reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56216 - Care Under Emergency Circumstances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each PCCM plan shall provide information
					 to members on obtaining medical services on a 24-hour-a-day, seven-days-a-week
					 basis in the event of an emergency as defined in section
					 51056(a).
(b) Written procedures shall be developed and
					 followed by the PCCM plan regarding care under emergency circumstances provided
					 by nonplan providers in and outside the service area. These procedures shall
					 include but shall not be limited to the following:
(1) Verification of membership.
(2) Transfer of medical management of the
					 member to the PCCM plan.
(3)
					 Payment for PCCM plan authorized services that are included in the PCCM
					 contract as a covered service.
(4)
					 Notice to nonplan providers of the right to:
(A) Dispute the PCCM plan's rejection or
					 reduction of the claim.
(B) Submit
					 the dispute to the Department for resolution in accordance with section
					 56262.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56220 - Member Billing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A PCCM plan, affiliate, vendor, subcontractor or
						sub-subcontractor shall not submit a claim to, demand, or otherwise collect
						reimbursement from, a member or persons acting on behalf of a member for any
						services provided under this chapter except to collect third-party payment in
						accordance with section
						56222(a).
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56222 - Recovery from Other Sources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) PCCM plans may recover and retain the
					 cost of capitated services rendered to a member under the terms of this
					 chapter, to the extent that the member is covered for these services under any
					 other state or federal medical care program or under other contractual or legal
					 entitlement, including but not limited to, a private group or individual
					 indemnification program.
(b) PCCM
					 plans shall not attempt recovery in circumstances involving casualty insurance,
					 tort liability, or workers' compensation awards to PCCM plan members.
					 Circumstances which may result in casualty insurance payments, tort liability
					 payments, or workers' compensation awards shall be reported, in writing, to the
					 Department within ten calendar days after discovery by the PCCM plan.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56230 - Facilities and Service Sites

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each PCCM plan shall have available
					 within the service area, sufficient facilities and service sites to meet its
					 contractual obligations.
(b) Each
					 facility shall meet the following requirements:
(1) Licensing, and accreditation where
					 applicable, by appropriate agencies.
(2) Continued compliance with licensing
					 standards.
(3) Compliance with all
					 applicable local, state and federal standards including those for fire and
					 safety.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56242 - Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A provider of services employed by or under subcontract
						to a PCCM plan shall meet those standards for participation as a provider of
						health care services under the Medi-Cal program set forth in Chapter 3, Article
						3, beginning with section
						51200.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56246 - Medical Director

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each PCCM plan shall appoint a physician as medical
						director. The medical director's responsibilities shall include, but not be
						limited to:
(a) Ensuring that medical
					 decisions are rendered by qualified medical personnel.
(b) Ensuring that authorized physicians and
					 medical personnel are trained on Treatment Authorization Requests,
					 authorization requirements, and procedures for noncapitated services.
(c) Ensuring that the PCCM plan's medical
					 standards are followed.
(d)
					 Developing and implementing medical policy.
(e) Resolving medically related grievances.
					 The medical director shall refer nonmedical grievances to the PCCM plan's
					 grievance procedure pursuant to section
					 56260.
(f) Actively participating in the functioning
					 of the PCCM plan grievance procedures.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56251 - Assumption of Financial Risk

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) PCCM plans shall be responsible for the
					 total costs, except as otherwise provided in this chapter, of services covered
					 at risk rendered to members under PCCM contracts.
(b) If so agreed by contract, the Department
					 shall bear the costs of providing medically necessary covered services to a
					 member when costs, based on Medi-Cal schedules of reimbursement and exclusive
					 of third-party recoveries, exceed the risk limit in the aggregate during the
					 12-month period specified in the contract. The risk limit shall be determined
					 annually, at the same time and using the same data base as used in the
					 determination of new annual rates pursuant to section
					 56321, and shall be stated in the
					 contract. The Department shall bear costs only for the period of time between
					 the date on which the aggregate amount exceeds the risk limit, and the end of
					 the 12-month period specified in the contract. Within 90 calendar days after
					 submittal of the documentation required in subdivision (b)(2), the Department
					 shall determine whether services are medically necessary and the amounts
					 payable under the schedule of Medi-Cal benefits are reasonable prior to
					 payment.
(1) Members whose cost of care
					 exceeds the risk limit in the 12-month period shall not be disenrolled by the
					 PCCM plan solely for that reason. The PCCM plan shall continue to provide case
					 management and any other services specified by its PCCM contract with the
					 Department.
(2) PCCM plans shall
					 submit to the Department documentation of accumulated costs which result in
					 reaching the risk limit and of all costs in excess of the
					 limit.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56252 - Reinsurance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The provisions
					 of section
					 56251 notwithstanding, the PCCM
					 plan may obtain reinsurance for the cost of providing capitated services,
					 subject to the following conditions:
(1)
					 Reinsurance shall not reduce the PCCM plan's liability below the minimum
					 liability per member for any one12-month period, as set forth in the PCCM
					 contract.
(2) Reinsurance may cover
					 both of the following:
(A) The total cost of
					 capitated services provided to members under emergency circumstances by nonplan
					 providers.
(B) Up to 90 percent of
					 all expenditures related to the contract exceeding 115 percent of the PCCM
					 plan's gross income from capitation payments and third-party recoveries under
					 the terms of the contract during any PCCM plan fiscal
					 year.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56260 - Grievance Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each PCCM plan shall establish and maintain a procedure
						for submittal, processing and resolution of all member and provider grievances
						and complaints.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14088.5
						  and
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56261 - Notice to Members of PCCM Plan Action to Deny, Defer or Modify a Request for Medical Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 PCCM plan shall provide members with a notice of an action taken by the PCCM
					 plan to deny a request by a provider for any medical service. Notice in
					 response to an initial request from a provider shall be provided in accordance
					 with this section. Notice in response to a request for continuation of a
					 medical service shall be provided in accordance with section
					 51014.1. Notice of denial shall
					 not be required in the following situations:
(1) The denial is a denial of a request for
					 prior authorization for coverage for treatment that has already been provided
					 to the member.
(2) The denial is a
					 non-binding verbal description to a provider of the services which may be
					 approved by the PCCM plan.
(3) The
					 denial is a denial of a request for drugs, and a drug identical in chemical
					 composition, dosage, and bioequivalence may be obtained through prior
					 authorization from the PCCM plan or from the list, established by the PCCM
					 plan, of drugs available without prior authorization from the
					 plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56262 - Provider Grievance and Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider of medical services may submit
					 a grievance or complaint concerning the authorization or denial of a service or
					 the processing, payment or nonpayment of a claim by a PCCM plan as follows:
(1) The provider shall initiate a first level
					 appeal, by submitting a grievance or complaint in writing, within 30 calendar
					 days of the action precipitating the grievance or complaint, to the PCCM plan
					 identifying the claim involved and specifically describing the disputed action
					 or inaction regarding the claim.
(2) The PCCM plan shall acknowledge the
					 written grievance or complaint within 15 calendar days of its
					 receipt.
(3) The PCCM plan may
					 refer a grievance or complaint to professional peer review.
(A) When the grievance or complaint is not
					 referred to professional peer review, the PCCM plan shall review the merits of
					 the grievance or complaint and send a written report of its conclusion and
					 reasons to the provider within 30 calendar days of the acknowledgement of the
					 receipt of the grievance or complaint.
(B) When the grievance or complaint is
					 referred to professional peer review:
1. All
					 parties concerned shall be notified that a referral has been made to
					 professional peer review and that a final determination may require up to 60
					 calendar days from the acknowledgement of the receipt of the grievance or
					 complaint.
2. The professional peer
					 review shall make its evaluation and submit its findings and recommendations to
					 the PCCM plan and the provider within 30 calendar days after the receipt of the
					 referral from the PCCM plan.
3. The
					 PCCM plan, after taking into consideration the findings and recommendations of
					 the professional peer review, shall send a written report of its conclusions
					 and reasons to the provider within 30 calendar days of receipt of the
					 recommendation.
4. The PCCM plan
					 shall retain all documentation related to the peer review in accordance with
					 section 56310.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56264 - Member Complaints. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Repealed by operation of Government Code section
						11346.1(g)
						(Register 92, No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14088.16
						  and
						  14088.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56280 - Quality of Care. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Repealed by operation of Government Code section
						11346.1(g)
						(Register 92, No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56284 - Confidentiality of Medical Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each PCCM plan shall maintain confidentiality of medical
						records in accordance with the provisions of section
						51009 and with section
						14100.2,
						Welfare and Institutions Code.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14088.16
						  and
						  14100.2,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56286 - Continuity of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 PCCM plan shall designate a primary care physician to supervise and coordinate
					 each member's health care. Any member dissatisfied with the primary care
					 physician shall be allowed to select another if more than one is available. Any
					 PCCM plan physician dissatisfied with the professional relationship with any
					 PCCM plan member may request that another primary care physician be substituted
					 to supervise the member's care.
(b)
					 Each PCCM plan shall establish and operate a case management system, which
					 shall assure continuity of care through appropriate referral of members needing
					 specialty health services, documentation of referral services in member's
					 medical records, monitoring of members with ongoing medical conditions,
					 documentation in the member's medical records of emergency medical encounters
					 with appropriate follow-up as medically indicated, and coordinated hospital
					 discharge planning including necessary post-discharge care.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order transmitted to
						OAL 7-19-91 and filed 8-19-91 (Register 92, No.
						1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56310 - Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each PCCM plan
					 shall maintain or cause to be maintained all records necessary to verify
					 information and reports required by statute, regulation or contractual
					 obligation for three years from the date of submission of information or
					 reports, except as specified in subdivision (b). Such records shall include but
					 shall not be limited to:
(1) Working papers
					 used in the preparation of reports to the Department.
(2) Reports to the Department.
(3) Financial documents.
(4) Medical records.
(5) Prescription files, if pharmacy services
					 are provided under the contract.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56312 - Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each PCCM plan shall submit reports to the Department as
						specified below:
(a) Annual reports
					 shall include:
(1) Any financial audit
					 required by section
					 56340. This audit report shall be
					 submitted no later than 90 calendar days after the close of the PCCM plan's
					 contract year.
(2) Any disclosure
					 statement required by the PCCM contract.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56314 - Statistical Data

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On a
					 quarterly basis, each PCCM plan shall supply statistical data and information
					 to the Department.
(b) The
					 statistical data shall include but are not limited to:
(1) Utilization of services covered at
					 risk.
(2) Costs of health care
					 services covered at risk.
(3)
					 General and administrative expenses.
(4) Unaudited financial
					 statements.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56320 - Capitation Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Payment to each PCCM plan shall be on a monthly capitation payment basis. Each
					 PCCM plan shall be at risk for capitated services provided under the PCCM
					 contract. The capitation payment shall:
(1)
					 Constitute payment in full by the Department for health care and administrative
					 services rendered under the PCCM contract.
(2) Be based upon a count of eligible members
					 furnished to the PCCM plan monthly by the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56321 - Capitation Payment Rates Determination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall determine capitation
					 payment rates annually by actuarial methods.
(b) The rates shall not exceed actuarially
					 equivalent Medi-Cal fee-for-service costs. These costs shall be determined by
					 viewing the total services at risk and requirements, including administration,
					 provided under this chapter by a PCCM plan as though the same services and
					 requirements, including administration, were reimbursable under Chapter 3
					 commencing with section
					 51001.
(c) The rates shall be effective for one year
					 beginning the first day of July each year.
(1)
					 In the event that payment of new rates is delayed beyond the first day of July,
					 continued payment of the rate in effect shall be an interim payment
					 only.
(2) Final payment shall be:
(A) Adjusted by increase or decrease to the
					 level of the new rates.
(B)
					 Effective as of the first day of July.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56322 - Capitation Rate Redetermination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Capitation rates shall be redetermined
					 during the rate year only when all of the following conditions are met:
(1) A change occurs in the obligations of the
					 PCCM plan which results in increased or decreased costs of performing under the
					 PCCM contract.
(2) The change in
					 subdivision (1) is the result of either of the following:
(A) A change in federal or state law or
					 regulation.
(B) A change in the
					 Department's interpretation or implementation of federal or state law or
					 regulation.
(3) The
					 projected difference in the actuarial equivalent costs associated with the
					 conditions set forth in subdivision (a)(2) exceeds one percent of the statewide
					 average capitation rate for services covered at risk for the affected
					 categories of members.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56322.1 - Savings Sharing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Notwithstanding section
					 56320, the Department shall
					 calculate and disburse savings sharing to PCCM plans in accordance with the
					 methodology and disbursement schedule specified in the PCCM contract.
(b) The savings sharing amount for a given
					 PCCM plan is determined by comparing the expected fee-for-service cost for all
					 services provided to PCCM plan members to the actual cost, which is the
					 capitation payment plus the cost of noncapitated services paid through the
					 fee-for-service system. If the expected fee-for-service cost exceeds the actual
					 cost minus the State savings on the capitation payment, the difference is the
					 amount saved, a portion of which is paid to the PCCM plan.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56324 - Financial Resources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each PCCM plan shall maintain adequate financial resources to carry out its
					 contractual obligations. The Department shall determine the level of adequate
					 financial resources for each PCCM plan by considering factors which include,
					 but shall not be limited to, the following:
(1) Tangible net equity.
(2) Working capital trends.
(3) Profit and loss trends.
(4) Enrollment growth.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56326 - Financial Security

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each PCCM plan that requests payment for medical services in advance of
					 providing those services shall provide evidence of and maintain financial
					 security. Financial security shall be maintained through the duration of the
					 PCCM contract.
(b) Financial
					 security may be in the form of, but is not limited to, one of the following:
(1) A guarantee bond.
(2) A letter of credit.
(3) A time certificate of deposit.
(4) A trust agreement.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56330 - Affiliate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Upon request by the Department every affiliate
						shall:
(a) Furnish to the PCCM plan
					 and to the Department financial reports relevant to the disposition of funds
					 paid to the affiliate by the PCCM plan. Reports shall be prepared according to
					 generally accepted accounting principles and shall provide all financial data
					 required by the PCCM plan to fulfill its obligations to the Department for
					 financial reporting pursuant to these regulations and the PCCM
					 contract.
(b) Make all books and
					 records which are pertinent to PCCM plan contracts with the Department
					 available for inspection by the Department and by the Department of Health and
					 Human Services. These books and records shall be retained in accordance with
					 section 56310.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56340 - Financial Audit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
					 PCCM plan, not operated by a public entity, that has an average enrollment of
					 5,000 members per month or more in any three consecutive months within a
					 contract year, shall have an audit performed at the close of the contract year
					 by an independent certified public accountant. Regardless of enrollments, all
					 PCCM plans not operated by a public entity shall have a independent certified
					 public accountant perform an audit at least once every third year after the
					 initial contract is signed with the Department.
(b) A PCCM plan operated by a public entity
					 shall have an annual audit performed in a manner specified in the PCCM
					 contract. The audit may be performed by, but is not limited to performance by:
(1) A certified public accountant.
(2) The county's financial accounting/audit
					 department.
(3) The State's Auditor
					 General office.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56350 - Civil Penalties and Sanctions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department may, except as provided in
					 section 56352(a), impose
					 one or more of the civil penalties specified in subdivision (b) below upon a
					 PCCM plan which fails to comply with the provisions of Chapter 7, Part 3,
					 Division 9, Welfare and Institutions Code, the provisions of this chapter, or
					 the terms of the PCCM contract.
(b)
					 Civil penalties may include but are not limited to:
(1) Restricting the PCCM plan's marketing
					 privileges.
(2) Delaying, or
					 denying payment, in whole or in part, of savings sharing.
(3) Terminating the PCCM contract.
(4) Delaying or withholding capitation
					 payments.
(5) Requiring the PCCM
					 plan to terminate any subcontract or sub-subcontract.
(6) Other penalties as set forth in the
					 contract.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 3 - OPERATIONAL REQUIREMENTS › Section 56352 - Contract Termination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department shall terminate a contract with a PCCM plan which the Secretary,
					 Department of Health and Human Services has determined does not meet the
					 requirements for participation in the Medicaid program stated in Title XIX of
					 the Social Security Act.
(b) The
					 Department may terminate a PCCM contract for noncompliance by the PCCM plan
					 with the requirements of state or federal law or regulations or terms of the
					 PCCM contract.
(c) The Department
					 shall give 30 calendar days written notice prior to the termination of a PCCM
					 contract to:
(1) The PCCM plan.
(2) PCCM plan members.
(3) Other entities, organizations, and
					 persons that the Department deems appropriate.