reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53864 - Financial Standards/Resources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall demonstrate fiscal
					 soundness and maintain adequate financial resources to carry out its
					 contractual obligations. Such resources shall be determined by the department
					 and shall include, but not necessarily be limited to, the following:
(1) Tangible net equity as defined in Title
					 10, section
					 1300.76
(2) Working capital and current ratio of one
					 of the following:
(A) A current ration of at
					 least 1:1, or
(B) Prior
					 demonstration to the department that the contractor is now meeting financial
					 obligations on a timely basis and has been doing so for at least the preceding
					 two years, or
(C) Evidence that
					 sufficient noncurrent assets, which are readily convertible to cash, are
					 available to achieve an equivalent working capital ratio of 1:1, if the
					 noncurrent assets are considered current.
(3) Demonstration through its history of plan
					 operations that the plan's arrangements for health care are financially sound,
					 and provide for the achievement and maintenance of a positive cash flow,
					 including provisions for retirement of existing and proposed
					 indebtedness.
(4) Enrollment
					 growth.
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 6 - Operational Requirements › Section 53866 - Member Billing and Recovery from Other Sources

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region may bill plan members or
						third-party payers for services provided as long as such member billings or
						recovery efforts from third-parties are conducted in accordance with the
						requirements of sections
						53220 and
						53222.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3 and
						  14087.4, Welfare and Institutions
						  Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53867 - Subcontracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Procedures and requirements for the processing and
						approval of subcontracts for each plan in a designated region shall conform to
						those specified in section
						53250. Subcontracts with federally
						qualified health centers shall be exempt from the 60-day automatic approval
						provisions specified in section
						53250, unless the department has
						previously approved, in writing, the plan's proposed reimbursement methodology
						and rates of payment for federally qualified health centers. Delegation of any
						obligation or requirement to a subcontractor by a plan shall not release the
						plan from the responsibility to discharge any obligation or comply with any
						requirement contained in the contract between the plan and the
						department.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53868 - Reinsurance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region may purchase reinsurance
						to provide indemnification against unanticipated financial liabilities provided
						that such coverage is purchased in accordance with the specification and
						requirements of section
						53252.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53870 - Affiliated Organizations and Persons

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every affiliate of a plan in each
					 designated region shall:
(1) Furnish, upon
					 request, to the plan and to the department financial reports relevant to the
					 disposition of funds paid to the affiliate by the plan. Reports shall be
					 prepared according to generally accepted accounting principals and shall
					 provide all financial data required by the plan to fulfill its obligations to
					 the department for financial reporting.
(2) Make all books and records, which are
					 pertinent to plan contracts with the department available for inspection by the
					 department and the United States Department of Health and Human Services. These
					 books and records shall be retained for at least five years from the close of
					 each fiscal year in which the contract is in effect.
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 6 - Operational Requirements › Section 53871 - Financial Audit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall have an annual
						audit performed by an independent certified public accountant in accordance
						with the provisions of section
						53340, except that this audit
						shall be received by the department no later than 120 days after the close of
						the plan's fiscal year, or 180 days for public entities whose audits are
						conducted by a county grand jury.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53872 - Civil Penalties. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
3. Change without regulatory effect repealing section
						filed 10-13-2022 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2022, No. 41).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4
						  and
						  14304,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53873 - Contract Termination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In terminating a contract with a plan in a designated
						region, the department shall adhere to the procedures and requirements
						prescribed in section
						53352, except for subsection (d)
						and (e).
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4
						  and
						  14304,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53874 - Conflict of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In entering into contracts or subcontracts, each plan in
						a designated region shall comply with the prohibitions against contracting
						relating to conflict of interest set forth in section
						53600 except as otherwise provided
						in Welfare and Institutions Code, sections
						14087.31(k),
						14087.35(p)(1),
						14087.36(v)(1),
						14087.38(h),
						and
						14087.969.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53875 - Emergency Services Claims Disputes

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In resolving disputes over claims for reimbursement for
						emergency services provided to plan members by nonplan providers, the involved
						parties and the department shall adhere to the procedures and requirements set
						forth in Article 7 of Chapter 4, commencing with section
						53620 except subsection (e) of
						section 53676.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53876 - Cultural and Linguistic Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a designated region shall
					 implement and adhere to the cultural and linguistic services requirements of
					 the contract between the plan and the department. The contract at a minimum
					 shall include requirements for:
(1)
					 Interpreters.
(2) Translated
					 signage.
(3) Translated written
					 materials.
(4) Referrals to
					 culturally and linguistically appropriate community services
					 programs.
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 53880 - Marketing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a
					 designated region shall limit its marketing activities to printed, illustrated,
					 or video taped materials, and media advertising. Plans may participate in an
					 organized community or neighborhood health fair in a public place for marketing
					 purposes.
(1) Printed and illustrated
					 materials may be available to members or prospective members, as follows:
(A) By mail. Printing, postage, and any
					 related costs of material mailed to prospective members shall be paid by the
					 plan. The department shall conduct all mailings to ensure the confidentiality
					 of Medi-Cal beneficiaries is protected.
(B) By posting materials in public
					 places.
(C) At health care options
					 presentations, which shall be conducted pursuant to section
					 53886.
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 53882 - Member Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Enrollment in a plan in a designated region shall be mandatory for those
					 eligible beneficiaries specified in section
					 53845(a), and
					 voluntary for those specified in section
					 53845(b).
(b) Enrollment shall be limited to eligible
					 beneficiaries who reside within the designated region, except as provided in
					 section 53845(d).
(c) The department or the Health Care Options
					 Program shall mail an enrollment form and plan information to each eligible
					 beneficiary described in section
					 53845(a) who does
					 not attend a health care options presentation as described in section
					 53886. The mailing shall include
					 health care options information and instructions to enroll in a plan within
					 thirty days of the postmark date on the mailing envelope. At a minimum, the
					 mailing shall include instructions on how to enroll, how to request an
					 exemption from mandatory enrollment for medical or nonmedical reasons, and how
					 to request a medical exemption certification form.
(d) Each eligible beneficiary described in
					 section 53845(a) shall
					 select a plan within thirty days of receipt of an enrollment form unless
					 requesting an exemption to plan enrollment is submitted to the Health Care
					 Options Program within 30 days of receipt as prescribed in section
					 53887(b), or
					 within thirty days of the postmark date of the health care options information
					 if mailed, with instructions from the department or the Health Care Options
					 Program to select a plan.
(1) In the event an
					 eligible beneficiary described in section
					 53845(a) does not
					 select a plan within thirty days, the Health Care Options Program shall assign
					 the eligible beneficiary to a plan, in accordance with section
					 53883.
(2) For purposes of selecting a plan:
(A) In the case of a family group, eligible
					 beneficiary means the individual or entity with legal authority to make a
					 choice on behalf of dependent family members.
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 53883 - Assignment of Eligible Beneficiaries to Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Health Care Options Program shall
					 assign an eligible beneficiary described in section
					 53845(a) to a
					 plan within a designated region, from which to receive health care services, in
					 the following situations:
(1) In the event
					 the eligible beneficiary does not select a plan within thirty days of receiving
					 an enrollment form pursuant to section
					 53882(d).
(2) In the event a member requests and is
					 granted disenrollment from either plan within that region, pursuant to section
					 53891, but does not enroll in the
					 competing plan, unless that member was granted approval by the department or
					 its designee to receive health care services through the fee-for-service
					 Medi-Cal program, pursuant to section
					 53887.
(3) In the event the competing plan is at
					 capacity, the fee-for-service Medi-Cal option shall be made
					 available.
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 53884 - Assignment System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Health Care Options Program shall implement a system within each designated
					 region approved by the department to assign an eligible beneficiary described
					 in section
					 53845(a), to a
					 plan, in the event the beneficiary does not select a plan pursuant to section
					 53882(d).
(b) In assigning an eligible beneficiary to a
					 plan, the Health Care Options Program's system shall, at a minimum, consider
					 the following:
(1) Zip code of eligible
					 beneficiary matched to zip codes served by the plan in accordance with the
					 provisions of section
					 50185.5(f).
(2) Enrollment capacity and availability of
					 the plan.
(3) Plan's ability to
					 render linguistically appropriate services and the eligible beneficiary's need
					 for those services, if made known to the Health Care Options Program.
(4) Assignment of family members to the same
					 plan to the extent possible.
(5)
(A) Assignments between plans shall be
					 distributed in accordance with an agreement, approved by the Department,
					 between a local initiative and a commercial plan in a designated region;
					 or
(B) in the absence of an
					 approved agreement, the Department shall determine how assignments shall be
					 distributed in a designated region.
(6) In approving an agreement between a local
					 initiative and a commercial plan, or when the Department determines how
					 assignments shall be distributed, the Department may consider the following
					 factors:
1. The potential for a high level of
					 informed beneficiary choice of plans and providers.
2. The potential for the local initiative to
					 achieve an enrollment level that reasonably allows it to spread financial risk
					 and a reasonable opportunity for it to attain financial viability.
3. Maintaining the level of disproportionate
					 share hospital days and safety net providers in the region so that neither is
					 adversely affected by the mandatory enrollment of Medi-Cal beneficiaries in
					 managed care, when compared to Medi-Cal program levels prior to implementing
					 the two-plan model in the region.
4. The need to assure that a commercial plan
					 is not precluded from receiving default assignments, other than during a
					 limited time period immediately preceding and following local initiative
					 start-up.
5. The ability of the
					 department's enrollment contractor to accurately and timely perform the
					 selected assignment distribution methodology.
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 53885 - Travel Distance Standards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall ensure that primary health care services provided through the
					 plan are no more than 30 minutes travel time or ten (10) miles travel distance
					 from each member's place of residence, unless the department has approved an
					 alternative time and distance standard.
(b) An eligible beneficiary may voluntarily
					 choose to receive services from a plan service site with a travel time or
					 distance that exceeds the requirements in subsection (a).
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: 14087.3 and 14087.4, Welfare and
						  Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53886 - Health Care Options Presentation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Health Care Options Program shall
					 provide, in each designated region, a presentation of plan options to each new
					 and continuing eligible beneficiary who meets the mandatory enrollment criteria
					 specified in section
					 53845 and to any eligible
					 beneficiary who meets the voluntary enrollment criteria specified in section
					 53845 and requests a presentation.
					 For non-English or limited English speaking beneficiaries, presentations shall
					 be made in the beneficiary's preferred language. Reasonable accommodations
					 shall be made for persons who are blind, deaf or hearing impaired. At the
					 department's discretion, the presentation may be in person or by mail. The
					 department shall ensure that any eligible beneficiary requesting a face-to-face
					 presentation is provided the opportunity to have such presentation at the
					 earliest possible time and in the most convenient location possible, or is
					 given the opportunity to speak with a telephone representative provided by the
					 Health Care Options Program for assistance in making a plan
					 selection.
(b) The health care
					 options presentation shall include, at a minimum, the following information:
(1) The names of each plan.
(2) Each plan's service area.
(3) The name, address, telephone number, and
					 specialty, if any, of each primary and specialty care provider or clinic
					 participating in each plan. Providers participating in each plan will be listed
					 alphabetically by last name and grouped by geographic area.
(4) The process for selecting or changing a
					 primary care provider and an explanation that beneficiaries have the right to
					 select a primary care clinic as their primary care provider and to change their
					 primary care provider at any time.
(5) Services covered by each plan.
(6) Procedures for accessing and receiving
					 health care services from each plan.
(7) Hospitals used by each plan.
(8) Any features or additional services,
					 including cultural and linguistic services, provided by each plan, pursuant to
					 the contract.
(9) An explanation
					 that a beneficary eligible for voluntary enrollment may submit a request for
					 disenrollment from the plan at any time, in accordance with the provisions of
					 section 53891.
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 53888 - Enrollment/Disenrollment Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Health Care Options Program shall make the enrollment/disenrollment form
					 available in the Health Care Options information packets mailed to mandatory
					 eligible beneficiaries, at the Health Care Options presentations, and at
					 department-approved Health Care Options Program sites. The Health Care Options
					 Program shall mail the enrollment/disenrollment form to a beneficiary within
					 three working days of receiving a telephone or written request for a
					 form.
(b) Plans shall make the
					 enrollment/disenrollment form available at the member services departments and
					 shall mail the form to a beneficiary within three working days of receiving a
					 telephone or written request for a form.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
3. Repealer and new section and NOTE filed 12-19-2000
						as an emergency; operative 12-19-2000. Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Ch. 722/92) (Register
						2000, No. 51).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53890 - Assignment of Primary Care Physician

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a designated region shall
					 have a mechanism in place and approved in writing by the department to ensure
					 that each member is assigned to a primary care physician, by either:
(1) Allowing each member to select a primary
					 care physician from the plan's network of affiliated physicians, if the member
					 chooses to do so; or
(2) Assigning
					 a primary care physician to each member within forty days from the effective
					 date of enrollment, if the member does not select one within the first thirty
					 days of the effective date of enrollment in the plan. This assignment shall
					 meet the conditions of both:
(A) The member
					 shall be assigned to a primary care physician within the maximum travel
					 distances specified in section
					 53885.
(B) The member shall be assigned to a primary
					 care physician who is or has office staff who are linguistically and culturally
					 competent to communicate with the member or have the ability to interpret in
					 the provision of health care services and related activities during the
					 member's office visits or contacts, if the language or cultural needs of the
					 member are known to the plan.
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 53890.5 - Assignment of a Primary Care Provider

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the plan utilizes nonphysician
					 practitioners, members may select, be assigned to, or change such providers in
					 accordance with the provisions of section
					 53890.
(b) In all cases where a nonphysician
					 practitioner is a member's primary care provider, the plan shall ensure that a
					 primary care physician is responsible for the overall coordination of the
					 member's health care, consistent with applicable state and federal laws and
					 regulations.
1. New
						section filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53892 - Problem Resolution Process for Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any member of a plan may request
					 assistance by telephone, facsimile, in writing, or in person from the Health
					 Care Options Program in resolving problems associated with mandatory or
					 voluntary enrollment or disenrollment in the Two-Plan Model Program or
					 assignment to a plan.
(b) If the
					 Health Care Options Program is not able to resolve the problem through the
					 procedures for processing enrollment and disenrollment specified in section
					 53889, then the Health Care
					 Options Program shall first direct the beneficiary to the plan in which the
					 beneficiary is a member, unless the beneficiary has already been to the plan to
					 attempt to resolve problems resulting from plan enrollment or disenrollment. If
					 the beneficiary wishes to disenroll from the plan, the Health Care Options
					 Program shall advise the beneficiary of the options to:
(1) Be referred to the plan's problem
					 resolution process.
(2) Be referred
					 to the department's Medi-Cal Managed Care Ombudsman and the Department of
					 Managed Health Care's Office of the Patient Advocate.
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 53893 - Medi-Cal Managed Care Ombudsman

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The department may designate a Medi-Cal
					 Managed Care Ombudsman. The Ombudsman shall provide Medi-Cal beneficiaries
					 access to a service which investigates and resolves complaints about managed
					 care plans by, or on behalf of, Medi-Cal beneficiaries.
(b) The duties of the Ombudsman shall
					 include, but not be limited to the following:
(1) Encouraging beneficiaries to avail
					 themselves of the opportunity to obtain health care through Medi-Cal managed
					 care plans.
(2) Assisting
					 beneficiaries by removing inappropriate barriers to accessing care.
(3) Educating and informing managed care
					 plans of the specific needs of Medi-Cal beneficiaries.
(4) Educating beneficiaries on how to use the
					 managed care system effectively.
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 53894 - Notice to Members of Plan Action to Deny, Defer or Modify a Request for Medical Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan shall provide members with a notice of an action taken by the plan to
					 deny a request by a provider for any medical service. Notice in response to an
					 initial request from a provider shall be provided in accordance with this
					 section. Notice in response to a request for continuation of a medical service
					 shall be provided in accordance with section
					 51014.1. Notice of denial of a
					 medical service shall not be required in the following situations:
(1) The denial is a denial of a request for
					 prior authorization for coverage for treatment that has already been provided
					 to the member.
(2) The denial is a
					 non-binding verbal description to a provider of the services which may be
					 approved by the plan.
(3) The
					 denial is a denial of a request for drugs, and a drug identical in chemical
					 composition, dosage, and bioequivalence may be obtained through prior
					 authorization from the plan or from the list, established by the plan, of drugs
					 available without prior authorization from the plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53896 - Annual Information to Members

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall revise, if
						necessary, and distribute the information specified in section
						53895(a) to each
						member or the member's family unit at least once every twelve
						months.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section heading, section and NOTE and
						new section heading, section and NOTE filed 3-4-97; operative 3-4-97. Submitted
						to OAL for printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4
						  and
						  14406,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53897 - Notification of Changes in Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall revise, obtain the
						approval of the department, and distribute the information specified in section
						53895(a) at least
						thirty days prior to any changes which the plan makes in services provided or
						in the locations at which services may be obtained, to each member affected by
						that change. Notification shall be provided at least fourteen days prior to any
						changes in cases of unforeseeable circumstances.
1. New
						section filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4
						  and
						  14406,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 7 - MARKETING, ENROLLMENT, ASSIGNMENT, AND DISENROLLMENT › Section 53898 - Information for Departmental Dissemination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall furnish the
						department and the Health Care Options Program the information required in
						section 53895(a), as it
						changes and upon request, for dissemination to prospective
						members.
1. New
						section filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 1 - GENERAL PROVISIONS › Section 53900 - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In defined
					 geographic areas designated by the department, health care services shall be
					 provided to eligible beneficiaries as follows:
(1) Medical services shall be provided
					 through Prepaid Health Plans (PHPs) and Primary Care Case Management (PCCM)
					 plans.
(2) Dental services shall be
					 provided through dental-only Knox-Keene licensed PHPs.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 1 - GENERAL PROVISIONS › Section 53904 - GMC Plan Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each GMC plan shall:
(1) Agree to provide or
					 arrange for the provision of, to the extent allowed by state and federal law,
					 the scope of Medi-Cal program benefits set forth by GMC contract to eligible
					 beneficiaries who either select or are assigned to that GMC plan.
(2) Share in the risk of providing health
					 care services.
(3) Provide readily
					 available and accessible health care services and utilize preventive health
					 care programs to improve the health status of its members.
(4) Case manage members' utilization of
					 health care services.
(5) Inform
					 eligible beneficiaries about non-medical transportation services that may be
					 available to them under the Medi-Cal program, including the conditions under
					 which non-medical transportation services will be provided to members by the
					 GMC plan and how a member is to request those services, if the plan opts to
					 provide them.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 1 - GENERAL PROVISIONS › Section 53906 - Eligible Beneficiaries

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Enrollment in GMC plans shall be
					 mandatory for eligible beneficiaries who meet all of the following criteria:
(1) Are eligible to received Medi-Cal
					 services that are not limited in scope;
(2) Have been determined to have a share of
					 cost equal to zero;
(3) Do not meet
					 the criteria for selecting an alternative to GMC plan enrollment, specified in
					 Section 53923.5;
(4) Are eligible for any of the following:
(A) Programs linked to the Aid to Families
					 with Dependent Children (AFDC) program, as defined in Section
					 50019;
(B) The Medically Indigent program for
					 children under age 21, as defined in Section
					 50251(a);
					 or
(C) Foster Children
					 program.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53910 - Organization and Administration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan shall have the
					 organizational and administrative ability to carry out its contractual
					 obligations, including but not limited to the following:
(1) Each PHP and dental plan shall meet the
					 organizational and administrative requirements contained in Section
					 53200.
(2) Each PCCM plan shall meet the
					 organizational and administrative requirements contained in Section
					 56200.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53910.5 - Scope of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each GMC plan shall provide or arrange for the provision of Medi-Cal services
					 in accordance with the requirements for PHPs and PCCM plans, as set forth in
					 Chapters 4 and 6, beginning with Sections
					 53210 and
					 56210, respectively, unless
					 services are specifically included or excluded under the terms of the GMC
					 contract, and the following:
(1) Initial
					 medical or dental health assessments. An initial health assessment shall
					 include a history of the member's medical or dental health, an identification
					 of risks, an assessment of need for preventive screens or services and health
					 education, and the diagnosis and plan for treatment of any diseases.
(2) Health education.
(3) Preventive services.
(4) Identification and treatment of
					 disease.
(5) Primary and urgent
					 care.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53911 - Availability of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each GMC plan shall obtain written departmental approval
						prior to making any substantial change in the availability or location of
						services to be provided under the GMC contract, except in the case of a natural
						disaster or emergency circumstances. A proposal to change the location for the
						provision of covered services or to reduce their availability shall be given to
						the department at least sixty days prior to the proposed effective date. The
						department's denial of the proposal shall prohibit implementation of the
						proposed changes.
1. New
						section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only
						pursuant to section
						147, SB 485 (Chapter 722,
						Statutews of 1992) (Register 94, No. 15).
Note: Authority cited: Sections
						  10725,
						  14089.7,
						  14105,
						  14124.5,
						  14203
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14089,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.5 - GEOGRAPHIC MANAGED CARE PROGRAM › Article 2 - OPERATIONAL REQUIREMENTS › Section 53911.5 - Accessibility to Physicians and Dentists

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each GMC plan that is a PHP or PCCM plan
					 shall retain sufficient professional medical staff to provide access to
					 preventive and managed health care services to its members. Access to
					 physicians shall be as follows:
(1) Each PHP
					 and PCCM plan shall provide at least one full-time equivalent primary care
					 physician for every 2,000 patients, or have in place an alternative mechanism
					 for ensuring access, approved in writing by the department.
(2) Each PHP and PCCM plan shall provide at
					 least one full-time equivalent physician for every 1,200 plan members, or have
					 in place an alternative mechanism for ensuring access, approved in writing by
					 the department.
(3) If utilized by
					 a PHP or PCCM plan, mid-level practitioners, such as nurse practitioners and
					 physicians assistants, shall meet the requirements of existing practice and
					 licensure standards for mid-level practitioners, as specified in Sections
					 1399.541 and
					 1470, Title 16, CCR, including
					 physician supervision, as specified in Section
					 2746.5,
					 Business and Professions Code.