(c) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section, in whole or in part, by means of provider bulletins or other similar instructions, without taking any further regulatory action.
(d) The department shall develop the eligibility criteria, methodologies, and parameters for the payments and rate increases maintained pursuant to subdivision (a), and may revise the eligibility criteria, methodologies, and parameters, for purposes including, but not limited to, obtaining or maintaining any necessary federal approvals as required by subdivision (b).
(Added by Stats. 2022, Ch. 47, Sec. 91. (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 3 - Administration › Section 14105.200.

14105.200. (a) The Medi-Cal Provider Payment Reserve Fund is hereby created in the State Treasury.
(b) Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on moneys in the Medi-Cal Provider Payment Reserve Fund shall be retained in the fund and used solely for the purposes specified in this section.
(c) (1) Subject to an appropriation made by the Legislature, the department shall use the funds transferred to the Medi-Cal Provider Payment Reserve Fund pursuant to paragraph (3) of subdivision (d) of Section 14199.82 for purposes of funding targeted increases to Medi-Cal payments or other investments that advance access, quality, and equity for Medi-Cal beneficiaries and promote provider participation in the Medi-Cal program.
(2) The expenditures of funds appropriated pursuant to paragraph (1) shall include, but not be limited to, all of the following:
(A) Increased costs incurred as a result of the reimbursement requirements established in Section 14105.201.
(B) Transfers authorized in paragraph (2) of subdivision (e) of Section 129385 of the Health and Safety Code.
(C) Transfers, or an appropriation in the annual Budget Act, to the University of California in the amount of seventy-five million dollars ($75,000,000) each calendar year to expand graduate medical education programs, in order to achieve the goal of increasing the number of primary care and specialty care physicians in the state based on demonstrated workforce needs and priorities.
(D) Transfers, or an appropriation in the annual Budget Act, to the Small and Rural Hospital Relief Fund, as established in Section 130077 of the Health and Safety Code, in the amount of fifty million dollars ($50,000,000) in state fiscal year 2023–24 to support the Small and Rural Hospital Relief Program for seismic assessment and construction.
(E) Effective no sooner than January 1, 2025, increased costs for targeted increases to Medi-Cal payments or other investments pursuant to the plan described in Section 14105.202.
(d) The department shall provide an annual report to all health plans accounting for the funds deposited in, and expended from, the Medi-Cal Provider Payment Reserve Fund, in a time and manner as deemed appropriate by the director.
(e) Notwithstanding any other law, the Controller may use the funds in the Medi-Cal Provider Payment Reserve Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code.
(Added by Stats. 2023, Ch. 42, Sec. 139. (AB 118) Effective July 10, 2023.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.202.

14105.202. (a) The department shall submit to the Legislature, as part of the 2024–25 Governor’s Budget, a plan for targeted increases to Medi-Cal payments or other investments as described in subdivision (c) of Section 14105.200. The targeted increases or other investments shall be designed to advance access, quality, and equity for Medi-Cal beneficiaries and promote provider participation in the Medi-Cal program in the following domains, pursuant to criteria established by the department, which may account for, and be inclusive of, the exemption of applicable services from payment reductions pursuant to Section 14105.192:
(1) (A) Primary care services, including those provided by physicians or nonphysician health professionals, as defined in Section 51170.5 of Title 22 of the California Code of Regulations.
(B) Obstetric care services, and doula services as described in Section 14132.24.
(C) Outpatient mental health services that are not the financial responsibility of county mental health plans operating pursuant to Chapter 8.9 (commencing with Section 14700).
(2) Specialty care services.
(3) Community or hospital outpatient procedures and services.
(4) Family planning services and women’s health providers.
(5) Hospital-based emergency and emergency physician services.
(6) Ground emergency transport services.
(7) Designated public hospitals, as defined in subdivision (f) of Section 14184.101.
(8) Behavioral health care for beneficiaries in hospital and institutional long-term care settings.
(9) Investments to maintain and grow the health care workforce.
(b) (1) The payments implemented pursuant to subdivision (a) shall be supported by the managed care organization provider tax revenue, pursuant to Article 7.1 (commencing with Section 14199.80), or other state funds appropriated to the department as the state share for this purpose, including, but not limited to, funds transferred to the Medi-Cal Provider Payment Reserve Fund in accordance with Sections 14105.200 and 14199.82 and, for applicable services as determined by the department, to the Healthcare Treatment Fund in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code.
(2) Notwithstanding any other law, increases to fee-for-service reimbursement rates and managed care directed payments that are made pursuant to subdivision (a) constitute increases in accordance with subdivision (a) of Section 30130.55 of the Revenue and Taxation Code, and all other fee-for-service supplemental payments and managed care directed payments for services identified in subdivision (a), as applicable, that are made pursuant to subdivision (a) of Section 30130.55 of the Revenue and Taxation Code shall be discontinued on the date the payments implemented pursuant to subdivisions (a) are effective.
(Added by Stats. 2023, Ch. 42, Sec. 141. (AB 118) Effective July 10, 2023.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.2.

14105.2. (a) The allowable markup payable for the dispensing of medical supplies, including diabetic supplies except as indicated in subdivision (b), by assistive device and sickroom supply dealers and pharmacies shall not exceed 23 percent of the estimated acquisition cost of the item dispensed, as defined by the department.
(b) Payment for diabetic test strips, lancets, and insulin syringes shall not exceed the estimated acquisition cost of the item dispensed, as defined by the department, plus a fee equal to the maximum professional fee component used in the payment for legend generic drug types.
(c) In determining the estimated acquisition costs of products pursuant to this section, the department shall consider provider related costs of the product that include, but are not limited to, shipping, handling, storage, and delivery.
(d) This section shall become operative on July 1, 2022.
(Repealed (in Sec. 92) and added by Stats. 2022, Ch. 47, Sec. 93. (SB 184) Effective June 30, 2022. Operative July 1, 2022, 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 3 - Administration › Section 14105.21.

14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.
(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.
(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, for prosthetic and orthotic appliances, and the list shall be published in provider manuals.
(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services.
(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.
(f) The department may implement this section by provider manual or bulletin. Notwithstanding the provisions of the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of the Government Code, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
(Added by Stats. 2003, Ch. 230, Sec. 63. Effective August 11, 2003.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.221.

14105.221. Notwithstanding Section 51501(a) of Title 22 of the California Code of Regulations, donation of, or discounts for, clinical laboratory tests or examinations or laboratory services to a federally qualified health center, as defined in Section 1396d(l)(2)(B) of Title 42 of the United States Code, for the purpose of serving its uninsured patients, shall not be considered as a basis for the reduction of Medi-Cal payments below the reimbursement rate established pursuant to Section 14105.22.
(Added by Stats. 2012, Ch. 738, Sec. 1. (AB 969) Effective January 1, 2013.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.222.

14105.222. (a) Notwithstanding Section 14105.22, the department shall not seek to retroactively implement the reductions and limitations to the reimbursement for clinical laboratory or laboratory services set forth in Section 14105.22 for dates of service from January 1, 2020, to June 30, 2021, inclusive. The payment reductions implemented pursuant to Section 14105.192 shall continue to apply for clinical laboratory or laboratory services.
(b) The department shall not seek to recoup any overpayments for clinical laboratory or laboratory services resulting from the reductions and limitations to the reimbursement for clinical laboratory or laboratory services pursuant to Section 14105.22 for dates of service from January 1, 2020, to June 30, 2021, inclusive. Any overpayments for clinical laboratory or laboratory services resulting from the reductions implemented pursuant to Section 14105.192 shall continue to be recouped.
(c) For dates of service from July 1, 2021, to June 30, 2022, inclusive, the department shall establish the reimbursement rates for clinical laboratory or laboratory services at the rates in effect and approved in the Medi-Cal State Plan as of December 31, 2019.
(d) For dates of services on or after July 1, 2022, the department shall establish the reimbursement rates for clinical laboratory or laboratory services pursuant to Section 14105.22.
(e) 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 this section, in whole or in part, by means of provider bulletins or notices, policy letters, or other similar instructions, without taking any further regulatory action.
(f) The department shall implement this section in a manner that is consistent with federal Medicaid law and regulations. The department shall seek any necessary federal approvals for the implementation of this section. This section shall be implemented only to the extent that federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.
(Added by Stats. 2021, Ch. 143, Sec. 377. (AB 133) Effective July 27, 2021.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.23.

14105.23. (a) Reimbursement for portable X-ray transportation services, as defined in paragraph (2) of subdivision (b) of Section 51531 of Title 22 of the California Code of Regulations, shall not exceed 100 percent of the lowest maximum allowance for California established by the federal Medicare Program for the same or similar services.
(b) Notwithstanding subdivision (a) of Section 14105 and the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the director may establish the rates of reimbursement for the services described in subdivision (a) by means of a provider bulletin or manual, or similar instructions.
(Added by Stats. 2005, Ch. 80, Sec. 23. Effective July 19, 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 3 - Administration › Section 14105.25.

14105.25. (a) Notwithstanding any other provision of law, to the extent permitted by federal law and regulations, the maximum rate of reimbursement under the Medi-Cal program for any service or item that is a benefit under Part B of the Medicare program, excluding physician and diagnostic clinical laboratory services, shall not exceed the lowest maximum allowance established by the federal Medicare program for that service or item in any area of the state.
(b) The director shall reduce the rate of reimbursement for any service or item, as required, to comply with subdivision (a).
(c) The director shall administer this section and establish standards, procedures, and rates of reimbursement, as the director deems necessary in carrying out this section. Reimbursement rates are not required to be adopted as regulations pursuant to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(Added by Stats. 1992, Ch. 722, Sec. 91. Effective September 15, 1992.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.332.

14105.332. State and federal rebates that are owed to the state for drugs dispensed to Medi-Cal beneficiaries shall not be reduced to the state if a manufacturer reports, to the federal Centers for Medicare and Medicaid Services or the department, a revised drug product’s average manufacturer price or best price as these terms are defined pursuant to Section 1927 of the federal Social Security Act (42 U.S.C. Sec. 1396r-8) for any calendar quarter in which the rebate was due.
(Amended by Stats. 2011, Ch. 3, Sec. 96. (AB 97) Effective March 24, 2011.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 3 - Administration › Section 14105.34.

14105.34. (a) The department shall provide for an annual written report of Medi-Cal pharmacy costs or Medi-Cal drug costs, as defined in subdivision (e) of Section 14105.31.
(b) The annual report shall be consistent with the relevant sections of the Quarterly Report of Expenditures for the Medi-Cal Assistance Program, known as the CMS-64 Report, provided to the federal Centers for Medicare and Medicaid Services. The report shall include the following expenditure and receipt information:
(1) The total annual rebate amounts received by the department pursuant to agreements with the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.
(2) The total annual rebate amounts received pursuant to state contracts with drug manufacturers.
(3) Total drug cost amounts upon which rebate payments were made.
(Amended by Stats. 2011, Ch. 3, Sec. 97. (AB 97) Effective March 24, 2011.)