reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51338 - Home Health Aide Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 6-5-67 as an emergency; effective upon filing. Certificate of
						Compliance filed 6-9-67 (Register 67, No. 23).
2. Amendment filed
						5-31-68; effective thirtieth day thereafter (Register 68, No.
						21).
3. Amendment filed 11-15-68; effective thirtieth day thereafter
						(Register 68, No. 43).
4. Repealer filed 9-27-72; designated
						effective 11-1-72 (Register 72, No. 40).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51339 - Special Duty Nursing. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 5-8-69; effective thirtieth day thereafter (Register 69, No.
						19). For prior history, see Register 67, No. 52.
2. Repealer filed
						9-30-71 as an emergency; designated effective 10-1-71 (Register 71, No.
						40).
3. Certificate of Compliance--Sec.
						11422.1, Gov. Code, filed 1-25-72
						(Register 72, No. 5).
4. Editorial correction of HISTORY 1 and 3
						(Register 95, No. 45).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51340 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services and EPSDT Supplemental Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) EPSDT screening services as defined in
					 Section 51184(a)(1) are a
					 program benefit when provided through the Child Health and Disability
					 Prevention program in accordance with Title 17, California Code of Regulations,
					 Sections 6800 et seq. EPSDT screening
					 services as defined in Sections
					 51184(a)(2) and
					 (a)(3) are covered when provided by a
					 certified Medi-Cal provider meeting the requirements of this chapter, if such
					 services are otherwise reimbursable under the program.
(b) EPSDT diagnosis and treatment services as
					 defined in Section
					 51184(b) are
					 covered subject to the provisions of this chapter.
(c) Unless otherwise specified in this
					 Chapter, EPSDT supplemental services are covered subject to prior authorization
					 if the requirements of subsections (e) or (f), as appropriate, are met. The
					 Department shall review requests for services resulting from EPSDT screening
					 services for compliance with this section whether the screen was performed by a
					 Medi-Cal provider or a non-Medi-Cal provider.
(d) Requests for prior authorization for
					 EPSDT supplemental services pursuant to subsection (c) shall state explicitly
					 that the request is for EPSDT supplemental services, and shall be accompanied
					 by the following information:
(1) The
					 principal diagnosis and significant associated diagnoses.
(2) Prognosis.
(3) Date of onset of the illness or
					 condition, and etiology if known.
(4) Clinical significance or functional
					 impairment caused by the illness or condition.
(5) Specific types of services to be rendered
					 by each discipline with physician's prescription where applicable.
(6) The therapeutic goals to be achieved by
					 each discipline, and anticipated time for achievement of goals.
(7) The extent to which health care services
					 have been previously provided to address the illness or condition, and results
					 demonstrated by prior care.
(8) Any
					 other documentation available which may assist the Department in making the
					 determinations required by this section.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51340.1 - Requirements Applicable to EPSDT Supplemental Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) When the particular EPSDT Supplemental
					 Services identified in this section are requested, the request for service
					 shall be approved only when the criteria and requirements set forth in this
					 section are met. Requests for all other EPSDT Supplemental Services shall be
					 approved only when the requirements set forth in Section
					 51340(e)(1) or
					 (e)(3) are met.
(b) Dental Services
(1) Dental services, other than orthodontic
					 services
Requests for dental services, as EPSDT Supplemental
						Services, including but not limited to services necessary for the relief of
						pain and infections, restoration of teeth or maintenance of dental health,
						shall be evaluated under Section
						51340(e)(1) or
						(e)(3), as applicable.
(2) Orthodontic services
Orthodontic services are covered only:
(A) When medically necessary pursuant to the
					 criteria set forth in the Medi-Cal "Manual of Criteria for Medi-Cal
					 Authorization," Chapter 8.1, as incorporated by reference in Section
					 51003(e)
					 or
(B) When medically necessary for
					 the relief of pain and infections, restoration of teeth, maintenance of dental
					 health, or the treatment of other conditions or defects, pursuant to the
					 criteria set forth in Section
					 51340(e)(1) or
					 (e)(3), as
					 applicable.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51342 - Acute Administrative Days

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Acute administrative days are covered,
					 when authorized by a Medi-Cal consultant pursuant to Section
					 51003, subject to the following:
(1) The acute inpatient facility has made
					 appropriate and timely discharge planning.
(2) All other coverage has been
					 utilized.
(3) The acute inpatient
					 facility meets the requirements contained in the Manual of Criteria for
					 Medi-Cal Authorization.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51344 - In-Home Medical Care Waiver Services and Nursing Facility Waiver Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In-home medical
					 care waiver services and nursing facility waiver services are covered when
					 prescribed by a physician and provided at the beneficiary's place of residence
					 in accordance with a written treatment plan indicating the need for in-home
					 medical care waiver services or nursing facility waiver services and in
					 accordance with a written agreement between the Department and the provider of
					 service.
(b) All in-home medical
					 care waiver services are subject to prior authorization. Authorization will be
					 granted only:
(1) If the beneficiary for whom
					 in-home medical care waiver services are requested would otherwise require care
					 in an inpatient acute care hospital for at least 90 consecutive days;
					 and
(2) If the total cost incurred
					 by the Medi-Cal program of providing in-home medical care waiver services and
					 other medically necessary Medi-Cal services to the beneficiary is less than the
					 total cost incurred by the Medi-Cal program in providing all medically
					 necessary services to the beneficiary in an inpatient acute care hospital
					 and;
(3) If the beneficiary under
					 21 years of age for whom prior authorization for provision of in-home medical
					 care waiver services in the beneficiary's home is requested has a relative,
					 foster parent, or related or non-related legal guardian, or other responsible
					 adult who is willing to become and remain involved in the care of the child,
					 and become and remain proficient in performing the tasks necessary to care for
					 the child. This requirement shall not be interpreted to mean that such person
					 must provide any particular number of daily hours of care to the child.
					 Notwithstanding this requirement, there shall be a responsible adult who is
					 able to learn and perform the tasks necessary to care for the child. This
					 person shall demonstrate his/her proficiency by performing these tasks as
					 average of four hours per week (minimum of 16 hours each month) in order to
					 maintain the skills necessary to take care of the child at home.
(4) If the beneficiary for whom in-home
					 medical care waiver services are requested has, or will be placed in, a
					 residence which meets the following criteria, as determined by the Department;
(A) The residence is large enough to
					 accommodate the medical equipment and supplies required to maintain the patient
					 in the residence; and
(B) The
					 residence includes those physical adaptations which are necessary to ensure the
					 health and safety of the waiver beneficiary; and
(C) The residence is clean and free of
					 insects or pests.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51345 - Nurse Midwife Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Nurse midwife services permitted under state law are covered when provided by a
					 certified nurse midwife.
(b)
					 Services are limited to:
(1) The care of
					 mothers and newborns through the maternity cycle of pregnancy, labor, birth,
					 and the immediate postpartum period, not to exceed six weeks.
(2) Primary care as defined in Section
					 51170.5.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51345.1 - Certified Family Nurse Practitioner and Certified Pediatric Nurse Practitioner Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Services provided by certified family nurse practitioners and certified
					 pediatric nurse practitioners within the scope of their practice as authorized
					 by California law are covered except as provided in (b).
(b) Services rendered to a person eligible
					 for Medicare benefits, which are reimbursable by Medicare when performed by a
					 physician shall be covered only when Medicare makes reimbursement for those
					 services by that nurse practitioner.
(c) Services shall be subject to the
					 requirements specified in Section
					 51305, to the extent that such
					 requirements are applicable.
1. New
						section filed 8-13-86; effective upon filing (Register 86, No.
						33).
2. Amendment of section heading, text and NOTE filed 5-3-93 as
						an emergency; operative 5-3-93 (Register 93, No. 19). A Certificate of
						Compliance must be transmitted to OAL 8-31-93 or emergency language will be
						repealed by operation of law on the following day.
3. Reinstatement
						of section as it existed prior to emergency amendment filed 5-3-93 by operation
						of Government Code section
						11346.1(f)
						(Register 93, No. 44).
4. Amendment of section heading, text and
						NOTE refiled 10-27-93 as an emergency; operative 10-27-93 (Register 93, No.
						44). A Certificate of Compliance must be transmitted to OAL by 2-25-94 or
						emergency language will be repealed by operation of law on the following
						day.
5. Certificate of Compliance as to 10-27-93 order including
						amendment of NOTE transmitted to OAL 10-18-93 and filed 12-2-93 (Register 93,
						No. 49).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14132.41,
						  Welfare and Institutions Code. Reference: Sections
						  14115.6
						  and
						  14132.41,
						  Welfare and Institutions Code; and Sections
						  2834,
						  2835,
						  2835.5
						  and
						  2836,
						  Business and Professions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51346 - Home and Community-Based Waiver Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Home and community-based waiver services
					 shall be provided and reimbursed as Medi-Cal covered benefits only:
(1) For the duration of the applicable
					 federally approved waiver;
(2) To
					 the extent the services are set forth in the applicable waiver approved by the
					 Department of Health and Human Services; and
(3) To the extent the Department can claim
					 and be reimbursed federal funds for these services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51347 - Swing Bed Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Swing bed services are covered pursuant to the
						requirements specified in Section
						51335.
1. New
						section filed 1-17-86; effective upon filing pursuant to Government Code
						Section
						11346.2(d)
						(Register 86, No. 3).
2. Editorial correction of NOTE (Register 97,
						No. 37).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  1339.5,
						  1339.7
						  and
						  1339.9,
						  Health and Safety Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51348 - Comprehensive Perinatal Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Comprehensive perinatal services, as
					 defined in Section
					 51179, are covered to the extent
					 specified in this section. Prior authorization is required for nutrition,
					 psychosocial and health education services which exceed the Maximum Frequency
					 amounts as set forth in Section
					 51504.
(b) Except where a capitated health system
					 contract entered into by the Department provides otherwise, obstetrical
					 services in addition to all necessary medical care shall include, but are not
					 limited to:
(1) A written assessment of each
					 patient's obstetrical status.
(2)
					 Preparation of the individualized care plan obstetrical
					 component.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51348.1 - Comprehensive Perinatal Standards of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Services shall be provided in conformance
					 with:
(1) "Standards for
					 Obstetric-Gynecologic Services, Sixth Edition," herein incorporated by
					 reference in its entirety and available from the American College of
					 Obstetricians and Gynecologists, 600 Maryland Avenue, South West, Suite 300
					 East, Washington D.C., 20024-2588.
(2) Newborn Screening Regulations as set
					 forth in Title 17, California Administrative Code, Section
					 6500 et seq.
(3) Hemolytic Disease of the Newborn
					 Requirements as set forth in Title 17, California Administrative Code, Section
					 6510 et seq.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51348.2 - Patient Rights

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Patient participation in the comprehensive perinatal services program shall be
					 voluntary. Each eligible patient shall be informed about the services available
					 in the program, the potential risks and benefits of participation, and
					 alternative obstetrical care if she chooses not to participate in the
					 program.
(b) Prior to the
					 administration of any assessment, drug, procedure, or treatment, the patient
					 shall be informed of potential risks or hazards which may adversely affect her
					 or her unborn infant during pregnancy, labor, birth, or postpartum and the
					 alternative therapies available to her. The patient has a right to consent or
					 refuse the administration of any assessment, drug, procedure or
					 treatment.
(c) The patient has the
					 right to be treated with dignity and respect, to have her privacy and
					 confidentiality maintained, to review her medical treatment and record with her
					 physician or practitioner, to be provided explanations about tests and clinic
					 procedures, to have her questions answered about procedures, to have her
					 questions answered about her care, and to participate in the planning and
					 decisions about her management during pregnancy, labor and delivery.
1. New
						section filed 2-17-87 as an emergency; effective upon filing (Register 87, No.
						8). A Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 6-17-87.
2. New section
						refiled 6-5-87 as an emergency; operative 6-17-87 (Register 87, No. 25). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 10-15-87.
3. Certificate of
						Compliance filed 9-17-87 (Register 87, No. 38).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14053,
						  14132
						  and
						  14134.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51349 - Hospice Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Hospice
					 care, as defined in Section
					 51180 is covered to the extent
					 specified in this section.
(b) Of
					 the four levels of care described in subsection (j), only general inpatient
					 care is subject to prior authorization. Authorization for general inpatient
					 care shall be granted only when all applicable requirements, as set forth in
					 the Criteria for Authorization of Hospice Care section of the Department's
					 Manual of Criteria for Medi-Cal Authorization, are met.
(c) Services shall be limited to individuals
					 who have been certified as terminally ill in accordance with the procedures
					 specified in Title 42, Code of Federal Regulations, Part 418, Subpart B, and
					 who directly or through their representative voluntarily elect to receive such
					 benefits in lieu of other care as specified.
(d) An individual who elects to receive
					 hospice care, or that individual's representative as defined in Section
					 51180.7 must file an election
					 statement with the hospice providing the care. The election statement shall
					 include:
(1) Identification of the
					 hospice.
(2) The individual's or
					 representative's acknowledgement that:
(A)
					 Hospice care provided to adults shall be palliative rather than curative in
					 nature, or
(B) Hospice care
					 provided to a child, under the age of 21, may be palliative and curative at the
					 discretion of the treating physician.
(C) For adults, certain Medi-Cal benefits as
					 specified in subsection (f) are waived by the election.
(3) The effective date of the
					 election.
(4) The signature of the
					 individual or representative.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51351 - Targeted Case Management Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Targeted case management services shall
					 include at least one of the following service components:
(1) A documented assessment identifying the
					 beneficiary's needs. The assessment shall support the selection of services and
					 assistance necessary to meet the assessed needs and shall include the
					 following, as relevant to each beneficiary:
(A) Medical/mental condition.
(B) Physical needs, such as food and
					 clothing.
(C) Social/emotional
					 status.
(D) Housing/physical
					 environment.
(E) Familial/social
					 support system.
(F) Training needs
					 for community living.
(G)
					 Educational/vocational needs.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51351.1 - Targeted Case Management Provider Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A targeted case management services
					 provider may contract with a nongovernmental entity or the University of
					 California, or both, to provide targeted case management services on its
					 behalf, when the following conditions exist:
(1) The targeted case management services
					 provider employs at least one case manager who provides all of the service
					 components that constitute a targeted case management service, as described in
					 Section 51351.
(2) The nongovernmental entity shall not be a
					 local educational agency.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51355 - Tuberculosis (TB) Related Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following outpatient services shall
					 be covered as Tuberculosis (TB) Related Services as defined in Section
					 51187.1 when provided in
					 accordance with the requirements of this chapter:
(1) Physician Services as specified in
					 Section 51305.
(2) Laboratory Services as specified in
					 Section 51311.
(3) Radiologic Services as specified in
					 Section 51311.
(4) Anti-Tuberculosis Medications.
(5) Directly Observed Therapy as defined in
					 Section 51187.1.
(6) Targeted Case Management Services as
					 specified in Section
					 14132.44,
					 Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51356 - Licensed Midwife Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 following services shall be covered as licensed midwife services under the
					 Medi-Cal Program when provided by a licensed midwife as specified in Section
					 51255:
(1) Attendance at cases of normal childbirth
					 and
(2) The provision of prenatal,
					 intrapartum, and postpartum care, including family planning care, for the
					 mother, and immediate care for the newborn.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51360 - Local Educational Agency (LEA) Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Local Educational Agency (LEA) Services,
					 as defined in Section
					 51190.4, are covered to the extent
					 specified in this section. Frequency limitations are set forth in Section
					 51535.5.
(b) LEA Services shall include (1) through
					 (8) below:
(1) LEA health and mental health
					 evaluation and health and mental health education services, which include any
					 or all of the following:
(A) Nutritional
					 assessment and nutrition education, consisting of assessments and non-classroom
					 nutrition education delivered to the LEA eligible beneficiary based on the
					 outcome of the nutritional health assessment (diet, feeding, laboratory values,
					 and growth).
(B) Vision assessment,
					 consisting of examination of visual acuity at the far point conducted by means
					 of the Snellen Test.
(C) Hearing
					 assessment, consisting of testing for auditory impairment using at-risk
					 criteria and appropriate screening techniques as defined in Title 17,
					 California Code of Regulations, Sections
					 2951(c).
(D) Developmental assessment, consisting of
					 examination of the developmental level by review of developmental achievement
					 in comparison with expected norms for age and background.
(E) Assessment of psychosocial status,
					 consisting of appraisal of cognitive, emotional, social, and behavioral
					 functioning and self-concept through tests, interviews, and behavioral
					 evaluations.
(F) Health education
					 and anticipatory guidance appropriate to age and health status, consisting of
					 non-classroom health education and anticipatory guidance based on age and
					 developmentally appropriate health education.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51365 - Targeted Case Management Services Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Persons who are eligible to receive
					 targeted case management services shall consist of the following Medi-Cal
					 beneficiary groups:
(1) High-risk persons as
					 defined in Section
					 51185.
(2) Persons who have language or other
					 comprehension barriers and:
(A) Are unable to
					 access or appropriately utilize services themselves,
(B) Have demonstrated noncompliance with
					 their medical regimen;
(C) Are
					 unable to understand medical directions because of language or other
					 comprehension barriers; or
(D) Have
					 no community support system to assist in follow-up care at
					 home.
(3) Persons who are
					 18 years of age and older and who:
(A) Are on
					 probation and have a medical and/or mental condition; or
(B) Have exhibited an inability to handle
					 personal, medical, or other affairs; or
(C) Are under public conservatorship of
					 person and/or estate; or
(D) Have a
					 representative payee; or
(E) Are in
					 frail health and in need of assistance to access services in order to prevent
					 institutionalization.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51401 - Medically Needy Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51406 - Nursing Home and Convalescent Home Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51407 - Blood and Blood Derivatives

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51409 - Physical Therapy Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Section
						  14133,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51410 - Podiatrists' Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Note: Authority cited: Sections
						  10553.1,
						  10554,
						  10554.1,
						  11004,
						  11050,
						  11100,
						  14005.1,
						  14005.2,
						  14005.4,
						  14005.6,
						  14005.7,
						  14016,
						  14017,
						  14023,
						  14051,
						  14053,
						  14100.1,
						  14105,
						  14124.5
						  and
						  14132,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 5 - Scope and Duration of Supplemental Schedule of Benefits [Repealed] › Section 51427 - Inpatient Hospital Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51452 - Violation of Regulations, Administrative Sanctions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Violation of any Medi-Cal statute, rule
					 or regulation relating to the provision of health care services under the
					 California Medical Assistance Program by an individual, partnership, clinic,
					 group, association, corporation, or institution, or any officer, director,
					 agent or employee, shall be deemed contrary to public health, safety, welfare,
					 morals, and to said program, and to constitute grounds for issuing a reprimand;
					 placing the provider on probationary status; or suspension from participation
					 in said program.
(b) The type and
					 degree of the sanction shall be governed by the severity of the violation.
					 Mitigating circumstances shall be considered in reaching a final determination
					 on whether administrative sanctions will be imposed and the extent and degree
					 of their severity.
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No.
						9).
2. Amendment filed 4-9-80; effective thirtieth day thereafter
						(Register 80, No. 15).
3. Editorial correction of NOTE filed
						12-14-84 (Register 84, No. 50).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51453 - Recommendation for Suspension

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Director may commence proceedings under Chapter 5
						(commencing with Section
						11500) of Part 1 of Division 3 of
						Title 2 of the Government Code leading to the suspension of any individual,
						partnership, clinic, group, association, corporation or institution from
						participation in the California Medical Assistance Program, upon the
						recommendation of a county, a fiscal intermediary, any state or federal
						department, agency, board or commission, a person or group of persons, or upon
						his own motion; however, only the Director or other personnel employed by the
						Department shall be authorized to sign an accusation to commence the
						proceedings referred to herein.
1.
						Amendment filed 11-15-68; effective thirtieth day thereafter (Register 68, No.
						43). For prior history, see Register 67, No. 52.
2. Amendment filed
						2-25-70; designated effective 4-1-70 (Register 70, No. 9).
3.
						Amendment filed 1-18-74; effective thirtieth day thereafter (Register 74, No.
						3).
4. New NOTE filed 12-14-84 (Register 84, No.
						50).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14123, Welfare and Insitutions
						  Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51454 - Provider Defined

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article, "provider" shall have the same
						meaning as in Section
						51051.
1. New
						section filed 2-25-70; designated effective 4-1-70 (Register 70, No.
						9).
2. New NOTE filed 12-14-84 (Register 84, No. 50).
3.
						Amendment of section and NOTE filed 9-28-99 as an emergency; operative 9-28-99
						(Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL
						by 3-27-2000 or emergency language will be repealed by operation of law on the
						following day. Submitted to OAL for printing only pursuant to section
						78, AB 1107 (Chapter 146, Statutes
						of 1999).
4. Amendment of section and NOTE refiled 11-24-99 as an
						emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of
						Compliance must be transmitted to OAL by 5-22-2000 or emergency language will
						be repealed by operation of law on the following day. Submitted to OAL for
						printing only pursuant to section
						78, AB 1107 (Chapter 146, Statutes
						of 1999).
5. Amendment of section and NOTE refiled 5-5-2000 as an
						emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of
						Compliance must be transmitted to OAL by 9-19-2000 or emergency language will
						be repealed by operation of law on the following day.
6. Amendment
						of section and NOTE refiled 8-28-2000 as an emergency; operative 9-6-2000
						(Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL
						by 1-4-2001 or emergency language will be repealed by operation of law on the
						following day.
7. Certificate of Compliance as to 8-28-2000 order
						transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No.
						6).
Note: Authority cited: Sections
						  10725,
						  14043.75
						  and
						  14124.5,
						  Welfare and Institutions Code; and Section
						  78, Chapter 146, Statutes of 1999.
						  Reference: Sections
						  14043,
						  14043.1
						  and
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51454.1 - Provider of Personal Care Services Defined

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For purposes of this article, providers of personal care
						services are defined in Section
						51181.
1. New
						section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for
						printing only pursuant to section
						8, AB 1773 (Chapter 939, Statutes
						of 1992) (Register 93, No. 16).
Note: Authority cited: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  8, Chapter 939, Statutes of 1922;
						  Section 3, Chapter 7, Statutes of 1993.
						  Reference: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  1396 d(a)(7) of Title 42, of the
						  United States Code; Article 7 (commencing with Section
						  12300) of Part 3 of Division 9 of
						  the Welfare and Institutions Code; Section
						  440.170(f) of
						  Title 42 of the Code of Federal
						  Regulations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51455 - Prior Authorization

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any provider may be subjected to a
					 requirement of prior authorization for all or certain specified services to be
					 rendered under the California Medical Assistance Program, by written notice
					 served on such provider from the Director or a carrier. The requirement for
					 prior authorization may be imposed on such provider by the Director upon a
					 determination that the provider has been rendering unnecessary services to a
					 Medi-Cal beneficiary.
(b) As used
					 in this regulation, "unnecessary services" includes but is not limited to any
					 of the following which exceed customary and usual practices in terms of
					 frequency, quantity, propriety, or length of treatment:
(1) Office, home or inpatient
					 visits.
(2) Furnishing, prescribing
					 or ordering drugs, appliances, services, hospital, skilled nursing facility or
					 intermediate care facility admissions.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51456 - Signing Treatment Authorization Requests

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Any provider who prescribes a service shall not sign a
						Treatment Authorization Request (TAR) until the patient has been examined and
						all of the following information appears on the TAR:
(a) Beneficiary identification;
(b) Provider identification;
(c) Diagnosis and other pertinent medical
					 information;
(d) Service or item
					 requested.
All signatures shall constitute certification that the
						information submitted is current, accurate and complete and that the services
						or items requested on the Treatment Authorization Request are medically
						indicated and necessary.
1. New
						section filed 11-4-74; effective thirtieth day thereafter (Register 74, No.
						45).
2. Editorial correction of NOTE filed 12-14-84 (Register 84,
						No. 50).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14103.6,
						  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 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51457 - Administrative Action. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 2-25-70; designated effective 4-1-70 (Register 70, No. 9). For
						prior history, see Register 68, No. 43.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51458 - Cause for Suspension

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The conviction of a provider of either (1) a felony, or (2) any offense,
					 misdemeanor or felony, involving moral turpitude shall be grounds for
					 suspension from participation in the California Medical Assistance Program. The
					 record of such conviction shall be conclusive evidence of the fact that the
					 conviction occurred. The Department may inquire into the circumstances
					 surrounding the commission of the crime in order to determine if such
					 conviction was of an offense involving moral turpitude and suspension is
					 warranted. A plea or verdict of guilty or a conviction following a plea of nolo
					 contendere made to a charge of a felony, or any offense involving moral
					 turpitude, shall be deemed to be a conviction within the meaning of this
					 section.
(b) The Department may
					 suspend a provider from the program based upon a judgment of conviction
					 regardless of whether the provider obtains a subsequent order under the
					 provisions of section
					 1203.4 of the
					 Penal Code allowing him to withdraw his plea of guilty, and to enter a plea of
					 not guilty, or setting aside the verdict of guilty, or dismissing the
					 information or indictment.
(c)
					 Suspension of a provider of service from participation in the Medicare program
					 shall be grounds for suspension of that provider from participation in the
					 Medi-Cal Program.
(d) The
					 suspension or revocation of a provider's license, certification, permit or
					 registration or the failure to obtain such license, certification permit or
					 registration shall be grounds for suspension from participation in the
					 California Medical Assistance program, when such license, certification, permit
					 or registration is required for program participation in accordance with
					 article 3.
1. New
						section filed 1-22-71; designated effective 3-1-71 (Register 71, No.
						4).
2. New subsection (c) filed 12-28-73 as an emergency; designated
						effective 1-1-74. Certificate of Compliance included (Register 73, No.
						52).
3. New subsection (d) filed 2-23-79; effective thirtieth day
						thereafter (Register 79, No. 8).
4. Amendment filed 9-28-79;
						effective thirtieth day thereafter (Register 79, No. 39).
5.
						Editorial correction of NOTE filed 12-14-84 (Register 84, No.
						50).
6. Amendment of subsection (d) filed 2-15-91; operative 3-17-91
						(Register 91, No. 11).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code; and Section
						  208,
						  Health and Safety Code. Reference: Section
						  14123,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51458.1 - Cause for Recovery of Provider Overpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall recover overpayments
					 to providers including, but not limited to, payments determined to be:
(1) In excess of program payment ceilings or
					 allowable costs.
(2) In excess of
					 the amounts usually charged by a provider.
(3) For services not documented in the
					 provider's records, or for services where the provider's documentation
					 justifies only a lower level of payment.
(4) Based upon false or incorrect claims or
					 cost reports from providers.
(5)
					 For services deemed to have been excessive, medically unnecessary or
					 inappropriate.
(6) For services
					 prescribed, ordered or rendered by persons who did not meet the standards for
					 participation in the Medi-Cal program at the time the services were prescribed,
					 ordered or rendered.
(7) For
					 services not covered by the program.
(8) For services to persons not eligible for
					 program coverage when the services were provided.
(9) For Medi-Cal covered services already
					 paid for by the beneficiary, but not yet refunded, or for services already
					 reimbursed by the Department or other coverage.
(10) For services that should have been
					 billed to other coverage.
(11) For
					 services not ordered or prescribed, when an order or prescription is
					 required.
(12) For services not
					 authorized, when a treatment authorization request is required.
(13) In violation of any other Medi-Cal
					 regulation where overpayment has occurred.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51458.2 - Statistical Extrapolation of Medi-Cal Provider Reviews

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall make a demand to
					 recover an amount due from a Medi-Cal provider (as specified in Section
					 51458.1) using probability
					 sampling to extrapolate the recoverable amount when the extrapolated recovery
					 amount exceeds the cost to the Department of doing the audit.
(b) Probability sampling shall be done in
					 conformance with generally accepted statistical standards and procedures
					 described in any textbook on statistical sampling methods.
(c) Whenever the results of a probability
					 sample are used to extrapolate the amount to be recovered, the demand for
					 recovery shall be accompanied by a clear description of:
(1) The universe from which the sample was
					 drawn,
(2) The sample size and
					 method used to select the sample,
(3) The formulas and calculation procedures
					 used to determine the amount to be recovered, and
(4) The confidence level used to calculate
					 the precision of the extrapolated overpayment.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 6 - Eligibility for Payment › Section 51459 - Reinstatement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A provider whose participation in the California Medical
						Assistance Program has been suspended may petition the Department for
						reinstatement or reduction of term of suspension after a period of not less
						than one year has elapsed from the effective date of the decision, or from the
						date of the denial of a similar petition. The Department shall give notice to
						the Attorney General of the filing of the petition, and the Attorney General
						and the petitioner shall be afforded an opportunity to present written argument
						to the Department. The Department shall decide the petition, and the decision
						shall include the reasons therefor.
1.
						Amendment filed 6-23-66 as an emergency; effective upon filing; Certificate of
						Compliance included (Register 66, No. 19).
2. Amendment filed
						11-15-68; effective thirtieth day thereafter (Register 68, No.
						43).
3. Repealer and new section filed 2-25-70; designated effective
						4-1-70 (Register 70, No. 9).
4. New NOTE filed 12-14-84 (Register
						84, No. 50).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14124.6,
						  Welfare and Institutions Code.