reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54406 - Activity Coordinator

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The activity coordinator shall have one of the following qualifications:
(1) Two years' experience in a social
					 recreational or educational program within the past five years, one year of
					 which was full-time in an activities program in a health care, mental health or
					 handicapped program setting.
(2) Be
					 an occupational therapist, art therapist, music therapist, dance therapist,
					 recreation therapist, occupational therapist assistant or qualified social
					 worker.
(3) Completion of at least
					 36 hours training in a course designed specifically for this position and
					 approved by the Department and shall receive regular consultation from an
					 occupational therapist, qualified social worker or recreation
					 therapist.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54407 - Grievance Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each adult day health care provider shall establish and maintain a procedure
					 for submittal, processing and resolution of grievances of participants
					 regarding care and administration by the provider. Such procedure shall be
					 approved by the Department and shall provide for the following:
(1) Recording each grievance in
					 writing.
(2) Maintaining a log of
					 all grievances submitted, including notes on progress towards
					 resolution.
(3) A written finding
					 of fact and decision within 30 days of the recording of any grievance
					 received.
(4) Transmittal of the
					 following to the participant within five days of decision:
(A) A written copy of the finding of
					 fact.
(B) An explanation of the
					 decision concerning the grievance.
(C) Information concerning the participant's
					 right to a fair hearing in accordance with Section
					 54409.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54409 - Participant Fair Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each participant shall have the right to a fair hearing for matters relative to
					 an unresolved grievance regarding care and administration by the adult day
					 health care provider.
(b) The adult
					 day care provider shall present its position at the fair hearing and implement
					 the fair hearing decision adopted by the Director.
(c) Implementation of the fair hearing
					 decision shall not be the basis for discharge of the participant by the adult
					 day health care provider.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54411 - Reports

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each provider
					 of adult day health care services shall furnish to the Director or the
					 Director's designee scheduled or requested information and reports including
					 but not limited to information and reports listed below:
(1) Monthly Services Report for each
					 participant.
(2) Agreements of
					 Participation.
(3) Discharge
					 requests.
(4) Initial and
					 successive individualized plans of care.
(5) Treatment Authorization
					 Request.
(6) Annual demographic
					 report.
(7) Financial
					 Reporting.
(8) Any other reports
					 requested by the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54413 - Financial Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The adult day health care provider shall maintain financial records on an
					 accrual basis and shall submit to the Department an annual audit performed by
					 an independent certified public accountant. All verified financial statements
					 shall be filed with the Department as soon as practical after the close of the
					 center's fiscal year, and in any event, within a period not to exceed 90 days
					 thereafter. The Department may grant exceptions to this time limit, for good
					 cause.
(b) The audit report
					 prepared by the independent certified public accountant shall include a table
					 of contents and at least the following:
(1) A
					 balance sheet reflecting the assets, liabilities and net worth of the adult day
					 health care provider at the close of the fiscal year under audit.
(2) A statement of income and expenses
					 reflecting all sources and amounts of income and expenses.
(3) A statement of changes in financial
					 position, reflecting the adult day health care provider's sources and
					 applications of funds and the net increase or decrease in working capital for
					 the fiscal year just ended.
(4) All
					 notes relating to the financial statements specified in (1), (2) and
					 (3).
(5) A statement that the audit
					 was conducted in accordance with generally accepted auditing standards and,
					 further where in the accountant's opinion, the financial statements fairly
					 present the financial position, results of operations and changes in financial
					 position in conformity with generally accepted accounting principles applied on
					 a consistent basis. If the accountant is unable to express an unqualified
					 opinion, this shall be stated in his report and the report shall specify the
					 reason or reasons.
(6) Financial
					 statements shall be public records.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54415 - Medical Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each adult day health care center shall be reviewed by a Department of Health
					 medical review team at least annually. The review shall include but is not
					 limited to assessment of:
(1) The
					 participant's current medical, psycho-social and functional status.
(2) The appropriateness of care
					 provided.
(3) The quality of care
					 provided.
(4) The necessity for the
					 services rendered.
(5) Staffing
					 requirements.
(6) The system for
					 participant care.
(7) Medical
					 records.
(8) Professional review
					 system and reports.
(9) Grievances
					 relating to health care and their disposition.
(10) Procedures for controlling the
					 utilization of services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54417 - On-Site Visits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each adult day health care center shall be subject to periodic on-site visits
					 by Department representatives. Such visits shall include but are not limited to
					 observation of the following:
(1) General
					 operation.
(2) Availability and
					 provision of services.
(3) Degree
					 of participant satisfaction with the adult day health care center.
(4) Administrative
					 operation.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54419 - Utilization Review Committee

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each adult day health center shall
					 establish a utilization review committee. Membership in this committee shall
					 include, but is not limited to, a representative from the adult day health
					 center, and professional personnel such as a physician, psychiatrist, nurse,
					 social worker, occupational, physical or speech therapist who are not employed
					 by the center.
(b) The committee
					 shall evaluate the appropriateness of the health care provided by reviewing
					 individual records of participants and shall make recommendations to the center
					 to correct any deficiencies identified. Procedures for the utilization review
					 committee and the method of selecting records for review shall be approved by
					 the Department. This committee shall meet at least quarterly.
(c) All activities of the utilization review
					 committee shall be reported quarterly to the Department in a format approved by
					 the Department. As a minimum, the report shall include the:
(1) Number of cases reviewed.
(2) Nature and extent of the problems
					 encountered.
(3) Summaries of the
					 actions taken by the review system.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54421 - Advisory Committees

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each adult day health care center may establish an advisory committee composed
					 of community and participant representatives other than those comprising the
					 governing body. The functions of this committee shall be:
(1) To serve as informational
					 resources.
(2) To provide liaison
					 between the center and the community.
(3) To resolve individual issues.
(4) To contribute specific expertise as
					 needed.
(5) To assist in reaching
					 those in need of services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54423 - Staffing Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The program director, a registered nurse with public health background, a
					 medical social worker, a program aide and the activity coordinator shall be on
					 duty. Other staff shall be employed in sufficient numbers to provide services
					 as prescribed in the individual plans or care, in accordance with the following
					 minimal requirements, determined by each center's average daily attendance
					 based on the previous quarter experience.
(1)
					 Centers with an average daily attendance of 10 or less shall provide at least:
(A) A total of 40 hours per month in the
					 following areas: Physical therapy, speech therapy and occupational therapy and
					 psychiatric or psychological services.
(B) Two hours per month of nutritional
					 services provided by a dietitian.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54425 - Participant Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each center shall maintain a complete health record for each participant in the
					 program in the format established by the Department. Each medical record shall
					 include, but is not limited to:
(1)
					 Identifying information including:
(A) Name,
					 address, telephone number, sex, age, ethnic background, Social Security and
					 Medi-Cal numbers.
(B) Name, address
					 and phone number of responsible person.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54429 - Solicitation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Adult day
					 health centers shall not:
(1) Hire persons
					 solely for the purpose of solicitation of participants.
(2) Offer money or any valuable consideration
					 as an inducement to become a participant.
(3) Make false statements in advertising in
					 any media.
(4) Make false
					 statements to prospective participants regarding any aspect of the
					 program.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54431 - Service Area

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 adult day health center shall serve only participants living in the service
					 area specified in the county plan and approved by the Department. An exception
					 to this requirement may be granted only if the center meets a special need of a
					 particular individual residing outside the service area. Special needs shall be
					 limited to:
(1) The individual does not reside
					 in an adult day health service area.
(2) The adult day health care center in the
					 individual's service area does not provide a needed service.
(3) The individual is a former resident of
					 the service area.
(4) The center
					 offers strong ties to the cultural background of the individual which are not
					 available in the area in which the individual resides.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54433 - Subcontracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All
					 subcontracts shall be in writing.
(b) Each subcontract shall be submitted to
					 the Department at least 60 days prior to the effective date. If the Department
					 does not formally act on a subcontract within 60 days after receipt, the adult
					 day health care provider may use the services of the subcontractor.
(c) Each subcontract shall include at least
					 the following:
(1) Full disclosure of the
					 amount of compensation or other consideration to be received by the
					 subcontractor from the adult day health center. That requirement provision
					 shall not apply to subcontracts with providers employed or salaried by the
					 adult day health care provider.
(2)
					 Specification of the services to be provided and the times and days when these
					 services are available to members.
(3) A provision that the subcontract shall be
					 governed by and construed in accordance with all laws, regulations and
					 contractual obligations incumbent upon the adult day health care
					 provider.
(4) A provision that the
					 Department and the Department of Health, Education and Welfare shall have the
					 right to inspect or reproduce all books and records of the subcontractor as
					 they relate to the provision of goods and services under the terms of the
					 subcontract. Such books and records shall be available for inspection or
					 reproduction at all reasonable times at the subcontractor's place of business
					 for a term of at least four years from the effective date of the
					 subcontract.
(5) A provision
					 requiring the subcontractor, upon written request, to furnish financial reports
					 relating to the provision of services under the subcontract and the payment
					 therefore to the adult day health center and to the Department in such form and
					 at such times as required by the adult day health care provider to fulfill its
					 obligations for financial reporting to the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54435 - Civil Rights of Participants

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The adult health center shall not discriminate against participants because of
					 race, color, creed, national origin, sex, physical or mental handicaps in
					 accordance with Title VI of the Civil Rights Act of 1964,
					 42 U.S.C., Section
					 2000d, rules and regulations on the grounds
					 of race, color, creed, national origin or physical or mental handicaps include,
					 but are not limited to, the following:
(1)
					 Denying a participant any service or benefit or availability of a
					 facility.
(2) Providing any service
					 or benefit to a participant which is different or is provided in a different
					 manner or at a different time from that provided to other
					 participants.
(3) Restricting a
					 participant in any way in the enjoyment of any advantage or privilege enjoyed
					 by others receiving any service or benefit.
(4) Treating a participant differently from
					 others in satisfying any admission, enrollment quota, eligibility, membership
					 or other requirement or condition which individuals must meet in order to be
					 provided any service or benefits.
(5) Assignment of times or places for the
					 provision of services on the basis of the race, color, creed or national origin
					 of the participants to be served.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54437 - Civil Rights of Employees

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The center will not discriminate against any employee or applicant for
					 employment because of race, color, creed, sex, national origin or mental or
					 physical handicaps. The center will take affirmative action to ensure that
					 applicants are employed and that employees are treated during employment
					 without regard to their race, color, creed, sex, national origin, or mental or
					 physical handicaps. Such action shall apply to all forms of personnel
					 actions.
(b) The center shall, in
					 all solicitations or advertisements for employees placed by or on behalf of the
					 adult day health care provider, state that all qualified applicants will
					 receive consideration for employment without regard to race, color, creed, sex,
					 national origin, or mental or physical handicaps.
(c) The adult day health care provider shall
					 send a notice provided by the Department to each labor union or representative
					 of workers, with which it has a collective bargaining agreement or other
					 contract or understanding, advising the labor union or workers' representative
					 of the provider's equal opportunity commitments. Copies of the notice shall be
					 posted in conspicuous places available to employees and applicants for
					 employment.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54439 - Confidentiality of Data

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Names of persons receiving public social services are confidential as provided
					 in Section
					 10850,
					 California Welfare and Institutions Code, and are to be protected from
					 unauthorized disclosure. Release of any information pertaining to adult day
					 health care participants shall be made in accordance with the provisions of
					 Section 51009, Title 22, California
					 Administrative Code.
(b) All
					 information, records, data and data elements collected and maintained for the
					 operation of an adult day health center and pertaining to participants shall be
					 protected by the adult day health care provider from unauthorized
					 disclosure.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54443 - Informational Material

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Informational material provided to potential participants must have prior
					 approval of the Department and must include the following:
(1) The name, address and phone number of the
					 center.
(2) The service area
					 boundaries.
(3) Eligibility
					 criteria.
(4) A description of
					 services provided at the center.
(5) The days and hours of
					 operation.
(6) The cost per
					 day.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54445 - Conflict of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) No
					 state officer or state employee shall have a direct financial interest in a
					 center or a direct financial interest in any contract with the adult day health
					 care provider.
(b) No state officer
					 or state employee shall provide legal or management services to the adult day
					 health care provider, outside of specific duties as a state officer or state
					 employee. No state officer or state employee shall share in the income or any
					 remuneration derived from providing legal or management services to an adult
					 day health care provider.
(c) No
					 state officer or state employee shall receive anything of value for the purpose
					 of influencing or attempting to influence the negotiations for approval or
					 renewal of the provider agreement with the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 5 - ADMINISTRATION › Section 54447 - Provider Sanctions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department shall, after warning, impose one or more of the following
					 sanctions on adult day health care providers for violating time requirements as
					 specified in Sections
					 54217(d),
					 54403(a),
					 54411,
					 54413 and
					 54507.
(1) Suspension of admission
					 privileges.
(2) Forfeiture of all
					 or part of the Medi-Cal reimbursement for each day the required documents are
					 late.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 6 - PAYMENT OF SERVICES › Section 54503 - Fee Schedule

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each approved adult day health care provider shall
						establish a fee schedule for services to the general public.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 6 - PAYMENT OF SERVICES › Section 54504 - Transition Visits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
					 adult day health care provider may be reimbursed for a maximum of five
					 transition visits per institutionalized participant, each visit consisting of
					 two to four hours at the adult day health center. Transition visits to an adult
					 day health care center may be made by an inpatient of:
(1) An acute hospital utilizing
					 administrative days,
(2) An
					 Intermediate Care Facility, or
(3)
					 A Skilled Nursing Facility.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 6 - PAYMENT OF SERVICES › Section 54505 - Initial Assessment Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An approved adult day health care
					 provider shall be reimbursed for one initial assessment by the provider's
					 multidisciplinary team for each new participant. Assessment made after a
					 discharge and for reentry is not reimbursable for a reentry less than 12 months
					 after the discharge of the same participant.
(b) Reimbursement for the initial assessment
					 shall be based on the center's current approved daily rate plus five
					 percent.
(c) Reimbursement for the
					 initial assessment shall be limited to a maximum of three days.
1.
						Amendment of subsection (b) filed 9-17-79 as an emergency; effective upon
						filing (Register 79, No. 38). A Certificate of Compliance must be filed within
						120 days or emergency language will be repealed on 1-15-80.
2.
						Amendment of subsection (a) filed 9-19-79; effective thirtieth day thereafter
						(Register 79, No. 38).
3. Certificate of Compliance filed 11-29-79
						(Register 79, No. 48).
Note: Authority cited: Sections
						  14105,
						  14124.5
						  and
						  14570,
						  Welfare and Institutions Code and Chapter 1066, Statutes of 1977. Reference:
						  Sections
						  14105
						  and
						  14571,
						  Welfare and Institutions Code and Chapter 1066, Statutes of
						  1977.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 6 - PAYMENT OF SERVICES › Section 54507 - Billing Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 All charges submitted for payment shall be on billing forms approved by the
					 Department. The billing shall include a monthly invoice, the number of days of
					 attendance for each participant and monthly service reports.
(b) Billing shall be submitted by the adult
					 day health care provider directly to the Department for the month of service.
					 Billings are due by the 15th of the month following the month of
					 service.
(c) Billing for initial
					 assessments days shall be submitted on the invoice and shall meet the
					 requirements of (a) and (b).
1.
						Amendment filed 9-19-79; effective thirtieth day thereafter (Register 79, No.
						38).
Note: Authority cited: Chapter 1066, Statutes of 1977.
						  Reference: Chapter 1066, Statutes of
						  1977.
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 55100 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions shall control the construction of
					 this chapter unless the context requires otherwise.
(a) County organized health system means a
				  Medi-Cal managed care plan contracting with the department to serve enrolled
				  beneficiaries under the authority of Welfare and Institutions Code, Section
				  14499.5,
				  or Welfare and Institutions Code, Division 9, Part 3, Chapter 7, Article 2.8,
				  commencing with Section
				  14087.5.
(b) Disenrollment means the process under
				  which a member's entitlement to receive services from a Medi-Cal managed care
				  plan is terminated.
(c) Federally
				  qualified health center means an entity which:
(1) Is receiving a grant under Section
				  330 of the Public Health Service
				  Act;
(2) Is receiving funding from
				  such a grant under a contract with the recipient of such a grant, and meets the
				  requirements to receive a grant under Section
				  330 of such Act;
(3) Based on the recommendation of the Health
				  Resources and Services Administration within the Public Health Service, is
				  determined by the Secretary of Health and Human Services to meet the
				  requirements for receiving such a grant; or
(4) Was treated by the Secretary, for
				  purposes of Part B of Title XVIII, as a comprehensive federally funded health
				  center as January 1, 1990; and
(5)
				  May be an outpatient health program or facility operated by a tribe or tribal
				  organization under the Indian Self-Determination Act (Public Law 93-638)
				  or by an urban Indian organization receiving funds under Title V of the Indian
				  Health Care Improvement Act for the provision of primary health
				  services.
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 55110 - Enrollment of Indians in Medi-Cal Managed Care Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Indians shall not be required to enroll
				  in any Medi-Cal managed care plans, with the exception of county organized
				  health systems.
(b) Indians who are
				  enrolled in a Medi-Cal managed care plan, including county organized health
				  systems, shall not be restricted in their access to Indian Health Service
				  Facilities by the Medi-Cal managed care plan.
(c) Notwithstanding any other regulations in
				  this title, Indians who are enrolled in a Medi-Cal managed care plan other than
				  a county organized health system shall be permitted to disenroll from the
				  Medi-Cal managed care plan without cause as of the beginning of the first
				  calendar month following a full calendar month after the request for
				  disenrollment is made. Indians shall not be subject to any lock-in provisions
				  which may apply to other members of Medi-Cal managed care plans.
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.
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 55130 - Indian Health Service Facilities as Fee-for-Service Managed Care Plans

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If, under the
				  option provided in Section
				  55120(d), the
				  Indian Health Service Facility elects to become a fee-for-service managed care
				  plan, the Indian Health Service Facility shall act as primary care case manager
				  for Medi-Cal beneficiaries who are Indians or non-Indians currently receiving
				  services from the Indian Health Service Facility, once they voluntarily enroll
				  with the Indian Health Service Facility fee-for-service managed care plan. The
				  plan shall be responsible to provide or arrange for health care services for
				  its members as agreed to in the contract between the department and the Indian
				  Health Service Facility. The department shall inform Medi-Cal beneficiaries who
				  are Indians or non-Indians currently receiving services from the Indian Health
				  Service Facility of their option to enroll in the Indian Health Service
				  Facility fee-for-service managed care plan through the health care options
				  program.
(b) To participate as a
				  fee-for-service managed care plan, the Indian Health Service Facility must
				  demonstrate sufficient resources and capability to implement the
				  fee-for-service managed care contract, including, but not limited to:
(1) Medical and administrative
				  staff.
(2) Information
				  systems.
(3) Organizational
				  structure.
(4) Financial
				  solvency.
(5) Quality improvement
				  system.
(6) Member grievance
				  system.
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 55140 - Indian Health Service Facility Reimbursement When Subcontracting with a Medi-Cal Managed Care Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  Medi-Cal managed care plan subcontracting with an Indian Health Service
				  Facility shall reimburse the Indian Health Service Facility for services
				  according to one of the following reimbursement options:
(1) If the Indian Health Service Facility is
				  a rural health clinic or qualifies as a federally qualified health center, the
				  Medi-Cal managed care plan shall reimburse the facility at the facility's
				  interim per visit rate as established by the department, or through an
				  alternate reimbursement methodology approved in writing by the
				  department.
(2) If the Indian
				  Health Service Facility is a rural health clinic or a federally qualified
				  health center and the facility and the Medi-Cal managed care plan have agreed
				  to an at-risk rate and the Indian Health Service Facility has waived its right
				  to cost-based reimbursement under the subcontract, the Medi-Cal managed care
				  plan shall reimburse the facility at the negotiated rate.
(3) If, prior to the effective date of these
				  regulations, a Medi-Cal a managed care plan has negotiated a subcontract, which
				  has been approved by the department, with an Indian Health Service Facility
				  that is a federally qualified health center or a rural health clinic, and this
				  subcontract contains terms for reimbursement other than cost-based
				  reimbursement as described in subsection (c), the Medi-Cal managed care plan
				  may continue to reimburse the facility at the agreed rate under the
				  subcontract.
(4) If the Indian
				  Health Service Facility is entitled to be reimbursed as an Indian Health
				  Service provider by the federal government at a reimbursement rate other than
				  the rate described in subsection (a)(1), the Medi-Cal managed care plan shall
				  reimburse the facility at the Indian Health Service payment
				  rate.
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 55160 - Indian Health Service Facility Fee-for-Service Managed Care Plan Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
If the Indian Health Service Facility provides services as
					 a fee-for-service managed care plan, the department shall reimburse the
					 facility at the applicable reimbursement rate that would have been received by
					 the Indian Health Service Facility if the service had been rendered to a
					 Medi-Cal beneficiary through the Medi-Cal fee-for-service program for each
					 qualifying visit by a member of the fee-for-service managed care plan. In
					 addition, the department shall pay a monthly case management fee established by
					 the department for each member. If the Indian Health Service Facility qualifies
					 for reasonable cost reimbursement, as provided in federal law, the department
					 shall reimburse or recover from the Indian Health Service Facility at least
					 annually an amount equalling the difference between the payments received from
					 the department, excluding case management fees, and reasonable cost
					 reimbursement, or a percentage of reasonable cost, as provided in
					 42 U.S.C.
					 1396a(a)(13)(C).
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,
						14087.3,
						14087.5,
						14088,
						14089,
						14089.05,
						14200
						and
						14499.5,
						Welfare and Institutions Code; and Title 25, United States Code, Sections
						13 and
						1601; and Title 42, United States
						Code, Sections
						1396(b)(m)(2)(A)(ix)
						and 1396(d)(l)(2).
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 55170 - Indian Health Service Facilities and Non-Indian Beneficiaries

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Indian Health Service Facility will determine the
					 number of non-Indian Medi-Cal beneficiaries which the facility will accept as
					 patients with the following limitations:
(a) The facility must ensure that it
				  maintains its historical and cultural character as an Indian Health Service
				  Facility;
(b) The facility must
				  ensure that it provides care to Indian patients at a satisfactory level, as
				  required by federal law;
(c) If the
				  Indian Health Service Facility subcontracts with a Medi-Cal managed care plan,
				  the number of non-Indian members may be negotiated between the
				  parties.
(d) In the two-plan model
				  or a Geographic Managed Care program, if the Indian Health Service Facility
				  elects to participate as a fee-for-service managed care plan, the Indian Health
				  Service Facility shall enroll only Indians and the number of non-Indians
				  receiving services from the Indian Health Service Facility at the time of its
				  application to the department.
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.
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 55180 - Indian Health Service Facilities and the Health Care Options Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In geographic
				  areas served by a Geographic Managed Care program, the two-plan model, or where
				  the health care options program is operating, Indian Health Service Facilities
				  shall be listed as an option in the presentation and informing materials used
				  to advise beneficiaries of their options for receiving Medi-Cal benefits.
				  Indians and non-Indians currently receiving services from an Indian Health
				  Service Facility in such an area may, as an alternative to enrollment in a
				  Medi-Cal managed care plan, and upon request, choose to receive health care
				  services through the Indian Health Service Facility. Such a request shall be
				  made to the health care options program.
(b) In areas covered by subsection (a), if
				  the Indian Health Service Facility provides the department with current
				  information on Indian Medi-Cal beneficiaries and non-Indian Medi-Cal
				  beneficiaries who are currently receiving services from the facility in the
				  form agreed to between the department and the Indian Health Service Facility,
				  the following shall apply:
(1) If an Indian
				  Medi-Cal beneficiary, who is identified by the Indian Health Service Facility
				  as currently receiving services from the facility, does not make a choice of
				  options, that beneficiary shall not be assigned to a Medi-Cal managed care
				  plan, but shall remain in the fee-for-service Medi-Cal program to allow the
				  beneficiary to continue to receive care from the Indian Health Service
				  Facility. This requirement shall apply whether or not the Indian Health Service
				  Facility has subcontracted with a Medi-Cal managed care plan, but shall not
				  apply if the Indian Health Service Facility is a fee-for-service managed care
				  plan.
(2) Non-Indian Medi-Cal
				  beneficiaries may be identified by the Indian Health Service Facility as
				  currently receiving services from the facility. Such beneficiaries who do not
				  make a choice of options shall not be assigned to a Medi-Cal managed care plan,
				  but shall remain in the fee-for-service Medi-Cal program to allow those
				  beneficiaries to continue to receive care from the Indian Health Service
				  Facility. This requirement shall apply whether or not the Indian Health Service
				  Facility has subcontracted with a Medi-Cal managed care plan, but shall not
				  apply if the Indian Health Service Facility is a fee-for-service managed care
				  plan.
(3) If the Indian Health
				  Service Facility is a fee-for-service managed care plan, beneficiaries
				  identified in subdivisions (1) and (2) who fail to make a choice shall be
				  assigned to the Indian Health Service Facility's fee-for-service managed care
				  plan.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 1 - GENERAL PROVISIONS › Section 56000 - 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 PCCM plans.
					 PCCM plans shall:
(1) Contract with the
					 Department to provide or arrange for the provision of the full scope of
					 Medi-Cal services, unless certain services are specifically excluded under the
					 terms of the contract, to Medi-Cal beneficiaries voluntarily electing to obtain
					 health care services from the PCCM 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) Case manage members' utilization of
					 health care services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 2 - DEFINITIONS › Section 56100 - Acceptable Medical Care. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Repealed by operation of Government Code section
						11346.1(g).
						(Register 92, No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 6 - PRIMARY CARE CASE MANAGEMENT PLANS › Article 2 - DEFINITIONS › Section 56101 - 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,
						geographic location, scope of services, and other appropriate factors in order
						to be comparable with the costs for Medi-Cal beneficiaries who are members of
						each PCCM plan.
1. New
						section filed 3-9-90 as an emergency; operative 3-9-90 (Register 90, No. 12). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-9-90.
2. New section
						refiled 7-9-90 as an emergency; operative 7-9-90 (Register 90, No. 35). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed by operation of law on
						11-6-90.
3. Request to readopt section on an emergency basis
						pursuant to Government Code section
						11346.1
						granted and filed 11-6-90 as an emergency; operative 11-6-90 (Register 91, No.
						6). A Certificate of Compliance must be transmitted to OAL by 3-6-91 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-6-90 order transmitted to
						OAL 2-22-91; disapproved by OAL on 3-25-91 (Register 91, No. 18).
5.
						New section filed 3-25-91 as an emergency; operative 3-25-91 (Register 91, No.
						18). A Certificate of Compliance must be transmitted to OAL by 7-23-91 or
						emergency language will be repealed by operation of law on the following
						day.
6. Certificate of Compliance as to 3-25-91 order including
						amendment of section transmitted to OAL 7-19-91 and filed 8-19-91 (Register 92,
						No. 1).
Note: Authority cited: Sections
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14088.16,
						  Welfare and Institutions Code.