California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 4 - Risk Categories and Family Contributions › Section 2699.6805 - Designation of Community Provider Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For each benefit year, the Board will
				designate as the community provider plan in each county the participating
				health plan with a service area that includes zip codes in which at least
				eighty-five percent (85%) of the residents of the county reside and that has
				the highest percentage of traditional and safety net providers pursuant to the
				calculation in subsection (g) below.
(b) In November of the benefit year
				immediately preceding the benefit year described in subsection (a), the Board
				shall compile and make available a list for each county of all Child Health and
				Disability Prevention Program (CHDP), clinic and hospital traditional and
				safety net providers.
(c) The lists
				shall be compiled as follows:
(1) The CHDP
				list shall include all CHDP providers, except for clinical laboratories, that
				were on the Department of Health Care Services (DHCS) CHDP Master File as of
				October 1st of the benefit year immediately preceding the benefit year
				described in subsection (a) and that provided a State-only funded CHDP service
				as identified on the CHDP Paid Claims Tape to at least one (1) child aged one
				(1) through eighteen (18) in the state fiscal year that ended immediately prior
				to the most recently ended state fiscal year. For each listed provider, the
				list shall indicate the percentage of county children that received State-only
				funded CHDP services from the listed provider. The percentage shall be
				calculated by dividing the number of county children receiving State-only
				funded services from the listed provider by the total number of county children
				receiving State-only funded services from all listed providers in the
				county.
(2) The clinic list shall
				include all Community Outpatient Hospital Based Clinics, Rural Health Clinics,
				Federally Qualified Health Centers, Free Clinics, Community Clinics, Clinics
				Exempt from Licensure, County Clinics Not With Hospital and County Hospital
				Outpatient Clinics, in the county, that were so identified by the Medi-Cal
				program as of October 1st of the benefit year immediately preceding the benefit
				year described in subsection (a) and were identified on the Medi-Cal Paid
				Claims Tape as having provided at least (1) service to a child aged one (1)
				through eighteen (18) in the state fiscal year that ended immediately prior to
				the most recently ended state fiscal year. The list shall indicate a percentage
				for each clinic which shall be equal to one (1) divided by the number of listed
				clinics in the county.
(3) The
				hospital list shall be compiled as follows:
(A) For a county that has, located in the
				county, at least one hospital which, as of October 1st of the benefit year
				immediately preceding the benefit year described in subsection (a), was a
				hospital eligible for the inpatient disproportionate share hospital payment
				program as reported by the Department of Health Care Services (DHCS), a
				University teaching hospital, a Children's Hospital (as defined in Section
				10727
				of the Welfare and Institutions Code), or a county owned and operated general
				acute care hospital, the list shall include all hospitals of one of these types
				whether or not they are located in the county and which reported to the Office
				of Statewide Health Planning and Development (OSHPD) discharging at least one
				resident of the county who was a Medi-Cal, county indigent, or charity care
				patient aged one (1) through eighteen (18) in the year for which OSHPD most
				recently released its annual compilation of Discharge Data. The list shall
				indicate, for each hospital, the percentage of the Medi-Cal, county indigent,
				and charity care discharges of county residents aged one (1) through eighteen
				(18) from the listed hospital. The hospital list shall not include acute
				psychiatric hospitals (as defined in Section
				1250(b)
				of the Health and Safety Code), psychiatric health facilities (as defined in
				Section
				1250.2(a)
				of the Health and Safety Code), or chemical dependency recovery hospitals (as
				defined in Section
				1250.3(a)
				of the Health and Safety Code).
(B)
				For all other counties, the list shall include all hospitals located in the
				county and all hospitals located outside the county, which, as of October 1st
				of the benefit year immediately preceding the benefit year described in
				subsection (a), discharged at least one resident of the county who was a
				Medi-Cal, county indigent, or charity care patient aged one (1) through
				eighteen (18) in the year for which OSHPD most recently released its annual
				compilation of Discharge Data and which were hospitals eligible for the
				inpatient disproportionate share hospital payment program as reported by the
				DHCS, a university teaching hospital, a children's hospital (as defined in
				Section
				10727
				of the Welfare and Institutions Code), or a county owned and operated general
				acute care hospital. The list shall indicate, for each hospital, the percentage
				of the Medi-Cal, county indigent, and charity care discharges of county
				residents aged one (1) through eighteen (18) from the listed hospital. The
				hospital list shall not include acute psychiatric hospitals (as defined in
				Section
				1250(b)
				of the Health and Safety Code, psychiatric health facilities (as defined in
				Section
				1250.2(a)
				of the Health and Safety Code), or chemical dependency recovery hospitals (as
				defined in Section
				1250.3(a)
				of the Health and Safety Code).