California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53887 - Exemption from Plan Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An eligible beneficiary meeting the
					 criteria specified in section
					 53845(a), who
					 satisfies the requirements in (1) or (2) below, may request fee-for-service
					 Medi-Cal for up to 12 months as an alternative to plan enrollment by submitting
					 a request for exemption from plan enrollment to the Health Care Options Program
					 as specified in (b) below.
(1) An eligible
					 beneficiary who is an American Indian as specified in section
					 55100(i), a
					 member of an American Indian household, or chooses to receive health care
					 services through an Indian Health Service facility and has written acceptance
					 from an Indian Health Service facility for care on a fee-for-service
					 basis.
(2) An eligible beneficiary
					 who is receiving fee-for-service Medi-Cal treatment or services for a complex
					 medical condition, from a physician, a certified nurse midwife, or a licensed
					 midwife who is participating in the Medi-Cal program but is not a contracting
					 provider of either plan in the eligible beneficiary's county of residence, may
					 request a medical exemption to continue fee-for-service Medi-Cal for purposes
					 of continuity of care.
(A) For purposes of
					 this section, conditions meeting the criteria for a complex medical condition
					 include, and are similar to, the following:
1.
					 An eligible beneficiary is pregnant.
2. An eligible beneficiary is under
					 evaluation for the need for an organ transplant; has been approved for and is
					 awaiting an organ transplant; or has received a transplant and is currently
					 either immediately post-operative or exhibiting significant medical problems
					 related to the transplant. Beneficiaries who are medically stable on
					 post-transplant therapy are not eligible for exemption under this
					 section.
3. An eligible beneficiary
					 is receiving chronic renal dialysis treatment.
4. An eligible beneficiary has tested
					 positive for HIV or has received a diagnosis of acquired immune deficiency
					 syndrome (AIDS).
5. An eligible
					 beneficiary has been diagnosed with cancer and is currently receiving
					 chemotherapy or radiation therapy or another course of accepted therapy for
					 cancer that will continue for up to 12 months or has been approved for such
					 therapy.
6. An eligible beneficiary
					 has been approved for a major surgical procedure by the Medi-Cal
					 fee-for-service program and is awaiting surgery or is immediately
					 post-operative.
7. An eligible
					 beneficiary has a complex neurological disorder, such as multiple sclerosis, a
					 complex hematological disorder, such as hemophilia or sickle cell diseases, or
					 a complex and/or progressive disorder not covered in 1. through 6. above, such
					 as cardiomyopathy or amyotrophic lateral sclerosis, that requires ongoing
					 medical supervision and/or has been approved for or is receiving complex
					 medical treatment for the disorder, the administration of which cannot be
					 interrupted.
8. An eligible
					 beneficiary is enrolled in a Medi-Cal waiver program that allows the individual
					 to receive sub-acute, acute, intermediate or skilled nursing care at home
					 rather than in a sub-acute care facility, an acute care hospital, an
					 intermediate care facility or a skilled nursing facility.
9. An eligible beneficiary is participating
					 in a pilot project organized and operated pursuant to sections
					 14087.3,
					 14094.3,
					 or
					 14490
					 of the Welfare and Institutions Code.
(B) A request for exemption from plan
					 enrollment based on complex medical conditions shall not be approved for an
					 eligible beneficiary who has:
1. Been a member
					 of either plan on a combined basis for more than 90 calendar days,
2. A current Medi-Cal provider who is
					 contracting with either plan, or
3.
					 Begun or was scheduled to begin treatment after the date of plan
					 enrollment.
(3)
					 Except for pregnancy, any eligible beneficiary granted a medical exemption from
					 plan enrollment shall remain with the fee-for-service provider only until the
					 medical condition has stabilized to a level that would enable the individual to
					 change physicians and begin receiving care from a plan provider without
					 deleterious medical effects, as determined by a beneficiary's treating
					 physician in the Medi-Cal fee-for-service program, up to 12 months from the
					 date the medical exemption is first approved by the Health Care Options
					 Program. A beneficiary granted a medical exemption due to pregnancy may remain
					 with the fee-for-service Medi-Cal provider through delivery and the end of the
					 month in which 90 days post-partum occurs.
(4) Any extension to the 12-month medical
					 exemption time limit shall be requested through the Health Care Options Program
					 no earlier than 11 months after the starting date of the exemption currently in
					 effect. The Health Care Options Program will notify the beneficiary 45 days
					 before the expiration of an approved medical exemption and will inform the
					 beneficiary how to request an extension. An extension to the medical exemption
					 shall be approved if the eligible beneficiary continues to meet the
					 requirements of subsection (a)(2).