2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 7 - Basic Health Care › ARTICLE 4.9 - Medi-Cal Managed Care Benefits for Nondisabled Persons with HIV › Section 14149.3.

14149.3. (a) Subject to subdivisions (b) and (c), paragraph (2) of subdivision (f), and subdivision (k), the department shall, commencing July 1, 2003, or the date that all necessary federal waivers have been obtained, whichever is later, expand eligibility for benefits under this chapter, with the exception of those prescription drug benefits provided pursuant to ADAP, to any person with HIV who meets both of the following criteria:
(1) The person is enrolled in the ADAP program pursuant to Section 120960 of the Health and Safety Code, and maintains enrollment in that program.
(2) The person would otherwise qualify for Medi-Cal benefits if the person were disabled as defined in subdivision (h).
(b) Any person eligible for benefits pursuant to subdivision (a), and seeking enrollment in Medi-Cal pursuant to this article shall be enrolled on a first-come-first-served basis pursuant to an allocation mechanism that shall be developed by the department.
(c) Any person who is eligible for enrollment in Medi-Cal pursuant to this article shall be required to elect a Medi-Cal managed care plan in those counties in which a managed care plan is available, unless the department determines that the cost-neutrality requirements provided for in subdivision (f) and the enrollment goals provided for in this article can be achieved without this requirement.
(d) In implementing this article, the department shall ensure that all of the following standards are met:
(1) All state and federal laws and regulations that apply to the state’s Medi-Cal managed care program shall apply to the expansion provided by this article and to the beneficiaries eligible for Medi-Cal pursuant to this article.
(2) The Medi-Cal benefits provided under this article shall include prescription drugs not provided by the AIDS Drug Assistance Program.
(3) All participating plans that assume full risk for all health care services, including inpatient and outpatient services, shall be licensed pursuant to the Knox-Keene Act (Article 1 commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), except as provided in Section 1343 of the Health and Safety Code.
(4) Health care service plans participating in the Medi-Cal managed care program shall comply with the applicable sections of the Knox-Knee Act (Article 1 (commencing with Section 1340) of Chapter 2.2 of Division 2 of the Health and Safety Code), including Sections 1367 and 1374.16 of the Health and Safety Code and the regulations adopted pursuant to Section 1374.16 of the Health and Safety Code.
(5) Primary care case management plans participating in the Medi-Cal managed care program shall comply with the applicable sections of Article 2.9 ( commencing Section 14088). Primary care case management plans are required to maintain grievance and appeal procedures consistent with the existing Medi-Cal managed care program, to address beneficiary grievances.
(e) The department shall establish capitation rates to be paid to Medi-Cal managed care plans for services provided pursuant to this section. These capitation rates may not exceed 95 percent of the fee-for-service equivalent costs to the Medi-Cal program for medical services for persons with HIV.
(f) (1) The department shall meet federal revenue neutrality requirements through the savings generated by the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS, and who are either receiving Medi-Cal benefits on a fee-for-service basis as of January 1, 2003, or who become eligible to receive Medi-Cal benefits on or after January 1, 2003. The savings generated by increased voluntary enrollments in Medi-Cal managed care shall be used to fund enrollment by individuals eligible for the expansion of Medi-Cal eligibility provided for pursuant to subdivision (a). Nothing in this subdivision shall preclude the department from implementing other means of meeting the federal revenue neutrality requirements, provided that all requirements of this article are met.
(2) The department may not enroll individuals described in subdivision (a) until the department can ensure sufficient savings, pursuant to paragraph (1), equal to or greater than the cost of providing benefits to these individuals.
(g) The department shall encourage the voluntary enrollment into Medi-Cal managed care of persons who are disabled as a result of AIDS. The department shall conduct all outreach and awareness activities necessary to implement this requirement in a manner consistent with Section 14407 to ensure that persons who enroll in managed care do so voluntarily. These outreach and awareness activities shall include information on how electing managed care may alter provider relationships and how persons may revert to fee-for-service if they prefer to return to fee-for-service.
(h) For the purposes of this section, “disabled” means a person who meets the eligibility criteria for the federal Supplemental Security Income for the Aged, Blind and Disabled program (Subchapter 16 (commencing with Section 1381) of Chapter 7 of Title 42 of the United States Code).
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article, without taking any regulatory action, by means of an all-county letter or similar instruction. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(j) Commencing January 1, 2003, the department shall seek the appropriate federal waiver under Section 1115 of the Social Security Act (42 U.S.C. Sec. 1315) to implement the expansion of eligibility provided for pursuant to this section. The department shall maximize the federal reimbursement received for services provided under this article to those eligible pursuant to this section.
(k) This article shall be implemented only if, and to the extent that, the department determines that federal financial participation is available pursuant to Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(Added by Stats. 2002, Ch. 684, Sec. 1. Effective January 1, 2003.)