California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5.5 - INDIANS AND INDIAN HEALTH SERVICE FACILITIES IN MEDI-CAL MANAGED CARE PROGRAMS › Section 55120 - Indian Health Service Facility Participation in Medi-Cal Managed Care Programs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Indian Health Service Facilities may participate in the Medi-Cal managed care
				  program as a subcontractor with a Medi-Cal managed care plan, if agreement is
				  reached between the parties to the subcontract and the subcontract is approved
				  by the department. Approval by the department shall be based on the
				  subcontract's compliance with standards applicable to all subcontracts held by
				  Medi-Cal managed care plans, including standards relative to appropriate
				  reimbursement rates.
(b) In the
				  two-plan model, the department shall require the local initiative to offer a
				  subcontract to each Indian Health Service Facility located in the designated
				  region served by the local initiative under the two-plan model. If there is no
				  local initiative in a county and the department exercises its option under
				  Section 53800(b)(3), the
				  department shall establish participation standards for Indian Health Service
				  Facilities that provide that at least one of the two Medi-Cal managed care
				  plans participating in the program shall offer a subcontract to each Indian
				  Health Facility located in the designated region served by the plans under the
				  two-plan model. The terms of these subcontracts shall be consistent with the
				  requirements of this chapter and, in other respects, shall be consistent with
				  the terms and conditions offered to other subcontractors providing a similar
				  scope of services.
(c) In counties
				  with mandatory enrollment in Medi-Cal managed care programs other than the
				  two-plan model and county organized health systems, the department shall
				  establish participation standards for Indian Health Service Facilities. These
				  standards shall provide that at least one Medi-Cal managed care plan
				  participating in the program in the county shall offer a subcontract to each
				  Indian Health Facility located in the geographic region served by the program.
				  The terms of these subcontracts shall be consistent with the requirements of
				  this chapter and, in other respects, shall be consistent with the terms and
				  conditions offered to other subcontractors providing a similar scope of
				  services.
(d) In the two-plan model
				  program or in a Geographic Managed Care program, if the Indian Health Service
				  Facility does not participate as a subcontractor, the department shall accept
				  applications to the extent permitted by federal law from an Indian Health
				  Service Facility interested in contracting as a fee-for-service managed care
				  plan under Section
				  55130. The fee-for-service managed
				  care plan may only enroll Indians and the number of non-Indians receiving
				  services from the Indian Health Service Facility at the time of application to
				  the department. If departmental resources limit the implementation and
				  monitoring of additional fee-for-service managed care plans, the department may
				  discontinue the acceptance of applications and implemention of any additional
				  fee-for-service managed care programs by providing six months written notice of
				  its intent to discontinue acceptance and implementation to the California Area
				  Office, Indian Health Service, Public Health Service, Department of Health and
				  Human Services.
1. New
					 section filed 4-3-98; operative 4-3-98. Submitted to OAL for printing only
					 pursuant to section
					 147, Senate Bill 485 (Ch. 722/92)
					 (Register 98, No. 15).
2. Change without regulatory effect amending
					 NOTE filed 4-9-98 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 98, No. 15).
Note: Authority cited: Stats. 1992, Ch. 722; Sections
						10725,
						14089.7,
						14105,
						14124.5,
						14203
						and
						14312,
						Welfare and Institutions Code. Reference: Sections
						14000,
						14016.5,
						14087.3,
						14087.305,
						14087.4,
						14087.5,
						14088,
						14089,
						14089.05,
						14200
						and
						14499.5,
						Welfare and Institutions Code; and Title 25, United States Code, Sections
						13 and
						1601.