reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4 - Prepaid Health Plans › Article 7 - Emergency Services Claims Disputes › Section 53666 - Hearing Officer

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer, designated by the Director, shall conduct proceedings on
					 emergency claims disputes governed by this article.
(b) The hearing officer may:
(1) Administer oaths and
					 affirmations.
(2) Issue subpoenas
					 and subpoenas duces tecum authorized by this article.
(3) Determine the order in which evidence
					 shall be received.
(4) Control the
					 taking of evidence as appropriate to ascertain the facts and safeguard the
					 rights of the parties.
(5) Rule on
					 offers of proof.
(6) Question any
					 witness and call and examine additional witnesses in order to fully develop the
					 hearing record.
(7) Dispose of
					 procedural requests or similar matters.
(8) Take other action authorized by
					 law.
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 7 - Emergency Services Claims Disputes › Section 53668 - Medical Consultant

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The hearing officer may be assisted by a medical consultant employed by the
					 Department. The medical consultant shall have expertise or qualifications
					 appropriate to the subject matter of the dispute, when possible.
(b) The medical consultant shall:
(1) Investigate and review the subject matter
					 of the dispute, as directed by the hearing officer.
(2) Submit a written report of the resulting
					 opinions, findings or conclusions. A copy of the report shall be:
(A) Entered in the hearing record.
(B) Provided to each
					 party.
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 7 - Emergency Services Claims Disputes › Section 53670 - Evidence Rules

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Oral evidence shall be taken only on oath or affirmation.
(b) Each party shall have the right to:
(1) Call and examine witnesses.
(2) Introduce exhibits.
(3) Cross-examine opposing witnesses on any
					 matter relevant to the issues even though that matter was not covered in the
					 direct examination.
(4) Impeach any
					 witness regardless of which party first called the witness to
					 testify.
(5) Rebut any
					 evidence.
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 7 - Emergency Services Claims Disputes › Section 53672 - Affidavits As Evidence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An affidavit shall have the same effect as oral testimony
						if the party wishing to introduce the affidavit complies with Section
						11514,
						Government Code.
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53674 - Official Notice

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The hearing officer may take official notice of generally
						accepted technical or scientific matter within the Department's special field
						or facts which may be judicially noticed by the courts of this State, in
						accordance with Section
						11515,
						Government Code.
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53676 - Hearing Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The hearing shall be open to the parties and to such other persons as the
					 hearing officer may deem necessary and proper.
(b) Oral testimony shall be taken only on
					 oath or affirmation.
(c) Each party
					 shall have the right to:
(1) Be represented
					 by counsel.
(2) Call and examine
					 witnesses.
(3) Introduce
					 exhibits.
(4) Cross-examine
					 opposing witnesses on any matter relevant to the issues even though that matter
					 was not covered in the direct examination.
(5) Impeach any witness regardless of which
					 party first called the witness.
(6)
					 Rebut any evidence presented.
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 7 - Emergency Services Claims Disputes › Section 53678 - Record of Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A complete record of the proceedings at the hearing shall
						be made by electronic recording. The parties may obtain copies of the recording
						or any transcript, at cost and on reasonable notice.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53680 - Joint Hearings. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53682 - Severance of Issues. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  1412
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53684 - Oral and Written Argument

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer shall permit oral argument, at the request of any party, and
					 determine the manner and duration of argument. Written argument may be
					 permitted at the request of any party. The parties shall be advised concerning
					 the time and manner for filing written arguments.
(b) The hearing officer may, at any time,
					 direct the parties to file written briefs or memoranda discussing any or all
					 issues raised by the proceedings.
1.
						Amendment of subsection (b) filed 9-3-82; effective thirtieth day thereafter
						(Register 82, No. 36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53686 - Continued Hearings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 hearing officer, prior to issuance of a proposed decision in the matter, may
					 continue or reopen a hearing:
(1) On the
					 hearing officer's own initiative.
(2) At the request of any party only upon a
					 showing of good cause.
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 7 - Emergency Services Claims Disputes › Section 53688 - Additional Evidence. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53690 - Burden of Proof

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 provider shall bear the burden of proving, by a preponderance of the evidence,
					 all facts supporting entitlement to relief.
(b) The plan shall bear the burden of
					 proving, by a preponderance of the evidence, all facts presented in defense
					 against the claim.
(c) The party
					 bearing the burden of proof of a particular fact shall initially bear the
					 burden of producing evidence of that fact.
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53691 - Decisions by the Hearing Officer

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing officer may issue a decision
					 or order in accordance with paragraph (b) which shall be final. The hearing
					 officer shall be deemed to act for and on behalf of the Director. The decision
					 shall recite the Director's name as the signatory of such decision, in the
					 following form: "(Name of Director), Director of Health Services, by (signature
					 of hearing officer), Hearing Officer."
(b) Decisions by the hearing officer may be
					 issued pursuant to this section, if:
(1) The
					 hearing officer finds that the claim should be dismissed, pursuant to Section
					 53630.
(2) A claim has been withdrawn or settled,
					 pursuant to Section
					 53642.
(3) Either party defaults in accordance with
					 the provisions of Section
					 53634.
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 7 - Emergency Services Claims Disputes › Section 53692 - Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hearing
					 officer shall submit a proposed decision to the Director in writing within 60
					 days after the record has been closed. The proposed decision shall contain
					 findings of fact, a determination of the issues presented, and an
					 order.
(b) The Director may take
					 any of the following actions within 30 days after submission of the hearing
					 officer's proposed decision:
(1) Adopt the
					 proposed decision.
(2) Reject the
					 proposed decision and order that a new proposed decision be prepared based upon
					 the record.
(3) Direct the hearing
					 officer to reopen the hearing for the taking of further evidence and the
					 preparation of a new proposed decision.
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 7 - Emergency Services Claims Disputes › Section 53694 - Reconsideration

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reconsideration
					 of all or part of a decision, may be ordered by the Director within 30 days
					 after the delivery or mailing of a decision to the parties.
(b) Reconsideration may be ordered on the
					 Director's own motion or on the petition of any party to the action. The
					 petition shall be deemed denied if no action is taken within 30 days.
(c) Reconsideration of a case by the Director
					 may be on all pertinent parts of the record, and such additional evidence and
					 argument as may be permitted.
(1) As an
					 alternative, the case may be assigned to a hearing officer designated by the
					 Director.
(2) A reconsideration
					 assigned to a hearing officer shall be subject to the procedure provided in
					 Section 53692.
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 7 - Emergency Services Claims Disputes › Section 53696 - Relief from Decision or Order

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Director, upon written application,
					 may relieve a party from a decision, order or other proceeding for any of the
					 following:
(1) Fraud, misrepresentation or
					 other misconduct on the part of any party or the Department.
(2) Newly discovered evidence which could not
					 have been discovered earlier.
(3)
					 Circumstances beyond the control of the party.
(4) Any other good cause.
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 7 - Emergency Services Claims Disputes › Section 53697 - Judicial Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Any party to an administrative adjudication covered by
						Article 7 may obtain judicial review of the Director's decision by seeking a
						writ of mandate, in accordance with Section
						11523,
						Government Code.
1.
						Amendment filed 10-11-85; effective thirtieth day thereafter (Register 85, No.
						41).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  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 7 - Emergency Services Claims Disputes › Section 53698 - Standard of Liability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The plan's financial liability to the provider, if any, shall not exceed the
					 lower of the following rates applicable at the time the services were rendered
					 by the provider:
(1) The usual charges made
					 to the general public by the provider.
(2) The fee-for-service rates for similar
					 services under the Medi-Cal program. Upon determination of the plan's
					 liability, if no final rate has been established for a provider for the period
					 and type of services in question, then the applicable interim rate shall be
					 used for final determination of plan liability.
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 7 - Emergency Services Claims Disputes › Section 53700 - Liquidation of Liability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 A plan determined to be financially liable to the provider, shall within 30
					 days of the effective date of the decision:
(1) Reimburse the provider for the full
					 amount of the determined liability.
(2) Provide proof of reimbursement in such
					 form as the Director may require.
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 7 - Emergency Services Claims Disputes › Section 53702 - Liability Offset

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Director shall consult with the plan in developing a schedule for offset of any
					 unpaid liability against future capitation payments.
(b) The schedule shall be developed to
					 minimize the impact of offset on the plan's cash flow. An individual claim
					 shall not be liquidated by offset against fewer than two nor more than six of
					 the next monthly capitation payments.
(c) The offset from each capitation payment
					 shall be immediately forwarded to the appropriate provider.
1.
						Amendment filed 9-3-82; effective thirtieth day thereafter (Register 82, No.
						36).
Note: Authority cited: Sections
						  14312
						  and
						  14454,
						  Welfare and Institutions Code. Reference: Section
						  14454,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 1 - General Provisions › Section 53800 - General Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 In regions designated by the department, eligible Medi-Cal beneficiaries shall
					 receive health care services through one of two prepaid health plans, except as
					 provided in subsection (c) below.
(b) The two prepaid health plans in the
					 designated regions shall be selected as follows:
(1) The department shall award one contract
					 through a competitive bid process.
(2) The department shall award one contract
					 to a prepaid health plan which is:
(A)
					 Organized by the county government(s) or by stakeholders of a region designated
					 by the director under the Two-Plan Model, or
(B) Designated by the county government(s) or
					 by stakeholders of a region designated by the director under the Two-Plan
					 Model, and approved by the department at the department's sole
					 discretion.
(C) As a condition of
					 contract award, the prepaid health plan shall agree:
1. To include in its health care delivery
					 system under the contract any safety net provider as defined in Section
					 53810(ii)
					 physically located and operating within the designated region, as defined in
					 Section 53810(n), that is
					 willing to agree to provide services under the same terms and conditions that
					 the plan requires of any other similar provider to be included in the health
					 care delivery system under the contract, and
2. To establish participation standards for
					 any provider of medical or hospital services, physically located and operating
					 within the region, that will ensure the opportunity for substantial
					 participation of traditional providers, as defined in Section
					 53810(kk), in the
					 health care delivery system under the contract. Nothing in this subsection
					 shall be construed to prevent federally qualified health centers from
					 requesting cost-based reimbursement consistent with federal law in seeking to
					 enter into a subcontracting relationship with a plan in a designated
					 region.
3. If no health care
					 service plan is willing or able to contract with the department pursuant to
					 subsection (b)(2), the department may award two contracts pursuant to
					 subsection (b)(1). The two prepaid health plans shall agree to offer
					 subcontracts to safety net providers physically located and operating within
					 the designated region in accordance with policies developed by each prepaid
					 health plan and approved by the department prior to commencement of plan
					 operation.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 3 - MAXIMUM ENROLLMENT LEVELS › Section 53820 - Maximum Enrollment Levels

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The department shall implement the
					 two-plan model in regions designated by the department, pursuant to section
					 53800.
(b) For each designated region, the
					 department shall establish a maximum enrollment level of Medi-Cal beneficiaries
					 in the mandatory aid categories for the commercial plan under the two-plan
					 model, which will consider the following factors:
(1) The number of inpatient days qualifying
					 for DSH supplemental payments as the surrogate measure for services provided by
					 all safety net providers in the region.
(2) The impact of the enrollment of Medi-Cal
					 beneficiaries in the commercial plan on supplemental DSH payments, to the
					 extent that inpatient days provided to members of the commercial plan will be
					 diverted from safety net providers.
(3) The number of acute inpatient hospital
					 days attributable to the Medi-Cal beneficiaries not enrolled in prepaid health
					 plans or PCCM plans.
(4) The acute
					 inpatient hospital utilization rate for Medi-Cal beneficiaries in the mandatory
					 aid categories.
(5) The enrollment
					 levels of both plans of the two-plan model necessary to ensure true beneficiary
					 choice between plans and among providers within the two plans.
(6) The hospital inpatient care contracts the
					 commercial plan may have with disproportionate share hospitals.
(7) An agreement between a local initiative
					 and commercial plan in a designated region regarding local initiative minimum
					 and commercial plan maximum enrollment levels.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 4 - Prepaid Health Plan and Primary Care Case Management Plan Enrollment Growth During the Transition Period [Repealed] › Section 53830 - Prepaid Health Plan and Primary Care Case Management Plan Enrollment Growth During the Transition Period. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 5-14-93 as an emergency; operative 5-14-93. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						93, No. 20).
2. Amendment of subsections (a)-(b) and (d), new
						subsection (e), subsection redesignation and amendment of subsections (g)-(h)
						filed 7-1-94; operative 7-1-94. Submitted to OAL for printing only pursuant to
						section 147, SB 485 (Chapter 722, Statutes
						of 1992) (Register 94, No. 31).
3. New article 4 heading and
						amendment of subsection (a), (b) and (d) filed 7-1-96 as an emergency;
						operative 7-1-96. Submitted to OAL for printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
4. Editorial correction deleting erroneous second
						HISTORY 2 (Register 96, No. 46).
5. Repealer of section and NOTE and
						new section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
6. Repealer of article 4 (section
						53830) and section filed
						2-26-2014; operative 4-1-2014 (Register 2014, No.
						9).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4,
						  14088,
						  14088.16,
						  14088.25
						  and
						  17000,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 5 - TWO-PLAN MODEL REQUIREMENTS › Section 53840 - Two-Plan Model Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall:
(a) Obtain or maintain a license to operate
					 as a Knox-Keene health care service plan, and meet all requirements set forth
					 in Chapter 2.2 (commencing with Section
					 1340
					 of the Health and Safety Code) and related applicable regulatory requirements
					 throughout the term of the contract between the plan and the
					 department.
(b) Comply with all
					 applicable federal and state statutory, regulatory, and administrative
					 requirements, including, but not limited to, those organizational and
					 administrative requirements contained in the Social Security Act and the Code
					 of Federal Regulations.
(c) Comply
					 with all standards, requirements and responsibilities stipulated and agreed to
					 in the contract between the plan and the department including but not limited
					 to:
(1) Organization.
(2) Legal Capacity.
(3) Administration/Staffing.
(4) Management Information System.
(5) Reporting Requirements.
(6) Quality Improvement System.
(7) Provider Network and Geographic Access,
					 including a documented system for monitoring access to care.
(8) Scope of Services including preventive
					 services for adults and all required CHDP and EPSDT services.
(9) Medical Standards/Health
					 Education.
(10) Marketing and
					 Enrollment.
(11) Member
					 Services/Grievance System.
(12)
					 Cultural and Linguistic Services Requirements.
(13) Financial Solvency.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 5 - TWO-PLAN MODEL REQUIREMENTS › Section 53845 - Enrollment Criteria

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Enrollment in plans shall be mandatory for eligible beneficiaries who meet all
					 of the following criteria:
(1) Are eligible to
					 receive Medi-Cal services that are not limited in scope;
(2) Have been determined to have a share of
					 cost equal to zero;
(3) Do not meet
					 the criteria for exemption from plan enrollment, specified in section
					 53887;
(4) Have been determined by their county
					 welfare department to be eligible for one of the following programs:
(A) The section
					 1931(b) Program,
					 which consists of the services described in Welfare and Institutions Code
					 section
					 14005.30,
					 including persons whose Medi-Cal eligibility is based upon their receipt of
					 benefits under the California Work Opportunity and Responsibility to Kids
					 (CalWORKS) Program.
(B) The
					 Medically Indigent program for children under age 21, as specified in section
					 50251(a).
(C) The Medically Needy Program for families
					 and caretaker relatives, specified in sections
					 50203(a)(2) and
					 (3).
(D) The Other Public Assistance Program as
					 specified in section
					 50237.
(E) The Special Zero Share of Cost Program
					 for infants, as specified in section
					 50262; for children of age one to
					 age six, as specified in section
					 50262.5; and for children of age
					 six to age nineteen, as specified in section
					 50262.6.
(F) The Transitional Medi-Cal Program as
					 established in accordance with Section
					 1931 of the federal Social
					 Security Act (Title 42, United States Code, section
					 1396 u-1) and described in Welfare
					 and Institutions Code sections
					 14005.8
					 and
					 14005.81.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 5 - TWO-PLAN MODEL REQUIREMENTS › Section 53850 - Organization and Administration. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						article 6 (sections
						53850-53876) and section filed
						7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Editorial correction of section heading (Register
						96, No. 46).
3. Repealer filed 3-4-97; operative 3-4-97. Submitted
						to OAL for printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53851 - Scope of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan in a designated region shall provide or arrange for the provision of
					 all Medi-Cal covered services to be delivered, unless excluded under the
					 contract, in accordance with the terms and conditions of the contract between
					 the plan and the department.
(b)
					 The scope of services available to Medi-Cal members shall include:
(1) An initial health assessment, unless the
					 member's primary care physician determines that the member's medical record
					 contains complete information, updated within the previous 12 months,
					 consistent with the assessment requirements stated below, and with the
					 requirements of section
					 53840(c)(7). The
					 assessment, at a minimum shall include, a history of the member's physical and
					 mental health, an identification of risks, an assessment of need for preventive
					 screens or services and health education, and the diagnosis and plan for
					 treatment of any diseases. The plan shall ensure that care for pregnant women
					 is initiated at the earliest time possible.
(2) Health education.
(3) Preventive services.
(4) Primary and specialty care.
(5) Case management and coordination of care
					 as defined in section
					 53810(f).
(6) Emergency care.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53852 - Availability of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall obtain written
						departmental approval prior to making any substantial change in the
						availability or location of services to be provided under the contract, except
						in the case of a natural disaster or emergency circumstances. A proposal to
						change the physical location at which covered services are provided, or to
						reduce or change the hours, days or location at which the services are
						available, shall be given to the department at least sixty days prior to the
						proposed effective date. The department's denial of the proposal shall prohibit
						implementation of the proposed changes. The plan's proposal shall allow for
						timely notice to beneficiaries to allow them to change plans if
						desired.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53853 - Accessibility of Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan in a designated region shall retain sufficient professional medical
					 staff, including adequate numbers of specialists and subspecialists, to provide
					 access to preventive and managed health care services to its members. Access to
					 physicians or physician extenders shall be as follows:
(1) Each plan shall ensure its provider
					 network satisfies a ratio of at least one full-time equivalent primary care
					 physician for every 2,000 members.
(2) Each plan shall ensure its provider
					 network satisfies a ratio of at least one full-time equivalent physician for
					 every 1,200 plan members.
(3) Plans
					 that utilize nonphysician medical practitioners shall not allow a full-time
					 equivalent nonphysician medical practitioner to maintain a caseload of more
					 than 1,000 plan members. The plan shall ensure compliance with title 22, CCR,
					 sections 51240 and
					 51241.
(4) If utilized by a plan, members may select
					 a nonphysician practitioner as their primary care provider. Nonphysician
					 practitioners including certified nurse midwives, nurse practitioners and
					 physicians assistants, shall meet the requirements of existing practice and
					 licensure standards for mid-level practitioners, as specified in section
					 1399.541 and
					 1470, Title 16,
					 CCR.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53854 - Pharmaceutical Services and Prescribed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a designated region shall at
					 a minimum, make available to members during the hours of operation of each
					 member's primary care service site, either directly or through subcontracts,
					 the services of pharmacies and pharmacists in accordance with title 22, CCR,
					 section 53214.
(1) Pharmaceutical services shall, at a
					 minimum, be available to members during established service site
					 hours.
(2) When the course of
					 treatment provided to a member by a contracting provider under emergency
					 circumstances requires the use of drugs, a sufficient quantity of such drugs
					 will be provided to the member to last until the member can reasonably be
					 expected to have a prescription filled.
(3) Plans shall establish and document the
					 availability of after hours nonemergency pharmacy services. Plans shall make
					 available by telephone information regarding the availability, location and
					 hours of operation of pharmacies providing such services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53856 - Facilities, Service Locations, and Equipment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall comply with the
						requirements contained in section
						53230, and shall assure proper
						sterilization and disinfection of equipment, in accordance with California
						Occupational Safety and Health Administration (CAL/OSHA) standards, pursuant to
						California Labor Code, section
						6305 or any
						other applicable federal, state or local standard.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53857 - Medical Director

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan in a designated region shall appoint a physician as medical director
					 whose responsibilities shall include, but not be limited to, the following:
(1) Ensuring that medical decisions are:
(A) Rendered by qualified medical
					 personnel.
(B) Are not influenced
					 by fiscal or administrative management considerations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53858 - Member Grievance Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each plan in a designated region shall establish and maintain written
					 procedures for the submittal, processing, and resolution of all member
					 grievances and complaints. The grievance system shall include the handling of
					 complaints and shall:
(1) Operate according
					 to the written procedures, which shall be approved in writing by the department
					 prior to use. Amendments shall be approved in writing by the department prior
					 to implementation of the revised procedure.
(2) Be described in information sent to each
					 member within 7 days of the date of enrollment in the plan and annually
					 thereafter, pursuant to sections
					 53893 and
					 53894. The description shall
					 include:
(A) An explanation of the plan's
					 system for processing and resolving grievances, and how a member is to use
					 it.
(B) A statement that grievance
					 forms are available in the office of each primary care provider, or in each
					 member services department of the plan, in the case of a plan in which all
					 primary care providers are the exclusive providers of that plan and are
					 contiguously located.
(C) A
					 statement that grievances may be filed in writing or verbally directly with the
					 plan in which the member is enrolled or at any office of the plan's
					 providers.
(D) The local or
					 toll-free telephone number a member may call to obtain information, request
					 grievance forms, and register a verbal grievance.
(E) A written statement explaining the
					 member's right to request a fair hearing, provided pursuant to sections
					 50951,
					 51014.1,
					 51014.2, and
					 53894.
(F) An explanation of the state's Medi-Cal
					 Managed Care Ombudsman program and the program's voice and TDD telephone
					 numbers.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53859 - Provider Grievances and Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall have a formal process to resolve provider
						grievances and complaints. A provider of medical services may submit to a plan
						in a designated region a grievance or complaint concerning the authorization or
						denial of a service or the processing of a payment or nonpayment of a claim by
						that plan.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3
						  and
						  14087.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53860 - Quality of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 plan shall monitor, evaluate, and take effective action to address any needed
					 improvements in the quality of care delivered by all practitioners providing
					 services on its behalf in all types of settings, including, but not limited to,
					 ambulatory, inpatient and home settings.
(b) Each plan shall implement an effective
					 quality improvement program in accordance with the standards in Title 10,
					 section 1300.70.
(c) In addition to subsection (b), each plan
					 shall implement and maintain a quality improvement program including at a
					 minimum the following elements:
(1) A system
					 of accountability which includes the participation of the plan's governing
					 body, the designation of a quality improvement committee with oversight and
					 performance responsibility, the supervision of activities by the plan's medical
					 director, and the inclusion of contracted physicians and other health care
					 providers in the process of quality improvement program development and
					 performance review.
(2) Objective
					 and systematic monitoring and evaluation of the quality and appropriateness of
					 care and services rendered on an ongoing basis, including conducting quality of
					 care studies that address the quality of clinical care as well as the quality
					 of health services delivery.
(3) A
					 utilization management program, including, but not limited to procedures for
					 monitoring under and over-utilization of services, procedures to evaluate
					 medical necessity, prior authorization policies and procedures, and criteria
					 used for approval, referral and denial of services, pursuant to Health and
					 Safety Code, section
					 1363.5.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53861 - Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each plan in a
					 designated region shall maintain or cause to be maintained all records
					 necessary to verify information and reports required by statute, regulation or
					 contractual obligation for five years from the end of the fiscal year in which
					 the plan contract expires or is terminated. Each plan shall make such records
					 available for inspection or examination to the department, the United States
					 Department of Health and Human Services, the States Department of Justice, or
					 the Comptroller General of the United States or their duly authorized
					 representatives upon request. Records and documents shall include but not be
					 limited to:
(1) Working papers used in the
					 preparation of reports to the department.
(2) Reports to the department, specified in
					 section 53862.
(3) Financial documents.
(4) Medical records.
(5) Quality assurance and improvement
					 records.
(6) Prescription
					 files.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53862 - Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan in a designated region shall submit to the
						department:
(a) Annual reports which
					 shall include:
(1) The financial audit
					 required by section
					 53340. In addition to the annual
					 audited financial statements, the plan shall include the annual report required
					 under section
					 1300.84.06, Title 10. The plan's
					 annual report shall have a supplemental income statement, prepared in a format
					 consistent with the annual report, reflecting the plan's various Medi-Cal
					 contracts each as a separate line of business by designated region which come
					 included.
(2) An update of the
					 provider listing required in section
					 53242(b).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53863 - Assumption of Financial Risk

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each plan shall comply with the assumption of financial
						risk requirements in section
						53251.
1. New
						section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for
						printing only pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						96, No. 28).
2. Repealer of section and NOTE and new section and
						NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only
						pursuant to Section
						147, SB 485 (Ch. 722/92) (Register
						97, No. 10).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14312,
						  Welfare and Institutions Code. Reference: Sections
						  14087.3,
						  14087.4 and
						  14451.5 Welfare and Institutions
						  Code.