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 9 - Quality Assurance Fee and Long Term Care Reimbursement Methodology › Section 52514 - Out-of-State Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Reimbursement for out-of-state providers shall be the
						statewide facility-specific weighted average rate applicable to the rate year
						during which services are provided.
1. New
						section filed 7-22-2010 as an emergency; operative 7-22-2010 (Register
						2010,
						No. 30). A Certificate of Compliance must be transmitted to OAL by 1-18-2011 or
						emergency language will be repealed by operation of law on the following day.
						Any rules issued by provider bulletin by the Department of Health Care Services
						that are covered by or inconsistent with these emergency regulations are
						superseded as of the effective date of these emergency
						regulations.
2. New section refiled 1-10-2011 as an emergency;
						operative 1-18-2011 (Register 2011, No. 2). A Certificate of Compliance must be
						transmitted to OAL by 4-18-2011 or emergency language will be repealed by
						operation of law on the following day. Any rules issued by provider bulletin by
						the Department of Health Care Services that are covered by or inconsistent with
						these emergency regulations are superseded as of the effective date of these
						emergency regulations.
3. Certificate of Compliance as to 1-10-2011
						order transmitted to OAL 4-5-2011 and filed 5-17-2011 (Register 2011, No.
						20).
Note: Authority cited: Sections
						  20,
						  1324.20,
						  1324.21
						  and
						  1324.23,
						  Health and Safety Code; and Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14126.027,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14109.5,
						  14110.1,
						  14110.6,
						  14170
						  and
						  14171,
						  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 9 - Quality Assurance Fee and Long Term Care Reimbursement Methodology › Section 52515 - Hospice

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Reimbursement for hospice room and board services under
						the facility-specific rate methodology shall be 95 percent of the rate
						applicable to the facility in which the resident resides.
1. New
						section filed 7-22-2010 as an emergency; operative 7-22-2010 (Register
						2010,
						No. 30). A Certificate of Compliance must be transmitted to OAL by 1-18-2011 or
						emergency language will be repealed by operation of law on the following day.
						Any rules issued by provider bulletin by the Department of Health Care Services
						that are covered by or inconsistent with these emergency regulations are
						superseded as of the effective date of these emergency
						regulations.
2. New section refiled 1-10-2011 as an emergency;
						operative 1-18-2011 (Register 2011, No. 2). A Certificate of Compliance must be
						transmitted to OAL by 4-18-2011 or emergency language will be repealed by
						operation of law on the following day. Any rules issued by provider bulletin by
						the Department of Health Care Services that are covered by or inconsistent with
						these emergency regulations are superseded as of the effective date of these
						emergency regulations.
3. Certificate of Compliance as to 1-10-2011
						order transmitted to OAL 4-5-2011 and filed 5-17-2011 (Register 2011, No.
						20).
Note: Authority cited: Sections
						  20,
						  1324.20,
						  1324.21
						  and
						  1324.23,
						  Health and Safety Code; and Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14126.027,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14109.5,
						  14110.1,
						  14110.6,
						  14170
						  and
						  14171,
						  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 9 - Quality Assurance Fee and Long Term Care Reimbursement Methodology › Section 52600 - Provider Bulletin Authority

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For purposes of rate years occurring prior to August 1,
						2010, the Department may continue to apply those standards and other regulatory
						provisions and guidance issued in provider bulletins applicable to those rate
						years notwithstanding any changes in the prospective application of such
						bulletin provisions.
1. New
						section filed 7-22-2010 as an emergency; operative 7-22-2010 (Register
						2010,
						No. 30). A Certificate of Compliance must be transmitted to OAL by 1-18-2011 or
						emergency language will be repealed by operation of law on the following day.
						Any rules issued by provider bulletin by the Department of Health Care Services
						that are covered by or inconsistent with these emergency regulations are
						superseded as of the effective date of these emergency
						regulations.
2. New section refiled 1-10-2011 as an emergency;
						operative 1-18-2011 (Register 2011, No. 2). A Certificate of Compliance must be
						transmitted to OAL by 4-18-2011 or emergency language will be repealed by
						operation of law on the following day. Any rules issued by provider bulletin by
						the Department of Health Care Services that are covered by or inconsistent with
						these emergency regulations are superseded as of the effective date of these
						emergency regulations.
3. Certificate of Compliance as to 1-10-2011
						order transmitted to OAL 4-5-2011 and filed 5-17-2011 (Register 2011, No.
						20).
Note: Authority cited: Sections
						  20,
						  1324.20,
						  1324.21
						  and
						  1324.23,
						  Health and Safety Code; and Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14126.027,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14109.5,
						  14110.1,
						  14110.6,
						  14170
						  and
						  14171,
						  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 10 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT PROGRAM [REPEALED]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 Article 10 (Sections
					 52000-52014) filed 1-30-73;
					 effective thirtieth day thereafter (Reg. 73, No. 5). For history of former
					 Article 10, see Register 72, Nos. 40 and 43.
2. Repealer of Article
					 10 (Sections
					 52000-52014) filed 2-27-75;
					 effective thirtieth day thereafter (Register 75, No. 9). For prior history of
					 Article 10, see Register 73, Nos. 15, 26 and 28.
Note: Authority cited for Article 10: Sections
						14105,
						14106
						and
						14124.5,
						Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3.5 - PILOT AND DEMONSTRATION PROJECTS [REPEALED]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New Chapter
				  3.5 (Sections
				  52001-52011, not consecutive)
				  filed 3-1-79; designated effective 4-1-79 (Register 79, No. 9).
2.
				  Amendment of subsection (b) filed 1-30-80; effective thirtieth day thereafter
				  (Register 80, No. 5).
3. Repealer of Chapter 3.5 (Article 1,
				  Sections 52001-52011, not consecutive)
				  filed 11-24-82; effective thirtieth day thereafter (Register 82, No.
				  48).
Note: Authority cited: Sections
					 14124.5,
					 14132.5
					 and
					 14132.6,
					 Welfare and Institutions Code. Reference: Sections
					 14124.5,
					 14132.5
					 and
					 14132.6,
					 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 - Prepaid Health Plans › Article 1 - GENERAL PROVISIONS › Section 53000 - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Health care
					 services to eligible Medi-Cal beneficiaries may be provided through prepaid
					 health plans. These plans shall:
(1) Contract
					 with the Department to provide, to the maximum extent feasible, the full scope
					 of Medi-Cal program benefits to Medi-Cal beneficiaries voluntarily electing to
					 obtain their health care services from the plan.
(2) Share in the risk of providing health
					 care services.
(3) Provide readily
					 available health care services and utilize preventive health care programs to
					 improve the health status of their members.
(4) Be encouraged to utilize new and
					 innovative approaches in the delivery of health care services to assure that
					 care is provided in the most cost-effective manner
					 possible.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53100 - Acceptable Medical Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Acceptable medical care means medical care of a quality
						which equals or exceeds the standards for medical practice developed by the
						plan and approved by the Department pursuant to the provisions of Section
						53280.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53101 - Actuarial Equivalence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Actuarial equivalence means the per capita costs for
						Medi-Cal fee-for-service beneficiaries adjusted by age, sex, aid category,
						scope of services and other appropriate factors, as determined by the
						Department, in order to be comparable with the costs for Medi-Cal beneficiaries
						who are members of prepaid health plans.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53101.1 - Actuarial Method

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Actuarial method means any reasonable and adequate method
						of determining prospective per capita rates of payment for plan members that is
						based on recent comparable data from each prepaid health plan and other prepaid
						populations, as determined by the Department, where data is available
						including:
(a) Experience data to
					 determine the expected costs of services and other requirements for which the
					 rates will serve as payment.
(b)
					 Experience data to determine the expected utilization of each service and other
					 requirements for which the rates will serve as payment by the aid category, age
					 and sex of the Medi-Cal members.
(c) Projected inflation in the costs of the
					 services and other requirements during the period to be covered by the
					 rates.
(d) Costs of any new
					 services or requirements that will be required during the year for which the
					 rates are determined but which were not required during the previous
					 year.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b) (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a) (b),
						  14408(d),
						  14409(a) (b),
						  14410,
						  14411(a) (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a) (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477 14478, 14479, 14480, 14481
						  and 14482, 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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53102 - Affiliate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Affiliate means an organization or person that, directly
						or indirectly through one or more intermediaries, controls, or is controlled by
						or is under common control with, a plan and that provides services to or
						received services from a plan.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53104 - Carrier. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53106 - Catastrophic Coverage Limitation. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53108 - Contract

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Contract means the written agreement entered into between
						a health care service plan, as defined in Section
						1345,
						Health and Safety Code, and the Department and approved by appropriate state
						agencies to provide health care services to members under the provisions of the
						Waxman-Duffy Prepaid Health Plan Act, Section
						14200, et seq., Welfare and
						Institutions Code.
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14204,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53110 - Control

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Control means the possession, directly or indirectly, of
						the power to direct or cause the direction of the management or policies of a
						plan. Such power may be exercised through one or more intermediary companies,
						or alone, or in conjunction with, or pursuant to an agreement. Such power may
						be established through a majority or minority ownership or voting of
						securities, common directors, officers or stockholders, voting trusts, holding
						trusts, affiliates, contract or any other direct or indirect
						means.
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53111 - Department. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer and new section filed 7-5-78; effective thirtieth day thereafter
						(Register 78, No. 27).
2. Repealer filed 10-11-85; effective
						thirtieth day thereafter (Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53112 - Director. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer and new section filed 7-5-78; effective thirtieth day thereafter
						(Register 78, No. 27).
2. Repealer filed 10-11-85; effective
						thirtieth day thereafter (Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53114 - Disenrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Disenrollment means the process by which a member's
						entitlement to receive services from a plan is terminated.
1.
						Editorial correction adding NOTE filed 2-2-83 (Register 83, No.
						6).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14412
						  and
						  14413,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53115 - Door-to-Door Marketing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Door-to-door marketing means the use of any marketing
						presentation at the residence of an individual who has not requested such a
						presentation.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Editorial correction of NOTE filed 2-2-83 (Register 83, No.
						6).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14408(d),
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53115.5 - Effective Date of Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Effective date of enrollment means the first day of the
						first month in which a Medi-Cal beneficiary's name appears on the approved list
						of members furnished to the plan by the Department as a result of the
						completion of an application for enrollment in the prepaid health
						plan.
1. New
						section filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14406(a),
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53116 - Enrollment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Enrollment means the process by which a Medi-Cal
						beneficiary becomes a member of a plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53116.5 - Experience Data

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Experience data means cost and utilization data from the
						Medi-Cal fee-for-service program, prepaid health plans or other prepaid
						populations which is determined by the Director to be sufficient in quantity
						and extent to provide credibility.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment filed 12-10-79; effective thirtieth day thereafter
						(Register 79, No. 50).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  4456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53117 - Facility

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Facility means
					 any premises:
(1) Owned, leased, used or
					 operated directly or indirectly by or for the benefit of a plan or its
					 affiliates for purposes related to a contract between the plan and the
					 Department.
(2) Maintained by a
					 provider to provide services on behalf of a plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53117.3 - Formal Grievance. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50). For prior history, see Register 78, No. 27.
2. Repealer filed
						9-22-82; effective thirtieth day thereafter (Register 82, No.
						39).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14450,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53117.7 - Immediate Family. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53117.9 - Informal Grievance. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 12-10-79; effective thirtieth day thereafter (Register 79, No.
						50).
2. Repealer filed 9-22-82; effective thirtieth day thereafter
						(Register 82, No. 39).
3. Editorial correction of repealer filed
						9-22-82 and inadvertently left in print in Register 82, No. 39 (Register 82,
						No. 52).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14450(n),
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53118 - Marketing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Marketing
					 means:
(1) Any activity conducted by, or on
					 behalf of, a plan in which information regarding the services offered is
					 disseminated in order to persuade Medi-Cal beneficiaries to enroll or accept an
					 application for enrollment in that plan.
(2) Any presentation made by, or on behalf
					 of, a plan to any individual or organization to procure written or other public
					 endorsement of that plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53120 - Marketing Representative

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Marketing representative means any person engaged in
						marketing activities on behalf of a plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53121 - Medi-Cal Beneficiary. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53122 - Member

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Member means any Medi-Cal beneficiary who has enrolled in
						a plan pursuant to Section
						53420.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53124 - Prepaid Health Plan. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer and new section filed 7-5-78; effective thirtieth day thereafter
						(Register 78, No. 27).
2. Repealer filed 10-26-84; effective
						thirtieth day thereafter (Register 84, No. 43).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14251,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53126 - Prepaid Patient Population

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prepaid patient population means the entire patient
						population both Medi-Cal and non-Medi-Cal, that is entitled to receive medical
						care from a plan in consideration for a predetermined, periodic, fixed
						subscription premium.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53128 - Preventive Health Care. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53130 - Primary Care Physician. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53132 - Public Hearing. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53133 - Risk Limit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Risk limit means the per member dollar amount in excess
						of which the plan assumes no financial liability for the cost of services
						rendered to any member.
1. New
						section filed 9-22-82; effective thirtieth day thereafter (Register 82, No.
						39).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Section
						  14451.5,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53134 - Service Area

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Service area means the geographical area designated by
						the Department within which a plan shall provide, directly or through
						subcontract, health care services to its members who reside
						therein.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53136 - Service Location

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Service location means any plan location at which a
						member obtains any health care service.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53138 - Service Site

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Service site means the location designated by a plan at
						which members shall receive primary care physician services.
1.
						Editorial correction adding NOTE filed 2-2-83 (Register 83, No.
						6).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14406
						  and
						  14450,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53140 - State Employee

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 "State employee" pursuant to Welfare and Institutions Code includes:
(1) The Director of the Department of Health
					 Services, and
(2) The following
					 appointive and civil service employees of the Department:
(A) Chief deputy directors;
(B) Deputy directors;
(C) Chief counsel;
(D) Division chiefs;
(E) Branch chiefs;
(F) Section chiefs;
(G) Office, unit, bureau, project and program
					 chiefs.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53142 - State Officer. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53144 - Subcontract

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Subcontract
					 means an agreement between a plan and any of the following:
(1) A provider of health care services who
					 agrees to furnish such services to plan members, except for providers of
					 unusual or seldom-used health care services.
(2) A marketing organization.
(3) Any other person or organization who
					 agrees to perform any administrative function or service for the operation of
					 the plan specifically related to securing or fulfilling its contractual
					 obligations with the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53144.5 - Sub-Subcontract

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Sub-subcontract means any agreement, descending from and
						subordinate to a subcontract, which is entered into for the purpose of
						providing any goods or services connected with a prepaid health plan's
						obligations under a contract entered into pursuant to this
						Chapter.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53145 - Substantial Financial Interest. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 10-11-85; effective thirtieth day thereafter
						(Register 85, No. 41).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53150 - Unit Medical Record. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Repealer filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 2 - DEFINITIONS › Section 53152 - Vendor

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Vendor means any person who provides services or supplies
						to a prepaid health plan or subcontractor of a prepaid health plan and who does
						not have a subcontract with the prepaid health plan or plan
						subcontractors.
1. New
						section filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
Note: Authority cited: Sections
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14201,
						  14251,
						  14256,
						  14261,
						  14262(a) (b)
						  (c),
						  14300,
						  14301,
						  14302,
						  14303,
						  14303.1,
						  14303.2,
						  14304,
						  14308,
						  14312,
						  14402,
						  14405,
						  14406(a)
						  (b),
						  14408(d),
						  14409(a)
						  (b),
						  14410,
						  14411(a)
						  (b),
						  14412,
						  14413,
						  14450,
						  14451,
						  14451.5(a)
						  (b),
						  14452,
						  14452.5,
						  14454,
						  14455,
						  14456,
						  14459,
						  14460,
						  14475,
						  14476,
						  14477,
						  14478,
						  14479,
						  14480,
						  14481
						  and
						  14482,
						  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 - Prepaid Health Plans › Article 3 - OPERATIONAL REQUIREMENTS › Section 53200 - Organization and Administration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan shall have the organizational
					 and administrative ability to carry out its contractual obligations, including
					 but not limited to the following:
(1) An
					 unrestricted Knox-Keene license or pending application therefor.
(2) A medical director as specified in
					 Section 53246.
(3) A grievance procedure as specified in
					 Section 53260.
(4) Member and enrollment reporting systems
					 which fulfill the plan's contractual obligations.
(5) A data-reporting system which provides
					 reports required under the contract to the Department on a timely
					 basis.
(6) Financial records and
					 books of account fully disclosing the disposition of all Medi-Cal program funds
					 received. Such records and books shall be maintained on the accrual basis in
					 accordance with generally accepted accounting principles.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 3 - OPERATIONAL REQUIREMENTS › Section 53210 - Scope of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Except as provided in Section
					 14257
					 of the Welfare and Institutions Code, each plan shall provide the following
					 health care services:
(1) Physician
					 services.
(2) Hospital outpatient
					 department services.
(3) Laboratory
					 and X-ray services.
(4)
					 Pharmaceutical services and prescribed drugs.
(5) Hospital inpatient care.
(6) Skilled nursing facility care.
(7) A continuing program of preventive health
					 care services, appropriate to the needs of the projected plan population,
					 which:
(A) Satisfies the requirements of
					 Title 10, California Administrative Code, Section
					 1300.67(f).
(B) Includes the provision of Child Health
					 and Disability Prevention Program services to members under the age of 21 in
					 accordance with the provisions of Title 17, California Administrative Code,
					 Sections 6800-6874.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 3 - OPERATIONAL REQUIREMENTS › Section 53212 - Availability of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Director shall determine the availability of services to be provided under the
					 plan contract.
(b) Each plan shall
					 obtain departmental approval prior to making any substantial change in
					 availability or location of services to be provided under the contract, except
					 in the case of unforeseen circumstances. A proposal to change the location of
					 services or reduce their availability shall be given to the Department at least
					 30 days prior to the proposed effective date.
1.
						Amendment filed 7-5-78; effective thirtieth day thereafter (Register 78, No.
						27).
2. Amendment of subsection (h) filed 12-10-79; effective
						thirtieth day thereafter (Register 79, No. 50).
3. Repealer of
						subsections (c)-(h) filed 12-30-81; effective thirtieth day thereafter
						(Register 82, No. 1).
Note: Authority cited: Section
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14450,
						  14452.3,
						  14452.4
						  and
						  14452.5,
						  Welfare and Institutions Code.