reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53912 - Pharmaceutical Services and Prescribed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each PHP and PCCM plan shall provide,
					 either directly or through subcontracts, the services of pharmacies and
					 pharmacists. Pharmaceutical services shall be available to members during
					 service site hours.
(b) Prescribed
					 drugs shall be provided to members by licensed pharmacies and shall be
					 reimbursed by the PHP or PCCM plan in which the member is enrolled.
					 Professional standards reflected by reasonable and current prescribing
					 practices, based on reference to current medical literature and consultation
					 with provider organizations, academic and professional specialists, shall be
					 met, including but not limited to Title 16, Sections
					 1707.1,
					 1707.2, and
					 1707.3.
(c) Prescribed drugs may include the
					 provision of pre-packaged drugs dispensed under the direct supervision of the
					 professionally licensed personnel of the PHP or PCCM plan after the plan has
					 written approval granted by the department.
(d) Each dental plan shall provide written
					 prescriptions to members as necessary, and shall instruct each member to fill
					 any prescriptions at a pharmacy used by the PHP or PCCM plan in which the
					 member is enrolled. The PHP or PCCM plan in which the member is enrolled shall
					 reimburse the pharmacy for each prescription filled.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14089,
						  14132,
						  14133
						  and
						  14133.1,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53912.5 - Care Under Emergency Circumstances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall meet the requirements
					 specified in Section
					 53216.
(b) Each GMC plan shall arrange for and make
					 payment, at the lowest of the Medi-Cal fee-for-service rate or the plan
					 negotiated rate, for emergency services as defined in Section
					 51056.
(c) Each GMC plan shall make payment, at the
					 lowest of the Medi-Cal fee-for-service rate or the plan negotiated rate, for
					 the diagnostic portion of any emergency room or urgent care visit.
					 Specifically, each plan shall reimburse and shall not require prior
					 authorization for the following:
(1) Emergency
					 room services required to determine whether a member's condition requires
					 emergency services.
(2) All other
					 capitated services, such as radiology or pathology, necessary to diagnose the
					 possible emergency condition.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53913 - Facilities, Service Locations and Equipment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall comply with the
					 requirements contained in Section
					 53230, and shall assure proper
					 sterilization and disinfection of equipment, in accordance with California
					 Occupational Safety and Health Administration (Cal/OSHA) standards, pursuant to
					 California Labor Code, Section
					 6305.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14089,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53913.5 - Medical Director and Dental Director

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each PHP and PCCM plan shall appoint a
					 physician as medical director and each dental plan shall appoint a dentist as
					 dental director, whose responsibilities shall include, but not be limited to,
					 the following:
(1) Ensuring that medical or
					 dental decisions are rendered by qualified medical or dental personnel,
					 unhindered by fiscal or administrative management.
(2) Ensuring that the medical or dental care
					 provided meets the standards for acceptable medical and dental care.
(3) Ensuring that medical or dental protocols
					 and rules of conduct for plan medical or dental personnel are
					 followed.
(4) Developing and
					 implementing medical or dental policy.
(5) Resolving medical or dental quality of
					 care related grievances. The medical or dental director shall refer non-medical
					 or non-dental related grievances, and other grievances that are determined to
					 be appropriately resolved through the grievance procedure, to the grievance
					 coordinator.
(6) Actively
					 participating in the functioning of the plan grievance
					 procedures.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53914 - Member Grievance Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each GMC plan shall establish and maintain written procedures for the
					 submittal, processing, and resolution of all member grievances and complaints.
					 The grievance system shall include the handling of complaints and shall:
(1) Operate according to the written
					 procedures, which shall be approved in writing by the department prior to use.
					 Amendments shall be approved in writing by the department prior to
					 implementation of the revised procedure.
(2) Be described in information sent to each
					 member upon enrollment in the GMC plan and annually thereafter, pursuant to
					 Sections 53926.5 and
					 53927. The description shall
					 include:
(A) An explanation of the GMC plan's
					 system for processing and resolving grievances, and how a member is to use
					 it.
(B) A statement that grievance
					 forms are available in the office of each primary care provider, or in each
					 member services department of the GMC plan, in the case of a GMC plan in which
					 all primary care providers are the exclusive providers of that plan and are
					 contiguously located.
(C) A
					 statement that grievances may be filed in writing or verbally directly with the
					 GMC plan in which the member is enrolled or at any office of the GMC plan's
					 providers.
(D) The telephone number
					 a member may call to obtain information, request grievance forms, and register
					 a verbal grievance.
(E) A statement
					 that a member has a right to request a fair hearing, pursuant to Section
					 50951.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53914.5 - Provider Grievances and Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider of medical or dental services
					 may submit to a GMC plan a grievance or compliant concerning the authorization
					 or denial of a service or the processing payment or nonpayment of a claim by
					 that GMC plan. Each GMC plan shall comply with the provider grievance and
					 complaint requirements specified in Section
					 56262. These requirements shall
					 apply to PHPs, PCCM plans, and dental plans in the GMC program.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14089,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53915 - Quality of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 GMC plan shall provide care which meets or exceeds the standards for medical or
					 dental practice developed by the GMC plan and approved in writing by the
					 department. Each GMC plan shall use effective professional review in assessing
					 the care provided to its members in accordance with state standards, including
					 but not limited to Title 10, Section
					 1300.70.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14088.25,
						  14089,
						  14309
						  and
						  14458,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53915.5 - Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan
					 shall maintain or cause to be maintained all records necessary to verify
					 information and reports required by statute, regulation or contractual
					 obligation for five years from the date of submission of the information or
					 reports. Records and documents shall include but not be limited to:
(1) Working papers used in the preparation of
					 reports to the department.
(2)
					 Reports to the department, specified in Section
					 53916.
(3) Financial documents.
(4) Medical or dental records.
(5) Prescription files.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53916 - Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan
					 shall submit to the department:
(1) Reports
					 required in Section
					 53312.
(2) Reports specified in the GMC
					 contract.
(3) As frequently as it
					 changes, an updated listing of the GMC plan's provider network, by
					 specialty.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53920 - Marketing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan
					 shall limit its marketing activities to printed and illustrated materials, and
					 media advertising.
(1) Printed and
					 illustrated materials may be made available to members or prospective members,
					 as follows:
(A) By mail. Printing, postage,
					 and any related costs of material mailed to prospective members shall be paid
					 by the GMC plan. Mailings shall be coordinated with the department so that the
					 confidentiality of Medi-Cal beneficiaries is protected.
(B) By posting materials in public
					 places.
(C) At GMC options
					 presentations, which shall be conducted by the GMC enrollment contractor,
					 pursuant to Section
					 53923.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53920.5 - Marketing and Member Materials

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Evidence of Coverage, disclosure
					 form, and any marketing brochure developed by or for a GMC plan and distributed
					 to prospective members shall meet the requirements contained in Section
					 1300.63(a), Title
					 10, as to print size, readability, and understandability of text.
(b) All marketing materials distributed to
					 eligible beneficiaries by a GMC plan shall fully disclose the availability of
					 and restrictions upon the services provided by the GMC plan, and any exclusions
					 from coverage. Marketing materials shall, at a minimum, specify:
(1) The scope, access to, and availability of
					 services, including service site locations and telephone numbers, and the
					 service area authorized in that GMC plan's GMC contract.
(2) A description of the membership
					 identification card issued by the GMC plan, if applicable, and an explanation
					 as to its use in authorizing or assisting members to obtain services.
(3) That members shall obtain all Medi-Cal
					 covered nonemergency health care services through the GMC plan's
					 providers.
(4) That medical or
					 dental services required in an emergency may be obtained from specified GMC
					 plan providers or from non-plan providers, if necessary.
(5) The disenrollment process, and an
					 explanation that disenrollment is possible only under the conditions specified
					 in Section
					 53925.5 and is effective only
					 after the disenrollment transaction is completed by the department.
(6) The GMC plan's grievance process,
					 including instructions on how to use it.
(7) That members have the right to a fair
					 hearing, including instructions on how to request one.
(8) The interpretive, linguistic, and
					 cultural services available through plan personnel.
(9) Any transportation services to service
					 sites that are available through the GMC plan or under the Medi-Cal program.
					 This shall include a description of both medical and non-medical transportation
					 services, and the conditions under which non-medical transportation is
					 available to members, if available.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53921 - Member Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Enrollment in GMC plans shall be mandatory for those eligible beneficiaries
					 specified in Section
					 53906(a), and
					 voluntary for those specified in Section
					 53906(b).
(b) Enrollment shall be limited to eligible
					 beneficiaries who reside within the GMC program area.
(c) The department or the GMC enrollment
					 contractor shall mail an enrollment form and GMC plan information to each
					 eligible beneficiary described in Section
					 53906(a). The
					 mailing shall include GMC options presentation information and instructions to
					 enroll in GMC plans within thirty days of the postmark date on the mailing
					 envelope.
(d) Each eligible
					 beneficiary described in Section
					 53906(a) shall
					 enroll in GMC plans within thirty days of receipt of an enrollment from with
					 instructions from the department or the GMC enrollment contractor to select GMC
					 plans.
(1) In the event an eligible
					 beneficiary described in Section
					 53906(a) does not
					 enroll in GMC plans within thirty days, the GMC enrollment contractor shall
					 assign the eligible beneficiary to GMC plans, in accordance with Section
					 53921.5.
(2) For purposes of selection of GMC plans:
(A) In the case of a family group, eligible
					 beneficiary means the individual or entity with legal authority to make a
					 choice on behalf of dependent family members.
(B) In the case of a foster care child,
					 eligible beneficiary means the entity with legal authority to make a choice on
					 behalf of the child.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53921.5 - Assignment of Eligible Beneficiaries to GMC Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The GMC enrollment contractor shall
					 assign an eligible beneficiary described in Section
					 53906(a) to a GMC
					 plan, from which to receive health care services, in the following situations:
(1) In the event the eligible beneficiary
					 does not select a PHP or PCCM plan and a dental plan within thirty days of
					 receiving an enrollment form pursuant to Section
					 53921(c).
(2) In the event a member requests and is
					 granted disenrollment from a GMC plan, pursuant to Section
					 53925.5, but does not select a
					 different GMC plan in which to enroll, unless that member was granted approval
					 by the GMC enrollment contractor to receive health care services through the
					 fee-for-service Medi-Cal program, pursuant to Section
					 53923.5.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53922 - Equitable Distribution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The GMC enrollment contractor shall implement a system approved by the
					 department to assign an eligible beneficiary described in Section
					 53906(a), to GMC
					 plans, in the event the beneficiary does not select GMC plans pursuant to
					 Section 53921(d).
(b) The assignment shall ensure the equitable
					 distribution of eligible beneficiaries among GMC plans and include but not be
					 limited to the following considerations:
(1)
					 Zip code of eligible beneficiary matched to zip codes served by the GMC
					 plan.
(2) Enrollment capacity and
					 availability of the GMC plan.
(3)
					 GMC plan's ability to render linguistically appropriate services and the
					 eligible beneficiary's need for those services, if made known to the GMC
					 enrollment contractor.
(4) Rotation
					 of assignments among all GMC plans.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53922.5 - Travel Distance Standards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No member who is assigned to GMC plans
					 pursuant to Section
					 53921.5 shall be denied a request
					 for disenrollment if all primary health care services through that assigned GMC
					 plan are more than ten (10) miles from the eligible beneficiary's place of
					 residence.
(b) An eligible
					 beneficiary may voluntarily choose to receive services from a GMC plan with
					 service sites exceeding the maximum distance specified in (a).
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53923 - Options Presentation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The GMC enrollment contractor shall provide a presentation of GMC plan options
					 to each new and continuing eligible beneficiary who requests a
					 presentation.
(b) The GMC options
					 presentation shall include, at a minimum, the following information:
(1) The names of each GMC plan.
(2) Each GMC plan's service area.
(3) The locations of each GMC plan's service
					 sites.
(4) Services covered by GMC
					 plans.
(5) Procedures for accessing
					 and receiving health care services from GMC plans.
(6) Hospitals used by each PHP and PCCM
					 plan.
(7) Any features or
					 additional services provided by each GMC plan that are beyond those that must
					 be covered by GMC plans, pursuant to the GMC contract, such as non-medical
					 transportation services, languages spoken, health promotion, risk reduction,
					 health education and counseling services.
(8) An explanation that an alternative to GMC
					 plan enrollment exists for Indians, members of Indian households, and others
					 eligible to receive health care services through an Indian Health Service
					 program facility, and for individuals with complex medical conditions, as
					 specified in Section
					 53923.5(b).
(9) Assistance to eligible beneficiaries in
					 completing the enrollment form, as needed.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53923.5 - Alternative to GMC Plan Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An eligible beneficiary specified in Section
						53906(a) who
						meets the requirements of (a) or (b) may request from the GMC enrollment
						contractor an alternative to GMC plan enrollment.
(a) An eligible beneficiary who is an Indian,
					 is a member of an Indian household, or has written acceptance from an Indian
					 Health Service program facility to receive health care services through that
					 facility, may, as an alternative to GMC plan enrollment and upon request,
					 choose to receive health care services through an Indian Health Service program
					 facility. Any request for this alternative shall be made to the GMC enrollment
					 contractor at the GMC options presentation or through the problem resolution
					 process specified in Section
					 53926.
(b) On or before March 31, 1995, an eligible
					 beneficiary who is receiving treatment or services for a complex medical
					 situation from a physician who is participating in the Medi-Cal program, but is
					 not a contracted provider of any GMC plan, may request through the problem
					 resolution process specified in Section
					 53926, continued fee-for-service
					 Medi-Cal for the purposes of continuity of care. The department shall review on
					 a case-by-case basis and make a determination on each request presenting a
					 complex medical situation. The department may approve continued treatment under
					 the fee-for-service Medi-Cal program for any eligible beneficiary whose
					 diagnosis or treatment needs are verified in writing by the beneficiary's
					 Medi-Cal provider and meet one of the criteria below in 1 through 3 for
					 continued fee-for-service Medi-Cal.
(1) The
					 eligible beneficiary is under the care of a physician specialist:
(A) For treatment of a condition that is
					 within the specialist's scope of practice, pursuant to the Business and
					 Professions Code;
(B) That
					 specialty is not practiced by any physician within the available providers of
					 any GMC plan; and
(C) That
					 specialist is a participating Medi-Cal provider, but is not a contracted
					 provider of any GMC plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53924 - Enrollment/Disenrollment Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 department shall develop a combined enrollment/disenrollment form and shall
					 provide it to GMC plans and the GMC enrollment contractor.
(b) Each GMC plan shall send an
					 enrollment/disenrollment form to each member, as specified in Section
					 53926.5.
(c) Each GMC plan shall make
					 enrollment/disenrollment forms available during business hours:
(1) At each service site. In the case of a
					 GMC plan in which all primary care providers are the exclusive providers of
					 that plan and are contiguously located, enrollment/disenrollment forms shall be
					 available, at a minimum, in the member services department of the
					 plan.
(2) At each member services
					 department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53924.5 - Enrollment/Disenrollment Form Processing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Members shall submit
					 enrollment/disenrollment forms to the GMC enrollment contractor for
					 processing.
(b) Unless otherwise
					 notified in writing by the department, the GMC enrollment contractor shall
					 accept and process all requests for enrollment from eligible beneficiaries up
					 to the maximum enrollment levels specified in each plan's GMC
					 contract.
(c) The GMC enrollment
					 contractor shall transmit all completed enrollment/disenrollment forms to the
					 department within two working days of the date the GMC enrollment contractor
					 receives the completed form.
(d)
					 Each request for disenrollment shall be accompanied by a request for enrollment
					 in another GMC plan. If the member requesting disenrollment does not make an
					 enrollment selection, the member shall be assigned to a plan in accordance with
					 Section 53921.5.
(e) The GMC enrollment contractor shall
					 accept enrollment/disenrollment forms regardless of the prospective member's
					 race, creed, color, religion, age, sex, national origin, ancestry, marital
					 status, sexual orientation, or physical or mental disability, and without
					 reference to pre-existing medical or dental conditions.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14088.5,
						  14089,
						  14413
						  and
						  14495,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53925 - Assignment of Primary Care Provider

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall have a mechanism in
					 place and approved in writing by the department to ensure that each member is
					 assigned to a primary care provider, by either:
(1) Allowing each member to select a primary
					 care provider from the GMC plan's network of affiliated providers, if the
					 member chooses to do so; or
(2)
					 Assigning a primary care provider to each member within forty days from the
					 effective date of enrollment, if the member does not select one within the
					 first thirty days of the effective date of enrollment in the GMC plan.
(A) Assignment conducted pursuant to (a)(2)
					 shall meet both 1 and 2:
1. The member shall
					 be assigned to a primary care provider within the maximum travel distances
					 specified in Section
					 53922.5.
2. If available within the GMC plan, the
					 member shall be assigned to a primary care provider who is or has office staff
					 who are linguistically and culturally competent to communicate with the member
					 or have the ability to interpret in the provision of health care services and
					 related activities during the member's office visits or contacts, if the
					 language or cultural needs of the member are known to the GMC
					 plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53925.5 - Disenrollment of Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The GMC enrollment contractor shall disenroll any member who requests
					 disenrollment when one of the following conditions and (c) are met:
(1) A member requests disenrollment during
					 the first thirty days of enrollment.
(2) A member requests disenrollment during
					 the second through sixth month of enrollment in a PHP that is a federally
					 qualified Health Maintenance Organization, a PCCM plan, or a dental plan, for
					 good cause, as follows:
(A) To comply with any
					 of the criteria specified in Section
					 14407.8(b),
					 Welfare and Institutions Code;
(B)
					 To accommodate the needs of a foster care child;
(C) To comply with travel distance standards
					 specified in Section
					 53922.5; or
(D) To grant an alternative to GMC plan
					 enrollment as specified in Section
					 53923.5, if the process for
					 obtaining that alternative was initiated prior to the effective date of
					 enrollment in a GMC plan.
(3) A member requests disenrollment after
					 having met the six-month minimum enrollment period applicable to enrollment in
					 any PHP that is a federally qualified Health Maintenance Organization, a PCCM
					 plan, or a dental plan.
(4) Any
					 member of a PHP that is not a federally qualified Health Maintenance
					 Organization shall be granted disenrollment from that PHP at any
					 time.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53926 - Problem Resolution Process for Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any member may request assistance from
					 the GMC enrollment contractor in resolving problems associated with mandatory
					 participation in the GMC program, assignment to a GMC plan, enrollment, or
					 disenrollment.
(b) The request for
					 assistance from the GMC enrollment contractor shall be in writing and shall
					 state the nature of a problem.
(c)
					 The GMC enrollment contractor shall prepare a written response and mail it to
					 the member within ten days of receipt of a member's written request for problem
					 resolution.
(d) In the event a
					 member is dissatisfied with the response of the GMC enrollment contractor to a
					 request for problem resolution, the member may file an appeal with the
					 department.
(1) The member shall submit to the
					 department the information specified in (b) and the written response of the GMC
					 enrollment contractor.
(2) The
					 department shall prepare a written decision and mail it to the member within
					 ten days of receipt of a member's appeal.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53926.5 - Information to New Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each eligible beneficiary, prior to or upon either signing an enrollment
					 application or being assigned to GMC plans in accordance with Section
					 53921.5, shall be informed in
					 writing by the department or the GMC enrollment contractor of at least the
					 following:
(1) There will be a 15 to 45 day
					 processing time between the date of application and the effective date of
					 enrollment in GMC plans.
(2) Until
					 GMC plan enrollment is effective, the beneficiary may receive Medi-Cal covered
					 health care services from any Medi-Cal provider licensed to provide the
					 services.
(3) An alternative to GMC
					 plan enrollment exists.
(4)
					 Disenrollment from certain GMC plans, specified in Section
					 53925.5, is restricted during the
					 second through sixth month of enrollment.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53927 - Annual Information to Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall revise, if necessary,
					 and distribute the information specified in Section
					 53926.5(b)(2) to
					 each member or the member's family unit at least once every twelve
					 months.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14089
						  and
						  14406,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53927.5 - Notification of Changes in Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall revise and distribute
					 the information specified in Section
					 53926.5(b)(2) at
					 least thirty days prior to any changes which the GMC plan makes in services
					 provided or in the locations at which services may be obtained, to each member
					 affected by that change. Notification shall be provided at least fourteen days
					 prior to any changes in cases of unforeseeable circumstances.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code Reference: Sections
						  14089
						  and
						  14406,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 3 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53928 - Information for Departmental Dissemination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall furnish the
					 department and the GMC enrollment contractor the information required in
					 Section 53926.5(b)(2) and
					 (5), as it changes and upon request, for
					 dissemination to prospective members.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14089,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 1 - GENERAL PROVISIONS › Section 54001 - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Adult day
					 health care services may be provided to eligible Medi-Cal beneficiaries by
					 adult day health care providers which meet the requirements of this Chapter.
					 Adult day health care providers shall:
(1)
					 Sign an adult day health care provider agreement with the Department to provide
					 the services described under this Chapter to Medi-Cal beneficiaries who are
					 eligible for and voluntarily elect to participate in an adult day health care
					 program.
(2) Promote the social,
					 emotional and physical well-being of impaired individuals living in the
					 community, alone or with others, in order to maintain them at or restore them
					 to their optimal functional potential and to help them remain at or return to
					 their homes.
(3) Share with
					 families and other persons the burden of providing substantial care to impaired
					 elderly individuals by offering respite for one or several days during the
					 week.
(4) Supplement the diagnostic
					 evaluation conducted by other health professionals by means of a sustained
					 functional assessment.
(5) Provide
					 diagnostic and treatment services to persons who would otherwise require
					 admission to or continued stay in a hospital or other health care
					 facility.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 1 - GENERAL PROVISIONS › Section 54003 - Definitions and Standards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The definitions stated in Article 2, Chapter 3, Division
						3, Title 22, California Administrative Code, and the standards stated in
						Article 3, Chapter 3, Division 3 of the California Administrative Code, shall
						apply to this Chapter unless modified by regulations in this
						Chapter.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 1 - GENERAL PROVISIONS › Section 54005 - Grants

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Department shall grant funds for the establishment of
						Adult Day Health Centers from the one-time appropriation of $100,000 authorized
						by Chapter 1065, Statute of 1977. The grants shall be made to licensed centers
						in accordance with the departmental guidelines for AB 1612, issued January 3,
						1978.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54101 - Activity Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Activity program means a program as defined in Title 22,
						Division 5, Sections
						72381 and
						73377, California Administrative
						Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54103 - Adult Day Health Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Adult day health care means an organized day program of
						therapeutic, social and health activities and services, provided to elderly
						persons or other persons with physical or mental impairments for the purpose of
						restoring or maintaining optimal capacity for self-care.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54105 - Adult Day Health Center

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Adult day health center means a licensed facility which
						provides adult day health care, or a distinct portion of a licensed health
						facility in which such care is provided in a specialized unit, under a special
						permit issued by the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54107 - Adult Day Health Care County Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Adult Day Health Care County Plan means a county plan for
						a community-based system of adult day health care.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54108 - Adult Day Health Care Planning Council

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
"Adult Day Health Care Planning Council" means the
						council appointed by the county board of supervisors to develop the Adult Day
						Health Care County Plan.
1. New
						section filed 9-19-79; effective thirtieth day thereafter (Register 79, No.
						38).
Note: Authority cited: Chapter 1066, Statutes of 1977.
						  Reference: Chapter 1066, Statutes of
						  1977.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54109 - Affiliate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Affiliate means an organization or person that, directly
						or indirectly through one or more intermediaries, controls, or is controlled
						by, or is under common control with an adult day health care provider and that
						provides services to an adult day health center.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54111 - Beneficiary Agreement of Participation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Beneficiary agreement of participation means the
						agreement voluntarily signed by a beneficiary or the beneficiary's guardian or
						legal conservator in which the beneficiary agrees to receive day health
						services from the adult day health center.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54113 - Day of Attendance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Day of attendance means any calendar day during which a
						participant receives covered services at the center for a minimum of four
						hours, excluding transportation time.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54115 - Daily Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Daily rate means the amount paid by the Department per
						day of attendance to the adult day health center for administration and covered
						services provided under the adult day health care program.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54117 - Discharge

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Discharge means the termination of an agreement of
						participation.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54119 - Individualized Plan of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Individualized plan of care means a written plan designed
						to provide a participant of an adult day health center with appropriate
						treatment in accordance with the assessed needs of the
						participant.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54121 - Multidisciplinary Team

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Multidisciplinary team means the group within the adult
						day health center that conducts assessments and makes recommendations to the
						Department regarding admission, treatment and services provided, and discharge
						of participants by the adult day health center.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54123 - Nonmedical Transportation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Nonmedical transportation means the movement of
						participants to and from the adult day health center in vehicles that are not
						specially equipped for medical transportation services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 2 - DEFINITIONS › Section 54125 - Nutrition Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Nutrition service means a service provided by the adult day health center which
					 is organized, staffed and equipped to provide:
(1) Safe, appetizing and nutritional
					 food.
(2) Therapeutic diets
					 prescribed by the participant's physician.
(3) Counseling when therapeutic diets are
					 prescribed.