14050. Unless the context otherwise requires, the definitions set
forth in this article govern the construction of this chapter.
14050.1. For purposes of this chapter, "categorically needy person"
means a person whose coverage is mandatory under Title XIX of the
Social Security Act including, but not limited to, the individuals
covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the
United States Code.
14050.2. For the purposes of this chapter "aid" means financial
assistance provided to or in behalf of needy persons under the
provisions of Chapters 2 (commencing with Section 11200), 3
(commencing with Section 12000), and 5 (commencing with Section
13000) of this part.
14050.3. "A person in long-term care" means a person who is an
inpatient in a medical facility for more than the month of admission
who is expected to remain for the full month after the month of
admission.
14051. (a) "Medically needy person" means any of the following:
(1) An aged, blind, or disabled person who meets the definition of
aged, blind, or disabled under the Supplemental Security Income
Program and whose income and resources are insufficient to provide
for the costs of health care or coverage.
(2) A child in foster care for whom public agencies are assuming
financial responsibility, in whole or in part, or a person receiving
aid under Chapter 2.1 (commencing with Section 16115) of Part 4.
(3) A child who is eligible to receive Medi-Cal benefits pursuant
to interstate agreements for adoption assistance and related services
and benefits entered into under Chapter 2.6 (commencing with Section
16170) of Part 4, to the extent federal financial participation is
available.
(b) "Medically needy family person" means a parent or caretaker
relative of a child who meets the deprivation requirements of Aid to
Families with Dependent Children or a child under 21 years of age or
a pregnant woman of any age with a confirmed pregnancy, exclusive of
those persons specified in subdivision (a), whose income and
resources are insufficient to provide for the costs of health care or
coverage.
14051.5. (a) "Medically needy person" also means any person who
receives in-home supportive services pursuant to Section 12305.5 and
whose income and resources are insufficient to provide for the costs
of health care or coverage.
14052. "State-only Medi-Cal person" means a person who resides in a
nursing facility or any category of intermediate care facility for
the developmentally disabled, and who meets all of the following
requirements:
(a) Could not meet the definition of a categorically needy person
under Section 14050.1, a medically needy person under subdivision (a)
of Section 14051 or a medically needy family person under
subdivision (b) of Section 14051.
(b) Is over 21 years of age.
(c) Meets the eligibility requirements of Section 14005.4.
14052.1. "Cuban-Haitian entrant or refugee" means a person eligible
under the Cuban-Haitian Entrant Program or Refugee Resettlement
Program, as defined in federal regulations.
14053. (a) The term "health care services" means the benefits set
forth in Article 4 (commencing with Section 14131) of this chapter
and in Section 14021. The term includes inpatient hospital services
for any individual under 21 years of age in an institution for mental
diseases. Any individual under 21 years of age receiving inpatient
psychiatric hospital services immediately preceding the date on which
he or she attains age 21 may continue to receive these services
until he or she attains age 22. The term also includes early and
periodic screening, diagnosis, and treatment for any individual under
21 years of age.
(b) The term "health care services" does not include, except to
the extent permitted by federal law, any of the following:
(1) Care or services for any individual who is an inmate of an
institution (except as a patient in a medical institution).
(2) Care or services for any individual who has not attained 65
years of age and who is a patient in an institution for tuberculosis.
(3) Care or services for any individual who is 21 years of age or
over, except as provided in the first paragraph of this section, and
has not attained 65 years of age and who is a patient in an
institution for mental disease.
(4) Inpatient services provided to individuals 21 to 64 years of
age, inclusive, in an institution for mental diseases operating under
a consolidated license with a general acute care hospital pursuant
to Section 1250.8 of the Health and Safety Code, unless federal
financial participation is available for such inpatient services.
14053.1. Notwithstanding Section 14053, ancillary outpatient
services, pursuant to Section 14132, for any eligible individual who
is 21 years of age or over, and has not attained 65 years of age and
who is a patient in an institution for mental diseases shall be
covered regardless of the availability of federal financial
participation.
14053.3. As federal financial participation reimbursement is not
allowed for ancillary services provided to persons residing in
facilities that have been found to be institutions for mental disease
(IMD), and since, consistent with Part 2 (commencing with Section
5600) of Division 5 and Chapter 6 (commencing with Section 17600) of
Part 5, counties are financially responsible for mental health
services and related ancillary services provided to persons through
county mental health programs when Medi-Cal reimbursement is not
available, when it is determined that Medi-Cal reimbursement has been
paid for ancillary services for residents of IMDs, both the federal
financial participation reimbursement and any state funds paid for
the ancillary services provided to residents of IMDs shall be
recovered from counties by the State Department of Mental Health in
accordance with applicable state and federal statutes and
regulations.
14053.5. For the purposes of the Medi-Cal Act, the terms
"prescribed drug" and "prescription drug" shall not include any drug
which, because of differing prices charged by the manufacturer on a
discriminatory basis or discriminatory refusal to sell by the
manufacturer, or both, is not available on the same terms and
conditions to all providers of prescription services, or any drug
which is found to be overpriced in comparison to another drug which
has an equivalent therapeutic effect, unless the director determines
that the drug is vital to the program and no acceptable substitute is
available.
Before the director determines that any drug has an equivalent
therapeutic effect in comparison to another drug, or is vital to the
program and no acceptable substitute is available, he must have
received a report to that effect from the Medi-Cal Contract Drug
Advisory Committee.
Nothing in this section shall be construed to apply to quantity or
other nondiscriminatory discounts available on the same terms and
conditions to all providers of prescription services, to sales by
competitive bidding to federal, state or local governmental agencies,
or to sales to wholesalers so long as the manufacturer does not
require or induce the wholesalers to make the drug available other
than on the same terms and conditions to all providers of
prescription services.
This section shall not be construed to deny reimbursement to
hospitals for prescribed drugs furnished to inpatients or, unless the
regulations provide to the contrary, to registered outpatients.
14053.6. Prior to including or excluding any drug from the program,
the director shall give adequate notice to those California
associations of health professionals and those recognized national
associations of pharmaceutical manufacturers that are affected by
such action and shall seek and consider the advice of those
associations.
14053.7. (a) Notwithstanding any other provision of law, and only
to the extent that federal financial participation is available, the
department may provide Medi-Cal eligibility and reimbursement for
inpatient hospital services available under this chapter in
accordance with Section 5072 of the Penal Code.
(b) The department may disenroll inmates made eligible for
services under this section or in accordance with Section 5072 of the
Penal Code from Medi-Cal managed care health plans, and may exempt
inmates from enrollment into new or existing plans.
(c) Except as provided for in paragraph (2) of subdivision (e),
the Department of Corrections and Rehabilitation shall be responsible
for the nonfederal share of any reimbursement made for the provision
of inpatient hospital services rendered to inmates who are eligible
for and enrolled in a CEED project and receive services pursuant to
this section and Section 5072 of the Penal Code.
(d) (1) Notwithstanding any other provision of law, including
Section 11050, the state may make eligibility determinations and
redeterminations for inmates in accord with Section 5072 of the Penal
Code.
(2) The department may enroll and disenroll inmates eligible for
inpatient hospital services under this section or in accord with
Section 5072 of the Penal Code in Medi-Cal or in the CEED project in
which the inmate's county of last legal residence participates.
(e) (1) In accordance with the requirements and conditions set
forth under this section and Section 5072 of the Penal Code, the
county may seek from the Medi-Cal program or from the responsible
CEED project in which the county participates, reimbursement for the
provision of inpatient hospital services to adults involuntarily
detained or incarcerated in county facilities.
(2) (A) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9, the county shall be
responsible for the nonfederal share of the reimbursement.
(B) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for and enrolled in the CEED project in which
the county participates, the CEED project shall be responsible for
the nonfederal share of the reimbursement.
(f) Except as otherwise provided in subdivision (c) of Section
5072 of the Penal Code, the inpatient hospital services eligible for
reimbursement under this section shall be limited to only those
services which are subject to funding with federal financial
participation pursuant to Title XIX of the federal Social Security
Act.
(g) This section shall be implemented only if and to the extent
that existing levels of federal financial participation are not
otherwise jeopardized. To the extent that the department determines
that existing levels of federal financial participation are
jeopardized, this section shall no longer be implemented.
(h) The department shall seek any necessary federal approvals for
the implementation of this section. This section shall be implemented
only if and to the extent that any necessary federal approvals are
obtained.
(i) This section shall have no force of effect if there is a final
judicial determination made by any state or federal court that is
not appealed, or by a court of appellate jurisdiction that is not
further appealed, in any action by any party, or a final
determination by the administrator of the federal Centers for
Medicare and Medicaid Services, that disallows, defers, or alters the
implementation of this section or in accord with Section 5072 of the
Penal Code, including the rate methodology or payment process
established by the department that limits or affects the department's
authority to select the hospitals used to provide inpatient hospital
services to inmates.
(j) It is the intent of the Legislature that the implementation of
this section will result in state General Fund savings for the
funding of inpatient hospital services and any related administrative
costs to the inmate population.
(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may, without taking any further regulatory action,
implement this section by means of all-county letters or similar
instructions.
(l) For purposes of this section, the following terms have the
following meanings:
(1) The term "county of last legal residence" means the county in
which the inmate resided at the time of arrest that resulted in
conviction and incarceration in a state prison facility.
(2) The term "inmate" means an adult who is involuntarily residing
in a state prison facility operated, administered or regulated,
directly or indirectly, by the Department of Corrections and
Rehabilitation.
14054. "Share of cost" means the amount of the costs of health care
which a person or family eligible under Section 14005.4 or 14005.7
must incur prior to being certified by the department as specified in
Section 14018.
14054.5. "Elective services" means any treatment service which
generally can be postponed without seriously affecting the health of
the person requiring the service.
14056. "Minimum coverage" means prescribed drugs for public
assistance recipients as established by the director, and care or
coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of
Section 14053, except that it shall not include elective services.
14057.5. "Contract hospital" means a nonprofit medical facility
licensed pursuant to Chapter 2 (commencing with Section 1250) of
Division 2 of the Health and Safety Code, with which the board of
supervisors of a county which does not maintain a county hospital has
executed a contract, currently in effect, to care for medically
indigent individuals.
14059. Health care provided under this chapter may include
diagnostic, preventive, corrective, and curative services and
supplies essential thereto, provided by qualified medical and related
personnel for conditions that cause suffering, endanger life, result
in illness or infirmity, interfere with capacity for normal activity
including employment, or for conditions which may develop into some
significant handicap.
Medical care shall include, but is not limited to, other remedial
care, not necessarily medical. Other remedial care shall include,
without being limited to, treatment by prayer or healing by spiritual
means in the practice of the religion of any church or religious
denomination.
14059.5. A service is "medically necessary" or a "medical necessity"
when it is reasonable and necessary to protect life, to prevent
significant illness or significant disability, or to alleviate severe
pain.
14060. Every recipient who is entitled to visual care under this
chapter, which may be rendered either by an optometrist or a
physician, may select a duly licensed member of either profession to
render the service.
14061. As used in this chapter, "director" means the State Director
of Health Services.
14062. As used in this chapter, "department" means the State
Department of Health Services.
14063. As used in this chapter, "Medi-Cal" means the California
Medical Assistance Program.
14064. A. Inpatient intensive rehabilitation hospital services
shall consist of programs for:
1. Strengthening and training of selected muscle groups.
2. Preservation and restoration of joint mobility (prevention and
correction of contractures).
3. Training in application and use of equipment.
4. Training in activities of daily living, self-care, locomotion
and homemaking skills.
5. Cognitive reorganization and communication skills.
6. Resolution of psychological and social problems which are
impeding rehabilitation.
B. These programs shall use a multidiscipline approach carried out
under the general or direct supervision of a physician with special
training or experience in the field of rehabilitation. When medically
indicated, a program of this scope includes but is not limited to:
1. Skilled rehabilitation nursing care.
2. Physical therapy.
3. Occupational therapy.
4. Speech therapy.
5. Prosthetic or orthotic services.
6. Psychologist services.
7. Medical social worker services.
C. A typical program shall provide for:
1. Initial evaluation (7-10 days) for assessment of medical
condition, functional limitations, possible need for surgery,
attitude toward rehabilitation, functional goals and plans for
discharge.
2. Where the rehabilitation potential is undetermined, the patient
shall be placed on a 14-day trial program. If no improvement is
noted after this period, definitive plans for discharge should be
made.
3. Where the initial evaluation results in a conclusion by the
rehabilitation team that a significant practical improvement can be
expected in a reasonable period of time, the program should continue
until such time as further progress toward the established
rehabilitation goals is unlikely or it can be achieved in a less
intensive setting.
14065. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Director of
Health" and "Director of Benefit Payments" shall be construed to
refer to and mean the State Director of Health Services.
14066. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Department
of Health," "State Department of Health," "Department of Benefit
Payments," and "State Department of Benefit Payments" shall be
construed to refer to and mean the State Department of Health
Services.
14067. (a) The department, in conjunction with the Managed Risk
Medical Insurance Board, may develop and conduct a community outreach
and education campaign to help families learn about, and apply for,
Medi-Cal and the Healthy Families Program of the Managed Risk Medical
Insurance Board, subject to the requirements of federal law. In
conducting this campaign, the department may seek input from, and
contract with, various entities and programs that serve children,
including, but not limited to, the State Department of Education,
counties, Women, Infants, and Children program agencies, Head Start
and Healthy Start programs, and community-based organizations that
deal with potentially eligible families and children to assist in the
outreach, education, and application completion process. The
department shall implement the campaign if funding is provided for
this purpose by an appropriation in the annual Budget Act or other
statute.
(b) An annual outreach plan shall be submitted to the Legislature
by April 1 for each fiscal year for those years for which there is
funding in the annual Budget Act or other statute for the outreach
and education campaign. The plan shall address both the Medi-Cal
program for children and the Healthy Families Program and, at a
minimum, shall include the following:
(1) Specific milestones and objectives to be completed for the
upcoming year and their anticipated cost.
(2) A general description of each strategy or method to be used
for outreach.
(3) Geographic areas and special populations to be targeted, if
any, and why the special targeting is needed.
(4) Coordination with other state or county education and outreach
efforts.
(5) The results of previous year outreach efforts.
(c) In implementing this section, the department may amend any
existing or future media outreach campaign contract that it has
entered into pursuant to Section 14148.5. Notwithstanding any other
provision of law, any such contract entered into, or amended, as
required to implement this section, shall be exempt from the approval
of the Director of General Services and from the provisions of the
Public Contract Code.
(d) (1) The department, in conjunction with the Managed Risk
Medical Insurance Board, may award contracts to community-based
organizations to help families learn about, and enroll in, the
Medi-Cal program and Healthy Families Program, and other health care
programs for low-income children. The department shall implement this
subdivision if funding is provided for this purpose by an
appropriation in the annual Budget Act or other statute.
(2) Contracts for these outreach and enrollment projects shall be
awarded based on, but not limited to, all of the following criteria:
(A) Capacity to reach populations or geographic areas with
disproportionately low enrollment rates. If it is not possible to
estimate the number of uninsured children in a geographic area who
are eligible for the Medi-Cal program or the Healthy Families
Program, proxy measures for rates of eligible children may be used.
These measures may include, but are not limited to, the number of
children in families with gross annual household incomes at or below
the federal poverty levels pertinent to the programs.
(B) Organizational capacity and experience, including, but not
limited to, any of the following:
(i) Organizational experience in serving low-income families.
(ii) Ability to work effectively with populations that have
disproportionately low enrollment rates.
(iii) Organizational experiences in helping families learn about,
and enroll in, the Medi-Cal program and Healthy Families Program.
Organizations that do not have experience helping families learn
about, and enroll in, the Medi-Cal program and Healthy Families
Program shall be eligible only to the extent that they support and
collaborate with the outreach and enrollment activities of entities
with that experience.
(C) Effectiveness of the outreach and education plan, including,
but not limited to, all of the following:
(i) Culturally and linguistically appropriate outreach and
education strategies.
(ii) Strategies to identify and address barriers to enrollment,
such as transportation limitations and community perceptions
regarding the Medi-Cal program and Healthy Families Program.
(iii) Coordination with other outreach efforts in the community,
including the statewide Healthy Families Program and Medi-Cal program
outreach campaign, the state and federally funded county Medi-Cal
outreach program, and any other Medi-Cal program and Healthy Families
Program outreach projects in the target community.
(iv) Collaboration with other local organizations that serve
families of eligible children.
(v) Strategies to ensure that children and families retain
coverage and are informed of options for health coverage and services
when they lose eligibility for a particular program.
(vi) Plans to inform families about all available health care
programs and services.
14067.3. (a) (1) The department may maintain an allocation program
for the management and funding of county outreach and enrollment
plans to enroll and retain eligible children in the Medi-Cal program
and the Healthy Families Program.
(2) Notwithstanding any other provision of law, and in a manner
that the director shall provide, the department may allocate an
amount to fund county outreach and enrollment plans identified in
this section.
(b) (1) The sum of three million dollars ($3,000,000) in the
2006-07 fiscal year, and thereafter adjusted proportionately on a pro
rata basis contingent upon the annual appropriation, but not less
than two million dollars ($2,000,000), shall be set aside, from the
annual allocation for purposes of this section, for counties
identified in subdivision (d).
(2) Notwithstanding paragraph (1), the total of all county
allocations made pursuant to this section shall not exceed the annual
appropriation for the implementation of this section.
(c) The director shall make allocations to not more than 20
counties that have the highest number of children who appear to be
eligible for the Medi-Cal program or the Healthy Families Program, as
determined by the director, but who are not currently enrolled in
either program, and the highest number of Medi-Cal program and
Healthy Families Program cases for children. This number shall be
weighted to emphasize those who appear eligible, but are not
currently enrolled in the programs.
(d) With funds set aside under paragraph (1) of subdivision (b),
the director shall make allocations to those counties that have an
existing infrastructure for outreach, enrollment, retention, and
utilization, and that can demonstrate they have well established and
documented county coalitions for children's coverage with
organizations such as community-based organizations, schools,
clinics, labor organizations, and other safety net providers in place
for at least 12 months.
(e) (1) To obtain an allocation authorized under this section, a
county shall submit an allocation plan, which shall include an
outreach and enrollment plan, as outlined in paragraph (2). The
director shall establish the procedures and format for submission to
the department of all county allocation plans.
(2) The following shall constitute the minimum components required
of a county outreach and enrollment plan:
(A) An active collaboration with a wide range of organizations,
such as community-based organizations, schools, clinics, labor
organizations, and other safety net providers.
(B) A streamlined application assistance process.
(C) Establishment of an oversight, performance management, and
review program to ensure that the outreach and enrollment plan
submitted by the county is properly implemented and administered.
(D) A description of each of the following:
(i) The amount of the current funding and funding source for
application, enrollment, retention, and utilization activities.
(ii) The current application, enrollment, retention, and
utilization activities.
(iii) How the allocation funds awarded under this section will be
used to supplement and not supplant existing application, enrollment,
retention, and utilization activities.
(E) A detailed proposed budget of all expenditures for the
relevant fiscal year or years for the county's outreach and
enrollment plan activities, expenses, services, materials, and
support.
(f) Counties receiving an allocation under this section shall
provide reports to the department, as determined by the department,
on the progress made in achieving the objectives of the allocation
plan.
(g) (1) The funds allocated under this section shall be used only
for outreach, enrollment, retention, and utilization. The funds
allocated under this section may supplement, but shall not supplant,
existing local, state, and foundation funding of county outreach,
enrollment, retention, and utilization activities. Notwithstanding
Section 10744, the department may recoup or withhold all or part of a
county's allocation for failure to comply with the standards set
forth in the county's outreach and enrollment plan upon which the
allocation was based.
(2) Notwithstanding any other provision in this section, any
acquisitions made with funds allocated under this section shall be
made in compliance with federal law.
(h) Reimbursements for costs incurred under the allocation plan
authorized under this section shall be made in arrears and in a
manner as provided by the director. The allocations may be used only
to fund activities provided in each of the designated fiscal years
and in accordance with the county's approved outreach and enrollment
plan and budget for the fiscal year.
(i) As authorized by the director, on a case by case basis, funds
allocated pursuant to this section may be used to support automated
enrollment of children in the Medi-Cal program or the Healthy
Families Program. Funds under this subdivision shall further the goal
of increasing the enrollment of uninsured children, as well as
increasing the retention of children, in the Medi-Cal program and
Healthy Families Program in the same fiscal year for which the funds
are allocated.
(j) The department and the Managed Risk Medical Insurance Board
shall seek approval of any amendments to the state plan necessary to
implement this section for purposes of funding under Titles XIX and
XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq.
and 1397aa et seq., respectively). This section shall be implemented
only when federal approvals have been obtained and only to the extent
federal financial participation is available.
(k) The department shall reimburse a county pursuant to this
section in lieu of commencing a cooperative agreement or contract
with a county for the operation of an outreach program.
(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all county letters, provider bulletins, or similar
instructions.
(m) For the purposes of this section, "county outreach and
enrollment plan" means a county outreach program designed to identify
and enroll children who are eligible either for the Healthy Families
Program or the Medi-Cal program, but are not currently enrolled in
either program, and to facilitate the retention of eligible children
currently enrolled in these programs.
14067.5. The department shall encourage counties to outstation
additional Medi-Cal eligibility workers in nontraditional sites, such
as schools, private hospitals, clinics, mental health centers, sites
providing services under California Supplemental Food Program for
Women, Infants, and Children sites, and community-based
organizations. The department shall permit counties to redirect a
portion of existing funding for Medi-Cal eligibility administration
for this purpose. The department shall require counties that redirect
funds to provide an annual report on the cost of the additional
outstationed workers and their effectiveness in increasing or
facilitating Medi-Cal enrollment. Expenditures under this section
shall be subject to the availability of federal financial
participation, and shall not cause an increase in the allocation of
funds for the administration of the Medi-Cal program.
14068. In conducting outreach activities for the enrollment of
special needs populations into a Medi-Cal managed care program, the
department and its contractors, as deemed applicable by the
department, shall work with state, local, and regional organizations
with the ability to target low-income seniors and individuals with
disabilities in the communities where they live. This shall include,
but not be limited to, all applicable state departments that serve
these individuals, regional centers, seniors' organizations, local
health consumer centers, and other consumer-focused organizations
that are engaging in providing assistance to this population.
14050. Unless the context otherwise requires, the definitions set
forth in this article govern the construction of this chapter.
14050.1. For purposes of this chapter, "categorically needy person"
means a person whose coverage is mandatory under Title XIX of the
Social Security Act including, but not limited to, the individuals
covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the
United States Code.
14050.2. For the purposes of this chapter "aid" means financial
assistance provided to or in behalf of needy persons under the
provisions of Chapters 2 (commencing with Section 11200), 3
(commencing with Section 12000), and 5 (commencing with Section
13000) of this part.
14050.3. "A person in long-term care" means a person who is an
inpatient in a medical facility for more than the month of admission
who is expected to remain for the full month after the month of
admission.
14051. (a) "Medically needy person" means any of the following:
(1) An aged, blind, or disabled person who meets the definition of
aged, blind, or disabled under the Supplemental Security Income
Program and whose income and resources are insufficient to provide
for the costs of health care or coverage.
(2) A child in foster care for whom public agencies are assuming
financial responsibility, in whole or in part, or a person receiving
aid under Chapter 2.1 (commencing with Section 16115) of Part 4.
(3) A child who is eligible to receive Medi-Cal benefits pursuant
to interstate agreements for adoption assistance and related services
and benefits entered into under Chapter 2.6 (commencing with Section
16170) of Part 4, to the extent federal financial participation is
available.
(b) "Medically needy family person" means a parent or caretaker
relative of a child who meets the deprivation requirements of Aid to
Families with Dependent Children or a child under 21 years of age or
a pregnant woman of any age with a confirmed pregnancy, exclusive of
those persons specified in subdivision (a), whose income and
resources are insufficient to provide for the costs of health care or
coverage.
14051.5. (a) "Medically needy person" also means any person who
receives in-home supportive services pursuant to Section 12305.5 and
whose income and resources are insufficient to provide for the costs
of health care or coverage.
14052. "State-only Medi-Cal person" means a person who resides in a
nursing facility or any category of intermediate care facility for
the developmentally disabled, and who meets all of the following
requirements:
(a) Could not meet the definition of a categorically needy person
under Section 14050.1, a medically needy person under subdivision (a)
of Section 14051 or a medically needy family person under
subdivision (b) of Section 14051.
(b) Is over 21 years of age.
(c) Meets the eligibility requirements of Section 14005.4.
14052.1. "Cuban-Haitian entrant or refugee" means a person eligible
under the Cuban-Haitian Entrant Program or Refugee Resettlement
Program, as defined in federal regulations.
14053. (a) The term "health care services" means the benefits set
forth in Article 4 (commencing with Section 14131) of this chapter
and in Section 14021. The term includes inpatient hospital services
for any individual under 21 years of age in an institution for mental
diseases. Any individual under 21 years of age receiving inpatient
psychiatric hospital services immediately preceding the date on which
he or she attains age 21 may continue to receive these services
until he or she attains age 22. The term also includes early and
periodic screening, diagnosis, and treatment for any individual under
21 years of age.
(b) The term "health care services" does not include, except to
the extent permitted by federal law, any of the following:
(1) Care or services for any individual who is an inmate of an
institution (except as a patient in a medical institution).
(2) Care or services for any individual who has not attained 65
years of age and who is a patient in an institution for tuberculosis.
(3) Care or services for any individual who is 21 years of age or
over, except as provided in the first paragraph of this section, and
has not attained 65 years of age and who is a patient in an
institution for mental disease.
(4) Inpatient services provided to individuals 21 to 64 years of
age, inclusive, in an institution for mental diseases operating under
a consolidated license with a general acute care hospital pursuant
to Section 1250.8 of the Health and Safety Code, unless federal
financial participation is available for such inpatient services.
14053.1. Notwithstanding Section 14053, ancillary outpatient
services, pursuant to Section 14132, for any eligible individual who
is 21 years of age or over, and has not attained 65 years of age and
who is a patient in an institution for mental diseases shall be
covered regardless of the availability of federal financial
participation.
14053.3. As federal financial participation reimbursement is not
allowed for ancillary services provided to persons residing in
facilities that have been found to be institutions for mental disease
(IMD), and since, consistent with Part 2 (commencing with Section
5600) of Division 5 and Chapter 6 (commencing with Section 17600) of
Part 5, counties are financially responsible for mental health
services and related ancillary services provided to persons through
county mental health programs when Medi-Cal reimbursement is not
available, when it is determined that Medi-Cal reimbursement has been
paid for ancillary services for residents of IMDs, both the federal
financial participation reimbursement and any state funds paid for
the ancillary services provided to residents of IMDs shall be
recovered from counties by the State Department of Mental Health in
accordance with applicable state and federal statutes and
regulations.
14053.5. For the purposes of the Medi-Cal Act, the terms
"prescribed drug" and "prescription drug" shall not include any drug
which, because of differing prices charged by the manufacturer on a
discriminatory basis or discriminatory refusal to sell by the
manufacturer, or both, is not available on the same terms and
conditions to all providers of prescription services, or any drug
which is found to be overpriced in comparison to another drug which
has an equivalent therapeutic effect, unless the director determines
that the drug is vital to the program and no acceptable substitute is
available.
Before the director determines that any drug has an equivalent
therapeutic effect in comparison to another drug, or is vital to the
program and no acceptable substitute is available, he must have
received a report to that effect from the Medi-Cal Contract Drug
Advisory Committee.
Nothing in this section shall be construed to apply to quantity or
other nondiscriminatory discounts available on the same terms and
conditions to all providers of prescription services, to sales by
competitive bidding to federal, state or local governmental agencies,
or to sales to wholesalers so long as the manufacturer does not
require or induce the wholesalers to make the drug available other
than on the same terms and conditions to all providers of
prescription services.
This section shall not be construed to deny reimbursement to
hospitals for prescribed drugs furnished to inpatients or, unless the
regulations provide to the contrary, to registered outpatients.
14053.6. Prior to including or excluding any drug from the program,
the director shall give adequate notice to those California
associations of health professionals and those recognized national
associations of pharmaceutical manufacturers that are affected by
such action and shall seek and consider the advice of those
associations.
14053.7. (a) Notwithstanding any other provision of law, and only
to the extent that federal financial participation is available, the
department may provide Medi-Cal eligibility and reimbursement for
inpatient hospital services available under this chapter in
accordance with Section 5072 of the Penal Code.
(b) The department may disenroll inmates made eligible for
services under this section or in accordance with Section 5072 of the
Penal Code from Medi-Cal managed care health plans, and may exempt
inmates from enrollment into new or existing plans.
(c) Except as provided for in paragraph (2) of subdivision (e),
the Department of Corrections and Rehabilitation shall be responsible
for the nonfederal share of any reimbursement made for the provision
of inpatient hospital services rendered to inmates who are eligible
for and enrolled in a CEED project and receive services pursuant to
this section and Section 5072 of the Penal Code.
(d) (1) Notwithstanding any other provision of law, including
Section 11050, the state may make eligibility determinations and
redeterminations for inmates in accord with Section 5072 of the Penal
Code.
(2) The department may enroll and disenroll inmates eligible for
inpatient hospital services under this section or in accord with
Section 5072 of the Penal Code in Medi-Cal or in the CEED project in
which the inmate's county of last legal residence participates.
(e) (1) In accordance with the requirements and conditions set
forth under this section and Section 5072 of the Penal Code, the
county may seek from the Medi-Cal program or from the responsible
CEED project in which the county participates, reimbursement for the
provision of inpatient hospital services to adults involuntarily
detained or incarcerated in county facilities.
(2) (A) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9, the county shall be
responsible for the nonfederal share of the reimbursement.
(B) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for and enrolled in the CEED project in which
the county participates, the CEED project shall be responsible for
the nonfederal share of the reimbursement.
(f) Except as otherwise provided in subdivision (c) of Section
5072 of the Penal Code, the inpatient hospital services eligible for
reimbursement under this section shall be limited to only those
services which are subject to funding with federal financial
participation pursuant to Title XIX of the federal Social Security
Act.
(g) This section shall be implemented only if and to the extent
that existing levels of federal financial participation are not
otherwise jeopardized. To the extent that the department determines
that existing levels of federal financial participation are
jeopardized, this section shall no longer be implemented.
(h) The department shall seek any necessary federal approvals for
the implementation of this section. This section shall be implemented
only if and to the extent that any necessary federal approvals are
obtained.
(i) This section shall have no force of effect if there is a final
judicial determination made by any state or federal court that is
not appealed, or by a court of appellate jurisdiction that is not
further appealed, in any action by any party, or a final
determination by the administrator of the federal Centers for
Medicare and Medicaid Services, that disallows, defers, or alters the
implementation of this section or in accord with Section 5072 of the
Penal Code, including the rate methodology or payment process
established by the department that limits or affects the department's
authority to select the hospitals used to provide inpatient hospital
services to inmates.
(j) It is the intent of the Legislature that the implementation of
this section will result in state General Fund savings for the
funding of inpatient hospital services and any related administrative
costs to the inmate population.
(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may, without taking any further regulatory action,
implement this section by means of all-county letters or similar
instructions.
(l) For purposes of this section, the following terms have the
following meanings:
(1) The term "county of last legal residence" means the county in
which the inmate resided at the time of arrest that resulted in
conviction and incarceration in a state prison facility.
(2) The term "inmate" means an adult who is involuntarily residing
in a state prison facility operated, administered or regulated,
directly or indirectly, by the Department of Corrections and
Rehabilitation.
14054. "Share of cost" means the amount of the costs of health care
which a person or family eligible under Section 14005.4 or 14005.7
must incur prior to being certified by the department as specified in
Section 14018.
14054.5. "Elective services" means any treatment service which
generally can be postponed without seriously affecting the health of
the person requiring the service.
14056. "Minimum coverage" means prescribed drugs for public
assistance recipients as established by the director, and care or
coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of
Section 14053, except that it shall not include elective services.
14057.5. "Contract hospital" means a nonprofit medical facility
licensed pursuant to Chapter 2 (commencing with Section 1250) of
Division 2 of the Health and Safety Code, with which the board of
supervisors of a county which does not maintain a county hospital has
executed a contract, currently in effect, to care for medically
indigent individuals.
14059. Health care provided under this chapter may include
diagnostic, preventive, corrective, and curative services and
supplies essential thereto, provided by qualified medical and related
personnel for conditions that cause suffering, endanger life, result
in illness or infirmity, interfere with capacity for normal activity
including employment, or for conditions which may develop into some
significant handicap.
Medical care shall include, but is not limited to, other remedial
care, not necessarily medical. Other remedial care shall include,
without being limited to, treatment by prayer or healing by spiritual
means in the practice of the religion of any church or religious
denomination.
14059.5. A service is "medically necessary" or a "medical necessity"
when it is reasonable and necessary to protect life, to prevent
significant illness or significant disability, or to alleviate severe
pain.
14060. Every recipient who is entitled to visual care under this
chapter, which may be rendered either by an optometrist or a
physician, may select a duly licensed member of either profession to
render the service.
14061. As used in this chapter, "director" means the State Director
of Health Services.
14062. As used in this chapter, "department" means the State
Department of Health Services.
14063. As used in this chapter, "Medi-Cal" means the California
Medical Assistance Program.
14064. A. Inpatient intensive rehabilitation hospital services
shall consist of programs for:
1. Strengthening and training of selected muscle groups.
2. Preservation and restoration of joint mobility (prevention and
correction of contractures).
3. Training in application and use of equipment.
4. Training in activities of daily living, self-care, locomotion
and homemaking skills.
5. Cognitive reorganization and communication skills.
6. Resolution of psychological and social problems which are
impeding rehabilitation.
B. These programs shall use a multidiscipline approach carried out
under the general or direct supervision of a physician with special
training or experience in the field of rehabilitation. When medically
indicated, a program of this scope includes but is not limited to:
1. Skilled rehabilitation nursing care.
2. Physical therapy.
3. Occupational therapy.
4. Speech therapy.
5. Prosthetic or orthotic services.
6. Psychologist services.
7. Medical social worker services.
C. A typical program shall provide for:
1. Initial evaluation (7-10 days) for assessment of medical
condition, functional limitations, possible need for surgery,
attitude toward rehabilitation, functional goals and plans for
discharge.
2. Where the rehabilitation potential is undetermined, the patient
shall be placed on a 14-day trial program. If no improvement is
noted after this period, definitive plans for discharge should be
made.
3. Where the initial evaluation results in a conclusion by the
rehabilitation team that a significant practical improvement can be
expected in a reasonable period of time, the program should continue
until such time as further progress toward the established
rehabilitation goals is unlikely or it can be achieved in a less
intensive setting.
14065. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Director of
Health" and "Director of Benefit Payments" shall be construed to
refer to and mean the State Director of Health Services.
14066. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Department
of Health," "State Department of Health," "Department of Benefit
Payments," and "State Department of Benefit Payments" shall be
construed to refer to and mean the State Department of Health
Services.
14067. (a) The department, in conjunction with the Managed Risk
Medical Insurance Board, may develop and conduct a community outreach
and education campaign to help families learn about, and apply for,
Medi-Cal and the Healthy Families Program of the Managed Risk Medical
Insurance Board, subject to the requirements of federal law. In
conducting this campaign, the department may seek input from, and
contract with, various entities and programs that serve children,
including, but not limited to, the State Department of Education,
counties, Women, Infants, and Children program agencies, Head Start
and Healthy Start programs, and community-based organizations that
deal with potentially eligible families and children to assist in the
outreach, education, and application completion process. The
department shall implement the campaign if funding is provided for
this purpose by an appropriation in the annual Budget Act or other
statute.
(b) An annual outreach plan shall be submitted to the Legislature
by April 1 for each fiscal year for those years for which there is
funding in the annual Budget Act or other statute for the outreach
and education campaign. The plan shall address both the Medi-Cal
program for children and the Healthy Families Program and, at a
minimum, shall include the following:
(1) Specific milestones and objectives to be completed for the
upcoming year and their anticipated cost.
(2) A general description of each strategy or method to be used
for outreach.
(3) Geographic areas and special populations to be targeted, if
any, and why the special targeting is needed.
(4) Coordination with other state or county education and outreach
efforts.
(5) The results of previous year outreach efforts.
(c) In implementing this section, the department may amend any
existing or future media outreach campaign contract that it has
entered into pursuant to Section 14148.5. Notwithstanding any other
provision of law, any such contract entered into, or amended, as
required to implement this section, shall be exempt from the approval
of the Director of General Services and from the provisions of the
Public Contract Code.
(d) (1) The department, in conjunction with the Managed Risk
Medical Insurance Board, may award contracts to community-based
organizations to help families learn about, and enroll in, the
Medi-Cal program and Healthy Families Program, and other health care
programs for low-income children. The department shall implement this
subdivision if funding is provided for this purpose by an
appropriation in the annual Budget Act or other statute.
(2) Contracts for these outreach and enrollment projects shall be
awarded based on, but not limited to, all of the following criteria:
(A) Capacity to reach populations or geographic areas with
disproportionately low enrollment rates. If it is not possible to
estimate the number of uninsured children in a geographic area who
are eligible for the Medi-Cal program or the Healthy Families
Program, proxy measures for rates of eligible children may be used.
These measures may include, but are not limited to, the number of
children in families with gross annual household incomes at or below
the federal poverty levels pertinent to the programs.
(B) Organizational capacity and experience, including, but not
limited to, any of the following:
(i) Organizational experience in serving low-income families.
(ii) Ability to work effectively with populations that have
disproportionately low enrollment rates.
(iii) Organizational experiences in helping families learn about,
and enroll in, the Medi-Cal program and Healthy Families Program.
Organizations that do not have experience helping families learn
about, and enroll in, the Medi-Cal program and Healthy Families
Program shall be eligible only to the extent that they support and
collaborate with the outreach and enrollment activities of entities
with that experience.
(C) Effectiveness of the outreach and education plan, including,
but not limited to, all of the following:
(i) Culturally and linguistically appropriate outreach and
education strategies.
(ii) Strategies to identify and address barriers to enrollment,
such as transportation limitations and community perceptions
regarding the Medi-Cal program and Healthy Families Program.
(iii) Coordination with other outreach efforts in the community,
including the statewide Healthy Families Program and Medi-Cal program
outreach campaign, the state and federally funded county Medi-Cal
outreach program, and any other Medi-Cal program and Healthy Families
Program outreach projects in the target community.
(iv) Collaboration with other local organizations that serve
families of eligible children.
(v) Strategies to ensure that children and families retain
coverage and are informed of options for health coverage and services
when they lose eligibility for a particular program.
(vi) Plans to inform families about all available health care
programs and services.
14067.3. (a) (1) The department may maintain an allocation program
for the management and funding of county outreach and enrollment
plans to enroll and retain eligible children in the Medi-Cal program
and the Healthy Families Program.
(2) Notwithstanding any other provision of law, and in a manner
that the director shall provide, the department may allocate an
amount to fund county outreach and enrollment plans identified in
this section.
(b) (1) The sum of three million dollars ($3,000,000) in the
2006-07 fiscal year, and thereafter adjusted proportionately on a pro
rata basis contingent upon the annual appropriation, but not less
than two million dollars ($2,000,000), shall be set aside, from the
annual allocation for purposes of this section, for counties
identified in subdivision (d).
(2) Notwithstanding paragraph (1), the total of all county
allocations made pursuant to this section shall not exceed the annual
appropriation for the implementation of this section.
(c) The director shall make allocations to not more than 20
counties that have the highest number of children who appear to be
eligible for the Medi-Cal program or the Healthy Families Program, as
determined by the director, but who are not currently enrolled in
either program, and the highest number of Medi-Cal program and
Healthy Families Program cases for children. This number shall be
weighted to emphasize those who appear eligible, but are not
currently enrolled in the programs.
(d) With funds set aside under paragraph (1) of subdivision (b),
the director shall make allocations to those counties that have an
existing infrastructure for outreach, enrollment, retention, and
utilization, and that can demonstrate they have well established and
documented county coalitions for children's coverage with
organizations such as community-based organizations, schools,
clinics, labor organizations, and other safety net providers in place
for at least 12 months.
(e) (1) To obtain an allocation authorized under this section, a
county shall submit an allocation plan, which shall include an
outreach and enrollment plan, as outlined in paragraph (2). The
director shall establish the procedures and format for submission to
the department of all county allocation plans.
(2) The following shall constitute the minimum components required
of a county outreach and enrollment plan:
(A) An active collaboration with a wide range of organizations,
such as community-based organizations, schools, clinics, labor
organizations, and other safety net providers.
(B) A streamlined application assistance process.
(C) Establishment of an oversight, performance management, and
review program to ensure that the outreach and enrollment plan
submitted by the county is properly implemented and administered.
(D) A description of each of the following:
(i) The amount of the current funding and funding source for
application, enrollment, retention, and utilization activities.
(ii) The current application, enrollment, retention, and
utilization activities.
(iii) How the allocation funds awarded under this section will be
used to supplement and not supplant existing application, enrollment,
retention, and utilization activities.
(E) A detailed proposed budget of all expenditures for the
relevant fiscal year or years for the county's outreach and
enrollment plan activities, expenses, services, materials, and
support.
(f) Counties receiving an allocation under this section shall
provide reports to the department, as determined by the department,
on the progress made in achieving the objectives of the allocation
plan.
(g) (1) The funds allocated under this section shall be used only
for outreach, enrollment, retention, and utilization. The funds
allocated under this section may supplement, but shall not supplant,
existing local, state, and foundation funding of county outreach,
enrollment, retention, and utilization activities. Notwithstanding
Section 10744, the department may recoup or withhold all or part of a
county's allocation for failure to comply with the standards set
forth in the county's outreach and enrollment plan upon which the
allocation was based.
(2) Notwithstanding any other provision in this section, any
acquisitions made with funds allocated under this section shall be
made in compliance with federal law.
(h) Reimbursements for costs incurred under the allocation plan
authorized under this section shall be made in arrears and in a
manner as provided by the director. The allocations may be used only
to fund activities provided in each of the designated fiscal years
and in accordance with the county's approved outreach and enrollment
plan and budget for the fiscal year.
(i) As authorized by the director, on a case by case basis, funds
allocated pursuant to this section may be used to support automated
enrollment of children in the Medi-Cal program or the Healthy
Families Program. Funds under this subdivision shall further the goal
of increasing the enrollment of uninsured children, as well as
increasing the retention of children, in the Medi-Cal program and
Healthy Families Program in the same fiscal year for which the funds
are allocated.
(j) The department and the Managed Risk Medical Insurance Board
shall seek approval of any amendments to the state plan necessary to
implement this section for purposes of funding under Titles XIX and
XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq.
and 1397aa et seq., respectively). This section shall be implemented
only when federal approvals have been obtained and only to the extent
federal financial participation is available.
(k) The department shall reimburse a county pursuant to this
section in lieu of commencing a cooperative agreement or contract
with a county for the operation of an outreach program.
(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all county letters, provider bulletins, or similar
instructions.
(m) For the purposes of this section, "county outreach and
enrollment plan" means a county outreach program designed to identify
and enroll children who are eligible either for the Healthy Families
Program or the Medi-Cal program, but are not currently enrolled in
either program, and to facilitate the retention of eligible children
currently enrolled in these programs.
14067.5. The department shall encourage counties to outstation
additional Medi-Cal eligibility workers in nontraditional sites, such
as schools, private hospitals, clinics, mental health centers, sites
providing services under California Supplemental Food Program for
Women, Infants, and Children sites, and community-based
organizations. The department shall permit counties to redirect a
portion of existing funding for Medi-Cal eligibility administration
for this purpose. The department shall require counties that redirect
funds to provide an annual report on the cost of the additional
outstationed workers and their effectiveness in increasing or
facilitating Medi-Cal enrollment. Expenditures under this section
shall be subject to the availability of federal financial
participation, and shall not cause an increase in the allocation of
funds for the administration of the Medi-Cal program.
14068. In conducting outreach activities for the enrollment of
special needs populations into a Medi-Cal managed care program, the
department and its contractors, as deemed applicable by the
department, shall work with state, local, and regional organizations
with the ability to target low-income seniors and individuals with
disabilities in the communities where they live. This shall include,
but not be limited to, all applicable state departments that serve
these individuals, regional centers, seniors' organizations, local
health consumer centers, and other consumer-focused organizations
that are engaging in providing assistance to this population.
14050. Unless the context otherwise requires, the definitions set
forth in this article govern the construction of this chapter.
14050.1. For purposes of this chapter, "categorically needy person"
means a person whose coverage is mandatory under Title XIX of the
Social Security Act including, but not limited to, the individuals
covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the
United States Code.
14050.2. For the purposes of this chapter "aid" means financial
assistance provided to or in behalf of needy persons under the
provisions of Chapters 2 (commencing with Section 11200), 3
(commencing with Section 12000), and 5 (commencing with Section
13000) of this part.
14050.3. "A person in long-term care" means a person who is an
inpatient in a medical facility for more than the month of admission
who is expected to remain for the full month after the month of
admission.
14051. (a) "Medically needy person" means any of the following:
(1) An aged, blind, or disabled person who meets the definition of
aged, blind, or disabled under the Supplemental Security Income
Program and whose income and resources are insufficient to provide
for the costs of health care or coverage.
(2) A child in foster care for whom public agencies are assuming
financial responsibility, in whole or in part, or a person receiving
aid under Chapter 2.1 (commencing with Section 16115) of Part 4.
(3) A child who is eligible to receive Medi-Cal benefits pursuant
to interstate agreements for adoption assistance and related services
and benefits entered into under Chapter 2.6 (commencing with Section
16170) of Part 4, to the extent federal financial participation is
available.
(b) "Medically needy family person" means a parent or caretaker
relative of a child who meets the deprivation requirements of Aid to
Families with Dependent Children or a child under 21 years of age or
a pregnant woman of any age with a confirmed pregnancy, exclusive of
those persons specified in subdivision (a), whose income and
resources are insufficient to provide for the costs of health care or
coverage.
14051.5. (a) "Medically needy person" also means any person who
receives in-home supportive services pursuant to Section 12305.5 and
whose income and resources are insufficient to provide for the costs
of health care or coverage.
14052. "State-only Medi-Cal person" means a person who resides in a
nursing facility or any category of intermediate care facility for
the developmentally disabled, and who meets all of the following
requirements:
(a) Could not meet the definition of a categorically needy person
under Section 14050.1, a medically needy person under subdivision (a)
of Section 14051 or a medically needy family person under
subdivision (b) of Section 14051.
(b) Is over 21 years of age.
(c) Meets the eligibility requirements of Section 14005.4.
14052.1. "Cuban-Haitian entrant or refugee" means a person eligible
under the Cuban-Haitian Entrant Program or Refugee Resettlement
Program, as defined in federal regulations.
14053. (a) The term "health care services" means the benefits set
forth in Article 4 (commencing with Section 14131) of this chapter
and in Section 14021. The term includes inpatient hospital services
for any individual under 21 years of age in an institution for mental
diseases. Any individual under 21 years of age receiving inpatient
psychiatric hospital services immediately preceding the date on which
he or she attains age 21 may continue to receive these services
until he or she attains age 22. The term also includes early and
periodic screening, diagnosis, and treatment for any individual under
21 years of age.
(b) The term "health care services" does not include, except to
the extent permitted by federal law, any of the following:
(1) Care or services for any individual who is an inmate of an
institution (except as a patient in a medical institution).
(2) Care or services for any individual who has not attained 65
years of age and who is a patient in an institution for tuberculosis.
(3) Care or services for any individual who is 21 years of age or
over, except as provided in the first paragraph of this section, and
has not attained 65 years of age and who is a patient in an
institution for mental disease.
(4) Inpatient services provided to individuals 21 to 64 years of
age, inclusive, in an institution for mental diseases operating under
a consolidated license with a general acute care hospital pursuant
to Section 1250.8 of the Health and Safety Code, unless federal
financial participation is available for such inpatient services.
14053.1. Notwithstanding Section 14053, ancillary outpatient
services, pursuant to Section 14132, for any eligible individual who
is 21 years of age or over, and has not attained 65 years of age and
who is a patient in an institution for mental diseases shall be
covered regardless of the availability of federal financial
participation.
14053.3. As federal financial participation reimbursement is not
allowed for ancillary services provided to persons residing in
facilities that have been found to be institutions for mental disease
(IMD), and since, consistent with Part 2 (commencing with Section
5600) of Division 5 and Chapter 6 (commencing with Section 17600) of
Part 5, counties are financially responsible for mental health
services and related ancillary services provided to persons through
county mental health programs when Medi-Cal reimbursement is not
available, when it is determined that Medi-Cal reimbursement has been
paid for ancillary services for residents of IMDs, both the federal
financial participation reimbursement and any state funds paid for
the ancillary services provided to residents of IMDs shall be
recovered from counties by the State Department of Mental Health in
accordance with applicable state and federal statutes and
regulations.
14053.5. For the purposes of the Medi-Cal Act, the terms
"prescribed drug" and "prescription drug" shall not include any drug
which, because of differing prices charged by the manufacturer on a
discriminatory basis or discriminatory refusal to sell by the
manufacturer, or both, is not available on the same terms and
conditions to all providers of prescription services, or any drug
which is found to be overpriced in comparison to another drug which
has an equivalent therapeutic effect, unless the director determines
that the drug is vital to the program and no acceptable substitute is
available.
Before the director determines that any drug has an equivalent
therapeutic effect in comparison to another drug, or is vital to the
program and no acceptable substitute is available, he must have
received a report to that effect from the Medi-Cal Contract Drug
Advisory Committee.
Nothing in this section shall be construed to apply to quantity or
other nondiscriminatory discounts available on the same terms and
conditions to all providers of prescription services, to sales by
competitive bidding to federal, state or local governmental agencies,
or to sales to wholesalers so long as the manufacturer does not
require or induce the wholesalers to make the drug available other
than on the same terms and conditions to all providers of
prescription services.
This section shall not be construed to deny reimbursement to
hospitals for prescribed drugs furnished to inpatients or, unless the
regulations provide to the contrary, to registered outpatients.
14053.6. Prior to including or excluding any drug from the program,
the director shall give adequate notice to those California
associations of health professionals and those recognized national
associations of pharmaceutical manufacturers that are affected by
such action and shall seek and consider the advice of those
associations.
14053.7. (a) Notwithstanding any other provision of law, and only
to the extent that federal financial participation is available, the
department may provide Medi-Cal eligibility and reimbursement for
inpatient hospital services available under this chapter in
accordance with Section 5072 of the Penal Code.
(b) The department may disenroll inmates made eligible for
services under this section or in accordance with Section 5072 of the
Penal Code from Medi-Cal managed care health plans, and may exempt
inmates from enrollment into new or existing plans.
(c) Except as provided for in paragraph (2) of subdivision (e),
the Department of Corrections and Rehabilitation shall be responsible
for the nonfederal share of any reimbursement made for the provision
of inpatient hospital services rendered to inmates who are eligible
for and enrolled in a CEED project and receive services pursuant to
this section and Section 5072 of the Penal Code.
(d) (1) Notwithstanding any other provision of law, including
Section 11050, the state may make eligibility determinations and
redeterminations for inmates in accord with Section 5072 of the Penal
Code.
(2) The department may enroll and disenroll inmates eligible for
inpatient hospital services under this section or in accord with
Section 5072 of the Penal Code in Medi-Cal or in the CEED project in
which the inmate's county of last legal residence participates.
(e) (1) In accordance with the requirements and conditions set
forth under this section and Section 5072 of the Penal Code, the
county may seek from the Medi-Cal program or from the responsible
CEED project in which the county participates, reimbursement for the
provision of inpatient hospital services to adults involuntarily
detained or incarcerated in county facilities.
(2) (A) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9, the county shall be
responsible for the nonfederal share of the reimbursement.
(B) To the extent that a county seeks reimbursement for the
provision of inpatient hospital services to adults who are
involuntarily detained or incarcerated in county facilities and who
are otherwise eligible for and enrolled in the CEED project in which
the county participates, the CEED project shall be responsible for
the nonfederal share of the reimbursement.
(f) Except as otherwise provided in subdivision (c) of Section
5072 of the Penal Code, the inpatient hospital services eligible for
reimbursement under this section shall be limited to only those
services which are subject to funding with federal financial
participation pursuant to Title XIX of the federal Social Security
Act.
(g) This section shall be implemented only if and to the extent
that existing levels of federal financial participation are not
otherwise jeopardized. To the extent that the department determines
that existing levels of federal financial participation are
jeopardized, this section shall no longer be implemented.
(h) The department shall seek any necessary federal approvals for
the implementation of this section. This section shall be implemented
only if and to the extent that any necessary federal approvals are
obtained.
(i) This section shall have no force of effect if there is a final
judicial determination made by any state or federal court that is
not appealed, or by a court of appellate jurisdiction that is not
further appealed, in any action by any party, or a final
determination by the administrator of the federal Centers for
Medicare and Medicaid Services, that disallows, defers, or alters the
implementation of this section or in accord with Section 5072 of the
Penal Code, including the rate methodology or payment process
established by the department that limits or affects the department's
authority to select the hospitals used to provide inpatient hospital
services to inmates.
(j) It is the intent of the Legislature that the implementation of
this section will result in state General Fund savings for the
funding of inpatient hospital services and any related administrative
costs to the inmate population.
(k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may, without taking any further regulatory action,
implement this section by means of all-county letters or similar
instructions.
(l) For purposes of this section, the following terms have the
following meanings:
(1) The term "county of last legal residence" means the county in
which the inmate resided at the time of arrest that resulted in
conviction and incarceration in a state prison facility.
(2) The term "inmate" means an adult who is involuntarily residing
in a state prison facility operated, administered or regulated,
directly or indirectly, by the Department of Corrections and
Rehabilitation.
14054. "Share of cost" means the amount of the costs of health care
which a person or family eligible under Section 14005.4 or 14005.7
must incur prior to being certified by the department as specified in
Section 14018.
14054.5. "Elective services" means any treatment service which
generally can be postponed without seriously affecting the health of
the person requiring the service.
14056. "Minimum coverage" means prescribed drugs for public
assistance recipients as established by the director, and care or
coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of
Section 14053, except that it shall not include elective services.
14057.5. "Contract hospital" means a nonprofit medical facility
licensed pursuant to Chapter 2 (commencing with Section 1250) of
Division 2 of the Health and Safety Code, with which the board of
supervisors of a county which does not maintain a county hospital has
executed a contract, currently in effect, to care for medically
indigent individuals.
14059. Health care provided under this chapter may include
diagnostic, preventive, corrective, and curative services and
supplies essential thereto, provided by qualified medical and related
personnel for conditions that cause suffering, endanger life, result
in illness or infirmity, interfere with capacity for normal activity
including employment, or for conditions which may develop into some
significant handicap.
Medical care shall include, but is not limited to, other remedial
care, not necessarily medical. Other remedial care shall include,
without being limited to, treatment by prayer or healing by spiritual
means in the practice of the religion of any church or religious
denomination.
14059.5. A service is "medically necessary" or a "medical necessity"
when it is reasonable and necessary to protect life, to prevent
significant illness or significant disability, or to alleviate severe
pain.
14060. Every recipient who is entitled to visual care under this
chapter, which may be rendered either by an optometrist or a
physician, may select a duly licensed member of either profession to
render the service.
14061. As used in this chapter, "director" means the State Director
of Health Services.
14062. As used in this chapter, "department" means the State
Department of Health Services.
14063. As used in this chapter, "Medi-Cal" means the California
Medical Assistance Program.
14064. A. Inpatient intensive rehabilitation hospital services
shall consist of programs for:
1. Strengthening and training of selected muscle groups.
2. Preservation and restoration of joint mobility (prevention and
correction of contractures).
3. Training in application and use of equipment.
4. Training in activities of daily living, self-care, locomotion
and homemaking skills.
5. Cognitive reorganization and communication skills.
6. Resolution of psychological and social problems which are
impeding rehabilitation.
B. These programs shall use a multidiscipline approach carried out
under the general or direct supervision of a physician with special
training or experience in the field of rehabilitation. When medically
indicated, a program of this scope includes but is not limited to:
1. Skilled rehabilitation nursing care.
2. Physical therapy.
3. Occupational therapy.
4. Speech therapy.
5. Prosthetic or orthotic services.
6. Psychologist services.
7. Medical social worker services.
C. A typical program shall provide for:
1. Initial evaluation (7-10 days) for assessment of medical
condition, functional limitations, possible need for surgery,
attitude toward rehabilitation, functional goals and plans for
discharge.
2. Where the rehabilitation potential is undetermined, the patient
shall be placed on a 14-day trial program. If no improvement is
noted after this period, definitive plans for discharge should be
made.
3. Where the initial evaluation results in a conclusion by the
rehabilitation team that a significant practical improvement can be
expected in a reasonable period of time, the program should continue
until such time as further progress toward the established
rehabilitation goals is unlikely or it can be achieved in a less
intensive setting.
14065. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Director of
Health" and "Director of Benefit Payments" shall be construed to
refer to and mean the State Director of Health Services.
14066. As used in this chapter, Chapter 8 (commencing with Section
14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7
(commencing with Section 14520) of this part, the terms "Department
of Health," "State Department of Health," "Department of Benefit
Payments," and "State Department of Benefit Payments" shall be
construed to refer to and mean the State Department of Health
Services.
14067. (a) The department, in conjunction with the Managed Risk
Medical Insurance Board, may develop and conduct a community outreach
and education campaign to help families learn about, and apply for,
Medi-Cal and the Healthy Families Program of the Managed Risk Medical
Insurance Board, subject to the requirements of federal law. In
conducting this campaign, the department may seek input from, and
contract with, various entities and programs that serve children,
including, but not limited to, the State Department of Education,
counties, Women, Infants, and Children program agencies, Head Start
and Healthy Start programs, and community-based organizations that
deal with potentially eligible families and children to assist in the
outreach, education, and application completion process. The
department shall implement the campaign if funding is provided for
this purpose by an appropriation in the annual Budget Act or other
statute.
(b) An annual outreach plan shall be submitted to the Legislature
by April 1 for each fiscal year for those years for which there is
funding in the annual Budget Act or other statute for the outreach
and education campaign. The plan shall address both the Medi-Cal
program for children and the Healthy Families Program and, at a
minimum, shall include the following:
(1) Specific milestones and objectives to be completed for the
upcoming year and their anticipated cost.
(2) A general description of each strategy or method to be used
for outreach.
(3) Geographic areas and special populations to be targeted, if
any, and why the special targeting is needed.
(4) Coordination with other state or county education and outreach
efforts.
(5) The results of previous year outreach efforts.
(c) In implementing this section, the department may amend any
existing or future media outreach campaign contract that it has
entered into pursuant to Section 14148.5. Notwithstanding any other
provision of law, any such contract entered into, or amended, as
required to implement this section, shall be exempt from the approval
of the Director of General Services and from the provisions of the
Public Contract Code.
(d) (1) The department, in conjunction with the Managed Risk
Medical Insurance Board, may award contracts to community-based
organizations to help families learn about, and enroll in, the
Medi-Cal program and Healthy Families Program, and other health care
programs for low-income children. The department shall implement this
subdivision if funding is provided for this purpose by an
appropriation in the annual Budget Act or other statute.
(2) Contracts for these outreach and enrollment projects shall be
awarded based on, but not limited to, all of the following criteria:
(A) Capacity to reach populations or geographic areas with
disproportionately low enrollment rates. If it is not possible to
estimate the number of uninsured children in a geographic area who
are eligible for the Medi-Cal program or the Healthy Families
Program, proxy measures for rates of eligible children may be used.
These measures may include, but are not limited to, the number of
children in families with gross annual household incomes at or below
the federal poverty levels pertinent to the programs.
(B) Organizational capacity and experience, including, but not
limited to, any of the following:
(i) Organizational experience in serving low-income families.
(ii) Ability to work effectively with populations that have
disproportionately low enrollment rates.
(iii) Organizational experiences in helping families learn about,
and enroll in, the Medi-Cal program and Healthy Families Program.
Organizations that do not have experience helping families learn
about, and enroll in, the Medi-Cal program and Healthy Families
Program shall be eligible only to the extent that they support and
collaborate with the outreach and enrollment activities of entities
with that experience.
(C) Effectiveness of the outreach and education plan, including,
but not limited to, all of the following:
(i) Culturally and linguistically appropriate outreach and
education strategies.
(ii) Strategies to identify and address barriers to enrollment,
such as transportation limitations and community perceptions
regarding the Medi-Cal program and Healthy Families Program.
(iii) Coordination with other outreach efforts in the community,
including the statewide Healthy Families Program and Medi-Cal program
outreach campaign, the state and federally funded county Medi-Cal
outreach program, and any other Medi-Cal program and Healthy Families
Program outreach projects in the target community.
(iv) Collaboration with other local organizations that serve
families of eligible children.
(v) Strategies to ensure that children and families retain
coverage and are informed of options for health coverage and services
when they lose eligibility for a particular program.
(vi) Plans to inform families about all available health care
programs and services.
14067.3. (a) (1) The department may maintain an allocation program
for the management and funding of county outreach and enrollment
plans to enroll and retain eligible children in the Medi-Cal program
and the Healthy Families Program.
(2) Notwithstanding any other provision of law, and in a manner
that the director shall provide, the department may allocate an
amount to fund county outreach and enrollment plans identified in
this section.
(b) (1) The sum of three million dollars ($3,000,000) in the
2006-07 fiscal year, and thereafter adjusted proportionately on a pro
rata basis contingent upon the annual appropriation, but not less
than two million dollars ($2,000,000), shall be set aside, from the
annual allocation for purposes of this section, for counties
identified in subdivision (d).
(2) Notwithstanding paragraph (1), the total of all county
allocations made pursuant to this section shall not exceed the annual
appropriation for the implementation of this section.
(c) The director shall make allocations to not more than 20
counties that have the highest number of children who appear to be
eligible for the Medi-Cal program or the Healthy Families Program, as
determined by the director, but who are not currently enrolled in
either program, and the highest number of Medi-Cal program and
Healthy Families Program cases for children. This number shall be
weighted to emphasize those who appear eligible, but are not
currently enrolled in the programs.
(d) With funds set aside under paragraph (1) of subdivision (b),
the director shall make allocations to those counties that have an
existing infrastructure for outreach, enrollment, retention, and
utilization, and that can demonstrate they have well established and
documented county coalitions for children's coverage with
organizations such as community-based organizations, schools,
clinics, labor organizations, and other safety net providers in place
for at least 12 months.
(e) (1) To obtain an allocation authorized under this section, a
county shall submit an allocation plan, which shall include an
outreach and enrollment plan, as outlined in paragraph (2). The
director shall establish the procedures and format for submission to
the department of all county allocation plans.
(2) The following shall constitute the minimum components required
of a county outreach and enrollment plan:
(A) An active collaboration with a wide range of organizations,
such as community-based organizations, schools, clinics, labor
organizations, and other safety net providers.
(B) A streamlined application assistance process.
(C) Establishment of an oversight, performance management, and
review program to ensure that the outreach and enrollment plan
submitted by the county is properly implemented and administered.
(D) A description of each of the following:
(i) The amount of the current funding and funding source for
application, enrollment, retention, and utilization activities.
(ii) The current application, enrollment, retention, and
utilization activities.
(iii) How the allocation funds awarded under this section will be
used to supplement and not supplant existing application, enrollment,
retention, and utilization activities.
(E) A detailed proposed budget of all expenditures for the
relevant fiscal year or years for the county's outreach and
enrollment plan activities, expenses, services, materials, and
support.
(f) Counties receiving an allocation under this section shall
provide reports to the department, as determined by the department,
on the progress made in achieving the objectives of the allocation
plan.
(g) (1) The funds allocated under this section shall be used only
for outreach, enrollment, retention, and utilization. The funds
allocated under this section may supplement, but shall not supplant,
existing local, state, and foundation funding of county outreach,
enrollment, retention, and utilization activities. Notwithstanding
Section 10744, the department may recoup or withhold all or part of a
county's allocation for failure to comply with the standards set
forth in the county's outreach and enrollment plan upon which the
allocation was based.
(2) Notwithstanding any other provision in this section, any
acquisitions made with funds allocated under this section shall be
made in compliance with federal law.
(h) Reimbursements for costs incurred under the allocation plan
authorized under this section shall be made in arrears and in a
manner as provided by the director. The allocations may be used only
to fund activities provided in each of the designated fiscal years
and in accordance with the county's approved outreach and enrollment
plan and budget for the fiscal year.
(i) As authorized by the director, on a case by case basis, funds
allocated pursuant to this section may be used to support automated
enrollment of children in the Medi-Cal program or the Healthy
Families Program. Funds under this subdivision shall further the goal
of increasing the enrollment of uninsured children, as well as
increasing the retention of children, in the Medi-Cal program and
Healthy Families Program in the same fiscal year for which the funds
are allocated.
(j) The department and the Managed Risk Medical Insurance Board
shall seek approval of any amendments to the state plan necessary to
implement this section for purposes of funding under Titles XIX and
XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq.
and 1397aa et seq., respectively). This section shall be implemented
only when federal approvals have been obtained and only to the extent
federal financial participation is available.
(k) The department shall reimburse a county pursuant to this
section in lieu of commencing a cooperative agreement or contract
with a county for the operation of an outreach program.
(l) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all county letters, provider bulletins, or similar
instructions.
(m) For the purposes of this section, "county outreach and
enrollment plan" means a county outreach program designed to identify
and enroll children who are eligible either for the Healthy Families
Program or the Medi-Cal program, but are not currently enrolled in
either program, and to facilitate the retention of eligible children
currently enrolled in these programs.
14067.5. The department shall encourage counties to outstation
additional Medi-Cal eligibility workers in nontraditional sites, such
as schools, private hospitals, clinics, mental health centers, sites
providing services under California Supplemental Food Program for
Women, Infants, and Children sites, and community-based
organizations. The department shall permit counties to redirect a
portion of existing funding for Medi-Cal eligibility administration
for this purpose. The department shall require counties that redirect
funds to provide an annual report on the cost of the additional
outstationed workers and their effectiveness in increasing or
facilitating Medi-Cal enrollment. Expenditures under this section
shall be subject to the availability of federal financial
participation, and shall not cause an increase in the allocation of
funds for the administration of the Medi-Cal program.
14068. In conducting outreach activities for the enrollment of
special needs populations into a Medi-Cal managed care program, the
department and its contractors, as deemed applicable by the
department, shall work with state, local, and regional organizations
with the ability to target low-income seniors and individuals with
disabilities in the communities where they live. This shall include,
but not be limited to, all applicable state departments that serve
these individuals, regional centers, seniors' organizations, local
health consumer centers, and other consumer-focused organizations
that are engaging in providing assistance to this population.
