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 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14456.

14456. The department shall conduct annual medical audits of each prepaid health plan unless the director determines there is good cause for additional reviews.
The reviews shall use the standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975, as appropriate. Except in those instances where major unanticipated administrative obstacles prevent, or after a determination by the director of good cause, the reviews shall be scheduled and carried out jointly with reviews carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if reviews will be carried out within time periods which satisfy the requirements of federal law.
The department shall be authorized to contract with professional organizations or the Department of Managed Health Care, as appropriate, to perform the periodic review required by this section. The department, or its designee, shall make a finding of fact with respect to the ability of the prepaid health plan to provide quality health care services, effectiveness of peer review, and utilization control mechanisms, and the overall performance of the prepaid health plan in providing health care benefits to its enrollees.
The director shall publicly report the findings of finalized annual medical audits conducted pursuant to this section as soon as possible, but no later than 90 days following completion of any corrective action plan initiated pursuant to the audit, if any, unless the director determines, in his or her discretion, that additional time is reasonably necessary to fully and fairly report the results of the audit.
(Amended by Stats. 2014, Ch. 573, Sec. 5. (SB 964) Effective January 1, 2015.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14456.3.

14456.3. (a) The department shall share with the Department of Managed Health Care its findings from medical audits and monthly provider files of a Medi-Cal managed care plan that provides services to Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or this chapter and is subject to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code.
(b) To the extent that the department communicates its preliminary investigative audit findings to the Department of Managed Health Care under subdivision (a), those communications shall be exempt from disclosure under the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code).
(Amended by Stats. 2021, Ch. 615, Sec. 457. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14457.

14457. (a) In addition to the reviews required or authorized by Section 14456, the department shall conduct periodic onsite visits or additional visits after a determination by the director of good cause by departmental representatives to include observation of the general operation of the prepaid health plan, the condition of the facilities for delivering health care, the availability of emergency services, the degree of satisfaction of the enrollees, the operation of the plan’s grievance system, and the administrative and financial aspects of the operation of the prepaid health plan.
(b) Except when reviewing a plan’s grievance system or marketing activities, this evaluation shall use standards and criteria established pursuant to the Knox-Keene Health Care Service Plan Act of 1975. Except in those instances where major, unanticipated administrative obstacles prevent, or after a determination by the director of good cause, the visits shall be scheduled and carried out jointly with reviews carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if reviews under that act will be carried out within time periods that satisfy the requirements of federal law.
(c) The State Department of Health Services may contract with the Department of Managed Health Care to perform the periodic visits required by this section.
(Amended by Stats. 2023, Ch. 266, Sec. 6. (AB 614) Effective January 1, 2024.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14458.

14458. The prepaid health plan shall establish procedures for continuously reviewing the quality of care, performance of medical personnel, the utilization of services and facilities, and costs. Information derived from such review shall be made available to the department.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14459.

14459. (a) The prepaid health plan shall maintain financial records and shall have an annual audit or additional audits after a determination by the director of good cause, performed by an independent certified public accountant. A prepaid health plan operated by a public entity shall have an annual audit performed in a manner approved by the department. All certified financial statements shall be filed with the department as soon as practical after the end of the prepaid health plan’s fiscal year and in any event, within a period not to exceed 90 days thereafter. These financial statements shall be filed with the department and shall be public records. The department shall perform routine auditing of prepaid health plan contractors and their affiliated subcontractors. Except in those instances where major unanticipated obstacles prevent, or after a determination by the director of good cause, the audits shall be scheduled and carried out jointly with audits carried out pursuant to the Knox-Keene Health Care Service Plan Act of 1975, if audits under that act are carried out within time periods that satisfy the requirements of federal law. The department is authorized to contract with the Department of Managed Health Care to carry out the audits required by this section. The prepaid health plan shall make all of its books and records available for inspection, examination, or copying by the department during normal working hours at the prepaid health plan’s principal place of business or at such other place in California as the department shall designate. For good cause, the department may grant an exception to the time when annual financial statements are to be submitted to the department. The annual report required in Section 14313 shall include an itemization of expenditures made by each prepaid health plan for the following categories of expenditures: physician services, inpatient and outpatient hospital services, pharmaceutical services and prescription drugs, dental services, medical transportation services, vision care services, mental health services, laboratory services, X-ray services, enrollee education programs, marketing and enrollment costs, data-processing costs, other administrative costs and health service expenditures and any payments made to subcontractors, and the purposes of the payments, including, but not limited to, contributions to election campaigns.
(b) The requirements of a financial and administrative review by the department of any health care service plan licensed by the Director of the Department of Managed Health Care pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code may be waived upon submission of the financial audit for the same period conducted by the Department of Managed Health Care pursuant to Section 1382 of the Health and Safety Code.
(Amended by Stats. 2023, Ch. 266, Sec. 7. (AB 614) Effective January 1, 2024.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14459.5.

14459.5. (a) As delegated by the federal government, the department has responsibility for monitoring the quality of all Medicaid services provided in the state. A key component of this monitoring function is the performance of annual, independent, external reviews of the quality of services furnished under each state contract with a health maintenance organization, as specified by the federal Centers for Medicare and Medicaid Services.
(b) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall require, through its contracts, that each managed care plan inform the department whether it has been accredited by a private independent accrediting entity.
(c) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall require, through its contracts, that each managed care plan that has received accreditation by a private independent accrediting entity shall authorize the private independent accrediting entity to provide the department a copy of its most recent accreditation review, including all of the following:
(1) Accreditation status, survey type, and level, as applicable.
(2) Accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings.
(3) Expiration date of the accreditation.
(d) The Legislature finds and declares that the final report obtained from the external reviews will provide valid and reliable information regarding health care outcomes and the overall quality of care delivered by the managed care plans.
(e) The department shall make the final report of each external review available, within 30 calendar days of completion, to the fiscal and health policy committees of the Legislature.
(f) In accordance with Section 438.332 of Title 42 of the Code of Federal Regulations, the department shall make the accreditation status for each contracted entity available on its Internet Web site, including whether each entity has been accredited, and if applicable, the name of the accrediting entity, accreditation program, and accreditation level. The department shall update this information at least annually.
(g) Subdivisions (b), (c), and (f) shall be effective for the rating period for managed care plan contracts beginning on or after July 1, 2017.
(Amended by Stats. 2017, Ch. 511, Sec. 30. (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 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14459.7.

14459.7. (a) The department shall implement a Management Information System/Decision Support System (MIS/DSS) for the Medi-Cal Program, that shall integrate data from managed care plans to monitor and evaluate the quality of care provided to beneficiaries, including access to services, establish provider rates, and analyze ways to improve both the managed care and fee-for-service systems.
(b) The department shall provide the fiscal and health policy committees of the Legislature with an annual progress and status report on the implementation of the MIS/DSS. The annual progress and status report shall include a description of the current status of the project, including a list of the specific project objectives that have and have not been met at the time of the report and a comparison of the actual progress of the project with the most recent project schedule approved by the Legislature. The report also shall include estimated expenditures and staffing for the current fiscal year and proposed expenditures and staffing for the next fiscal year as well as a summary of cumulative total project expenditures to date and a projection of future expenditures necessary to complete the project.
(c) The department shall provide system or information access to the fiscal and health policy committees of the Legislature, with the most cost-effective technology available, by the conclusion of the third phase of this multiphase project. Access shall include both the management information system and ad hoc report systems, or their equivalent, with safeguards to block access to individual patient identities. Public access shall be provided to at least the management information system summary presentation, or an equivalent, by the time of project completion.
(Added by Stats. 1997, Ch. 294, Sec. 78. Effective August 18, 1997.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14459.8.

14459.8. (a) By no later than March 15, 2013, with annual updates thereafter, the department shall provide the fiscal and appropriate policy committees of the Legislature with either a comprehensive report or separate reports on dental managed care in the Counties of Sacramento and Los Angeles. This report shall articulate specific changes and improvements implemented to increase Medi-Cal beneficiary access to preventive services and dental treatment, the utilization of services, and beneficiary satisfaction. Key measures, outcomes, and department findings pertaining to participating dental managed care plans and provider networks shall also be included.
(b) Any report provided pursuant to subdivision (a) on the County of Sacramento shall also provide data regarding the outcomes and findings from the beneficiary dental exception (BDE) process implemented by the department pursuant to Section 14089.09, including the consideration of voluntary enrollment in the County of Sacramento as compared to the existing mandatory enrollment.
(c) The department may seek foundation funding or federal grant funding to facilitate data analysis and reporting as applicable for this purpose.
(Added by Stats. 2012, Ch. 23, Sec. 115. (AB 1467) Effective June 27, 2012.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14460.

14460. A schedule of reviews, visits, and audits shall be jointly established by the Department of Managed Health Care or the Department of Insurance, as the case may be, and the State Department of Health Services. Nothing in Section 14456, 14457, or 14459 shall be construed to prohibit the State Department of Health Services from conducting reviews, visits, or audits either jointly or individually, for the purpose of following up on findings resulting from reviews, visits, or audits carried out in accordance with this chapter.
(Amended by Stats. 2000, Ch. 857, Sec. 96. Effective January 1, 2001.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14461.

14461. Upon request by the department, each prepaid health plan shall submit to the department a copy of any financial report submitted to any other public or private organization, if such report differs in content or format from any financial report already submitted to the department.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14462.

14462. In accordance with Section 14081.5, the provisions of Section 15459 of the Government Code shall not be applicable to a hospital, whether or not it negotiates to obtain a contract pursuant to Article 2.6 (commencing with Section 14081), if the hospital predominantly serves or will predominantly serve members of a health maintenance organization that has negotiated in good faith to obtain a prepaid contract pursuant to this part or pursuant to Article 2.91 (commencing with Section 14089).
(Added by Stats. 1983, Ch. 1018, Sec. 3. Effective September 22, 1983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5 - Standards for Prepaid Health Plans › Section 14464.

14464. (a) The department may negotiate and establish an individual administrative cost limit in its contracts with each prepaid health plan or Medi-Cal managed care plan contracting under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) providing services to Medi-Cal beneficiary enrollees.
(b) As used in this section, prepaid health plan or Medi-Cal managed care plan “administrative costs” includes net profit or revenue in excess of expenditures, in addition to those items set forth in Section 1300.78 of Title 10 of the California Code of Regulations and those items set forth by the director.
(Added by Stats. 1995, Ch. 859, Sec. 10. Effective January 1, 1996.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5.3 - Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans › Section 14465.

14465. For purposes of this article and Section 14454, “emergency services” shall have the same meaning as that established in Section 1317.1 of the Health and Safety Code for “emergency services and care.”
(Added by Stats. 1992, Ch. 1052, Sec. 1. Effective January 1, 1993.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 5.3 - Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans › Section 14466.

14466. The plan shall make a request to the department to temporarily disenroll any enrollee for the month or months in which the patient is hospitalized and remains in stable condition, and refuses to be transferred from a nonplan provider’s facility to a plan’s facility when it is medically safe to do so.
This section shall only be applicable in Los Angeles County because of problems the county has experienced in treating nonplan Medi-Cal enrollees in county hospitals.
(Added by Stats. 1992, Ch. 1052, Sec. 1. Effective January 1, 1993.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14475.

14475. (a) No prepaid health plan or pilot program contract shall be approved or renewed by the department pursuant to this chapter if any state officer or state employee or his spouse or minor child has a substantial financial interest, as defined by Section 14478, in any of the following:
(1) The contract or the contracting organization.
(2) Any contract with the contracting organization.
(3) Procurement of a contract for the contracting organization.
(b) As used in subdivision (a), “state officer or state employee” means any person included in Section 14477 and includes any employee in the department who has a direct responsibility for the negotiation, development, or management of a prepaid health plan contracted under the provisions of this chapter. The director shall publish regulations determining the class of employees covered by this subdivision.
(Repealed and added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14476.

14476. The chief executive, sole proprietor, or managing partner of each prepaid health plan shall file with the department an annual statement disclosing any purchases or leases of services, equipment, supplies or real property by the plan from any entity in which any of the following persons have a substantial financial interest as defined by Section 14478:
(a) Any person also having a substantial financial interest in the plan.
(b) Any director, officer, partner, trustee or employee of the plan.
(c) Any member of the immediate family of any person designated in (a) or (b).
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14477.

14477. (a) For purposes of this article, “state officer” means a United States Senator or Member of Congress representing California, the Governor, Lieutenant Governor, Secretary of State, Controller, Treasurer, Attorney General, State Superintendent of Public Instruction, a Member of the Legislature, or a secretary of a state agency.
(b) For purposes of this article, “state employee” means any staff member of a state agency secretary who holds a policymaking position, any member of the Governor’s staff who holds a policymaking position, or any administrative aide or committee consultant of the Legislature. “State employee” includes the appointive or civil service employee of the highest class or grade in each department, system, program, section, or other administrative subdivision of the State Department of Health Services as defined in regulations adopted by the department.
(Amended by Stats. 1978, Ch. 429.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14478.

14478. (a) As used in this chapter, “substantial financial interest” means the ownership of common stock, preferred stock, warrants, options, loans, partnership interests, debt instruments, or other ownership interest, if consisting of, or convertible to, equity investments in an entity contracting with the department under the provisions of this chapter or an entity contracting with a current or proposed contractor doing business with the department under the provisions of this chapter, and such ownership interest in terms of fair market value is not less than the greater of the following:
(1) One thousand dollars ($1,000).
(2) Five percent or more of the total fair market value of all equity investments in the entity, including ownership interests convertible to such investments.
A convertible debt includes bonds, notes, debentures, and mortgages.
(b) As used in this chapter, “immediate family” means an individual’s spouse and minor dependent children and any other person over which the individual has legal control.
(Repealed and added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14479.

14479. (a) No prepaid health plan or pilot program contract shall be approved, renewed or continued by the department if a state officer or state employee is employed in a management or consultant position by the contractor or a subcontractor to the contractor within one year after the state officer or state employee terminated state employment.
(b) For purposes of this section, “state employee” means any appointive or civil service employee of the department or of the Health and Welfare Agency who, within two years prior to leaving state employment, was responsible for development, negotiation, contract management, or supervision of a prepaid health plan or prepaid health plan contract.
For purposes of this section, employees of the department who are assigned as contract managers shall not be subject to the provisions of this section unless they are employed by a prepaid health plan or a subcontractor of a prepaid health plan for which, within two years prior to leaving state employment, they were responsible for the development, negotiation, contract management, or direct supervision over the prepaid health plan contract. This section shall not apply to any employee, appointee, or person on contract with the department who is employed, appointed, or contracted with by the department either:
(1) To fulfill the purposes of a federal grant, provided that such person does not supervise, develop, manage, or negotiate a prepaid health plan contract; or
(2) To fulfill on a temporary basis, not to exceed 120 days, a specific function for the department which does not include supervising, developing, managing, or negotiating a prepaid health plan contract.
(c) The requirements of this section shall apply to any contract entered into on or after the operative date of this section and to any state officer or state employee who is employed by such contractor or subcontractor thereof on or after such operative date. This section shall not apply to any state officer or employee who terminated state employment prior to such operative date.
(Repealed and added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14480.

14480. No prepaid health plan or pilot program contract with an existing or proposed contractor shall be approved or renewed if a state officer or state employee provides legal or management services to the contracting organization. For the purposes of this section no state officer or state employee shall share in the income or any remuneration derived from the providing of legal or management services to a contracting organization.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14481.

14481. No prepaid health plan or pilot program contract shall be approved or renewed if any state officer or state employee receives anything of value for the purpose of influencing or attempting to influence the negotiations for approval or renewal of the contract.
(Amended by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 6 - Conflict of Interest › Section 14482.

14482. No prepaid health plan shall contract with any subcontractor other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, or an affiliate of the prepaid health plan whose financial statements are consolidated with that of the prepaid health plan at the time of the annual audit by the independent auditors of the plan and when the quarterly and annual financial statements are filed with the Director of the Department of Managed Health Care, if any of the following persons connected with the plan have a substantial financial interest, as defined by Section 14478, in such subcontractor:
(a) Any person also having a substantial financial interest in the plan.
(b) Any director, officer, partner, trustee, or employee of the plan.
(c) Any member of the immediate family of any person designated in (a) or (b).
(Amended by Stats. 2000, Ch. 857, Sec. 97. Effective January 1, 2001.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14490.

14490. In providing benefits under this chapter and Chapter 7 (commencing with Section 14000), the director shall aggressively seek the development of alternative forms of financing and delivering health care services. In carrying out the intent of this article, the director shall contract with institutional providers, counties, or other organizations to establish pilot programs that demonstrate the value, or lack thereof, of such a program in delivering or financing health care services in such a manner. Each pilot program shall be for a specified duration not to exceed five years, and each pilot program shall be evaluated annually for its efficiency, effectiveness, and quality.
Upon a finding by the director that a pilot program contributes substantially to the availability of high quality health services and that those services are cost-effective, the director shall enter into a contract for a period of up to five years.
Where the director recommends implementation of a pilot program on a permanent basis, but finds that he or she is not able to implement on a permanent basis that program immediately upon conclusion of the program’s term, he or she may extend the duration of the pilot program until the evaluation or permanent implementation can be accomplished. The extension shall be for a term not in excess of one year, but may be renewed for additional one-year terms, provided that the director has completed an evaluation to include findings that would qualify an extension.
(Amended by Stats. 1997, Ch. 17, Sec. 154. Effective January 1, 1998.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14491.

14491. The director shall pursue the feasibility of establishing the following as pilot programs:
(a) A capitated, risk-assuming contract with one or more regional fiscal intermediaries.
(b) A capitated, risk-assuming contract with acute care hospitals within a county or region.
(c) A capitated, risk-assuming contract with one or more organizations which provide payment to a specified class or classes of providers.
For purposes of this section, “risk-assuming” means the pilot program contractor agrees to assume the risk of utilization of services or costs of services, or both.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14493.

14493. The director shall also consider programs which demonstrate an innovative and economical use of health personnel and are approved pursuant to Article 18 (commencing with Section 429.70), Chapter 2, Part 1, Division 1 of the Health and Safety Code.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14494.

14494. The director may enter into other contracts under this article which do one or more of the following:
(a) Demonstrate an innovative and economical use of health personnel.
(b) Emphasize preventive care.
(c) Stress new methods for controlling utilization of services.
(d) Stress new methods of reviewing provider competency or quality of care.
(e) Stress a more economical organization of health care resources and delivery systems.
(f) Provide an incentive to beneficiaries to seek the most economical level of care.
(g) Demonstrate innovative methods for health care financing, such as prospective budgeting in regard to enrolled population or volume of services.
(h) Test or demonstrate the feasibility of allowing California citizens to purchase Medi-Cal coverage at a premium rate determined by the department on an actuarial basis.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14495.

14495. In establishing pilot programs, the director may do the following:
(a) Provide benefits based on class of recipient, class of benefit, geographical area, or any other reasonable classification.
(b) Modify, to the extent permitted by federal law, the scope and duration of benefits provided by Section 14132. The extent of coverage may be limited to a fixed number of days or to amount or duration of services.
(c) Modify, to the extent permitted by federal law, Medi-Cal eligibility determination processes or criteria.
(d) Allow for the provision of Medi-Cal benefits on a prepaid basis in a given geographical area exclusively by the pilot program.
(e) Assign persons eligible for Medi-Cal benefits to a pilot program or a prepaid health plan on a pilot basis, provided such persons shall be entitled to disenroll for any cause for a period of 30 days following the effective date of enrollment and to receive a Medi-Cal card pursuant to Section 14017.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14496.

14496. (a) Alternate methods of payment for a pilot program may include, but shall not be limited to, a prospectively negotiated reimbursement rate, fee-for-service, retainer, capitation, or other basis.
(b) In order to implement expeditiously the budgeting decisions of the Legislature, the director shall, to the extent permitted by federal law, adopt regulations setting rates payable to providers which reflect such decisions 30 days after the enactment of the Budget Act and of any other appropriation which changes the level of funding for Medi-Cal services. The proposed regulations shall be submitted to the Department of Finance five days prior to the date of adoption. With the written approval of the Department of Finance, the director shall adopt such regulations as emergency regulations in accordance with the provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340), Part 1, Division 3, Title 2 of the Government Code). For purposes of such act, the adoption of such regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare.
(c) In order to implement expeditiously the budgeting decisions of the Legislature, the director and the contractor shall, to the extent permitted by federal law, amend the pilot project contract to reflect such decisions 60 days after the enactment of the Budget Act and of any other appropriation which changes the level of funding for Medi-Cal services. Any approvals, ratifications, reviews, or analyses of such amendments required to be undertaken by any state agency or state department shall be completed within the 60-day period specified in this subdivision.
(Amended by Stats. 1990, Ch. 1516, Sec. 3. Effective September 30, 1990.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14497.

14497. The director shall call a public hearing pursuant to Section 14300 prior to entering into or renewing a pilot program. The director shall make available to the public a statement of objectives, program proposal, pilot program contract, and other details regarding the pilot program not less than five days prior to the public hearing.
(Added by Stats. 1977, Ch. 1036.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 7 - Pilot Programs › Section 14499.6.

14499.6. (a) The Santa Barbara Regional Health Authority may arrange with out-of-county Selective Provider Contracting Program hospitals that have negotiated hospital contracts and per diem rates under Article 5.1 (commencing with Section 14165) of Chapter 7, to provide medically justified emergency services or to provide specialized hospital services not available within Santa Barbara County to Medi-Cal beneficiaries who reside in Santa Barbara County. The authority may arrange medically justified inpatient hospital services with out-of-county program hospitals for those beneficiaries whose county of residence for purposes of eligibility determination is Santa Barbara, but who for medical or legal reasons physically reside in a county other than Santa Barbara.
(b) The out-of-county program hospitals shall not charge the authority more than their program negotiated rates when providing hospital services to authority patients under this section, except as provided in subdivision (c).
(c) In cases where an out-of-county program hospital can demonstrate that the cost of the services it is rendering to authority patients was not contemplated in the case mix and acuity assumptions on which the program rates are based, the program hospital and the authority shall negotiate in good faith equitable rates for payment for the provision of hospital services to authority patients. The established program rate shall serve as the base for those negotiations.
(d) (1) Notwithstanding any other provision of law, any records maintained by the authority that would enable a determination to be made regarding rates negotiated pursuant to Article 5.1 (commencing with Section 14165) of Chapter 7, shall be exempt from the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code).
(2) The authority shall establish guidelines to ensure that these rates are maintained as confidential records and that access to these records is restricted.
(3) The authority shall submit the established guidelines to the department for approval.
(Amended by Stats. 2021, Ch. 615, Sec. 458. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.7.

14499.7. The department may contract with one or more fiscal intermediaries in order to pay for benefits authorized under this chapter and Chapter 7 (commencing with Section 14000). Contracts entered into pursuant to this article may be awarded on a bid or nonbid basis.
(Added by Stats. 1985, Ch. 1579, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.71.

14499.71. For the purposes of this article, “fiscal intermediary” means an entity that agrees to pay for covered services provided to Medi-Cal eligibles in exchange for a premium, subscription charge, or capitation payment; to assume an underwriting risk; and is licensed by the Director of the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
(Amended by Stats. 2015, Ch. 455, Sec. 54. (SB 804) Effective January 1, 2016.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.73.

14499.73. A contract entered into under this article shall provide that a fiscal intermediary meets both of the following criteria:
(a) The fiscal intermediary shall provide or arrange for an adequate number of primary care physicians and supportive specialty care physicians.
(b) The fiscal intermediary shall implement a management and information reporting system in order to determine the costs of each type of health care service rendered to Medi-Cal recipients.
(Added by Stats. 1985, Ch. 1579, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.74.

14499.74. In determining the capitated rates to be paid to a fiscal intermediary during the first year of contracting under this article, the department shall utilize an acceptable actuarial process and historical data concerning Medi-Cal recipients in the geographical area which will, or is being, served by the fiscal intermediary. During the remaining years of the contract with the fiscal intermediary, the department shall utilize data concerning Medi-Cal expenditures for delivery of services based on the fee-for-service experience in comparable geographic areas. The capitated rates shall not exceed the total per capita amount (including the cost of adjustments to provide actuarial equivalence) which would be payable for all services and requirements covered under the fiscal intermediary contract adopted pursuant to this article if all those services and requirements were to be furnished to Medi-Cal beneficiaries under the fee-for-service Medi-Cal program provided for by Chapter 7 (commencing with Section 14000).
(Added by Stats. 1985, Ch. 1579, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.75.

14499.75. A fiscal intermediary may contract for the provision of services with any provider who would be eligible to provide services if services were to be provided on a fee-for-service basis without the use of a fiscal intermediary pursuant to this article.
(Added by Stats. 1985, Ch. 1579, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries › Section 14499.77.

14499.77. All services, except those specified for exclusion by the department, received by Medi-Cal recipients residing in the geographical area served by the fiscal intermediary shall be paid for by the fiscal intermediary. Services shall be provided only by providers which have entered into agreements with the fiscal intermediary, unless authorized by the fiscal intermediary.
(Added by Stats. 1985, Ch. 1579, Sec. 4.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.5 - Family Planning › Section 14500.

14500. An Office of Family Planning shall be established within the State Department of Health Services. The Office of Family Planning shall be under the control of an executive officer who shall be known as the Coordinator of the Office of Family Planning. The coordinator shall be appointed by the State Director of Health Services and shall be an individual with training and experience in family planning.
(Amended by Stats. 1977, Ch. 1252.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8.5 - Family Planning › Section 14500.5.

14500.5. (a) It is the intent of the Legislature that family planning includes, but is not limited to, an effective means to improve reproductive health by disease prevention and treatment, to reduce the incidence of unintended pregnancies, and to reduce the demand for abortions. It is the intent of the Legislature that no family planning shall be expended other than for the services enumerated in this chapter. It is also the intent of the Legislature that no funds received pursuant to this chapter be used for abortions or services ancillary to abortions.
(b) For purposes of this chapter, the following definitions shall apply:
(1) “Family planning” means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, natural family planning, abstinence methods, and the management of infertility. Family planning services include preconceptional counseling, maternal and fetal health counseling, and general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, and other services as described in Section 14503, except for abortions and services ancillary to abortions as prohibited in Section 14509. Family planning does not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care which is not incident to the diagnosis of a pregnancy, except as otherwise provided for in this chapter.
(2) “Abortion as a method of family planning” means the deliberate choice of abortion over other methods to limit the number, gender, and spacing of children, including, but not limited to, contraception, abstinence, and natural family planning methods.
(3) “Department” means the State Department of Health Care Services.
(4) “Director” means the Director of Health Care Services.
(5) “Grantee” means an agency, institution, or organization approved by the department to provide family planning services pursuant to this chapter.
(Amended by Stats. 2012, Ch. 23, Sec. 116. (AB 1467) Effective June 27, 2012.)