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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.

14195. It is the intent of the Legislature to provide medical assistance, including prescribed drugs, to the state’s eligible poor in a manner consistent with the provisions of the federal Medicaid Act, provided for under Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.). It is the further intent of the Legislature to test the effectiveness of an open formulary drug therapy program. In order to help achieve this goal, the Legislature hereby establishes an open drug formulary under the Medi-Cal program wherein a beneficiary may receive the most appropriate, most effective, and most cost-efficient drug available for the treatment of his or her illness. It is also the intent of the Legislature in enacting this article to establish a drug utilization review system which will evaluate and enhance the therapeutic outcome of drugs prescribed for persons eligible for Medi-Cal pursuant to this chapter.
(Amended by Stats. 1987, Ch. 1340, Sec. 1.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.2.

14195.2. The open drug formulary, as established pursuant to this article, shall be implemented in one pilot project site. The site shall be located in a northern California test area, comprised of Sacramento and Placer Counties which includes urban, suburban, and rural settings. This pilot project shall not be implemented until federal approval is secured and full federal financial participation is assured.
(Amended by Stats. 1987, Ch. 1340, Sec. 3.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.3.

14195.3. (a) For purposes of the open drug formulary pilot project as established by this article, a provider may be reimbursed for any drug prescribed to a beneficiary if the drug is prescribed by a licensed provider within the scope of his or her practice, as defined by law, and if the drug is approved for use by the federal Food and Drug Administration.
(b) Controlled substances shall be prescribed pursuant to the requirements of federal laws and regulations and the requirements set forth in Chapter 4 (commencing with Section 11150) of Division 10 of the Health and Safety Code.
(c) For purposes of the open drug formulary pilot project as established by this article, there shall be no requirement that prior authorization be obtained by a provider before prescribing any drug to a beneficiary if the provider determines the drug to be a medical necessity in the treatment of the beneficiary.
(d) For purposes of the open drug formulary pilot project as established by this article, a drug determined to be a medical necessity shall be one whose use in the treatment is reasonable and consistent with the objectives of the federal Medicaid Act as set forth in Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(Added by Stats. 1985, Ch. 135, Sec. 7. Effective July 1, 1985.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.4.

14195.4. A Medi-Cal Therapeutic Drug Utilization and Review Committee is hereby established. The committee shall be composed of 17 members who shall serve at the pleasure of the appointing powers as follows:
(a) The Governor shall appoint two representatives from the State Department of Health Services, one representative from the Health and Welfare Agency, and two representatives from schools of pharmacy.
(b) The Governor, the Speaker of the Assembly, and the Senate Rules Committee shall each appoint one representative from the following groups:
(1) Licensed pharmacists.
(2) Licensed physicians.
(3) Drug manufacturers.
(4) Medi-Cal beneficiaries.
(Added by renumbering Section 14195.1 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 4. Effective July 1, 1985.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.5.

14195.5. The Medi-Cal Therapeutic Drug Utilization and Review Committee shall set standards for evaluation of the therapeutic outcomes of prescribed drugs to be applied by an expert contractor to the department. The committee shall have the following responsibilities:
(a) Developing policy for monitoring and controlling therapeutically inappropriate drug utilization.
(b) Overseeing the establishment of a computer-based information system using the State Medicaid MMIS System, which shall provide timely information on drug prescription and consumption and shall be capable of tracking prescriptions by drug, by illness, by beneficiary, and by provider.
The committee shall consult with expert contractors experienced in therapeutically oriented drug utilization review in the discharge of this responsibility.
(c) Establishing standards, in consultation with an expert contractor experienced in the therapeutically oriented drug utilization review, for dosage, duration, and effectiveness of medications with respect to a particular diagnosis.
(d) Setting standards to serve as guidelines on misprescribing, overprescribing, and contraindicated drug use, and protocols for informing prescribers of inappropriate prescribing.
(Added by renumbering Section 14195.2 (as added by Stats. 1984, Ch. 1636) by Stats. 1985, Ch. 135, Sec. 5. Effective July 1, 1985.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.6.

14195.6. The department shall develop a request for a proposal, and may award a contract to an expert contractor to implement the standards and practices established by the Medi-Cal Therapeutic Drug Utilization Review System through use of a therapeutically oriented drug utilization review system by July 1, 1989. The contract shall include a requirement to analyze the therapeutic outcomes of the Medi-Cal Drug Program using the California MMIS for the period of July 1, 1987, through the date the standards established by this article are implemented. Thereafter, the contractor shall submit quarterly reports to the department and the Legislature analyzing therapeutic outcomes in a manner that will allow comparisons with the experience analyzed for the period of July 1, 1987, until implementation of the standards established by this article. The analysis shall include reports on at least the following items:
(a) Compatibility of medication to diagnosis.
(b) Overprescribing of drugs.
(c) Prescription of contraindicated or incompatible drugs.
(d) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or all categories of intermediate care for the developmentally disabled occurring because of the factors specified in subdivisions (a) to (c), inclusive.
(e) Number of days of drug-induced hospitalization and institutionalizati on in nursing facilities or any category of intermediate care facility for the developmentally disabled avoided due to changes in drug regimes which result from compliance by prescribers and beneficiaries with the standards established pursuant to this article.
The department is authorized to require the contractor to phase in implementation of the prescriber notification, as established by protocols for informing prescribers of inappropriate prescribing.
(Amended by Stats. 1990, Ch. 1329, Sec. 33. Effective September 26, 1990.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.7.

14195.7. This article shall not apply to any service rendered by a provider in conjunction with any capitated rate or primary care case contract negotiated pursuant to this chapter or Chapter 8 (commencing with Section 14200) by either the department or the California Medical Assistance Commission unless both parties to the contract mutually agree that application of the standards established by this article would be beneficial to the Medi-Cal eligibles enrolled in plans operating pursuant to capitated rate contracts.
(Added by Stats. 1984, Ch. 1636, Sec. 5.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14195.9.

14195.9. In no case shall the director’s discretion under Section 14120 be exercised to reduce reimbursement to providers of pharmaceutical services because of increased costs in the drug component of the Medi-Cal program arising from the implementation of the open formulary concept.
(Added by Stats. 1984, Ch. 1636, Sec. 5.)
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 6.1 - Medi-Cal Therapeutic Drug Utilization Review › Section 14196.

14196. (a) The department shall adopt any regulations necessary to implement this article. These regulations shall be adopted as emergency regulations in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, and, for the purposes of the Administrative Procedure Act, shall be deemed an emergency, and necessary for the immediate preservation of the public peace, health and safety, or general welfare.
(b) Any provision of this article which is in conflict with any federal statute or regulation shall be inapplicable to the extent of that conflict but the remainder of the provisions shall be in effect to the extent no conflict exists.
The department shall seek all federal waivers necessary to implement this article. The provisions for which federal waivers cannot be obtained shall not be implemented, but provisions for which waivers are either obtained or found to be unnecessary shall be unaffected by the inability to obtain federal waivers for the other provisions.
(c) The department shall seek maximum federal reimbursement for the MMIS-based Drug Establishment Review System established by this article.
(Added by Stats. 1984, Ch. 1636, Sec. 5.)
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 6.2 - Short-Term Community Transitions › Section 14196.2.

14196.2. (a) (1) The Legislature finds and declares that in order to reduce the risk of transmission of COVID-19 during the current pandemic and to further the objectives of the Money Follows the Person Rebalancing Demonstration, a temporary program is hereby established to facilitate the transition of individuals from an inpatient facility who have resided in that setting for fewer than 60 days.
(2) The department shall provide services consistent with the Money Follows the Person Rebalancing Demonstration program, pursuant to Section 6071 of Public Law 109-171, and subsequent amendments, for transitioning eligible individuals out of inpatient facilities.
(b) 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, interpret, or make specific this article by means of letters, provider bulletins, or similar instructions, without taking regulatory action.
(c) Commencing January 1, 2026, the department shall cease to enroll beneficiaries pursuant to this article and commencing January 1, 2027, the department shall cease to provide services pursuant to this article.
(Amended by Stats. 2022, Ch. 898, Sec. 2. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)
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 6.2 - Short-Term Community Transitions › Section 14196.4.

14196.4. The following definitions apply for purposes of this article:
(a)  “Eligible individual” means a Medi-Cal beneficiary who meets both of the following requirements:
(1) The individual meets the definition of an “eligible individual” under Section 6071(b)(2) of Public Law 109-171, and subsequent amendments, except that the individual is not required to have resided for at least 60 consecutive days in an inpatient facility.
(2) The individual is targeted to receive assistance in transitioning from an inpatient facility to a qualified residence, identified in the agreement between the department and the federal Centers for Medicare and Medicaid Services for the Money Follows the Person Rebalancing Demonstration, except the individual shall not be required to have resided for at least 60 consecutive days in an inpatient facility.
(b) “Inpatient facility” has the same meaning as that term is defined in Section 6071(b)(3) of Public Law 109-171, and subsequent amendments.
(Amended by Stats. 2021, Ch. 143, Sec. 412. (AB 133) Effective July 27, 2021. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)
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 6.2 - Short-Term Community Transitions › Section 14196.5.

14196.5 (a) A Medi-Cal beneficiary who has resided for at least 60 consecutive days in an inpatient facility, as required by the Money Follows the Person Rebalancing Demonstration, is ineligible for services under this article unless the department determines that any necessary federal approvals have been obtained and federal financial participation is available for this purpose.
(b) Services shall not be provided pursuant to this article during any period that the department has obtained any necessary federal approvals under the Money Follows the Person Rebalancing Demonstration to not apply the eligibility requirement that the beneficiary has resided for at least 60 consecutive days in an inpatient facility.
(Amended by Stats. 2021, Ch. 143, Sec. 413. (AB 133) Effective July 27, 2021. Repealed as of January 1, 2028, pursuant to Sec. 14196.6.)
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 6.2 - Short-Term Community Transitions › Section 14196.6.

14196.6. This article shall remain in effect only until January 1, 2028, and as of that date is repealed.
(Repealed and added by Stats. 2022, Ch. 898, Sec. 4. (SB 281) Effective January 1, 2023. Repealed as of January 1, 2028, by its own provisions. Note: Repeal affects Art. 6.2, commencing with Section 14196.2.)
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 6.3 - Medi-Cal Managed Care Plans › Section 14197.1.

14197.1. (a) The department shall ensure that all covered mental health benefits and substance use disorder benefits, as those terms are defined in Section 438.900 of Title 42 of the Code of Federal Regulations, are provided in compliance with Parts 438, 440, 456, and 457 of Title 42 of the Code of Federal Regulations, as amended March 30, 2016, as published in the Federal Register (81 Fed. Reg. 18390), and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services.
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. In doing so, the director shall consult with managed care plans and consumer advocates. By July 1, 2022, the department shall adopt regulations, where appropriate, 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.
(c) The department shall make any findings of noncompliance and corrective action plans available on its Internet Web site.
(d) For purposes of this section, “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:
(1) Article 2.7 (commencing with Section 14087.3), excluding dental managed care programs developed pursuant to Section 14087.46.
(2) Article 2.8 (commencing with Section 14087.5).
(3) Article 2.81 (commencing with Section 14087.96).
(4) Article 2.82 (commencing with Section 14087.98).
(5) Article 2.91 (commencing with Section 14089).
(6) Chapter 8 (commencing with Section 14200), excluding dental managed care plans.
(7) Chapter 8.9 (commencing with Section 14700).
(8) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
(Added by Stats. 2017, Ch. 768, Sec. 3. (SB 171) Effective January 1, 2018.)
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 6.3 - Medi-Cal Managed Care Plans › Section 14197.9.

14197.9. (a) To the extent permitted under federal law, the department shall require a Medi-Cal managed care plan that is not licensed by the Department of Managed Health Care to comply with the applicable requirements in Article 11.9 (commencing with Section 1399.870) of Chapter 2.2 of Division 2 of the Health and Safety Code for the purpose of serving applicable Medi-Cal beneficiaries.
(b) For purposes of this section, “Medi-Cal managed care plan” means an individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to this chapter or Chapter 8 (commencing with Section 14200).
(Added by Stats. 2021, Ch. 143, Sec. 415. (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 6.5 - Regional Burn and Trauma Center Program › Section 14198.1.

14198.1. (a) A hospital or its successor entity, that has received funds pursuant to Section 14198 shall maintain burn and trauma services and continue to provide medical services to beneficiaries of Medi-Cal or a successor program through the year 2028.
(b) The state and a hospital subject to this section shall negotiate in good faith to ensure continued hospital participation in the Medi-Cal program and to ensure adequate access to services for Medi-Cal patients.
(Added by Stats. 1998, Ch. 314, Sec. 1. Effective August 19, 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 7 - Clinic Workforce Stabilization Retention Payment Program › Section 14199.70.

14199.70. The Legislature finds and declares all of the following:
(a) Qualified clinics, as defined in this article, are fundamental to the California health care safety net, as their mission is to provide primary and preventive care to low-income and underserved populations.
(b) Stability in the California qualified clinic workforce will further the Legislature’s efforts to manage the COVID-19 pandemic and address other public health issues that face Californians.
(c) Retention payments will help retain qualified health care workers, in particular registered nurses, licensed vocational nurses, licensed clinical social workers, licensed mental health workers, medical assistants, and advanced practice professionals.
(Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 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 7 - Clinic Workforce Stabilization Retention Payment Program › Section 14199.73.

14199.73. (a) (1) Except as required by federal law, any payment made pursuant to this article shall be exempt from any adjustments or deductions made to Medi-Cal payments to qualified clinics, including, but not limited to, provider withholds or provider payment reductions.
(2) Payments made pursuant to this article to qualified clinics shall not be considered payments for patient care or medical services.
(3)  The HCAI, in consultation with appropriate stakeholders, shall release guidance to instruct qualified clinics how to report this revenue through the established clinical annual utilization reports, as required under Section 1216 of the Health and Safety Code.
(b) The department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis for purposes of implementing this article. A contract entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and from the State Administrative and State Contracting manuals, and shall be exempt from the review or approval of any division of the Department of General Services.
(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, interpret, or make specific this article, in whole or in part, by means of information notices or other similar instructions, without taking any further regulatory action.
(d) This article is a state law within the meaning of Section 1621(d) of Title 8 of the United States Code.
(e) This article shall be implemented only to the extent that the department determines that federal financial participation under the Medi-Cal program is not jeopardized.
(f) Funds distributed to qualified clinics and payments made by those qualified clinics pursuant to this article shall not be factored into any reconciliation process or prospective payment system (PPS) rate calculation, including, but not limited to, the reconciliation process detailed in Section 14132.100 of this code and subdivision (bb) of Section 1396a of Title 42 of the United States Code, to the maximum extent permissible by law.
(Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 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 7 - Clinic Workforce Stabilization Retention Payment Program › Section 14199.74.

14199.74. (a) In the event of a dispute as to the status of an employee as an eligible employee, the retention payment amount, or a qualified clinic’s failure to make a retention payment, an eligible employee or a labor organization that represents the employee may write to the qualified clinic and request a review of the employee’s eligibility status, retention payment amount, or the qualified clinic’s failure to make a retention payment. The qualified clinic shall have 30 days to review the request, disclose to the employee the amount received from the department subject to the methodology described in subdivision (e) of Section 14199.72, and cure any alleged deficiency. In the event the qualified clinic cures a deficiency alleged by an employee, the employee shall not be entitled to any further damages or other relief.
(b) If the qualified clinic does not conclude the review described in subdivision (a) within 30 days of receipt of the review request, or does not cure the alleged deficiency within 30 days of receipt of the review request, the employee may file a complaint with the Labor Commissioner as provided in Section 98 of the Labor Code, or the employee may file an action in court to recover the deficiency. If the court finds that the qualified clinic is liable for failing to make a required retention payment, or to designate an employee for a retention payment, the qualified clinic shall be ordered to make full payment of the unpaid amount, plus interest at the rate of interest specified in subdivision (b) of Section 3289 of the Civil Code, which shall accrue from the date that the retention payment funds were transmitted to the qualified clinic by the department as provided in Section 14199.72, or from the date the qualified clinic should have designated the employee for the retention payment. A claim before the small claims court is not subject to joinder pursuant to Section 378 of the Code of Civil Procedure.
(c) Notwithstanding any other law, the department shall not be liable for any payment, interest, damages, or attorney’s fees and costs awarded to an employee pursuant to this section, and shall not be required to indemnify a qualified clinic for any liability the qualified clinic incurs pursuant to this section.
(Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 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 7 - Clinic Workforce Stabilization Retention Payment Program › Section 14199.75.

14199.75. (a) In serving as a conduit for payments under this article, qualified clinics are carrying out a state program. This article does not create a private right of action in any civil litigation against qualified clinics regarding the administration of the retention payment program and in the receipt and transmittal of retention payment program funds except as set forth in Section 14199.74.
(b) This article does not create a private right of action in any civil litigation or administrative proceeding against the state or the department or any other state agency or department.
(c) Notwithstanding any other law, retention payments paid out pursuant to Section 14199.72 are not wages as defined in Section 200 of the Labor Code.
(d) Except as provided in Sections 1493 and 1494 of the Labor Code, and notwithstanding any other law, qualified clinics, the state, and the department and any other state agency or department shall not be liable for damages awarded under Section 3294 of the Civil Code or Sections 2698 to 2699.5, inclusive, of the Labor Code, or other damages imposed primarily for the sake of example and by way of punishing the defendant, in any civil litigation related to the payments described in this article.
(Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 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 7 - Clinic Workforce Stabilization Retention Payment Program › Section 14199.76.

14199.76. The provisions of this article are severable. If any provision of this article or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
(Added by Stats. 2022, Ch. 738, Sec. 19. (AB 204) Effective September 29, 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 7.1 - Managed Care Organization Provider Tax › Section 14199.80.

14199.80. The Legislature finds and declares all of the following:
(a) The Legislature continues to recognize that an enrollment-based managed care organization provider tax is an essential and necessary source of nonfederal funding for maintaining and improving access to care and reimbursement levels under, and maximizing federal financial participation for, the Medi-Cal program.
(b) The Legislature recognizes how the previous iterations of the managed care organization provider tax, in effect nearly continuously from July 1, 2016, enabled the state to provide ongoing funding for health care and prevention, while minimizing the need for any new reductions to the Medi-Cal program during the time periods when the tax was in effect.
(c) Implementation of a new managed care organization provider tax at the earliest possible effective date allowable under federal law will best position the state to maintain and improve access to care, maximize federal financial participation, and minimize the need for any new reductions to the Medi-Cal program.
(d) In furtherance of subdivisions (a) to (c), inclusive, it is the intent of the Legislature that the department implement a managed care organization provider tax effective April 1, 2023, to meet all of the following goals:
(1) Generate an amount of nonfederal funds for the Medi-Cal program that is greater than the nonfederal funds generated by the tax imposed pursuant to Article 6.8 (commencing with Section 14199.60).
(2) Comply with federal Medicaid requirements applicable to permissible health care-related taxes, including, but not limited to, Section 433.68 of Title 42 of the Code of Federal Regulations.
(3) Provide funding to support the health care delivery system with an emphasis on the impact to the Medi-Cal program.
(4) Minimize, to the extent possible, the need for any new reductions to the Medi-Cal program.
(Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
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 7.1 - Managed Care Organization Provider Tax › Section 14199.82.

14199.82. (a) The Managed Care Enrollment Fund is hereby created in the State Treasury.
(b) All revenues, less refunds, derived from the taxes provided for in this article shall be deposited in the State Treasury to the credit of the Managed Care Enrollment Fund.
(c) Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on moneys in the Managed Care Enrollment Fund shall be retained in the fund and used solely for the purpose specified in subdivision (d).
(d) Funds deposited in the Managed Care Enrollment Fund pursuant to this article shall, upon appropriation by the Legislature, be available to the department for the purpose of funding all of the following subcomponents to support the Medi-Cal program:
(1) The nonfederal share of increased capitation payments to Medi-Cal managed care plans accounting for their projected tax obligation pursuant to this article for the applicable fiscal year or years.
(2) The nonfederal share of Medi-Cal managed care rates for health care services furnished to children, adults, seniors and persons with disabilities, and persons dually eligible for the Medi-Cal program and the Medicare Program.
(3) Transfers to the Medi-Cal Provider Payment Reserve Fund established pursuant to Section 14105.200.
(e) The department shall provide an annual report to all health plans accounting for the funds deposited in, and expended from, the Managed Care Enrollment Fund, in a time and manner as deemed appropriate by the director. The report shall identify the taxes imposed on each health plan pursuant to this article and shall provide an itemized accounting of expenditures from the fund.
(f) Effective December 31, 2023, the Health Care Services Special Fund in the State Treasury, created pursuant to Section 14199.62, is hereby abolished. All moneys in the fund or moneys designated to be deposited to the fund shall be transferred to the Managed Care Enrollment Fund created pursuant to subdivision (a). Any remaining balance, assets, liabilities, and encumbrances of the Health Care Services Special Fund as of December 31, 2023, shall be transferred to, and become part of, the Managed Care Enrollment Fund.
(g) Notwithstanding any other law, the Controller may use the funds in the Managed Care Enrollment Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code.
(Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87.)
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 7.1 - Managed Care Organization Provider Tax › Section 14199.83.

14199.83. (a) The department shall determine for each health plan, using the base data source, all of the following:
(1) Total cumulative enrollment for the base year.
(2) Total Medicare cumulative enrollment for the base year.
(3) Total Medi-Cal cumulative enrollment for the base year.
(4) Total plan-to-plan cumulative enrollment for the base year.
(5) Total cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382) for the base year.
(6) Total other cumulative enrollment for the base year that is not otherwise counted in paragraphs (2) to (5), inclusive.
(b) Notwithstanding any other provision in this article, the director may correct any identified material or significant error in the data, including, but not limited to, the overall cumulative enrollment, Medicare cumulative enrollment, Medi-Cal cumulative enrollment, plan-to-plan cumulative enrollment, cumulative enrollment through the Federal Employees Health Benefits Act of 1959 (Public Law 86-382), and other cumulative enrollment. The director’s determination as to whether to exercise discretion under this section and any determination made by the director under this section shall not be subject to judicial review, except that a health plan may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department in correcting that health plan’s data when that correction results in a greater tax amount for that health plan pursuant to Section 14199.85.
(Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Conditionally operative as prescribed by Section 14199.87. Conditionally inoperative on or before January 1, 2027, as prescribed by Section 14199.87. Repealed as of January 1, 2028, pursuant to Section 14199.87.)
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 7.1 - Managed Care Organization Provider Tax › Section 14199.87.

14199.87. (a) This article shall become operative on the effective date, certified in writing by the director, of the federal approval necessary for receipt of federal financial participation, as described in subdivision (a) of Section 14199.86 for purposes of assessing the tax under this article.
(b) (1) All sections in this article, except for Section 14199.82 to the extent not in conflict with federal law, shall become inoperative on January 1, 2027, or on a date as specified in subdivision (b) or (c) of Section 14199.86, whichever occurs first. All sections in this article, except for Section 14199.82, are repealed on January 1, 2028.
(2) Notwithstanding paragraph (1), any tax and any applicable interest and penalties imposed under this article shall continue to be due and payable to the department until the tax and any applicable interest and penalties are fully paid.
(Added by Stats. 2023, Ch. 13, Sec. 2. (AB 119) Effective June 29, 2023. Repealed as of January 1, 2028, by its own provisions. Repeal affects Article 7.1, commencing with 14199.80, except Section 14199.82.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 1 - General Provisions › Section 14200.

14200. This chapter shall be known and may be cited as the Waxman-Duffy Prepaid Health Plan Act.
(Added by Stats. 1972, Ch. 1366.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 1 - General Provisions › Section 14200.1.

14200.1. The purpose of this chapter is to afford persons eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part the opportunity to enroll as regular subscribers in prepaid health plans, without reference to marital status or any characteristic listed or defined in Section 11135 of the Government Code.
(Amended by Stats. 2008, Ch. 682, Sec. 11. Effective January 1, 2009.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 1 - General Provisions › Section 14201.

14201. The intent of the Legislature is to provide, to the extent feasible, through the provisions of this chapter and the necessarily related provisions of Chapter 7 (commencing with Section 14000) of this part, recipients of public assistance and medically indigent aged and other persons with the opportunity to enroll in prepaid health plans. It is further intended that this legislation is to benefit the people of the State of California by:
(a) Encouraging the development of more efficient delivery of health care to Medi-Cal recipients.
(b) Reducing the inflationary costs of health care.
(c) Improving the quality of medical services rendered to those eligible enrollees as defined in this chapter and Chapter 7 (commencing with Section 14000) of this part.
(d) Reducing administrative costs of operating the Medi-Cal Act by allowing prepaid health plans to assume substantial costs of administration and utilization controls that are now assumed by the State Department of Health Services.
(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 - Prepaid Plans › ARTICLE 1 - General Provisions › Section 14203.

14203. (a) For purposes of administering this chapter and Chapter 7 (commencing with Section 14000) of this part, the department is hereby designated as the single or appropriate state agency with full power to administer and adopt regulations in order to secure full compliance with applicable provisions of state and federal laws.
(b) The department may adopt regulations implementing this chapter as emergency regulations in accordance with Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Initial regulations to implement this chapter may be adopted as emergency regulations. The adoption of these initial emergency regulations shall be considered by the Office of Administrative Law as necessary for the immediate preservation of the public peace, health, and safety, or general welfare. Initial emergency regulations adopted pursuant to this section shall remain in effect for no more than 180 days.
(c) This section shall become operative on January 1, 1995.
(Repealed (in Sec. 5) and added by Stats. 1993, Ch. 573, Sec. 6. Effective September 28, 1993. Section operative January 1, 1995, by its own provisions.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 1 - General Provisions › Section 14204.

14204. (a) Pursuant to the provisions of this chapter, the department may contract with one or more prepaid health plans in order to provide the benefits authorized under this chapter and Chapter 7 (commencing with Section 14000) of this part. The department may contract with one or more children’s hospitals on an exclusive basis for a specified population in a specified geographic area. Contracts entered into pursuant to this chapter may be awarded on a bid or nonbid basis.
(b) In order to achieve maximum cost savings the Legislature hereby determines that expedited contract process for contracts under this chapter is necessary. Therefore, contracts under this chapter shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.
(c) The department shall amend contracts with dental health plans in effect on the date the act that added this subdivision and Section 14459.6 become effective to provide Medi-Cal dental services authorized under this chapter and Chapter 7 (commencing with Section 14000) to Medi-Cal beneficiaries who reside in a specified geographic area to meet the requirements of Sections 14089.09 and 14459.6.
(Amended by Stats. 2012, Ch. 23, Sec. 112. (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 1 - General Provisions › Section 14205.

14205. Except where the context otherwise requires, or where specific exceptions are authorized, all provisions of Chapter 7 (commencing with Section 14000) of this part shall be applicable to the provisions of this chapter and the violation of the provisions of this chapter or any rule or regulation adopted pursuant thereto shall be deemed to be a violation of Chapter 7.
(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 1 - General Provisions › Section 14206.

14206. (a) No prepaid health plan or pilot program shall be deemed to transact insurance or to be subject to any provision of the Insurance Code by virtue of negotiating, executing, or performing a prepaid health plan or pilot program contract under this chapter, or by virtue of compliance with the provisions of such a prepaid health plan or pilot program contract, including, but not limited to, creation, segregation, or maintenance of security to protect or safeguard the performance of such a prepaid health plan or pilot program contract. The director may require such security in respect to any such contract including, but not limited to, securities, surety bonds, or evidences of governmental debt, of the kinds, in the manner, and to the extent provided by the prepaid health plan or pilot program contract.
(b) Prepaid health plans or pilot programs to which the state is a party under the provisions of this chapter, and contracts and arrangements embodying such plans or programs shall not be subject to the provisions of law prescribing the forms of hospital or medical service or insurance contracts or requiring approval thereof or of the form thereof, by any state officer or agency except the director or the department.
This exemption applies, but is not limited to: (1) Chapter 4 (commencing with Section 10270) of Part 2 of Division 2 of the Insurance Code, (2) Section 11069 of the Insurance Code, and (3) Section 11513 of the Insurance Code. However, the exemption provided for in this section shall not exempt any insurer subject to taxation under Part 7 (commencing with Section 12001) of Division 2 of the Revenue and Taxation Code from the tax imposed under such part on gross premiums derived from contracts under this chapter.
(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 2 - Definitions › Section 14250.

14250. Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter.
(Added by Stats. 1972, Ch. 1366.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14252.

14252. “Medi-Cal beneficiary” means a person who is eligible to receive benefits under Chapter 7 (commencing with Section 14000) of this part.
(Added by Stats. 1972, Ch. 1366.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14253.

14253. “Subcontract” means an agreement entered into by the prepaid health plan with any of the following:
(a) A provider of health care services who agrees to furnish such services to Medi-Cal beneficiaries enrolled in the prepaid health plan.
(b) A marketing organization.
(c) Any other person or organization who agrees to perform any administrative function or service for the operation of the prepaid health plan specifically related to securing or fulfilling its contractual obligations with the department.
(Added by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14254.

14254. (a) “Primary care physician” is a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner.
(b) A nonphysician medical practitioner, as defined in subdivision (c) of Section 14088, who is supervised by a primary care physician, has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care.
(Amended by Stats. 2013, Ch. 684, Sec. 5. (SB 494) Effective January 1, 2014.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14255.

14255. “Specialist” means a physician who is board certified or board eligible in the specialty of medical care provided.
(Amended by Stats. 1974, Ch. 983.)
2023 California Code › Welfare and Institutions Code - WIC › DIVISION 9 - PUBLIC SOCIAL SERVICES › PART 3 - AID AND MEDICAL ASSISTANCE › CHAPTER 8 - Prepaid Plans › ARTICLE 2 - Definitions › Section 14256.

14256. The “basic scope of health care benefits” means:
(a) Physician’s services;
(b) Hospital outpatient services;
(c) Laboratory and X-ray;
(d) Prescription drugs;
(e) Hospital inpatient care;
(f) Skilled nursing facility care.
(Amended by Stats. 1974, Ch. 1240.)