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 51311 - Laboratory, Radiological, and Portable Imaging Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Examinations, tests, and therapeutic
					 services ordered by a licensed practitioner, within his/her scope of practice
					 as defined by California law, for the purpose of providing information for the
					 diagnosis, prevention, or treatment of any disease, injury or impairment of, or
					 the assessment of the health of, human beings, or used as an aid in the
					 prevention, prognosis, monitoring, or treatment of a physiological or
					 pathological condition or illness in a human being are covered except that
					 laboratory services provided for chronic outpatient hemodialysis in renal
					 dialysis centers and community hemodialysis units are payable only when billed
					 by the renal dialysis center or community hemodialysis unit.
(b) Portable imaging services are covered
					 subject to prior authorization except when they are rendered in skilled nursing
					 and intermediate care facilities. Emergency portable imaging services performed
					 in locations other than skilled nursing and intermediate care facilities do not
					 require prior authorization.
(c)
					 Procedures and examinations that are not covered as portable imaging services
					 include:
(1) Procedures involving
					 fluoroscopy;
(2) Procedures
					 involving the use of contrast media;
(3) Procedures requiring the administration
					 of a substance to the patient or injection of a substance into the patient
					 and/or special manipulation of the patient;
(4) Procedures that require special medical
					 skill or knowledge possessed by a physician, dentist or podiatrist or that
					 require that medical judgment be exercised;
(5) Routine screening procedures;
(6) Procedures that are not of a diagnostic
					 nature; and
(7) Procedures that for
					 safety, and effectiveness to permit clear interpretation of the image by a
					 radiologist, need to be performed in a radiology facility; and require any of
					 the following:
(A) Immobilization of the
					 patient.
(B) Avoidance of excessive
					 radiation due to the number of views required.
(C) Special techniques to deal with complex
					 radiologic problems.
(D) Special
					 equipment and supplies.
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 51312 - Prayer or Spiritual Healing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prayer or spiritual healing services covered are limited
						to those allowed under Title XVIII of the Social Security Act. Such services
						are subject to the limitation set forth in Section
						51304(a).
1. New
						section filed 9-30-71 as an emergency; designated effective 10-1-71 (Register
						71, No. 40).
2. Certificate of Compliance--Section
						11422.1,
						Gov. Code, filed 1-25-72 (Register 72, No. 5).
3. Amendment filed
						8-8-78; effective thirtieth day thereafter (Register 78, No. 32).
4.
						Change without regulatory effect adding NOTE (Register 86, No.
						49).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14132,
						  14133
						  and
						  14133.1,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51313 - Pharmaceutical Services and Prescribed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Drugs on the Medi-Cal List of Contract
					 Drugs are covered, subject to limitations specified in this Section and Section
					 51313.3 when prescribed by a
					 licensed practitioner within the scope of the practitioner's practice as
					 defined by California law.
(b)
					 Drugs shall be furnished in quantities not to exceed a 100 calendar day supply
					 except for sodium fluoride tablets, drops and solutions or when necessary to
					 comply with minimum quantities specified in section
					 51513.
(c) Drugs not on the Medi-Cal List of
					 Contract Drugs and not excluded in Section
					 51313.3 are covered subject to
					 prior authorization in accordance with Section
					 51003.
(1) Authorization may be granted when:
(A) The clinical condition of the patient
					 requires the use of an unlisted drug and listed drugs have been adequately
					 considered or tried and do not meet the medical needs of the patient.
(B) The use of an unlisted drug results in a
					 less expensive treatment than would otherwise occur.
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 51313.3 - Limitations on Coverage of Drugs on the Medi-Cal List of Contract Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Drugs on the
					 Medi-Cal List of Contract Drugs shall have the limitations specified in (b)
					 through (g) below.
(b) Code 1 drugs
					 on the List of Contract Drugs marked "*", require prior authorization in
					 accordance with Section
					 51003 unless used under the
					 conditions specified on the Medi-Cal List of Contract Drugs, and are subject to
					 the prescription documentation requirements of Section
					 51476(c).
(c) Where drugs are listed by specific dosage
					 forms, their use is limited to such method of administration (e.g., ophthalmic
					 ointments are limited to ophthalmic use) unless prior authorization is
					 obtained.
(d) When a manufactured
					 dosage form or strength is specifically listed, only those dosage forms or
					 strengths listed are allowable for payment, unless prior authorization is
					 obtained. A listed drug, except intravenous solutions, when prepared by the
					 provider in an unlisted dosage form or strength, does not require prior
					 authorization. Long-acting dosage preparations require prior authorization
					 unless specifically listed. Long-acting dosage preparations are drug products
					 physically constructed to give slow-release therapeutic effect.
(e) Common household remedies and the
					 following items are not covered:
(1) Nonlegend
					 drug preparations;
A. Benzoic and Salicylic
					 Acid Ointment (precompounded)
B.
					 Salicylic Acid Cream or Ointment
C.
					 Salicylic Acid Liquid
D. Sodium
					 Chloride Tablets 1Gm
E. Sodium
					 Chloride Tablets 2.5Gm
F. Zinc
					 Oxide Paste
G. Nonlegend Analgesics
					 except for those in part 2 of the Medi-Cal List of Contract
					 Drugs.
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 51314 - Rehabilitation Center Outpatient Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Outpatient physical therapy, occupational therapy, speech
						therapy and audiology services provided in a rehabilitation center approved as
						meeting the standards set forth in Section
						51213 are covered as specified
						below:
(a) One visit in a six-month
					 period, for evaluation of the patient and preparation of an extended treatment
					 plan, is covered without prior authorization. Additional services in a
					 six-month period require prior authorization. The request for prior
					 authorization shall be accompanied by an extended treatment plan signed by a
					 physician. The extended treatment plan shall include all of the following:
(1) The principal and significant associated
					 diagnosis.
(2) Prognosis.
(3) Date of onset of illness or
					 injury.
(4) Specific type, number,
					 and frequency of services to be rendered by each discipline.
(5) Therapeutic goals to be achieved by each
					 discipline and the anticipated time required for achievement of these
					 goals.
(6) The extent to which
					 physical therapy, occupational therapy, speech therapy or audiology services
					 have been previously provided, and benefits or improvements demonstrated by
					 such prior care.
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 51315 - Amount, Scope, Duration, Limitation and Prior Authorization of Benefits for Orthotic and Prosthetic Appliances and Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Orthotic and prosthetic appliances and
					 services, to the extent necessary for the restoration of function or
					 replacement of a body part(s), or to support a weakened or deformed body
					 member, are covered under the Medi-Cal program as follows:
(1) Except as specified in subsection (a)(2),
					 and subject to Welfare and Institutions Code, Section
					 14131.10,
					 which excludes coverage for podiatric and adult dental services (with
					 exemptions), when prescribed by a licensed physician, a licensed podiatrist, a
					 licensed dentist or a licensed non-physician medical practitioner, within the
					 scope of their license, and furnished by a certified orthotist, a certified
					 prosthetist, a certified orthotist/prosthetist, a licensed physician, a
					 licensed dentist, a licensed podiatrist or a certified pharmacy pursuant to
					 subsection (a)(3) below. A certified orthotist, prosthetist and
					 orthotist/prosthetist shall hold current certification from The American Board
					 for Certification in Orthotics, Prosthetics and Pedorthics or the Board of
					 Certification/Accreditation or their successor organizations.
(2) Stock orthopedic and stock conventional
					 shoes, pursuant to Section
					 51315.1(k)(3)(A),
					 are covered when prescribed by a licensed physician or a licensed podiatrist
					 and furnished by a certified orthotist, a certified prosthetist or a certified
					 orthotist/prosthetist.
(3) Orthotic
					 and prosthetic appliances and services listed in the Medi-Cal provider manual,
					 pursuant to Welfare and Institutions Code Section
					 14105.21,
					 may be furnished and billed by pharmacies, when the pharmacy is certified and
					 enrolled in the Medi-Cal program as a provider.
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 51315.1 - Requirements Applicable to the Prior Authorization of Orthotic Appliances and Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Orthotic appliances and services shall be authorized
						under the Medi-Cal program when the supporting documentation and all other
						requirements specified in Section
						51315 and in this section are
						met.
For purposes of this section, medical conditions cited
						with each appliance/service or group of appliances/services shall not be
						construed to represent an exhaustive list of medical conditions appropriate to
						each appliance/service or group of appliances/services. Likewise, such medical
						conditions may not be appropriate for authorization of the requested
						appliance/service if medical necessity for the specific appliance/service is
						not documented.
(a) Shoe Supplies for
					 Diabetics shall include shoes and their fitting(s), modifications and inserts;
					 and shall be authorized when the patient has a diagnosis of diabetes mellitus
					 and requires one or more of the following shoe(s), shoe modification(s) or shoe
					 insert(s) to accommodate for or prevent foot ulceration and related foot
					 conditions:
(1) For prefabricated shoe(s) or
					 shoe insert(s), or modification(s) to prefabricated shoe(s) or shoe insert(s),
					 the patient has one or more of the following medical conditions, appropriate to
					 the requested procedure code(s):
(A) Foot
					 ulcer(s).
(B) Previous amputation
					 of the contralateral foot, or part of either foot, due to microvascular disease
					 secondary to diabetes.
(C) History
					 of foot ulceration(s) of either foot.
(D) Peripheral neuropathy with evidence of
					 callous formation of either foot.
(E) Deformity of either foot, such as rocker
					 bottom foot or Charcot foot.
(F)
					 Compromised vascular disease in either foot.
(G) Positive monofilament examination
					 indicating diabetic neuropathy.
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 51316 - Respiratory Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Respiratory care services provided by respiratory care practitioners acting
					 within their scope of practice, upon the written prescription of a physician or
					 surgeon, are covered as Medi-Cal benefits subject to the following:
(1) The respiratory care service is within
					 accepted respiratory treatment modalities and considered to be specific and
					 effective treatment for the beneficiary's condition; and
(2) The respiratory care service is shown to
					 be medically necessary for the treatment of the beneficiary's condition
					 pursuant to Section
					 51303.
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 51317 - Eyeglasses, Contact Lenses, Low Vision Aids, Prosthetic Eyes and Other Eye Appliances

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Eye appliances are covered on the written prescription of a physician or
					 optometrist, subject to the provisions of this section.
(1) Providers shall make a reasonable effort
					 to ascertain and record the age, source and characteristics of the
					 beneficiary's most recent ophthalmic correction. A review of the provider's
					 prior records and questioning the beneficiary concerning prior ophthalmic
					 corrections will satisfy this requirement.
(2) Lost, broken or significantly damaged eye
					 appliances may not be replaced unless the beneficiary or beneficiary's
					 representative supplies the provider with a signed statement outlining the
					 circumstances of the loss or destruction and the steps taken to recover the
					 lost item, and certifying that the loss, breakage or damage was beyond the
					 beneficiary's control. Providers shall not be held responsible for inaccurate
					 statements by beneficiaries. A provider may certify that specific items require
					 replacement due to normal wear and tear or aging and that no abuse is
					 evident.
(3) Repair or replacement
					 of ophthalmic frames for lenses that do not conflict with the criteria in
					 (c)(1), (2), (4)(A) and (B) is covered without a prescription.
(4) The following are not covered:
(A) Eyeglasses used primarily for protective,
					 cosmetic, occupational or avocational purposes.
(B) Eyeglasses prescribed for other than the
					 correction of refractive errors or binocularity anomalies.
(C) Double segment bifocal or no-line
					 multifocal lenses.
(D) Multifocal
					 contact lenses.
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 51317.1 - Interim Coverage of Eyeglass Lenses. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 9-1-82 as an emergency; effective upon filing (Register 82, No.
						37). A Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 12-30-82.
2. Certificate of
						Compliance transmitted to OAL 12-30-82 and withdrawn 1-28-83 (Register 83, No.
						10).
3. New section refiled 1-28-83 as an emergency; effective upon
						filing (Register 83, No. 10). (Corrected copy of 1-28-83 emergency order
						refiled 1-31-83.) A Certificate of Compliance must be transmitted to OAL within
						120 days or emergency language will be repealed on 5-28-83.
4.
						Emergency language repealed by operation of Government Code Section
						11346.1(f)
						(Register 83, No. 26).
5. New section filed 6-24-83 as an emergency;
						effective upon filing (Register 83, No. 26). A Certificate of Compliance must
						be transmitted to OAL within 120 days or emergency language will be repealed on
						10-22-83.
6. Certificate of Compliance transmitted to OAL 10-21-83
						and filed 11-23-83 (Register 83, No. 48).
7. Editorial correction of
						NOTE filed 12-20-83 (Register 83, No. 52).
8. Repealer filed 9-30-85
						as an emergency; effective upon filing (Register 85, No. 40). A Certificate of
						Compliance must be transmitted to OAL within 120 days or emergency language
						will be repealed on 1-28-86.
9. Certificate of Compliance
						transmitted to OAL 1-8-86 and filed 2-6-86 (Register 86, No.
						6).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14110.5,
						  14132,
						  14133
						  and
						  14133.1,
						  Welfare and Institutions Code; and Section
						  149, Chapter 323, Statutes of
						  1983.
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 51319 - Hearing Aids

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Hearing
					 aids are covered only when supplied by a hearing aid dispenser on prescription
					 of an otolaryngologist, or the attending physician where there is no
					 otolaryngologist available in the community, plus an audiological evaluation
					 including a hearing aid evaluation which must be performed by or under the
					 supervision of the above physician or by a licensed audiologist.
(b) Prior to prescribing a hearing aid, the
					 otolaryngologist or attending physician shall perform a complete ear, nose and
					 throat examination.
(c) Prior
					 authorization is required for the purchase or trial period rental of hearing
					 aids, and for hearing aid repairs which exceed a cost of $25.00 per repair
					 service. Claims for individual repair services shall not be cumulative for the
					 purposes of determining the need for prior authorization.
(1) Ear molds are covered without prior
					 authorization.
(2) Prior
					 authorization is required for all supplies and accessories necessary for the
					 operation of a hearing aid, except as provided in (1) above.
(3) Binaural hearing aids may be authorized
					 under any of the following conditions:
(A) The
					 hearing loss is associated with legal blindness.
(B) For beneficiaries 20 years of age or
					 under, tests of each ear reveal a hearing loss level of 30 dB or greater,
					 American National Standards Institute (ANSI), 1969, for 500, 1,000, and 2,000
					 Hertz (Hz) by pure tone air conduction. Cases shall be referred to California
					 Children Services for evaluation, consultation, or case management for patients
					 eligible for such coverage by California Children Services.
(C) For beneficiaries over 18 years of age,
					 tests of each ear reveal a hearing loss level of 35 dB or greater, ANSI, 1969
					 for 500, 1,000, and 2,000 Hertz (Hz) by pure tone air conduction. Where the
					 provision of a binaural hearing aid is the basis for employment, beneficiaries
					 with the above hearing loss shall be referred to the California Department of
					 Rehabilitation for evaluation, consultation, and case management as provided in
					 Section 51014.
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 51320 - Medical Supplies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Medical supplies are covered when prescribed by a licensed practitioner within
					 the scope of his practice as defined by California laws.
(b) Common household items and articles of
					 clothing are not covered.
(c)
					 Medical supplies for chronic outpatient hemodialysis provided in renal dialysis
					 centers and community hemodialysis units or for home dialysis are covered, but
					 are payable only when included in the all inclusive facility rate set forth in
					 Section 51509.2.
1.
						Amendment of subsection (a) filed 5-14-76 as an emergency; effective upon
						filing (Register 76, No.
						20).
						For prior history, see Register 73, No. 5.
2. Certificate of
						Compliance filed 9-8-76 (Register 76, No. 37).
3. Amendment filed
						4-24-81; designated effective 7-1-81 (Register 81, No. 17).
4.
						Change without regulatory effect amending subsection (a) and NOTE filed
						1-26-2009 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2009, No. 5).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14124.5,
						  14105.47,
						  14132,
						  and
						  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 4 - Scope and Duration of Benefits › Section 51321 - Durable Medical Equipment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Durable medical equipment, as defined in Section
					 51160, is covered in accordance
					 with the standards set forth in section
					 51303(a) and when
					 provided on the written prescription of licensed practitioners within the scope
					 of their practice as established in California law. Alterations or improvements
					 of real property are not covered except to the extent authorized for the
					 provision of home dialysis services. In addition to the prescribing
					 practitioner's signature, all of the following specific information, at a
					 minimum, shall be clearly provided on, or with the prescription form, or as an
					 attachment to the Treatment Authorization Request:
(1) Full name and telephone number of the
					 prescribing practitioner.
(2) Date
					 of prescription.
(3) Specific
					 item(s) being prescribed.
(4)
					 Patient's medical condition/diagnosis necessitating each item. This
					 documentation shall include:
(A) The patient's
					 medical status and functional limitation(s) and
(B) A description of the manner in which the
					 specific item being requested is expected to improve the medical status or
					 functional ability of the patient, stabilize the patient's condition, or
					 prevent additional deterioration of the medical status or functional ability of
					 the patient.
(5)
					 Estimated length of time the item is determined to be medically
					 necessary.
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 51323 - Medical Transportation Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Ambulance, litter van and wheelchair van
					 medical transportation services are covered when the beneficiary's medical and
					 physical condition is such that transport by ordinary means of public or
					 private conveyance is medically contraindicated, and transportation is required
					 for the purpose of obtaining needed medical care.
(1) Ambulance services are covered when the
					 patient's medical condition contraindicates the use of other forms of medical
					 transportation.
(2) Litter van
					 services are covered when the patient's medical and physical condition:
(A)
1.
					 Requires that the patient be transported in a prone or supine position, because
					 the patient is incapable of sitting for the period of time needed to
					 transport.
2. LEA specialized
					 medical transportation services shall not be subject to subsection
					 (a)(2)(A)1.
(B) Requires
					 specialized safety equipment over and above that normally available in
					 passenger cars, taxicabs or other forms of public conveyance.
(C) Does not require the specialized
					 services, equipment and personnel provided in an ambulance because the patient
					 is in stable condition and does not need constant
					 observation.
(3)
					 Wheelchair van services are covered when the patient's medical and physical
					 condition:
(A) Renders the patient incapable
					 of sitting in a private vehicle, taxi or other form of public transportation
					 for the period of time needed to transport.
(B)
1.
					 Requires that the patient be transported in a wheelchair or assisted to and
					 from residence, vehicle and place of treatment because of a disabling physical
					 or mental limitation.
2. LEA
					 specialized medical transportation services shall not be subject to subsection
					 (a)(3)(B)1.
(C) Requires
					 specialized safety equipment over and above that normally available in
					 passenger cars, taxicabs or other forms of public conveyance.
(D) Does not require the specialized
					 services, equipment and personnel provided in an ambulance, because the patient
					 is in stable condition and does not need constant
					 observation.
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 51325 - Blood and Blood Derivatives

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Blood is covered as ordered by a physician or dentist and
						only upon certification of the blood bank supplying the blood, or the facility
						where the transfusion is given, that voluntary blood donations cannot be
						obtained. Blood derivatives are covered as prescribed by a physician or dentist
						when appropriate to the diagnosis and condition of the
						beneficiary.
1.
						Amendment filed 6-23-66 as an emergency; effective upon filing; Certificate of
						Compliance included (Register 66, No. 19).
2. Amendment filed
						9-30-71 as an emergency; designated effective 10-1-71 (Register 71, No.
						40).
3. Certificate of Compliance--Section
						11422.1,
						Gov. Code, filed 1-25-72 (Register 72, No. 5).
4. Change without
						regulatory effect adding NOTE (Register 86, No.
						49).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14132(g)
						  and
						  14133.3,
						  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 51326 - Nurse Anesthetist Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Nurse anesthetist services are covered when provided by a
						nurse anesthetist within the scope of his or her licensure.
1. New
						section filed 5-1-75 as an emergency; effective upon filing (Register 75, No.
						18).
2. Certificate of Compliance filed 8-19-75 (Register 75, No.
						34).
3. Amendment filed 2-5-88; operative 3-6-88 (Register 88, No.
						8).
Note: Authority cited: Sections
						  14105,
						  14115.3
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14115.3,
						  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 51327 - Inpatient Hospital Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Inpatient hospital services are covered
					 as specified below:
(1) Hospital care for
					 newborns and hospitalization for delivery services are covered as follows:
(A) Inpatient delivery services in hospitals
					 designated as contract hospitals in closed areas or contract/non-contract
					 hospitals in open areas are covered without authorization up to a maximum of
					 two consecutive days prior to delivery, beginning at midnight at the beginning
					 of the day the mother is admitted, if delivery occurs within that two-day
					 period, and without authorization up to a maximum of two consecutive days
					 following vaginal delivery, or four consecutive days following delivery by
					 Cesarean section, beginning at midnight at the end of the day the mother
					 delivers. Continued medically necessary hospitalization beyond two days prior
					 to delivery, beyond two days following vaginal delivery, or beyond four days
					 following delivery by Cesarean section, requires timely submission of a request
					 for authorization, as defined in Section
					 51003(b)(3), for
					 Medi-Cal field office review. Authorization is required for all days of
					 hospitalization when delivery does not occur within two consecutive days of
					 admission. Hospitals under the onsite authorization procedure shall obtain
					 authorizations not later than the first regularly scheduled review day
					 following admission. Authorizations may be granted for up to a maximum of 30
					 days. For the purposes of this section, the following definitions shall apply:
1. "Closed areas" means areas in which the
					 proportion of bed capacity under contract between the Department and the
					 contracting hospitals exceeds the hospital bed needs of the Medi-Cal population
					 in that area.
2. "Open areas" means
					 areas in which the proportion of bed capacity under contract between the
					 Department and the contracting hospitals does not exceed the hospital bed needs
					 of the Medi-Cal population in that area.
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 51329 - Rehabilitation Center Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 3-20-70; designated effective 4-20-70 (Register 70, No. 21).
						For prior history, see Register 68, No. 21.
2. Amendment filed
						1-22-71; designated effective 3-1-71 (Register 71, No. 4).
3.
						Repealer filed 12-24-71, as an emergency; effective upon filing (Register 71,
						No. 52).
4. Certificate of Compliance filed 4-19-72 (Register 72,
						No. 18).
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 51330 - Chronic Hemodialysis

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Chronic hemodialysis is covered only as an outpatient service. Prior
					 authorization may be granted for dialysis, physician services, medical
					 supplies, equipment and drugs required for dialysis services, when provided by
					 renal dialysis centers or community hemodialysis units.
(b) Authorization for outpatient chronic
					 hemodialysis may be granted for up to 12 months at any one time.
(c) The following information shall be
					 provided on or attached to the authorization request form for home dialysis or
					 training:
(1) Evidence that the beneficiary,
					 the beneficiary's spouse, or other co-learner is suitable for training in home
					 dialysis.
(2) Evidence establishing
					 the suitability of the home facilities for dialysis.
(3) Evidence that the overall installation
					 costs in the home are reasonable and in no event exceed $750.00.
(4) Evidence that the water supply in the
					 home is suitable for renal dialysis.
(5) Evidence of the availability of a
					 qualified local physician to be responsible for the ongoing medical supervision
					 of the beneficiary.
(6) The plan
					 for continuing case management.
(7)
					 A budget for all expenses related to home dialysis, including supplies prorated
					 on a monthly cost basis.
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 51330.1 - Renal Homotransplantation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Renal homotransplantation is covered only when performed
						in a hospital which meets the standards established by the Department for renal
						homotransplantation centers.
1. New
						section filed 9-30-71 as an emergency; designated effective 10-1-71 (Register
						71, No. 40).
2. Certificate of Compliance--Section
						11422.1,
						Gov. Code, filed 1-25-72 (Register 72, No. 5).
3. Amendment filed
						9-27-72; designated effective 11-1-72 (Register 72, No. 40).
4.
						Amendment filed 1-18-74; effective thirtieth day thereafter (Register 74, No.
						3).
5. Change without regulatory effect adding NOTE (Register 86,
						No. 49).
Note: Authority cited: Section
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  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 4 - Scope and Duration of Benefits › Section 51331 - Hospital Outpatient Department Services and Organized Outpatient Clinic Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Hospital outpatient department services and organized outpatient clinic
					 services are covered to the extent listed:
(1)
					 Physician
(2) Optometric
(3) Psychology
(4) Podiatric
(5) Physical therapy
(6) Occupational therapy
(7) Speech pathology
(8) Audiology
(9) Acupuncture
(10) Dental
(11) Laboratory and X-ray
(12) Blood and blood derivatives
(13) Chronic hemodialysis
(14) Hearing aids
(15) Prosthetic and orthotic
					 appliances
(16) Durable medical
					 equipment
(17) Medical
					 supplies
(18) Prescribed
					 drugs
(19) Use of an emergency,
					 examining, or treatment room or other hospital facilities included in Section
					 51509(g), when
					 required for the provision of a covered physician's service.
(20) Adult Day Health
					 Care
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 51331.5 - Rural Health Clinic Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following services are covered as rural health clinic
						services when provided by a rural health clinic in accordance with the
						requirements of this chapter:
(a)
					 Physicians services.
(b) Primary
					 care services when provided by a nonphysician medical practitioner.
(c) Services and supplies incident to the
					 services provided under (a) and (b).
(d) Home nursing services, in those areas
					 designated by the Secretary, Department of Health and Human Services as having
					 a shortage of Home Health Agencies when provided in accordance with the
					 following:
(1) The services are furnished by a
					 registered nurse or licensed vocational nurse who is compensated by the
					 clinic.
(2) The services are
					 furnished to a homebound patient.
(3) The services are furnished in accordance
					 with a written treatment plan established by a physician or nonphysician
					 medical practitioner.
(4) The
					 treatment plan is approved and subsequently reviewed at least every 60 days by
					 the supervising physician employed by the clinic.
(5) The services do not include the
					 preparation of meals, housecleaning, or other nonmedical services not covered
					 by this chapter.
(6) The services
					 are documented in accordance with standards specified in Title 22, California
					 Administrative Code, Sections
					 75054 and
					 75056 regarding clinical and
					 administrative record keeping.
(7)
					 The services are provided on a part-time or intermittent basis unless provided
					 to patients who are approved in advance by the Department for in-home medical
					 care which is described in Section
					 14132(t)
					 of the Welfare and Institutions Code. If patients are approved for in-home
					 medical care, services can be provided on any Department approved
					 basis.
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 51332 - Organized Outpatient Clinic Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 9-27-72; designated effective 11-1-72 (Register 72, No.
						40).
2. Repealer filed 5-14-76 as an emergency; effective upon
						filing (Register 76, No. 20).
3. Certificate of Compliance filed
						9-8-76 (Register 76, No. 37).
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 51333 - Other Organized Outpatient Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-30-71 as an emergency; designated effective 10-1-71 (Register
						71, No. 40). For prior history, see Register 67, No. 52.
2.
						Certificate of Compliance--Section
						11422.5,
						Gov. Code, filed 1-25-72 (Register 72, No.
						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 51334 - Intermediate Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Intermediate care services are covered subject to the
						following:
(a) Intermediate care
					 services are covered only after prior authorization has been obtained from the
					 designated Medi-Cal consultant for the district where the facility is located.
					 The authorization request shall be initiated by the facility. The attending
					 physician shall sign the authorization request and shall certify to the
					 Department that the beneficiary requires this level of care.
(1) An initial treatment authorization
					 request shall be processed for each admission.
(2) An initial authorization may be granted
					 for up to one year from the date of admission.
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 51335 - Skilled Nursing Facility Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Skilled nursing facility services necessary for the
						treatment of illness or injury, are covered subject to the following:
(a) Skilled nursing facility services are
					 covered only after prior authorization has been obtained from the designated
					 Medi-Cal consultant for the district where the skilled nursing facility is
					 located. The authorization request shall be initiated by the facility and shall
					 be signed by the attending physician.
(b) An initial Treatment Authorization
					 Request shall be required for each admission.
(1) An initial authorization may be granted
					 for periods up to one year from the date of admission.
(2) An approved initial Treatment
					 Authorization Request shall be required prior to the transfer of a beneficiary
					 between skilled nursing facilities.
(3) For Medicare/Medi-Cal covered services
					 (crossover services) a request for authorization shall be received by the
					 Medi-Cal consultant's office on or before the 20th calendar day of skilled
					 nursing facility care. Medi-Cal shall not pay coinsurance for skilled nursing
					 facility care unless an authorization request has been approved covering the
					 21st and subsequent days of skilled nursing facility care. When the
					 authorization request is received by the Medi-Cal consultant's office after the
					 20th day of skilled nursing facility care, one day of coinsurance authorization
					 shall be denied for each day the request is late.
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 51335.1 - Transitional Inpatient Care Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 4-1-96 as an emergency; operative 4-1-96 (Register 96, No. 14). A
						Certificate of Compliance must be transmitted to OAL by 9-30-96 pursuant to
						Welfare and Institutions Code section
						14132.22
						or emergency language will be repealed by operation of law on the following
						day.
2. Editorial correction of subsection (c), NOTE, and HISTORY 1
						(Register 96, No. 35).
3. New section refiled 8-28-96 as an
						emergency; operative 9-30-96 (Register 96, No. 35). A Certificate of Compliance
						must be transmitted to OAL by 1-28-97 or emergency language will be repealed by
						operation of law on the following day.
4. Certificate of Compliance
						as to 8-28-96 order, including amendment of section, transmitted to OAL 1-23-97
						and filed 3-10-97 (Register 97, No. 11).
5. Change without
						regulatory effect repealing section filed 6-12-2006 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2006, No. 24).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14105.981
						  and
						  14132.22,
						  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 51335.6 - Pediatric Subacute Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Pediatric subacute care services are a
					 type of skilled nursing facility service, provided in a pediatric subacute care
					 unit which meets the requirements of Sections
					 51215.6,
					 51215.8,
					 51215.9,
					 51215.10 and
					 51215.11.
(b) Pediatric subacute care services provided
					 in a pediatric subacute unit in a licensed skilled nursing facility are covered
					 pursuant to the requirements specified in Sections
					 51124.6 and
					 51335(a) through (e) and
					 (g) excepting (b)(1), (c)(1), (f), (h), (j),
					 (k), (
l
), and (m).
(c) A Treatment Authorization Request shall
					 be required for each admission to a subacute unit caring for pediatric
					 patients, and may be granted for a period of up to six months and reauthorized
					 for a period of up to six months. A separate Treatment Authorization Request
					 shall be required for supplemental rehabilitation therapy services as provided
					 for in Section
					 51215.10(i) through
					 (m), and for ventilator weaning, as provided
					 for in Section
					 51215.11. Authorization requests
					 shall be initiated by the facility.
(d) Pediatric subacute bedhold days will be
					 authorized in accordance with Section
					 51535.1.
(e) Leave of absence for a Medi-Cal
					 beneficiary in the pediatric subacute unit will be authorized in accordance
					 with Section
					 51535.
(f) Pediatric subacute services shall be
					 covered only when care is provided in the pediatric subacute unit of the
					 nursing facility.
1. New
						section filed 4-13-94 as an emergency; operative 4-1-94. Emergency adoption
						submitted to OAL for printing only pursuant to section
						4, AB 36 (chapter 1030, Statutes
						of 1993) (Register 94, No. 15).
2. Certificate of Compliance as to
						4-13-94 order including amendment of section transmitted to OAL 9-26-94 and
						filed 10-20-94 (Register 94, No. 42).
3. Editorial correction of
						HISTORY 1 and 2 (Register 95, No. 14).
4. Amendment of subsections
						(a) and (c) and NOTE filed 6-30-97 as an emergency; operative 6-30-97 (Register
						97, No. 27). A Certificate of Compliance must be transmitted to OAL by 10-28-97
						or emergency language will be repealed by operation of law on the following
						day.
5. Certificate of Compliance as to 6-30-97 order transmitted to
						OAL 10-22-97 and filed 11-26-97 (Register 97, No.
						48).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14132.25,
						  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 51337 - Home Health Agency Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Home health agency services are covered
					 as specified below when prescribed by a physician and provided at the home of
					 the beneficiary in accordance with a written treatment plan which the physician
					 reviews every 60 days. The plan shall indicate a need for one or more of the
					 following:
(1) Part-time or intermittent
					 skilled nursing services by licensed nursing personnel.
(2) In-home medical care services as provided
					 in Section
					 14132(t)
					 of the Welfare and Institutions Code.
(3) Physical, occupational, or speech
					 therapy.
(4) Medical social
					 services.
(5) The services of a
					 home health aide.
(6) Provision of
					 medical supplies, other than drugs and biologicals.
(7) The use of medical appliances, provided
					 for under an approved treatment plan.