California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 4 - Beneficiary Application Process › Section 50185.5 - Medi-Cal Managed Care Plan Assigned Enrollment Prior to Two-Plan Model Implementation or for Geographic Areas Not Designated for Two-Plan Model Implementation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) This section applies to geographic areas
					 specified by the director, which may include geographic areas designated for
					 implementation of the two-plan model as defined in section
					 53810(n) prior to
					 implementation of the two-plan model, and geographic areas not designated for
					 two-plan model implementation. This section applies to aid categories specified
					 by the director, pursuant to Welfare and Institutions Code Section
					 14016.5
					 and
					 14087.305.
(b) The following definitions apply to this
					 section:
(1) Affiliate means an existing
					 Medi-Cal managed care plan that has a written agreement to become a
					 subcontractor to the local initiative or the commercial plan when the local
					 initiative or commercial plan commences operation, or an entity that has been
					 awarded the local initiative or commercial plan contract under the Two-Plan
					 Model and is an existing Medi-Cal prepaid health plan contractor that is
					 authorized under its Medi-Cal prepaid health plan contract to operate in the
					 service area to which the plan has been awarded the commercial plan or local
					 initiative contract under the Two-Plan Model.
(2) Assignment means the action taken by the
					 health care options contractor to enroll an eligible beneficiary or an eligible
					 family group into a Medi-Cal managed care plan when the beneficiary fails to
					 select a managed care plan and does not provide a written certification of an
					 established patient-provider relationship.
(3) Authorized affiliate means any existing
					 Medi-Cal prepaid health plan that has been awarded the local initiative or
					 commercial plan contract under the Two-Plan Model, or is an affiliate that has
					 been authorized by the department to receive assignments after a local
					 initiative or commercial plan has submitted a written request to the department
					 that assignments be made to that affiliate.
(4) Commercial plan means a prepaid health
					 plan in a designated geographic area awarded a contract by the department
					 pursuant to sections
					 53800(b)(1).
(5) Commercial plan enrollment maximum means
					 the enrollment level established by the department pursuant to section
					 53820(b).
(6) Confirmed conditional start date means
					 the date established by the department on which a local initiative or
					 commercial plan is authorized to begin operation under the Two Plan Model,
					 subject to the local initiative or commercial plan fulfilling the conditions
					 specified by the department at the time the confirmed conditional start date is
					 given by the department.
(7) CP/LI
					 ratio means the total enrollment of the commercial plan, or if the commercial
					 plan is not operational, the combined total enrollment of the commercial plan
					 affiliates, DIVIDED by the combined total enrollment of the local initiative
					 affiliates. The source of the enrollment totals is the department's monthly
					 Medi-Cal managed care capitation report.
(8) Fee-for-service managed care program
					 means a program operated in a designated geographic area by an entity
					 contracting with the Department under which services continue to be provided on
					 a fee-for-service basis, but each Medi-Cal beneficiary is provided with a
					 primary care provider who coordinates the beneficiary's Medi-Cal health
					 care.
(9) Health care options
					 contractor means the entity contracting with the department to provide
					 applicants and beneficiaries with information on the available options to
					 receive Medi-Cal benefits and to process applicant and beneficiary enrollment
					 choices or assignments in designated geographic areas.
(10) Health care options presentation means a
					 presentation in-person or by mail to Medi-Cal applicants and beneficiaries
					 which provides information on the Medi-Cal managed care plans and
					 fee-for-service options available within the designated geographic area in
					 which the applicant or beneficiary resides.
(11) Local initiative means a prepaid health
					 plan awarded a contract by the department pursuant to sections
					 53800(b)(2) and
					 53810(h).
(12) Local initiative enrollment minimum
					 means the total number of Medi-Cal beneficiaries in the mandatory aid
					 categories in the designated geographic area less the maximum enrollment level
					 established pursuant to section
					 53820 of the commercial
					 plan.
(13) Operational means a
					 managed care plan is providing covered services to enrolled Medi-Cal
					 beneficiaries and is entitled to receive capitation payments from the
					 department.