California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5.5 - INDIANS AND INDIAN HEALTH SERVICE FACILITIES IN MEDI-CAL MANAGED CARE PROGRAMS › Section 55000 - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The United
				  States Congress has declared that it is the policy of the United States, in
				  fulfillment of the special responsibilities and legal obligations to the
				  American Indian people, to meet the national goal of providing the highest
				  possible health status to Indians. In furtherance of these national goals and
				  national policy, special programs have been developed by the Federal Government
				  to address the health problems of Indians living on and near the Indian
				  reservations, in rural areas, and in urban centers.
(b) These regulations are intended to
				  recognize the inherent sovereignty of Indian tribes and nations, the
				  requirements of the Indian Health Care Improvement Act and the Indian
				  Self-Determination and Education Assistance Act, and to recognize the special
				  status of Indians, Indian tribes, and Indian Health Service programs under
				  federal law. This special status requires that separate considerations be
				  applied to the inclusion or exclusion of Indians and Indian Health Service
				  Facilities from Medi-Cal managed care plans.
(c) The programs operated by Indian tribes
				  and Indian organizations within California, referred to in these regulations as
				  Indian Health Service Facilities, are required by federal law to provide
				  services to all eligible Indians who present themselves for care. Indian Health
				  Service Facilities are also required by federal law to act as the payor of last
				  resort for eligible Indians and are required to obtain reimbursement for the
				  services provided to eligible Indians from all sources including the Medi-Cal
				  program. These facilities may serve non-Indians, but only to the extent that
				  such services do not result in the denial or diminution of health services to
				  eligible Indians.
(d) The
				  department intends to provide a single, clear, and accessible set of guidelines
				  which define how Indian Health Service Facilities will relate to the Medi-Cal
				  managed care plans in their respective locations; to ensure that individual
				  Indians continue to receive the required care to which they are entitled; and
				  to ensure that Indian Health Service Facilities may continue to provide
				  comprehensive services to eligible Indians.
(e) The department intends to ensure that the
				  Indian Health Service Facilities are reimbursed, if they are qualified for and
				  elect to receive reasonable cost reimbursement, as provided in federal law, at
				  their reasonable cost reimbursement rate, or a percentage of reasonable cost as
				  provided in 42 U.S.C.
				  1396a(a)(13)(C), whether
				  they elect to act as subcontractors of the Medi-Cal managed care plans or
				  out-of-plan providers.
(f) The
				  department also intends to ensure that Indian Health Service Facilities which
				  choose to be and are designated as Indian Health Service (IHS) providers by the
				  federal government will receive the IHS payment rate.
1. New
					 chapter 5.5 (sections
					 55000-55180) and section filed
					 4-3-98; operative 4-3-98. Submitted to OAL for printing only pursuant to
					 section 147, Senate Bill 485 (Ch. 722/92)
					 (Register 98, No. 15).
2. Change without regulatory effect amending
					 NOTE filed 4-9-98 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 98, No. 15).
Note: Authority cited: Stats. 1992, Ch. 722; Sections
						10725,
						14089.7,
						14105,
						14124.5,
						14203
						and
						14312,
						Welfare and Institutions Code. Reference: Sections
						14000,
						14016.5,
						14087.3,
						14087.305,
						14087.4,
						14087.5,
						14088,
						14089,
						14089.05,
						14200
						and
						14499.5,
						Welfare and Institutions Code; and Title 25, United States Code, Sections
						13 and
						1601.